Insights Into ‘Living Flat’: A Qualitative Study of Patients Who Have Mastectomy Without Reconstruction

BACKGROUND: Over 14,000 UK women undergo mastectomy annually, 70% of whom do not undergo breast reconstruction. These women are often left with suboptimal scars. AIMS: This study aimed to explore the attitudes of women towards their mastectomy scars, particular the aesthetic outcomes, and to raise awareness of the importance of achieving aesthetic flat closure. METHODS: Semi-structured interviews with women who had undergone mastectomy without reconstruction were recruited from a single UK teaching hospital. Thematic analysis was performed using the Framework Approach. RESULTS: Twenty women aged 47-91 years old were interviewed in 2024. Themes identified: satisfaction with scar cosmesis, physical impacts of scars, attitude towards flat mastectomy scars, body image and confidence, pre-operative counselling and scar revision surgery. There was widespread patient dissatisfaction with mastectomy scar cosmesis, although attitudes and emotional responses varied. Women viewed their scars as a necessity. Physical symptoms included discomfort from dog ears chafing on bra straps, or scar tightness restricting arm or shoulder mobility. Most women were interested in scar revision surgery, with some requesting more information, or referrals. Those who had scar revision surgery or chose contralateral symmetrising mastectomy displayed more positive attitudes. CONCLUSIONS: This study found considerable patient dissatisfaction with mastectomy scar cosmesis and demonstrated the profound impacts of poor cosmetic outcomes, highlighting the importance of optimising aesthetic outcomes and the need for scar revision surgery to help women achieve aesthetic flat closure. These findings demonstrate the importance of careful pre-operative planning and good surgical technique with more time allocated to manage expectations.