Red Flags for Flat Denial: Higher BMI or Being Older

Amanda Savage Brown, PhD, LCSW

Author, Busting Free

Kimberly Bowles

President, NPOAS

A BMI (body mass index) above “normal” (24.9) and age over 55 years was associated with an increased risk of flat denial in our 2019 survey. Over 73% of adults in the US have above “normal” BMIs and four out of five patients over age 60 choose to go flat. Moreover, the average breast cancer patient is diagnosed at age 63. Bottom line: a significant proportion of patients going flat may also have higher BMIs or older age, putting them at increased risk for flat denial.

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.”

Why do age and BMI impact flat denial risk? The shape and character of your body may make an aesthetic flat closure more simple or challenging. Understandably, more excess fat and skin requires more time and skill to remove, contour, and produce a good aesthetic result. This certainly contributes to the flat denial rate amongst patients with higher BMIs. There is a  well-established anti-fat bias in medicine. It may lead surgeons to discount the aesthetic wishes of larger patients. Similarly, ageism may  lead surgeons to believe that older women “don’t care how they look.” So,even when the patient has clearly communicated her desire  to have an aesthetic flat closure, internalized ageism may lead to less than best efforts for these patients.

What can you do to protect yourself? You have the right to be treated with dignity and respect, and you deserve an optimal aesthetic outcome regardless of your body’s size  or your age. Because these findings may be driven in part by harder-to-recognize internal biases, it’s important to name the elephant in the room. That doesn’t mean asking your surgeon about their personal (and potentially unrecognized) biases. Instead, simply make them aware of these findings while proactively stating: “Despite my higher BMI or older age, I still care about my chest’s appearance, my comfort, and my wishes being respected.” Then clearly communicate your wishes by bringing photos and discussing photos of their work. 

When you’re not sure that your wishes will be respected despite your BMI and age, don’t simply “hope for the best.” You only have one opportunity to be “one and done.” Seizing it is often important to anyone pursuing an AFC. Don’t risk missing your chance because of internalized biases. If you sense hesitation for any reason, ask if they’ll bring on a plastic surgeon to plan the incisions or perform the closure. And always seek a second (or third) opinion.

To see if there’s a recommended surgeon near you, check out the NPOAS Flat Friendly Surgeons Directory.

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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