‘You’re Beautiful’: Life After Double Mastectomy

Laurie Ratliff often appears shirtless on TikTok, talking openly about her double mastectomy and ongoing breast cancer journey. Although she is no longer reported for nudity, she still receives the occasional negative comment, which she has no problem shutting down.

“I am not showing my breasts because I have none,” Ratliff said in an interview with Managed Healthcare Executive. “[They] are imagining what used to be there, and that upsets [them] for whatever reason. It’s no different than showing my back.”

Laurie Ratliff

Ratliff is one of a number of women with surgically treated breast cancer who are deciding not to have reconstructive surgery. A study published in Annals of Surgical Oncology in 2023 that examined the reconstruction rates from 2004 to 2019 showed that 37.5% of women had reconstructive surgery whereas 62.5% did not. The proportion of women choosing flat closure after mastectomy declined for years until a landmark story in The New York Times in 2016 headlined “ ‘Going Flat’ After Breast Cancer.” After that, the proportion started to increase.

There are several options for breast reconstruction after mastectomy. Depending on the severity of the cancer and amount of tissue removed, patients can choose to have a reconstruction using implants or their own skin. Implant insertion takes at least two surgeries, with one to place tissue expanders where the implant will eventually go and then another to place the implants.

Tissue flap procedures, also known as autologous tissue reconstruction or tissue-based reconstruction, use tissue from the patients’ buttocks, thighs or stomach to create a more natural feeling breast.

During aesthetic flat closure, which was Ratliff’s choice, excess skin and fat are removed to make the chest appear as flat as possible. Thanks to the Women’s Health and Cancer Rights Act of 1998, most health insurance plans now cover this reconstructive surgery for eligible patients.

In some cases, surgeons have gone against their patients’ wishes for flat closure, performing a skin-sparing mastectomy instead. The reason? It’s in case the patient changes their mind about implants in the future and that it’s easier for a surgeon to place implants if some skin is left behind.

Ratliff is well-spoken, her voice even and calm. She seems taller on camera, something she says isn’t uncommon for people to assume. Despite some initial hesitancy to share her story, she opens up. We spoke for an hour and a half via Zoom.

Ratliff currently lives in South San Francisco, California, with Steven, her husband of 34 years. When she was 12 years old, she decided she wanted to be a dancer. “I didn’t have the body to actually be a professional dancer,” Ratliff said. “I was a D cup, which is pretty big for a dancer.”

At the time of her diagnosis, she worked in the archives of a performing arts library. Her ongoing cancer battle has made it difficult to return to work, so to keep busy, she frequently posts on TikTok, raising awareness for breast cancer. She currently has over 45,000 followers, and her videos have earned a total of 2 million likes.

BRCA gene mutations

Ratliff’s breast cancer story begins in November 1998 when she found a breast lump during a self-examination. She was 34 years old. “I was told in the beginning, ‘Oh, don’t worry about it, you’re too young for breast cancer,’” Ratliff said. But it was breast cancer. Further testing showed that it was metastatic and had spread into her bones. She was told there was just a 25% chance she’d survive for five years.

Because her cancer was already at stage 4, she received a single mastectomy just two weeks after detection. Afterward, surgeons told her that reconstruction with an implant would be tricky because the radiated skin was not flexible enough to hold an implant. This advice, coupled with infection risk and additional surgeries required for reconstruction, made Ratliff reconsider. Four years later, she decided she wanted the other breast removed. It turned out to be the right decision because Ratliff had positive test results for mutations to the BRCA gene that are associated with a greater risk of breast cancer.

“I wasn’t willing to risk it, and I was not that attached to my breasts to begin with,” Ratliff said. “To lose my breasts was not a tragedy. Losing my life would be the tragedy.”

After her double mastectomy, Ratliff was treated with tamoxifen and an aromatase inhibitor. But in 2022 during a routine scan, her doctor found two new tumors on her spine.

Ratliff is now in the process of finding the right medication combination. She’s currently being treated with one CDK4/6 inhibitor and injections of Faslodex (fulvestrant), an antiestrogen which blocks tumor growth. Although she’s thankful the new regimen doesn’t give her the devastating fatigue, nausea and body aches she had when she was being treated with Lynparza (olaparib), it does negatively affect white blood cell counts, which must be monitored closely.

Nearly 75% of women were satisfied with their decision to go with flat closure, but almost 25% said they did not feel their decision was supported by their surgeon, according to the results of a survey published in Annals of Surgical Oncology in 2021. In the same survey, 22% of patients experienced “flat denial,” with patients saying that “I was never given the choice of going flat; it was like I was ‘expected’ to have reconstruction’’ and ‘‘I stated multiple times that I intended to stay flat. … After surgery they told me they left extra skin in case I changed my mind.’’

A defining moment

Ratliff wasn’t always confident about her new body. For the first 15 years after her surgery, she wore breast prosthetics. She eventually grew tired of them but did not have the community support to encourage her to be openly flat-chested. “I tried the ‘camouflage’: the scarves, the ruffled things, and that wasn’t me either. I didn’t want to try to hide my reality anymore.” The defining moment happened one day on the internet when she saw a photo of a woman.

“It was snapshot of a woman on vacation on a beach wearing shorts and a hat, and that was it. She was sitting in the waves, and she had her kids running around her, and she was just sitting there smiling. She looked so relaxed, and it looked so natural. As I was looking at those pictures, I thought, ‘I want to feel that level of ease in my life with my body, with being flat. I want that. I want it to not ever be a big deal.’ ”

Ratliff said there has been an unexpected benefit from her social media outreach: support from and allyship with transgender men who have had top surgery and the nonbinary community. Although Ratliff identifies as a cisgender, heterosexual woman, she said that many people who find her account are queer and, seeing her flat chest, assume she is too. “I will get people who will say, ‘You’re still beautiful without your breasts,’ which is very nice, but I have noticed from [the] nonbinary community [that] they don’t use the word ‘still.’ They just say, ‘You’re beautiful.’ It is so much more of an affirming compliment. They behold me; there is no qualification.”