No breasts, no regrets for Wichita breast cancer survivor

After dealing with what she described as “wonky” implants after her mastectomy for breast cancer, Elizabeth Hotaling made a decision that many in America’s body-conscious society might find rather bold: She decided to go flat.

It’s a decision the 58-year-old Wichita woman calls no breasts, no regrets.

More than a year after her aesthetic flat closure (AFC) surgery to have her implants removed and her chest wall reconstructed, Hotaling is now part of a national advocacy movement that is working to destigmatize a woman’s choice to go flat-chested after dealing with breast cancer mastectomies or explant surgeries, when failed implants are removed.

In large part, it’s because she says she was never given that option when discussing reconstruction options with her breast surgeon.

In a study led by UCLA surgeon Dr. Jennifer Baker about flat closures, 34% of women reported not receiving adequate information about their surgical options.

“In what other condition does a doctor withhold information about options?” Hotaling said.

“Unfortunately, like me, many women facing mastectomy are not aware that flat is an option. Instead, they are led directly to breast mound reconstruction, something that isn’t always best for or desired by all. This is why I joined Renee Ridgeley on the body-positive campaign Stand Tall AFC.”

Ridgeley is a Hollywood actress who voices the role of Dr. Wendy Sage, a one-breasted hypnotherapist on “The Simpsons,” who has become the sort of mascot of the flat movement after having AFC surgery after undergoing a single mastectomy. Ridgeley is married to the show’s producer and writer, Matt Selman.

Ridgeley co-founded Stand Tall AFC, which is part of another advocacy group called Not Putting on a Shirt, in 2021.

As part of the Stand Tall AFC movement, Hotaling has been participating in several cancer walks across the nation with fellow self-described flatties and supporters of the surgery. She will be leading a team of her family and friends and some flatties in this Sunday’s Making Strides Against Breast Cancer Walk, put on by the American Cancer Society. The event begins at noon at the Mid-America All-Indian Museum, 650 N. Seneca.

Sometimes, walk organizers have proceeded cautiously with welcoming the women, Hotaling said.

At one walk, the group wasn’t allowed to have an information booth. At others, organizers have expressed discomfort about having the women walk shirtless. At one recent walk, organizers negotiated to connect the Stand Tall AFC movement with its thousands of social media followers if the women would not go topless.

At a march last year in Palm Springs, California, Hotaling and the other women who walked shirtless stopped to dance to “This is Me,” a sort of fight song about people not being accepted by society that is part of “The Greatest Showman” soundtrack. A clip of that dance went viral and got 5 ½ million views on TikTok.

Getting the diagnosis

Hotaling realizes the importance many women feel about having breasts and even the choice to augment them. She herself underwent cosmetic augmentation in 2000.

But that choice did mean more surgeries — three, in fact — to correct conditions caused by the implants over the next 18 years until she got her breast cancer diagnosis in 2018.

She got her first mammogram in 2001 but never continued getting them, despite her daughter Jordan bugging her to do that.

Now she credits Jordan for saving her life.

“It was only when she pleaded, ‘If you won’t do it for yourself, will you at least do it for me?’ that I scheduled” the 2018 mammogram in which they found Hotaling’s cancer, she said.

For Hotaling, who lived a healthy and active lifestyle — in fact she had founded a hugely popular women’s only group called the Adventurous Babes Society in Wichita in 2012 — and had no family history of breast cancer, the results came as a shock. She didn’t realize that only about 5-10% of breast cancer cases are hereditary, according to the Centers for Disease Control and Prevention.

Hotaling was diagnosed with stage 1B breast cancer, meaning cancer between 0.2mm and 2 mm, the latter of which is less than an inch, in the lymph nodes and a tumor can’t be detected.

The cancer spots were described to her as calcification, “where they see irregular kind of angry-looking cells. Think of calcification like what you would see on a car battery.”

She tested positive for both the HER2 protein and estrogen receptors, which meant her cancer was being fed by both, making it more aggressive.

She opted for a double mastectomy, to reduce her risk for getting cancer in her remaining breast. As far as reconstruction, her surgeon told her that because she’d already had implants before, she could get immediate reconstruction with implants at the time of her mastectomy. She also underwent 12 rounds of chemo.

But shortly after surgery, her implants went “wonky,” as Hotaling describes it. She developed capsular contraction. Instead of the scar tissue providing a soft or slightly firm protective capsule around the implant, the tissue hardened and became dense, causing her implant to flip front to back, with the mounded side now between her skin and the chest wall and the flat side being the outward-facing side.

The flipped implant made it uncomfortable to sleep. Hotaling had to find ways to conceal the symmetry with her clothes. She had known she would likely face more surgeries since implants have a shelf life of 10 or more years.

But she didn’t think her next surgery would be because they’d gone wonky. She’d fought too hard in her cancer battle, losing her hair, getting a physical trainer to get in shape, that she wasn’t going to be done in by implants. She consulted her plastic surgeon, Dr. Amy Sprole with Plastic Surgery Center, asking if she could remove her implants and provide her with an AFC. Still, she ended up putting off the surgery until 2021.

Shortly before her surgery, she heard a TED talk on breast implant failure and realized she had many of the symptoms the woman listed — headaches, autoimmune disease, digestive issues, skin rashes, and fatigue.

“Within weeks of going flat, I knew I had made the right decision. My headaches were less frequent, my energy levels were increasing and my skin was clear. The new challenges were the ones that I battled internally. How would I dress my new body? Would I still be attractive to my husband? Would I feel the stares and judgment from strangers in the grocery store?”

Her three-year ordeal to go flat is fueling her passion for letting other women know about AFC.

The flat choice

“There’s definitely a trend for patients to go flat and who don’t want to be left with dog ears or excess skin and wrinkles” following breast removal, said Dr. Terri Cusick, a breast surgeon since 1999 and the medical director of Breast Care Specialists in Wichita.

She has been providing that option all along, she said, although it’s not always been formally recognized as AFC.

The National Cancer Institute just added AFC to its dictionary of cancer terms in the past couple of years.

The NCI defines the AFC as a type of surgery done to rebuild the shape of the chest wall after one or both breasts are removed. It’s when extra skin, fat and other tissue are removed, with the surgeon tightening and smoothing out the remaining tissue so the chest wall is flat.

“Patients should know they have that right to go flat,” said Cusick. “I think it’s good that we are talking about it and letting women know it’s an option.”

For women who may bring up the option to their surgeons, some experience what’s called flat denial, “when a surgeon denies their patient an agreed upon flat closure either through negligence or disregard,” according to the UCLA study. In that study, 20% of the women said they didn’t feel their decision was supported by their surgeon.

Often, insurance companies will not cover another surgery to correct a bad mastectomy. Hotaling and her Stand Tall AFC group said sometimes insurance won’t cover the AFC following a mastectomy because it’s considered a chest wall reconstruction and not a breast reconstruction.

According to breastcancer.org, while a 1998 federal women’s health care law requires insurance plans to cover breast reconstruction, there’s no procedure code for a flat closure. The site recommends that patients call their insurance provider to confirm it will be covered and that surgeons code flat closure as reconstructive surgery, which is what Cusick does.

A journal article for plastic and reconstructive surgeons published earlier this year advocated that it’s “crucial to listen to the patient and to fully understand the patient’s concerns, wishes and particular aesthetic desired.”