Deciding to Go Flat: Yael Levin
At first, Yael Levin’s breast cancer treatment plan looked straightforward. Diagnosed in 2017 at age 34 with stage IIIa breast cancer and ductal carcinoma in situ (DCIS) in her right breast, she expected to have a mastectomy and then chemotherapy, radiation and breast reconstruction.
Yael, who lives in Philadelphia, was recommended genetic testing because of a history of cancer in her family, her Ashkenazi Jewish ancestry and her young age at diagnosis. The results showed that she had a mutation on the BRCA2 gene that put her at greater risk of a second breast cancer, so she decided to have a double mastectomy and breast reconstruction.
Because Yael is small and slender, her surgeons told her she was a better candidate for reconstruction with expanders and implants rather than flap reconstruction, which uses tissue taken from elsewhere on her body to rebuild each breast.
The doctors did not bring up another possibility: Yael could choose not to have her breasts reconstructed at all.
“I thought briefly about being flat, but because of my age, at the time I wanted expanders and reconstruction,” she says. That wasn’t what would happen.
Deciding to Go Flat
Yael had surgery in March 2017. The tumor in her right breast was large, close to the skin, and she had cancer cells in four lymph nodes. When all the affected tissue and skin were removed, there was not enough remaining to place an expander for reconstruction.
When she was in recovery, “I was led to believe that I could still have reconstruction with expanders [on both sides],” Yael says, which was what she wanted. Soon she found out it would only be possible if she also had surgery on her right side to provide the extra tissue and skin needed.
“I felt misled by the doctor. I was really upset that it wasn’t proceeding as it was supposed to,” she says. “I learned that every time you make plans with breast cancer, something changes, it’s out of your control and you have to readjust. I was really angry and then I grew to accept it.”
There were other challenges on the road to reconstruction. During chemotherapy, Yael was hospitalized for 10 days with an infection caused by a low white blood cell count, which delayed treatment. Then, just before finishing chemotherapy in October, she was diagnosed with thyroid cancer. That meant, after completing radiation therapy for breast cancer in January 2018, she needed another surgery to remove her thyroid. She also planned on having an oophorectomy to remove her ovaries due to her BRCA2 status.
“Knowing there would be more and more procedures, I became more accepting of my body and how it currently is,” Yael says. She thought again about not having reconstruction and started reading the few online articles she could find about making that choice.
She joined a Facebook group called Flat & Fabulous. Some members had their implants removed and not replaced, while others chose from the start to remain flat after breast cancer surgery. Reading these women’s stories “made me realize [that deciding against reconstruction] can be a good thing,” she says.
“The more I learned [from doctors and social media], the more my decision became solidified,” she says. “I have two young kids who I have nursed. I am so tired of surgeries and doctors and appointments. That has also really affected my decision.”
It’s possible to do reconstruction in the future, but she’s not thinking about it. “It’s not important enough for me,” says Yael, who is now 36 and works for a nonprofit organization. “If I really wanted to have those curves, maybe I’d get a prosthesis. There are new, light ones today.”
Adapting to a Changed Body
While on the phone being interviewed for this article, Yael was sitting topless, having her portrait painted by her artist sister-in-law, Juliette Aristides. But getting used to being flat didn’t happen easily.
“There were a lot of tears,” she says. “Part of it was losing my breasts because I didn’t have anything after, and part of it was just the shock of going through this process, which I think every breast cancer patient deals with. There definitely was a period of grieving and hiding, not letting my kids see my scars and my body.”
A few months after surgery, Yael became comfortable changing clothes in front of her 3- and 5-year-old daughters. “They knew that the doctor had to take bad cells out of my body to make me healthy,” she says. “For me, it’s important for them to see it. Part of that is [so they understand that] every woman’s body is different.”
Having once worn a D-cup bra, Yael now likes going braless but sometimes has trouble finding clothes in which she feels confident. In the online group, members share sources for great-fitting shirts, dresses or bathing suits, among other topics.
“It has been an adjustment,” Yael says. Yet she has gone flat to a job interview and several fancy parties. “I think I still need to work on my courage, maybe to go to a naked spa,” she says, with a laugh.
Now she feels more energetic, able to run around with her kids and enjoy life as a family and a couple. Her current treatment includes leuprolide (Lupron) and letrozole (Femara). The planned oophorectomy has not yet happened.
Yael wants women to know that not having reconstruction is an option after a breast cancer diagnosis. Doctors might not mention it, she notes, simply assuming that reconstruction is wanted. But reconstruction can cause discomfort, complications and lead to additional surgeries.
“People don’t have to go through the time that’s taken away and the pain and the suffering if they don’t want it,” Yael says. “There is a community of women who are embracing it and are happy with it.
“For me, I’ve had so many other issues that I don’t need more,” she adds. “I’m happy with my body, I’ve come to terms with it. There’s a freedom to that.”
This article was supported by the Grant or Cooperative Agreement Number 1 U58 DP005403, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.