Red Flags for Flat Denial: What Does Pre-Operative Pushback Look Like?

In our survey in 2019, patients who reported experiencing moderate to severe preoperative pushback from their surgeon about going flat were more than three times as likely to suffer intentional flat denial and twice as likely to experience negligent flat denial compared to those who reported little to no pushback. This means you may be able to reduce your risk for flat denial by recognizing surgeon pushback. This article helps you understand what pushback looks like, why it happens, and what to do if it happens to you or someone you love.

What is flat denial? Flat denial happens when your surgeon leaves excess skin against your consent, instead of making you flat as agreed. There are two types of flat denial.

• Intentional: Despite the surgical skills to perform an AFC, your surgeon leaves skin “in case you change your mind.” You are left with neat clean symmetric incisions atop significant excess skin and an intact inframammary fold.
•  Negligent: The surgeon simply lacks the skill or regard to produce an AFC. You are left with sloppy, puckered asymmetric incisions with significant excess skin and “dog ears.”

How does a surgeon “pushback” on going flat? 

• Not mentioning flat as an option along with other reconstruction options
• Making comments like, “You won’t be happy flat,” “Women change their mind,” or “Flat can’t be beautiful.”
• Repeatedly asking if you’re sure you don’t want reconstruction
• Insisting you get a psychological consultation to assess your soundness of mind over going flat
• Saying they can’t make you flat (or that you’ll need another surgery to be flat)*

*[Note: Your surgeon being honest about their skillset doesn’t necessarily constitute “pushback,” but when they tell you they can’t produce an AFC for you, you must take additional steps to avoid an unpleasant surgical outcome. If your surgeon says that they can’t get you flat in one surgery, seek a second opinion or ask them to bring on a plastic surgeon to plan the incisions or perform the closure.]

Why all the pushback? When your surgeon pushes back against your decision to go flat, it may mean they don’t understand, respect, or agree with your decision. Many surgeons believe that reconstruction offers psychological benefits and that flat patients suffer because of their choice. However, scientific literature on this matter shows mixed results and further studies are needed to explore quality of life measures among AFC patients. Surgeons also live within the same patriarchal system as the rest of us. Their minds learn the same unhelpful beliefs about women, breasts, and belonging. They may hold the sexist biases that breasts make women “whole,” are the icon of femininity, and impart societal value as sexual objects. Some surgeons may treat these biases like “rules” that must be followed or project their learned beliefs onto your body. Surgeons are, after all, only human.

What should you do if you experience pushback? Mild pushback that stops when you reiterate your decision with confidence may not be a red flag for flat denial; however, more pushback equals more risk. Pay attention to what your surgeon says and fails to say about going flat. Use your judgment. Honor your intuition. If you’re not absolutely sure that your surgeon respects your wishes, listen to that feeling and get a second opinion. You have the right to be treated with dignity and respect.

You only have one opportunity to be “one and done.” Seizing it is often important to anyone pursuing an AFC. You don’t want to miss your chance because of flat denial, whether it’s intentional or negligent. Nor do you want to “hope for the best” or blindly trust your surgeon to do no harm – especially given their socially inherited thinking about breasts may lead them to define harm differently than you. To see if there’s a recommended surgeon near you, check out the NPOAS Flat Friendly Surgeons Directory.