Blog - Not Putting on a Shirt

Flat Memoir: “Flat as a Pancake”

NPOAS sat down with “Flat as a Pancake: My Story of Breast Deconstruction, How I Lost My Boobs And Found Myself” author Lisa Konstadt to learn more about her and her memoir.

“Lisa Konstadt was diagnosed with breast cancer at the age of 44 years old. She had to make decisions quickly. Would she have a mastectomy? Would she have reconstructive surgery? How would she make these decisions when she had spent a lifetime struggling with codependency and detached from her inner voice?”

Tell us why you decided to write a book about your experience.

Twelve years ago, I stood in Barnes and Noble searching for a book to give me more information about choosing to say “no” to reconstructive surgery. I couldn’t find a single book. I knew that if I couldn’t find a book, other women couldn’t either. I decided in that moment that I would have to write one. Later, as I encountered doctors trying to convince me that I should reconstruct, I knew with more conviction that the book had to be written to support the women who I knew must be facing a similar situation. Later still, when I started hearing other women’s stories on Facebook about being pressured into reconstructing out of fear, that was it for me! The book HAD to be written.

What was it like for you writing the book? Cathartic? Traumatic? Both?

I would say that writing the book was more cathartic than traumatic. I had all these strong feelings inside me that I wanted to convey: Feelings of anger at being told I was going to suffer mental health issues if I didn’t reconstruct, feelings of sadness about losing my breasts, feelings of exhaustion from the experience, feelings of anxiety about cancer. Writing about these feelings gave me an outlet and a way to express myself. I also had many questions: Why was I able to say “no”? Why was I able to face the fear? How was I certain that I would be okay living without breasts? These questions required that I dig deeply into my past to discover how my experiences had led me to my current experience. Using my cancer experiences as a road map I retraced my past experiences from childhood – present and this was highly cathartic to say the least.

What do you hope people take away from reading your book?

I hope that people who read my book can relate to some part of it, whether they have had cancer or not. My themes are universal I think, themes of body image, co-dependency, finding and listening to your inner voice. I hope that I can let women know that happiness comes from within and that they need to listen to their gut in the face of people who may challenge their decisions. I am not advocating for any one decision. I am advocating for women to listen to their inner voice and make their decisions based on that. We are working hard to change the way doctors talk to women about reconstructive options and progress is being made. However, there are always going to be those doctors who tell women that they will feel less than without breasts. I hope my book can help women know that no other person gets to dictate how you will feel. Only you are able to decide that. I also hope that my words are words women can come back to again and again when they feel they need encouragement and support in remembering how badass they are.

Can you share your favorite part of the book with us?

That is a difficult question! There are so many parts I love for different reasons. If I had to pick, I would say the final Dear Reader letter is one part I like to read again and again. This is the final shot of strength! The final push to believe in yourself. I find it inspirational to read because it includes my list of the things that make me feel “whole”. Reading this list reminds me that I am more than this body and that my sense of wholeness comes from experiences outside myself which in turn create feelings of bliss inside. I also like this part because it reminds me that each experience I have had in my life, good or bad, happy or sad, connects with another experience and another and another. This helps me feel a thread of connection between everything and provides me with a framework to view the difficult times.

Any parting thoughts?

Yes! Pay attention to that little gnawing feeling in your gut. It’s trying to tell you something. Try to hear it. Don’t keep pushing it down and ignoring it. You are here to live authentically and be you. There is no other you in the entire world. Breasts or not, you are still you. Find peaceful moments every day. Pay attention to the feelings of bliss and happiness that arise when you are doing certain things and know that this is your list of what makes you feel whole. Also, no one can tell you how you will feel if you decide against reconstruction, no one knows. You won’t even know 100 percent because you can’t. You will have to decide ahead of time that you will be okay and you will have to jump into the unknown and the fear and embrace the possibility of strong emotions knowing that they will pass eventually if you focus on what truly makes you, you. Peace and happiness to you all.

Read reviews & purchase “Flat as a Pancake” here.

Flat Memoir: “Bye Bye Boobs”

NPOAS sat down with “Bye Bye Boobs” author Holly K. Thrasher to learn more about her and her memoir.

“Bye-Bye Boobs is both devastating and uplifting and she never loses her sense of humor as she truthfully shares her experience with BII. Holly has found her voice to educate and support both breast cancer survivors and breast implant illness sufferers. Speaking, writing, and supporting women has given Holly the confidence to live her life FLAT, fabulous, and unapologetic.”

Tell us why you decided to write a book about your experience.

I wrote “Bye Bye Boobs: My Real Ones Tried To Kill Me & My Fake Ones Made My Sick” in 2021 as a sequel to my first book, “Bittersweet: A Vulnerable Photographic Breast Cancer Journey” that was published in 2019. Bittersweet left the impression that my fully reconstructed breasts with implants were the silver lining of my breast cancer journey, but in reality, they were a nightmare!

What was it like for you writing the book? Cathartic? Traumatic? Both?

Writing the book was really cathartic for me because I felt so angry and betrayed by the medical community. I was never warned about breast implant illness or the dangers of implants and it was really traumatic losing my breasts a second time.

What do you hope people take away from reading your book?

I wanted to make sure that other breast cancer survivors knew the truth and had all of the information they needed to make the right decision for themselves with regard to breast reconstruction and breast implants.

Can you share your favorite part of the book with us?

My favorite part of Bye Bye Boobs is the final chapter where I share how empowering having Aesthetic Flat Closure was and how happy I am without the breast implants. I have come along way from being the woman that thought she had to have breasts to be whole, to the AFC advocate that I am today. I hope that Bye Bye Boobs empowers other breast cancer survivors to choose AFC and to feel proud of their decision and their body. You don’t need breasts to beautiful and I had to learn that the hard way, but I am so grateful for the experience.

Any parting thoughts?

I am also extremely grateful for the FLAT community and all of the women that support and lift each other up. It’s inspiring and so healing to know that I am not alone and that there are FLAT women all over the world that share my journey.

Read reviews & purchase “Bye Bye Boobs” here.

Flat Memoir: “FLAT”

NPOAS sat down with “FLAT” author Catherine Guthrie to learn more about her and her memoir.

“FLAT: Reclaiming my body after breast cancer is the cancer memoir you haven’t read — the compelling narrative of a young, queer woman pressed up against a life-threatening illness and cultural expectations of femininity.”

Tell us why you decided to write a book about your experience.

When I was diagnosed in 2009 there were no breast cancer memoirs (that I could find) written by women who chose to go flat. Instead, I found narrators focused on reconstruction and on how their diagnosis impacted their husbands and children. Those books certainly filled a niche, but they didn’t reflect my life. I couldn’t find a narrator unpacking questions about reconstruction and challenging the tacit assumptions about what women want or need to feel whole after breast cancer. My book, FLAT, was my response to what was missing from the breast cancer shelf.

What was it like for you writing the book? Cathartic? Traumatic? Both?

I imagine my experience was different than most folks because I am a health journalist. Before I was diagnosed with breast cancer, I’d covered it from every angle. How to treat it, how to talk about it, and how to survive it. After being diagnosed, I started a blog called “Pink Is Not Color,” as a way to process the dissonance of being thrust into a hyper-feminine medicalized space where people were showering me with pink tchotchkes and telling me how much I’d love my new breasts.

Upon finishing treatment, I thought I could shape my blog posts into a memoir, but I soon realized that as a journalist, I knew nothing about writing a memoir. Luckily, we’d just moved to Boston, home to the country’s largest writing nonprofit, Grub Street. I applied to and was accepted into a year-long, MFA-style memoir program and that’s where I learned how to write creative nonfiction, get an agent, and sell my book to a mainstream publisher. But, to answer your question more directly, yes — over the course of the year — I experienced catharsis and revisited many traumatic events. And it was 100 percent worth it because learning how to apply my love of writing to a new genre was one of the most intellectually engaging and satisfying experiences of my life.

What do you hope people take away from reading your book?

After reading my book, I hope people will have a better send of what breast cancer surgery involves, what kind of decisions you might be asked to make, and how to advocate for yourself or a loved one at the doctor’s office. I also hope that queer couples can see themselves and their lives reflected in the pages of my book.

Can you share your favorite part of the book with us?

My favorite part is the scene when Mary and I elope. Honestly, I was conflicted about ending the book that way. I always hated it when a memoir I was reading ending on marriage or motherhood. And then I did it! I tried to write other endings, but that exercise gave me newfound appreciation for why writers gravitate toward those milestone moments. These events punctuate our lives in meaningful ways. That sweet ceremony at Somerville City Hall bookended a very turbulent few years for me and for Mary. Marriage was something we’d been denied for 14 years. That denial was extraordinarily stressful. I discuss a few of those points in the book. But the precarity of my access to health insurance continued after we moved to Massachusetts.

As the final shape of the book was falling into place, I kept returning to the marriage scene as a capstone for the book’s emotional arc because, ultimately, the book is a love story. Mary lived through this ordeal just as much as I did. I’d even argue that her job was more difficult in some ways because she had to process her fear without my help. On the other hand, I processed 100 percent of my emotions with her. She is my best friend and my closest confidant. The last scene is less about marriage per se and more about our triumph as a couple.

Any parting thoughts?

Back in 2009, when I was first diagnosed and the word “flat” wasn’t even a thing in the breast cancer community, I couldn’t have imagined what is so easy to take for granted today: heaps of online support, community, and resources available for folks considering going flat after breast cancer. Not to mention, enough flat memoirs and guidebooks to fill an entire library shelf. I’m honored to have witnessed the progress we’ve made as a community, and I can only imagine where we are going next.

Read reviews & purchase “FLAT” here.

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.

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

Amanda Savage Brown, PhD, LCSW

Author, Busting Free

Kimberly Bowles

President, NPOAS

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.

My initial surgical result is not flat. Why?

One in Four Patients Are Unhappy With Their Outcome

Right now, about one in four women going flat end up with an initial surgical result that they are unhappy with. We hope this changes as patient advocacy moves the needle towards parity, but for now it’s one in four. The appearance of the chest contour after mastectomy exists on a spectrum – all the way from nearly perfectly smooth and flat, to good with minor imperfections, to egregiously poor results that rise to the level of flat denial. Why the variation? Why don’t more patients get optimal outcomes?

The first problem is the lack of clear language. It was only very recently that the National Cancer Institute defined “aesthetic flat closure” as a unique reconstructive procedure that involves an aesthetic surgical approach. So it has historically been difficult for patients to communicate exactly what they expect when they say they want to “go flat.” And there has been no clear consensus among providers as to what constitutes a “flat” mastectomy closure.

Determinants of Your Aesthetic Outcome

When you (the patient) HAVE been able to clearly communicate your affirmative choice to go flat, the quality of your initial surgical result is largely determined by three things: your specific anatomy, your medical situation and history, and the level of skill and regard on the part of your closure surgeon.

1. Your Anatomy

Your specific “body habitus” – the shape and character of your body – may make an aesthetic flat closure simple or challenging. More excess fat and skin requires more time and skill to remove and contour to produce a good aesthetic result. Whether or not you have concavity depends mostly on your bone and muscle structure – when the breast tissue is removed, the underlying topography is revealed.

2. Your Medical History

Your medical and surgical history presents constraints the surgeon must contend with, which can affect your contour. Large tumors, or tumors that are close to the chest wall or the skin, may require accommodation that impacts your contour. The incisions may be asymmetric and removal of tumors and affected lymph nodes can produce divots.

If you had tissue expanders or breast implants prior to going flat, there may be some damage to the pectoral muscles and/or the ribcage that can make any concavity more pronounced. Radiation therapy can cause extensive scarring and adhesions that distort or contract the contour.

Treatment of surgical complications (such as infection, wound healing problems, hematoma or persistent seroma) and the constraints these complications present can affect the contour as well.

3. Surgeon Skill & Regard

Surgical skill is the technical ability your surgeon brings to the operating table. Skill varies considerably among surgeons (and it can be difficult for patients to assess this in consult). Plastic surgeons are specially trained in aesthetic closure but they aren’t usually present at the initial mastectomy.

Regard is the degree of respect and consideration the surgeon has for your choice to go flat as affirmative and deserving of an aesthetic approach. A poor contour due to excess tissue left on purpose “in case you change your mind” is called intentional flat denial, and it’s a grievous and traumatic battery against the patient.

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

If You’re Unhappy With Your Aesthetic Outcome

Revision surgery can improve your chest wall contour both by removing excess skin (excision) and filling in areas of concavity (fat grafting). Recovery is typically easier than the mastectomy, but this varies depending on how much tissue needs to be removed and how extensive the surgery is. Typically it is a plastic surgeon who performs revision surgeries. Visit our Flat Friendly Surgeons Directory to find a revision surgeon near you!

Action Alert! Access to DIEP Reconstruction at Risk

Women in the United States are about to lose access to DIEP flap breast reconstruction, thanks to an obscure insurance coding change by the government that happened in 2019 and is set to take full effect by 2024. BreastCancer.org has written an excellent article explaining the situation here.

Is this an issue YOU want to get involved in? There is a way you can!

The government must reverse the coding change and restore access to DIEP flap reconstruction, and the more people they hear from, the more likely a result that will support ALL women’s various choices!

Breast reconstruction plastic surgeon Dr. Elisabeth Potter is leading an advocacy effort on this matter – visit her website at DrPotter.com/Advocacy for form letters and a how-to guide for contacting your Congressional representatives today!

NPOAS at Breast Surgery Conference April 2023

Critical Flat Closure Advocacy

The NPOAS Board will be attending the American Society of Breast Surgeons annual conference again this year, in Boston, MA, with an exhibitor’s booth to advocate for aesthetic flat closure. We will be engaging providers one on one, providing brochures for surgeons to take back home and use in their practices, learning about and supporting coding and oncoplastic training, and engaging with researchers. Read the 2022 Conference recap here!

We thank you in advance for your contribution to this critical endeavor that we are undertaking on behalf of all women!

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About The ASBrS Conference

The American Society of Breast Surgeons (ASBrS) is a professional medical society of general surgeons specializing in the treatment of breast disease. Their annual meeting is held every Spring, and brings members together to network, learn about the latest research in the field, and to participate in hands-on trainings.

Why We Are Attending

The conference provides unique advocacy opportunities.

Not Putting on a Shirt collaborates with diverse stakeholders to effect durable institutional change, and chief among these are breast surgeons. By meeting these medical professionals where they’re at, we are able to leverage unique advocacy opportunities to:

Engage providers in one-on-one discussion about aesthetic flat closure
Give interested providers brochures to take back and use in their practice
Network with other stakeholders – including the NAPBC – to promote our mission
Learn about the latest research in oncoplastic breast surgery
Offer a flat closure patient’s perspective during debates
Engage with researchers to promote further studies to support an improved, evidence-based standard of care for aesthetic flat closure

LEARN MORE

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FLAT New Year’s Milestones

We are thrilled to report TWO New Year’s FLAT milestones at NPOAS!

Today, Fierce, FLAT, Forward reached 10,000 members! This number represents lives touched and even saved by the peer & community support provided therein. A heartfelt thank you to group founder and NPOAS VP Christy Avila for her compassionate, steady leadership.

As of January 06, 2023, we have over 500 surgeons listed on the Flat Friendly Directory! Thanks to our surgeons and their recommenders!

Recommend your surgeon here; find a surgeon here.

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Providers: Here’s How You Can Help

If you’re a surgical professional interested in getting more involved in flat advocacy and wanting to support patients going flat, here are eight ways you can help today!

Apply to be listed on our Flat Friendly Surgeons Directory. Connect with more patients going flat and showcase your flat closure expertise.
Order My Choice: AFC brochures for your clinical practice. These brochures are available free of charge and support your patients in their decision making process.
Update your practice website to include AFC. This is an important part of presenting going flat as an equal option alongside breast reconstruction.
Submit before & after photos of your patients to the AFC Surgical Photo Database at AestheticFlatClosure.com. Help us populate this database, which will be used for research as well as setting expectations.
Lobby within your professional associations for an improved standard of care for AFC, especially better training for general surgery residents. Aesthetic flat closure should involve careful removal of all redundant lateral tissue, obliteration of the inframammary fold, and the production of smooth, symmetric incision closures (Karp et. al., 2022).
Join the NPOAS Advisory Council or the AFC Research & Training Working Group (AFC-WG). The AFC-WG is a council of breast and plastic surgeons, researchers and patient advocates working to identify and advance a research and surgical training agenda to support the development of an evidence-based, optimal standard of care for aesthetic flat closure. Contact us with questions, comments or ideas!
Sign up for our newsletter for flat advocacy news, updates & volunteering opportunities
Donate to support our work. As NPOAS is an all-volunteer organization, 100% of your donation funds our advocacy work.