A Conversation with the Authors of Flat and Happy

Keri Stephens:

Hi, welcome to the MEDQOR Podcast Network. This is Keri Stephens and I’m joined today by my co-host Alison Werner. We are the co-chief editors of Plastic Surgery Practice. Thank you for joining us for today’s podcast. Today, we are joined by Dr. Camelia Lawrence, the director of breast surgery at Hospital of Central Connecticut and MidState Medical Center, Hartford Healthcare. And Katrin van Dam, a breast cancer survivor, and the author of Flat and Happy which she wrote alongside of Dr. Lawrence. Today, we will be talking about this new book and what plastic surgeon should know about a patient’s decision to stay flat post vasectomy. Dr. Lawrence and Kat, thank you for joining us today.

Katrin van Dam:

Thank you so much for having us.

Camelia Lawrence, MD:

Thanks for having us.

Keri Stephens:

Of course. So my first question is for Kat and just what led you to write a book about your decision to go flat after your mastectomy?

Katrin van Dam:

Yeah, thank you. So, when I first started having conversations with my breast surgeon after my diagnosis, I was presented with two options. I could either have lumpectomy with radiation or as she described it mastectomy with reconstruction and she really presented that like it was one thought in the same way that radiation was a medical decision that went along with lumpectomy. Reconstruction was presented as sort of the obvious decision that you would make if you were having mastectomy. And that didn’t sit well with me because I was pretty sure I didn’t want to have reconstruction. I didn’t want to have any more surgeries than I needed to, and I didn’t want to have foreign bodies in my body. So, and also I wasn’t particularly attached to the idea of having breasts. It wasn’t a huge part of my identity. I know that for many women, the idea of having breast is important. For me, it didn’t happen to be. So I was pretty sure that I wanted to go flat, but I wanted some affirmation for that choice.

Katrin van Dam:

I wanted to make sure that I wasn’t going to regret that decision. And so I started doing a whole lot of research looking for resources that would guide me on that. And at the time there really wasn’t much available. My surgeon strongly urged me to talk to a plastic surgeon just to be sure about reconstruction or not. And she actually said to me, women are just happier if they have reconstruction. And while I didn’t really buy that as an idea, I did follow her advice. I spoke with the surgeon that she recommended. She was lovely. She didn’t pressure me in any way, gave me a lot of good information. And I came out of that conversation saying, yeah, okay, I’ve made a decision. I’m not going have reconstruction. I followed that instinct. And it was a great decision for me. I really could not be happier with that choice hence the title of the book.

Katrin van Dam:

So after the surgery and starting to encounter other women who had gone flat or who were contemplating that choice in various communities online, I started learning more about some of the complications that women had faced. Many of these women had reconstruction that are now contemplating ex planting. And so I read a lot about some complications that came up and also just the pressure that women were under by certain doctors to have reconstruction. I wouldn’t say that my doctor pressured me, but she certainly encouraged me strongly.

Katrin van Dam:

And I would read these stories about honestly, usually male plastic surgeons telling their patients that they would regret it if they did not have reconstruction. And that really touched a nerve for me. And I thought there needs to be a resource. There’s all these women coming behind me who are trying to make those same decisions that I had to make not that long ago and they’re going to be looking for that same resource. They need to be affirmed in this decision and to know their own minds. And I figured if the resource didn’t exist, then I ought to try to create it.

Alison Werner:

Well, Kat in the opener of your book, you make a disclaimer about the difference between going flat after mastectomy and undergoing gender affirming top surgery. And you said, “To compare the two is to deny the grief of one and the relief of the other.” Can you elaborate on this? I found it a really interesting statement.

Katrin van Dam:

Ah, thanks for bringing that up. I actually, I had a really interesting conversation with a non-binary reader of the book who said that that paragraph in the introduction was very important for them as they were grappling with the emotional roller coaster that they were on. I think that there’s a tendency to think of breast cancer as being a women’s issue. But as Dr. Lawrence can attest, there are a lot of people who don’t identify as women who undergo mastectomy. And actually when I first started working on the book, a few people said to me, oh, this is so topical right now because transgender issues and top surgery, that’s all over the media. And I thought, boy, I really have to sit with this because I know that’s not, that’s a false comparison, right? Like I could instinctively know that, but I wasn’t able to just immediately put my finger on what was wrong with that.

Katrin van Dam:

Ultimately, I sort of thought it through for myself. And I realized like, if you identify as a woman and that’s whether you’re cis or transgender, your breast can be a huge part of your identity. Society places a lot of importance on these notions of femininity. So if you’ve spent your whole life associating your breasts with your identity, losing them can be a serious blow to your psyche. On the other hand, if you’re a trans man or non-binary person who’s confronting the loss of your breasts, that’s a very different emotional context. Obviously you’re still grieving because of having cancer, but the loss of your breasts could actually be tinged with some relief because you will be saying goodbye to a body part that may have always sat in conflict with your identity.

Katrin van Dam:

So, if you’re a plastic surgeon who’s discussing gender affirming top surgery with a patient, the tone is very different from if you’re talking to a woman identifying person about losing her breasts. And even though the two procedures may have some technical similarities, the emotional context are so different. And then also if you imagine a trans or non-binary cancer patient, who’s opting to go flat after mastectomy, again, very different. Their particular experience and identity have to be taken into account when you’re considering the cosmetic aspects of the surgery. But also it’s going to color the emotional tone of the conversation.

Alison Werner:

Yeah, absolutely. Well, and yeah, and I thought it really kind of, it was nice to see that you had that discussion and you brought that into this and laid that out from the beginning, so.

Katrin van Dam:

I wanted the book to be as inclusive as it could possibly be. And I really struggled with even using the pronoun, she in the book, because I knew that that was going to leave some people behind. Ultimately, because it was my experience, I thought, okay, I’m going to speak to what I know and I’m going to upfront say, I see you, I’m sorry. I wish that I had a better solution for this. Right now I don’t.

Keri Stephens:

Well, I will say your book really spoke to me. I did undergo a mastectomy in 2020, and I was never presented with the option to go flat. It was never discussed. In any of my appointments no one ever mentioned that. It was okay, you’re going to have a mastectomy, you’re going to have new breasts. And it was just, that’s what it was. But this question is for Dr. Lawrence. I thought the book was really great at explaining the process of a mastectomy. Something that I really wish I had had in 2020 when I underwent mine. And you gave a checklist for mastectomy patients about questions to ask our plastic surgeons about implant reconstruction, which is what I had. Do you think that most women who choose implant reconstruction go into that first appointment blindly? Because I know that I did, I was completely blind.

Camelia Lawrence, MD:

Oh, I definitely do. I mean, I think most women are in a state of shock when you’re diagnosed with breast cancer. I think so many may be having thoughts running through their head, such as why did this happen to me? What does this diagnosis mean? Can it be treated? Is it survivable? And unless you have a medical background about the diagnosis and treatment of breast cancer, it’s almost impossible for you to have the right questions at the outset. But I think the good news is that the decision unfolds, the decision making process unfolds over a period of time and you should never feel rush to make that decision. So women will have time to read, to consult with others who may have undergone similar procedures and have had to make the choice.

Camelia Lawrence, MD:

And the final decision, before you make that final decision one of the book, and that’s the beauty of Katrin’s book is that that’s the optimal window where you can consult a book such as Katrin, where there’s none like it currently available in the literature. I mean, it’s concise, it’s accurate. It’s very comprehensive. And while the book title Flat and Happy, I thought Kat did a really good job at presenting the alternative option, which is for those who undergo a reconstruction. But you’re absolutely right. I think there’s a bias within the medical community that if a woman is undergoing a mastectomy, we automatically assume that they desire reconstruction. And in some cases, as in Kat’s case, that’s not the case. They’re quite happy being flat and happy.

Alison Werner:

Dr. Lauren thinning off of that answer, there’s a misconception among the public that implant-based breast reconstruction is quote unquote, a free boob job. How do we shape the public’s perception or how do we move away from that idea and help women and the people around them understand that that’s not what’s going on here?

Camelia Lawrence, MD:

Yeah. I often sometimes smile when I first hear that comment because they’re such very different operations. I mean, a boob job enhances the existing breast in terms of shape and size, while it preserve an anatomical function and innervation. For example, most women who undergo reconstruction or augmentation, they can breastfeed after, the sensation remains intact. And quite the contrast for a woman facing a breast cancer diagnosis that’s undergoing a mastectomy with reconstruction because it involves complete removal of the anatomical breast with the reconstruction in terms of implant or other methods used to restore the shape in appearance. And in most cases, to be honest with you, the innervation is lost along the entire chest wall. And in some cases, the nipple is removed. And even when preserve is often in sensate.

Camelia Lawrence, MD:

So it’s a much more complex and a lengthy operation with more risk associated with it. And it’s often time not one and done when you’re having an implant based reconstruction, because typically a tissue expander is placed. It’s expanded over a time period. And then you go back for the final implant placement. And even after that surgery, you may need other tweaks along the way in order to receive some sort of symmetry.

Keri Stephens:

I mean, I can attest that. I just went through my third. It’s not one and done. And I think I’m really glad you said that because I thought it was. I think I was so misinformed. I at least thought okay after my expanders came out, but it’s yeah, no, it’s been surgery after surgery and still, I mean, luckily I was a previvor not a survivor, so I consider myself lucky with that. But Kat, you do talk about plastic surgery and the patriarchy, particularly the concept of [inaudible 00:12:39] aesthetic, flat closure. What do you want to tell plastic surgeons about this option from your patient perspective?

Katrin van Dam:

That is a juicy question. I can spend a lot of time talking about this. I will try to keep it to just a couple main points. All right. So the first thing I would say is, please don’t tell your patients they’re going to be unhappy if they don’t have reconstruction. So yes, without questions, some women are not happy going flat. I would point out that some women are also not happy with their reconstruction. Plenty of women on both sides of that equation are happy. It’s a highly individual choice. And that said, you’d be amazed at how often I hear women who have gone flat saying, oh, my doctor told me I was going to regret this. So yes, the first thing that I would say to plastic surgeons is please listen to your patients. It’s not a one size fits all. You need to work with them to figure out what’s going to make them as happy as possible under their particular circumstances.

Katrin van Dam:

And by the way, you may have read studies that indicate that women experience some kind of psychosocial wellbeing boost if they have reconstruction. But the methodology of those studies is really very flawed. And there’s better, more recent data that shows that satisfaction is actually just about neck and neck for the two choices, reconstruction and going flat if, this is a very important if, if their doctors support their decision and they give them a nice, smooth, flat closure. The support of the doctor is hugely important in that satisfaction score. And by the way, aesthetics are just as important in flat closure as they are in reconstruction. Just because I don’t care about having breast mounds doesn’t mean that I don’t care about my appearance.

Katrin van Dam:

The other thing that I do want to say is if your patient is going to have reconstruction, discuss the risks and potential complications with them. I mean, you don’t have to get crazy granular about it and go into every possible thing that could go wrong because nobody needs that inside their heads. But I hear all the time from women who are experiencing complications, nobody told me that this could happen. So if they’re having implant surgery, tell them, tell them about breast implant illness for one thing. There’s still an awful lot of doctors who deny that BII even exists. They tell their patients, oh, that’s just a social media hoax. But as you doubtless know, the data on this is very clear. A huge majority of women who explant experience like almost instantaneous relief from their symptoms. Even the FDA acknowledges that BII is real. It’s not just in women’s imagination.

Katrin van Dam:

So I would say inform your patients of what the symptoms are so they know what to look for. Follow up with them to make sure they aren’t missing any signs. And yeah, like there’s a long term responsibility there. To me, if you put a foreign object into someone’s body, I think that there’s a responsibility to ensure that that object isn’t going do them any harm in the long term.

Keri Stephens:

Yeah. And final question for Dr. Lawrence as a breast surgeon, how can breast surgeons and plastic surgeons work together better to improve outcomes among mastectomy patients?

Camelia Lawrence, MD:

That’s an excellent question. I think a balanced and a transparent team approach between the breast surgeon and the plastic surgeon is crucial and that’s what’s going to yield the best outcome. I think it’s important for the plastic surgeon to enter each consultation with an open mind as Kat pointed out before. Because you’re seeing a patient that’s facing the mastectomy doesn’t necessarily mean that she plans to proceed with reconstruction. As a result, all options, including forgoing reconstruction should be presented without bias. Patients have aesthetic goals that they’ll like to reach. And they want our advice on how to reach those goals. And they want our support. And some patients have complex wishes and a single surgery just isn’t enough to produce optimal results, but we need to convey that to them during the consultation.

Camelia Lawrence, MD:

One of our primary goal is to ensure that our patient experience shorter hospital stays and less post-operative discomfort. So may be a woman who’s affected by breast cancer, who would like to restore the size, shape, and the appearance of her breasts after a mastectomy or a woman who would like to forego reconstruction of the breast, the breast surgeon and the plastic surgeon must work collaboratively to center those wishes and to respect the patient’s preference. So I really think it’s all rooted in communication.

Camelia Lawrence, MD:

And what I’d like to point out is in some cases, a woman who elects to forgo reconstruction, the breast surgeon may be the one to perform the aesthetic flat closure as in my case. But I do come across sometimes cases where you do need the plastic surgeon’s assistant in order to achieve an aesthetic flat closure. One of the common, not side effect, but sequelae from a mastectomy is what we call the [inaudible 00:18:02] that needs to be addressed. And who’s better to help you address that than a plastic surgeon that has the skills and expertise. So even though the patient is not undergoing reconstruction, they may still benefit from a collaborative approach between the breast surgeon, as well as the plastic surgeon to achieve the best aesthetic result.

Alison Werner:

Well, Kat and Dr. Lawrence, thank you so much for taking the time to speak to us and our audience today about this. Their book Flat and Happy: a Mastectomy and Flat Closure. A Personal, Practical Guide is available on Amazon. And to our listeners, thank you for joining us for this episode. Be sure to subscribe to the MEDQOR Podcast Network to keep up with the latest Plastic Surgery Practice Podcast episodes, and be sure to check out plasticsurgerypractice.com for the latest plastic surgery news. Until next time, take care.