Should I Confront My Surgeon?

Confronting Your Surgeon After Flat Denial: A Personal Choice


Preface by NPoaS Founder, Kim Bowles

If you have been a victim of flat denial, I wrote this for you. Before we delve into the issue of confronting your surgeon, I want to make sure that you hear this:

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  1. You’re not alone;
  2. This is not your fault;
  3. It can be fixed; and
  4. I will not stop fighting for you, and all other victims, until flat denial is a thing of the past.

It’s undeniable that flat denial is a serious trauma. And while each victim’s situation and response are unique, there are some common themes. My hope is that you will come away from reading this discussion feeling that your experience and feelings are valid, and with a stronger sense of what the right course is for YOU to pursue moving forward with your healing process.


The Experience of Flat Denial

First, what is flat denial?

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Counterclockwise: Bottom left – negligent flat denial. Bottom right – intentional flat denial. Top right – good flat result. Top left – minor defects, referred patient, and bringing on a plastic surgeon

It’s when a mastectomy patients’ wishes to have a smooth flat chest after their surgery are denied by the unilateral actions of their surgeon(s), either intentionally despite technical competence (“I’ll just leave a little extra in case you change your mind”), or by default through incompetence. These results are not minor imperfections; they are truly egregious in quality. And, critically, they are avoidable with proper skill and care.

When you, as a patient, affirmatively decide to go flat after mastectomy, and communicate this clearly to your surgeon, you expect to wake up to a flat result. You have made peace with your reconstructive decision and come to accept that you will wake up without breasts.

When you instead discover, with shock and dismay, an egregiously poor cosmetic result that is in no way flat, you experience this as a violation of your consent and as a loss of bodily integrity. This is not a personal failing or weakness. It is a normal response to a trauma in which you did not have control over your body and could not protect yourself from battery (touching without consent).


Victim’s Responses

Some victims of flat denial choose to deal with this shock and dismay by trying to move on with their lives and accept, or even forget, what happened to them.

Many if not most victims simply don’t comprehend the reality of the violation, because the surgeons who inflict flat denial routinely gaslight their victims and convince them to disbelieve what they see with their own eyes (“I didn’t leave extra… it’ll tighten up,” etc.) And until very recently, no one spoke openly about it and when it was mentioned, it was not affirmed as a traumatic event. Sentiments like “just be grateful you’re alive,” “it’s not that bad,” “you’ll get used to it,” and the like serve only to gaslight the victim even further.

Many victims decide to pursue revision surgery in order to repair the damage that was done to them.

And some victims decide to fight back.

Fighting back can take many forms, including filing formal complaints, pursuing legal action, protesting privately or publicly, or becoming an advocate.  Perhaps the most common way of fighting back is to confront your surgeon directly.


Making the call to confront your surgeon

NOTE: If you have retained an attorney to pursue legal action regarding your surgical experience, please follow their instructions carefully in all related matters. Confrontation may not be advisable in your specific legal situation.

The choice to confront the surgeon who inflicted flat denial upon you, is a highly personal one. Don’t feel obligated to do so for any reason – put your own physical and 

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 emotional health first. Flat denial is a traumatic experience and while there are aspects of healing from the trauma that all victims share, no two victims have exactly the same values and priorities. Your first duty is to yourself – to heal from this trauma as best you can.

As with any major decision, it can help to think about the pros and the cons of confronting your surgeon. Let’s be conservative and start with the cons.

Reasons Not to Confront Your Surgeon

You should know that most victims of flat denial do not confront their surgeons. There are many reasons for this:

  • Some patients fear that confrontation may compromise their medical care via retaliation from the surgeon, hospital, or medical community at large. Even if you have retained another surgeon for your surgical care, addressing flat denial socially and legally is largely uncharted territory and your decisions must be carefully evaluated in light of your specific circumstances.
  • Many victims don’t understand what happened to them and may have internalized blame and shame. After flat denial its routine for the surgeon to gaslight their victims, and until recently there was no one discussing the problem publicly to counteract this.
  • Until recently there was no clear language available to victims to articulate their experience. How do you confront your abuser if you can’t name the abuse as such? Some surgeons will say they “did you a favor,” or were “able to leave you some cleavage,” as though you should be grateful for their violation of your consent. That is emotional abuse, piled on top of the initial physical abuse of your body.
  • Confrontation is a highly stressful and therefore unpleasant prospect for many victims. Victims can reasonably anticipate negative reactions from their surgeons when faced with an accusation of flat denial. Since confrontation is not required in order to proceed with revision surgery at another surgical practice, the stress may not be worth the emotional cost – and many victims choose to move forward without confrontation.

Reasons to Confront Your Surgeon

Bear in mind that while confrontation has potential emotional risks, it may also have emotional benefits. How you come away from the confrontational interaction will depend on many factors – your level of comfort with conflict, your social support system, your personal physical and emotional reserves, and the surgeon’s response to the confrontation – to name a few. What are some reasons patients choose to confront their surgeon?

  • To achieve a sense of closure
  • To fulfill a sense of moral obligation to ensure the surgeon is fully aware of the consequences of their actions
  • Because they don’t want to pursue legal action but do desire some kind of acknowledgment of their experience

Consider Whether Your Flat Denial Was Negligent or Intentional

Whether your surgeon inflicted flat denial upon you intentionally or through negligence is also an important consideration when making the decision to confront:

Negligence. A surgeon who lacked technical skill and didn’t fully inform you of this fact prior to surgery is probably more likely to respond positively to confrontation, than a surgeon whose actions were intentional. Since flat denial has been a taboo subject until very recently, you may very well be the first of your surgeon’s patients to bring your dissatisfaction to their attention. They may be appreciative of your efforts to enlighten them, and the confrontation may materially change the way they treat mastectomy patients in the future. That’s the best possible outcome.

Intentional Disregard. A surgeon who had the technical skill to create a smooth flat contour but chose instead to “leave a little extra in case you change your mind” intentionally and against your clear directive, will likely be less receptive to your message than a surgeon who was negligent. These surgeons have crossed an ethical line further into the red zone than negligent surgeons and have likely rationalized their actions. Confronting such an individual with the reality of their severe moral and professional failure may provoke a strong negative reaction.

Consider the Possible Outcomes

When faced with an anxiety-provoking decision, it can help to try to imagine what possible outcomes might look like, both positive and negative, to take away some of the fear of the unknown.

Negative Outcomes. What are some of the worst things that could happen? That depends on who is asking the question but some possible scenarios include:

  • the surgeon not responding at all and leaving the room to avoid facing you
  • your being asked to leave the hospital either by the surgeon or by hospital staff
  • the surgeon denying what happened or using other techniques to invalidate your experience
  • the surgeon blaming you – your actions or your physical attributes (age, weight, size of breasts) – for your cosmetic outcome
  • the surgeon using abusive language

Positive Outcomes. What are some of the best things that could happen?

  • your feeling a sense of closure or relief
  • the surgeon genuinely apologizing
  • the surgeon’s regret leading to improvement in their treatment of future mastectomy patients (by seeking additional training in flat closure, bringing on a plastic surgeon for their patients going flat, or appropriately referring these patients to a competent colleague)

Proceeding With Confrontation

If you feel that part of your personal healing process may involve confronting the surgeon – directly addressing the surgeon, naming the trauma they inflicted, and sharing your sentiments – there are two ways to go about this. You can confront them in person, you can confront them in writing.

Confrontation in person will mean scheduling an appointment with the surgeon. Prepare for your visit by:

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  • writing out what you plan to say;
  • practicing how you will address various responses the surgeon may have to your message;
  • bringing a trusted support person with you who can provide emotional and/or informational support during the confrontation – they should commit to maintaining a calm demeanor during the visit;
  • if you are considering recording your discussion, keep in mind that the legality of this option varies by region and exercise due diligence
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Confrontation in writing allows you to avoid real-time interaction with the surgeon, both positive 

and negative. You can request that it be included in your medical record. No support person is required.


Things to Keep in Mind for Your Confrontation

It’s up to you to define your personal experience of flat denial – what happened, what it meant to you, how it affected you. The following general principles may also be helpful.

  • Informed consent was not obtained. Your surgeon is a medical professional and as such they are responsible for obtaining informed consent before operating. The fact is that they failed to inform you of the expected outcome of your surgery – therefore, they failed to obtain informed consent. The onus is on the surgeon, not the patient, to ensure that informed consent is obtained.
  • This decision belonged to you. The surgeon may indeed have experienced past patients changing their mind about reconstruction after initially choosing to go flat… but that does not excuse disregarding a patient’s clear directive. No person can predict the future with 100% certainty, and that’s not a reasonable expectation to have of any person, including patients facing mastectomy.
  • Flat denial harms patients medically. Revision surgery on an area that has local lymphatic system disruption can reasonably be considered a risk for lymphedema. Operating on irradiated tissue can lead to wound healing complications. There are risks associated with general anesthesia, which may be required for revision surgery. And every additional surgery increases the cumulative risk of infection and other complications.
  • Flat denial harms patients financially. Additional surgery can be costly for the patient financially as well. Deductibles, time off of work, travel expenses, etc.
  • Flat denial harms patients emotionally. Victims can experience everything from minor distress to PTSD. Flat denial is a serious trauma.
  • The harms of flat denial are avoidable.
  • Moral degradation. Some of the same attributes that lead a person to join the surgical profession – high intelligence and self confidence, ability to (hopefully reversibly) objectify their patients in order to successfully operate – may leave them vulnerable to moral degradation over time. Most surgeons consider themselves to be highly ethical, and most start out that way.
  • Oncoplastic training is available. Training is available for breast and general surgeons in oncoplastic breast surgery techniques – flat closure after mastectomy falls under this category – through the American Society of Breast Surgeons and elsewhere.

Conclusion

The choice to confront your surgeon is a highly personal one. Flat denial is a traumatic experience and your first duty is to yourself. Put your well-being first. Fighting back can take other forms if you feel you want to fight back but aren’t ready for or don’t want to pursue confrontation.

My hope is that by reading through this discussion, you have felt some validation of your experience and your feelings. And I hope that it helps you to decide what the right course of action is for YOU to pursue moving forward with your healing process.


Questions? Comments?

Please email us at NotPuttingonaShirt@gmail.com

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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