Sarah Lavender Smith, a 56-year-old mountain runner from Colorado, has made a profound personal decision that reflects a broader societal shift. After living with breast implants for over two decades, she underwent explant surgery to return to her natural, flat chest. Her story illuminates the complex motivations behind cosmetic enhancement and the growing movement towards body acceptance.
The Decision to Go Flat
For 22 years, Smith carried what she describes as "small bags of saline water" on her chest, a secret she shared with only a few close friends. As an outdoorsy athlete, she increasingly felt that her implants contradicted her desire to age naturally and model authenticity. "At 56, I want to model ageing naturally, but having breast implants ran counter to that," she explains. The surgery to remove them without replacement marked a significant turning point in her relationship with her body.
Smith originally opted for implants at age 34, during a period of low self-confidence as a stay-at-home mother. "I seized on the idea as a way to make us both happier," she recalls, though her husband never suggested the procedure. She requested "runner boobs – like, ballerina boobs" from her plastic surgeon, seeking subtle enhancement rather than dramatic change. Looking back, she wishes she had pursued counselling instead, acknowledging that her obstetrician had reassured her that post-breastfeeding changes were normal and a sign her body had done its job.
A Surging Trend
Smith's experience is part of a notable increase in breast implant removal procedures. A December 2024 report by the International Society for Aesthetic Plastic Surgery found that explant surgeries worldwide nearly doubled between 2017 and 2022. This rise, described as "escalating at a pace surpassing that of other mammoplasties," suggests changing perceptions about breast implants among patients.
Dr Matthew Swelstad, a plastic surgeon in Grand Junction, Colorado with over 18 years of experience, confirms this trend. "Breast implant removal definitely has been 'a growth area' in my practice," he says. He observes that contemporary aesthetic preferences have shifted towards smaller, more athletic proportions, with many women prioritising comfort over size. "The aesthetic favored in the 1990s onwards was 'truly a lot bigger'," he notes. "With times changing, there are a lot of different ways to be a woman, and there's more acceptance of those differences … You can still be feminine with a flat chest."
Psychological and Physical Liberation
For Smith, the decision to remove her implants evolved gradually. Several years ago, they began to harden due to capsular contracture, a condition affecting 10-15% of women with implants, where scar tissue around the implant thickens. This made sleeping uncomfortable and prompted medical advice to replace them. However, Smith also became aware of broader risks, including potential loss of nipple sensitivity and breast implant illness (BII), an umbrella term for symptoms like joint pain and autoimmune reactions that some attribute to implants.
Her perspective shifted after speaking with Junko Kazukawa, a distance runner who chose to stay flat after a bilateral mastectomy for breast cancer. "I realized I could be like her. I could be my flat self," Smith says. She opted for permanent removal, which cost $5,617 out-of-pocket, compared to $8,403 for replacement with new implants. The recovery involved drainage tubes and restrictions on exercise, but she emerged feeling "wonderfully aerodynamic" during runs and appreciating the freedom of going braless.
Shared Narratives of Regret and Release
Dr Swelstad identifies a common psychological thread among his explant patients. "Their narrative is really similar," he observes. "'I never really wanted them to begin with. I got them years ago when I was younger, and there was this other person in my life who wanted them, and I can't believe I did this to my body.'"
This resonates with the experience of Jaime McDonald from North Carolina, who got implants at 19 during a period of psychological struggle. She emerged from surgery with larger breasts than desired and later had them removed after finding love with a woman who accepted her naturally. "It literally felt like a weight lifted off my shoulders. They never were me," McDonald says.
Similarly, 74-year-old athlete Debbie Sironen from Idaho removed implants she had gotten to please an ex-husband. She advises younger women: "Don't do it, unless you really want to look different, but I think in the long run you'd regret it. Be happy your body works and can run, hike, work out or whatever, and just stay healthy – that's the most important thing."
Embracing Natural Ageing
Smith acknowledges the challenge of existing in a culture where cosmetic procedures are increasingly normalised. She briefly tried Botox in her 40s but rejected further treatments, viewing them as a "slippery slope" towards perpetual maintenance. "It's a trap that encourages preservation over acceptance, maintenance over meaning," she reflects.
Now, she finds solidarity with other women who have chosen flatness, such as her friend Kelly Ridgway-Smith, who stayed flat after a mastectomy for breast cancer. "I have absolutely no regrets," Ridgway-Smith says. "We don't need that to be a full woman." Both women have prosthetic forms but rarely use them, growing more confident in their natural appearance.
For Smith, this journey represents a hard-won liberation from appearance expectations. "At long last, I'm letting go of caring about being attractive in the eyes of others," she says. Her story underscores a broader cultural reevaluation of beauty standards, ageing, and the true meaning of body confidence.
