“Going flat doesn’t mean just breast removal… it means being flat and having a nice chest contour” – Dr. Minas Chrysopoulo

DiepCFoundation patient advocate Terri Coutee has written an insightful article from the perspective of a woman who chose reconstruction, and who advocates for educating patients about their reconstruction options.  She read about flat denial in Catherine Guthrie’s Cosmopolitan article and was saddened by the victimization and trauma that the women featured were describing.  Terri remembers how difficult it was for her to look at her own skin-sparing result following mastectomy, even though she wanted and expected that result as she was planning on delayed reconstruction.  Victims of flat denial, on the other hand, are often left with a skin-sparing result against their consent, and it is just another layer of trauma for these women.  Terri says, rightly:

“[We] have a right to choose what our bodies will ultimately look like after surgery…

The Responsibility for Aesthetic Outcomes Ultimately Lies on the Surgeon.

This is true of both breast surgeons and plastic surgeons who are part of the surgical process for mastectomy patients.”

– Terri Coutee, Patient Advocate at DiepCFoundation

In the article, Terri links to a video entitled Aesthetic Questions to Ask Your Surgeon if Going Flat after Mastectomy, in which she interviews two plastic surgeons from PMRA in San Antonio, TX, including Dr. Minas Chrysopoulo, the creator of the Breast Advocate app.  Both surgeons recommend that women who choose to go flat after mastectomy consult with plastic surgeons in order to maximize the quality of their cosmetic result.  Dr. Chrysopoulo was clear that patients expect a decent flat result when they decide against reconstruction – they don’t anticipate a surgeon simply removing the breast and making no good faith attempt to achieve a truly flat contour:

“So, going flat doesn’t mean just breast removal. It means being flat and having a nice chest contour – not having significant contour defects if they can be avoided… the choice not to reconstruct leads you down another pathway that in itself, going flat, is an in-depth conversation in terms of expectations so that you actually get what you expect to get and what you want to get… plastic surgery techniques are very, very helpful for women who don’t wish to have reconstruction.” – Dr. Minas Chrysopoulo, Plastic Surgeon

Unfortunately, as we now know, in cases of intentional disregard, even a skilled plastic surgeon that the patient hires solely to perform a flat closure can unilaterally choose to leave excess tissue against the patient’s consent, and they will not be held accountable (see Kim’s story).  But as Dr. Garza advises below, as the patient, you can minimize this risk by selecting a surgeon who has a proven track record of producing decent flat closures.  If your surgeon has not done a flat closure in the past, or if they are unwilling to share photos to illustrate what type of result you can reasonably expect… it would be prudent to find another surgeon.  The full video and transcript are below:

Aesthetic Questions to Ask Your Surgeon if Going Flat after Mastectomy

YouTube video (April 24, 2018) link

Host: Terri Coutee, patient advocate at DiepCFoundation,”providing education and resources to empower women and men with information to make an informed decision about options for breast reconstruction after a mastectomy”

Transcript (by Not Putting on a Shirt)

Terri:  Hi, this is Terri Coutee from DiepCFoundation.  I have an important topic that I would like to bring up today with Dr.s Ramon Garza [left] with Dr. Minas Chrysopoulo [right].  When a woman faces a mastectomy, which I have, we have choices. We have choices to reconstruct our breast, or not. So when a woman goes into a surgeon’s office, what discussion should they have with their surgeon if they choose not to have reconstruction and they choose to go flat?  Gentlemen, I’ll let you take over.

Dr. Chrysopoulo: Great question.  So… When you ask a lady who wants to go flat, why? Part of that discussion, it’s important to realize what their expectations are.  So, going flat doesn’t mean just breast removal. It means being flat and having a nice chest contour – not having significant contour defects if they can be avoided.  Not having issues with clothing because of tissue that’s been left behind on the side of the chest. Some women, I’ve seen several women who already know ahead of time that they want to go flat and they want to have a very elaborate tattoo…  Well, what they have left behind to tattoo is important, in terms of contour, in terms of the chest wall contour.

So there are ways in which a mastectomy is performed that will determine what that person is left with. So I’ve seen a handful of quite unhappy patients.  The women are not unhappy with their decision not to reconstruct, they were unhappy with what they were left with by going flat. “This isn’t what I had in my mind… I”m not flat…I’m actually concave, there’s this big defect in the middle, I can feel my chest bone, my ribs, there’s excess tissue left behind everywhere else… I’m not even at all. I’m not flat, I’m uneven.”

So the choice not to reconstruct leads you down another pathway that in itself, going flat, is an in-depth conversation in terms of expectations so that you actually get what you expect to get and what you want to get. So I’ve actually done fat grafting on ladies who choose to go flat just to fix the contour so that they are truly flat and not concave. There are other things you can do for the tissue that’s left behind on the side to fix the contour there over the outer part of the chest.  So ironically, more plastic surgery techniques are very, very helpful for women who don’t wish to have reconstruction.

Terri:   That’s good information.  In terms of that, Dr. Garza, really, going flat is an aesthetic question too, and they could ask their breast surgeon, their plastic surgeon, tell me about the scarring.  What kind of questions should they be asking prior to the mastectomy if they decide to go flat, about the scarring?

Dr. Garza:  And those are all great questions. With respect to the scar, in general the scar is going to be a longitudinal line going horizontally across the chest.  That’s the typical scar pattern left when somebody goes flat. The biggest thing I think is patient selection. Not every patient has the same body shape, some patients have a wider chest, extra tissues as Dr. Chrysopoulo said, on the sides, that’s just part of their normal anatomy.  When going flat, that tissue becomes more apparent. And a lot of times patients are unhappy, who have gone flat initially because they feel that tissue is more prominent now, and it is relative to the tissue deficiency in the front that area becomes more prominent and that’s something that they weren’t expecting.

So I think, seeing patient pictures, talking to your general surgeon who’s doing the cancer surgery and also talking to a plastic surgeon even if you don’t want to have any reconstruction per se, you want to choose to go flat, that’s a discussion to have with a plastic surgeon who has experience seeing patients that have made that decision and may have had a similar body type to you, and they kind of help with the expectation aspect of things.

Terri:  Which I would call the aesthetic outcome. Because we know that breast reconstruction is a choice. Going flat is a choice. Great information gentlemen, thank you so much.

Let’s be clear that in cases of flat denial, the patient has specifically requested a flat result, their surgeon has agreed to do their best to achieve a flat result, and then the patient wakes up to a distinctly NOT FLAT result.  This happens either through intentional disregard or through lack of care/skill.

When a patient requests a flat result… it is incumbent upon the surgeon to be honest about whether or not they can achieve that, and if they cannot, to bring on plastics or refer the patient.  No patient should wake up feeling betrayed by their surgeon.  If the patient’s expectations, as discussed in consult, were enormously divergent from what they have woken up to after surgery… was that patient adequately informed going in?  Clearly not.  And if they were not informed, did they give informed consent? No.

As Terri says in her article, the responsibility for aesthetic outcomes ultimately lies with the surgeon.

Published by Not Putting on a Shirt

Founder of Not Putting on a Shirt, a mastectomy patients' rights organization that advocates for optimal surgical outcomes for patients going flat.

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