Vlog with Stacie-Rae: Flat Closure Informed Consent and Advocacy

NPOAS President Kim Bowles spoke with Stacie-Rae, professional restorative tattoo artist, innovator, and quality advocate. They discuss aesthetic flat closure, informed consent in medicine, managing expectations, and advocacy strategy.

Flat Closure Zoom with Kim & Stacie-Rae: Informed Consent and Advocacy

Informed Consent

An agreement between patient and provider after full disclosure of all medical options and their risks and benefits, to a specific medical intervention (treatment, test, or procedure). There are flour elements to informed consent.

  1. The patient must have the capacity (ability) to make a decision
  2. The provider must disclose all relevant information on the intervention
  3. The patient must comprehend the information provided
  4. The patient must give consent without coercion or duress

Restorative Tattoo: A highly specialized practice of paramedical tattooing, which restores the appearance of the nipple and/or areola (reference). Surgical reconstruction of the nipple can produce a nipple-like contour (shape) but permanent coloration and detail restoration requires modification with ink.

Learn more about Stacie-Rae’s work

Stacie-Rae is a leading restorative tattoo artist and founder of the Areola Restorative Tattoo (A.R.T.) training and certification program (and print book). Stacie-Rae is also the creator of Nipplebacks temporary nipple tattoos. As a mastectomy patient herself who recently explanted to flat after her implants were recalled, she’s a tireless advocate for optimal quality standards for restorative tattooing.

My Body, My Choice: Aesthetic Flat Closure After Mastectomy

Our Bodies Ourselves published our guest post about aesthetic flat closure!

Thanks to Our Bodies Ourselves for helping spread the word about aesthetic flat closure! This pioneering organization has worked to promote women’s health and bodily autonomy for decades. Every woman facing mastectomy deserves full and fair disclosure of all of her reconstructive options, and for her choice to be respected.

One of the questions we ask is “Why?” Why do so many women end up looking far different than they expected?

We believe these outcomes are the direct result of decades of unclear language, unchecked paternalism and protectionism, and medical training which reinforces the myth that women cannot be “whole” without breasts.

One problem is that “flat” is an ambiguous term. To address this, flat advocates have been fighting to get official recognition of flat closure as a reconstructive choice deserving of the same respect and consideration as breast mound reconstruction.

Finally, institutions are starting to listen. Recently, as a result of our efforts at Not Putting on a Shirt, the National Cancer Institute added the term “aesthetic flat closure” to its official Dictionary of Cancer Terms, defining it as a reconstructive and aesthetic surgical procedure. And just like that, women have the clear language we’ve been needing so desperately for so long, to tell our surgeons exactly what we want.

Kim Bowles, for Our Bodies Ourselves

Read the whole guest post here.


Pioneers in Flat Advocacy: Nikki “Trip” Tripplett

Pioneers in Flat Advocacy

A blog series designed to highlight and amplify the voices of the flat advocates who blazed the trail and laid the foundation for those that followed.

Nikki “Trip” Tripplett

Nikki “Trip” Tripplett was diagnosed with multifocal breast cancer at age 36, in 2015. She had a strong family history of breast cancer, and had the full battery of treatments – chemo, single mastectomy followed by contralateral mastectomy, radiation, and more surgery. Trip lives in Texas with her longtime partner, Unique, and is a runner, influencer, entrepreneur, and breast cancer advocate. In 2018 she walked the runway during NY Fashion Week 2020 for the #Fearless fashion show by #Cancerland and #AnaOno benefitting Metavivor – she also interviewed other participants. She was interviewed on Houston’s Isaiah Factor Uncensored about her experience. Trip has worked extensively with the Young Survival Coalition to fundraise, provide support programs to cancer survivors, represent her community and get information about breast cancer into the community discourse, and has been featured in both Forbes and Glamour Magazine. Find her on Instagram at @ThatDamnTrip and on Instagram and Facebook @TheCancerPreneur.

When you were making your reconstructive choice, how did you end up choosing flat?

“I was NEVER making a reconstruction choice, I just knew that I didn’t want to live with JUST ONE Breast.  It took me a year of wearing Hospital socks stuffed in my bra and constant lopsidedness for me to even realize that I needed to make a choice.  I knew prosthetics were Not the route I would be choosing because they were heavy AF, and they were never made to match the skin color of a black woman… Nothing worse than a black breast prosthetic and a cinnamon Mocha almond Naturally colored breast 😉 When I had finally had a year of living lopsided and the mental anguish that came along with it, I called my surgeon and told her we needed to talk…  It was NEVER my intentions to be flat, yet reconstruction was NEVER an option to me either… By speaking with my surgeon and explaining to her where I was mentally, she understood that all I was longing for in my recovery was ‘Symmetry’!!! And when I heard those words, it was like it was describing my needs to a T!!  I wanted symmetry back in my life and going FLAT offered the BEST option for me to have that.”

How has your surgical result affected your healing process moving forward?

“I believe I would’ve never begun to heal mentally or emotionally had I never made the choice of symmetry!  I was lost with how my body was ‘Supposed to look’ with 1 breast…  My confidence about my Physical appearance was Under my shoe!  My posture was terrible due to me trying so hard to ‘Hide’ the fact that I only had 1 breast!  And my sex life with my Long time partner was NON EXISTENT to say the least!!  

When I made the choice and listened to my Doctor to clearly know that this was the RIGHT choice is when I finally accepted what was to be and opened up to the idea!! I started to be FREE just be making the decision.  I thank God everyday that my surgeon was soooo vain about her work, therefore she created a BEAUTIFUL masterpiece out of my Chest!  Besides the scars it looks as if I have been flat for eternity and I can look at myself with total admiration and awe!  I love my new Body and appreciate my medical team for even allowing me the OPTION without the Guilt or pressure to reconstruct!  That was a big factor as well..  “

How did you decide that you wanted to be an advocate?

“I have no problems running my mouth about the Good, the Bad and the UN Fucking Fair!! Advocating became a part of my Daily routine during treatment because I was BLACK, GAY and battling breast cancer (Triple entendre) which to most people in the medical field seemed to be FUCKING RARE… I was told everyday what I couldn’t do with my body!  Healthcare professionals left me out of the same health conversations that they were having with the white patients and I was determined to get the same level of care that I was seeing them get!  It was ADVOCATE or DIE!!”

What is your proudest accomplishment as an advocate?

“Being in Forbes.com with a Gold Grill in my mouth the reads, ‘Fuck Cancer’ all BIG, BOLD and Ghetto as hell!! But that is what I was going for because to me Cancer is BIG! It doesn’t care about your status, your money or your Privilege. Cancer will try to find a way to let you know it is BIGGER than you If You Let It!  Cancer is BOLD!  It doesn’t give a fuck how it humiliates you, its gonna get what it wants at Whatever cost to you…  And, cancer loves the Underserved.  It’s the Cancer VIP section and just like anything else, it’s seen as a secret killer in most of our Ghettos.  This shit needs to stop and the only way to stop it is to get the attraction in a ‘ghetto ass way’ so to speak!”

What has been your biggest challenge as an advocate?

“Keeping the emotion out of the business.  Too many people are dying and I feel like I shouldn’t even make friends in the community anymore.  It’s hard to focus on advocating when on days you feel like shit… But I think of those that Can’t speak for themselves or those that don’t even know what to say!  I advocate from the heart and it can be mentally draining.  Plus I suck at knowing stats and such, I just know that people are dying! I know that peoples options are being denied! and I know that at a time like this in people’s lives, that shit can SUCK sometimes just as bad if not worse than the cancer itself!”

What have you learned as an advocate that you would like other advocates to know?

“It’s Okay to advocate YOUR WAY!! Being it through organizing support groups to being on the senate steps topless demanding a difference!  Hell I advocate for the Hood and that has landed me in some of the biggest names and on the biggest stages and in the Largest magazines that one could ever dream of being on!! Advocate from the Heart and watch how many lives you touch along the way.”

What is your vision for flat advocacy generally? What do you want the future to look like for women going flat?

“It may sound a bit corny, but I’m not a ‘Flat Advocate,’ I’m more so a, ‘Live you life the way you fuckin’ feel good’ kinda advocate!  And if for some that means making the hard decision to go flat, then I will support them by all means. I do want individuals Gay or straight to know that going flat is Their choice and not anyone else’s to make.  It can be a Beautiful way to continue life but they Must speak up for themselves and Do the due diligence of finding the right doctors that understand their wants and needs.  It’s a life changing decision so I want people to know that yes, people’s perceptions of them will change and Yes, there will be those that criticize your choices… But in the end, it’s about Life and living on our terms and with that we deserve the best care and the best options for our choice. Period!”

A pioneer may start as a lone voice in the wilderness, but their passion for and commitment to their cause inspires others to join them. This has led to exponential growth in the field of flat advocacy over the last decade or so. In 2020, we have flat photography projects, full length memoirs, nonprofit organizations, communities on social media, and even gatherings across the world… all made possible by the work of the advocates who blazed the trail.

If you know of a pioneer in flat advocacy that you’d like to see featured, please let us know!

Disclaimer: Any and all information published by Not Putting on a Shirt (NPOAS) on behalf of a third party is for informational purposes only and should not be taken as a substitute for medical or legal advice from a licensed professional. Views expressed and claims made by third parties do not necessarily represent the views of NPOAS.

Summary of Our Flat Closure Research from #SABCS19

“Flat closure after mastectomy: are your patients satisfied with the results?”

Poster #P6-11-23, “Flat closure after mastectomy: are your patients satisfied with the results?”
NPOAS founder Kim Bowles presenting a research poster on flat closure at SABCS 2019

NPOAS presented our poster at the 2019 San Antonio Breast Cancer Symposium (#SABCS19) last December. This research explored patient experience going flat, including decision factors, satisfaction with aesthetic flat closure cosmesis, provider push back, and more. Our abstract – the summary of our important findings – is now available online at the American Association for Cancer Research (AACR):

“Flat closure after mastectomy: are your patients satisfied with the results?”

The Abstract

“Although the majority of breast cancer patients choose some form of breast mound reconstruction after mastectomy, a large group of women – 27% of early-stage patients in the United States (Jagsi et. al., J Clin Oncol. 2014 Mar 20; 32(9): 919-926)) – affirmatively choose to “go flat.” The language is evolving but these patients will often request a smooth, breastless chest contour, or “flat closure.” The problem is that there is a near complete deficit in the existing body of scientific literature addressing these patients’ satisfaction with the surgery’s cosmetic result. As a result, patients face significant uncertainty in the quality of their surgical management and outcome, and report struggling to advocate for and protect their reconstructive choice.

“To address this deficit, we conducted two ad-hoc surveys to gather preliminary data on patient experience with flat closure cosmesis. The surveys were prepared and organized into Google Forms for online distribution to several private social media support groups for women going flat after mastectomy. Participant identities were anonymized via participant code. The pilot analysis included 142 (of 147 after necessary exclusions) responses collected from July 1, 2018 to February 1, 2019, and the second survey included 175 (of 183) responses from April 26, 2019 to June 09, 2019. Mean elapsed time between surgery and survey was 2.7 years (range = 3 months to 30 years) for the pilot and 3.2 years (range = 0 to 24 years) for the second survey.

“In the pilot, the majority of respondents (75%) were satisfied (rating = 6-10) with their initial result; this approaches the 64-69% satisfaction at two years that has been established for patients who have undergone breast mound reconstruction (Santosa et. al., JAMA Surg. 2018 Oct; 153(10): 891-899). No change in satisfaction from surgery to present day was observed for those patients who did not have revision surgery, meaning additional surgery to improve the post-mastectomy chest contour. However, for patients who did pursue revision, we saw drastically improved satisfaction, from a mean of 2/10 before, to a mean of 9/10 after. Overall, the incidence of intentional flat denial (IFD) – which we define as leaving the patient with excess tissue to facilitate future reconstruction against her consent – was 5% (n = 8). Among those who reported dissatisfaction with their cosmetic result (rating ≤ 4), the IFD incidence was close to one in five (19%).

The second survey found a similar overall IFD incidence of 4% (n = 7). The incidence of negligent flat denial (NFD) – which we defined as a very poor “expectation match” (divergence of actual vs. expected cosmetic result, rating ≤ 2/10) together with the reported presence of excess tissue – was 7% (n = 13). Patients reported experiencing moderate to severe preoperative pushback from their surgeon about their reconstructive choice (rating ≥ 6/10) at rates of 71% (IFD), 46% (NFD), and 23% (no flat denial). Overall, 81% of patients reported that minimizing their surgical recovery period was a very important decision factor in going flat (rating ≥ 8/10). The incidence of revision surgery – which extends the surgical recovery period – was 26% overall, but was much higher for those patients subjected to IFD (43%) and NFD (54%).

“These data suggest that implementation of uniform surgical management and improved respect for patient consent in this population could result in significantly improved patient experience and satisfaction. Specifically, the need for surgical revision could be reduced to better align these patients’ experience with their stated priorities. We hope that these results will encourage the commission of larger scale studies using validated tools, translating to an improved, evidence-based standard of care for women who choose to go flat after mastectomy.”

Conclusions & Next Steps

Negligent flat denial (NFD) prevalence was 7%, and intentional flat denial (IFD) prevalence was 5%. That’s 12% of patients going flat who receive an egregiously poor aesthetic result.
Our data suggests room for improvement in:
  • Aesthetic surgical management
  • Incidence of surgical revision
  • Patient experience and satisfaction
  • Respect for patient consent
Next Steps: RESEARCH
  • Larger scale studies with validated tools (ex. Breast-Q)
  • End goal: an evidence-based standard of care that optimally serves these patients’ interests
Next steps – ADVOCACY
  • Expand oncoplastic training resources to improve aesthetic outcomes
  • Optimize insurance reimbursement rates for flat closure and revision services
  • Improve systems of support and accountability to reduce the incidence of both NFD and IFD

The Critical Importance of the Official Term “Aesthetic Flat Closure”

The data we analyzed for this abstract was collected prior to the NCI’s adoption of the official term, “aesthetic flat closure.” Without clear language, women have struggled to ensure their surgeon understands exactly what they want – a smooth, flat chest with no “dog ears” and no extra skin at all. And although it’s hard to hear, the fact is that a few “bad apple” providers have weaponized that ambiguity to intentionally override their patient’s consent.

That’s intentional flat denial (IFD), and it happens to 1 in 20 women going flat. Another 2-3 of those women receive egregiously poor aesthetic results due to a lack of skill or care. Our studies were small in scale, but there’s no avoiding the fact that flat denial is a serious problem.

But now, the landscape of patient-provider communication has changed. Thanks to the National Cancer Institute’s collaboration with patient advocates, we now have clear language: aesthetic flat closure. The ambiguity is gone, and it’s gone forever.

Time will tell, but we expect the prevalence of both IFD and NFD to plummet as a result of this language empowering women to advocate for their choice. And we look forward to seeing larger scale research studies bear this out.

Our Thanks

Thanks to all the women who participated in the surveys, to our advisors who helped inform this project, and to the SABCS organizers for giving NPOAS and other advocates a platform to interface with providers and researchers to advance the interests of patients facing mastectomy. And a very special thanks to Charise Isis for letting us use her beautiful imagery from The Grace Project!

Want to Support Our Work?


What if I want to go flat, but my surgeon wants to do “skin sparing”?

Tell your surgeon you want an “aesthetic flat closure” as defined by the National Cancer Institute – and make sure it’s recorded in your medical record.

It’s a positive thing that your surgeon is using the term “skin sparing” with you. This means that they are doing the right thing in being clear and honest about their intentions. A skin sparing procedure can be the best option for a patient who is undecided about reconstruction. However, if you’ve decided to go flat, skin sparing is not the right procedure for YOU. The procedure that will give you an optimal flat result is an “aesthetic flat closure” as defined by the National Cancer Institute.

Left: intentional flat denial – this patient received a skin sparing mastectomy against her consent. Right: after aesthetic flat closure at revision.
Top: intentional flat denial – this patient received a skin sparing mastectomy against her consent. Bottom: after aesthetic flat closure at revision.

Your job now is to be sure your surgeon understands that you’ve made your final decision: you do not want reconstruction, ever. You want an aesthetic flat closure. Clarify this right away by speaking directly with your surgeon. Make sure that your decision is recorded in your medical record. It should always be recorded in your consult notes. If possible, it should also be on your surgical consent form – when you sign this document (nowadays this is usually done on the computer), you’re legally giving consent to whatever procedure is listed.

The NCI definition of aesthetic flat closure is very clear that all excess skin should be removed and the area should be contoured in such a way to produce a smooth flat result.

Keep in mind that this is a very new term. This may be the first time your surgeon has heard of aesthetic flat closure, but the procedure itself is not new. We just didn’t have official recognition of the term until recently. Your surgeon may hesitate or push back, because conventional mastectomy doesn’t always include contouring, historically. Some surgeons may not feel comfortable performing the contouring themselves. In this case, you can ask if your surgeon will consider bringing on a plastic surgeon. Our Provider Resources may also be helpful.

If you need a mastectomy for breast cancer, you will not want to delay it significantly because of concerns about aesthetics. However, you do deserve an optimal result. If your surgeon is not receptive to your decision to have an aesthetic flat closure, getting a second opinion may be the best thing to do. But don’t cancel your surgery until you have scheduled with the new surgeon!

The bottom line is that your surgeon needs to understand that what you want is an aesthetic flat closure, and this needs to be in your medical record. You deserve to get an aesthetic result you can live with!

Visit our website for tools and resources to help you advocate for your choice to go flat. Find a Flat Friendly surgeon in your area, and print out one of our helpful brochures for use in consult!

Aesthetic Flat Closure – Word is Spreading!

Pioneering breast cancer research organization, the Dr. Susan Love Research Foundation, has added “aesthetic flat closure” to their webpage on breast reconstruction options! This is just the beginning. We expect to see online platforms adopt this new term quickly as word continues to spread.

Aesthetic Flat Closure is now on Wikipedia

More good news. Spread the word! Aesthetic flat closure is now on Wikipedia, the open source online encyclopedia!


Spread the Word: Aesthetic FLAT Closure

For all those facing mastectomy who don’t want breast mound reconstruction…

Going FLAT? Let’s Be Clear.

Tell your surgeon you want an “aesthetic flat closure” as defined by the National Cancer Institute so your surgeon will know exactly what you want: a smooth, flat chest.

Spread the word!

Share our infographic on social media. Don’t forget the hashtags!


Prof. Abigail Bakan Publishes Treatise on Going Flat & the Politics of Choice

Professor of social sciences and social justice education at The University of Toronto, Abigail Bakan just published her in-depth and insightful feminist analysis of the situation women face after being diagnosed with breast cancer today. She addresses the insidious narrative of “going flat” as an inferior choice, head on, and her writing is informed both by personal experience and by her study of and interaction with the flat advocacy movement. Read the full article here. Thank you Prof. Bakan and Imaginations for working to #putflatonthemenu !

How We Do It

An inside look at NPOAS’ work to #putflatonthemenu

Announcements of major milestones for flat parity – like the Oncoplastic Breast Consortium adding “optimal flat closure” to their mission statement, or the National Cancer Institute adding “aesthetic flat closure” to their Dictionary of Cancer Terms may seem like they drop out of the sky, like manna from heaven. But these announcements are just the tip of the iceberg. Behind the scenes are months to years of tireless, diligent, creative work. Successes, failures, obstacles overcome, lessons learned… and never, ever giving up. That’s how we do it. We will always be grateful for the flat advocates whose work created the foundation for our successes in 2020 and beyond. Here’s a glimpse of some of the “inner workings” at NPOAS as we continue to push for progress – and a look at what the future holds.

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From the Streets to SABCS

We start with our inception in June 2018. At first, NPOAS was a one woman operation. After her Cleveland Clinic surgeon intentionally denied her a flat closure, Kimberly Bowles realized that the problem was a systemic one, and began working to put an end to flat denial. Her topless street protests helped to put the issue in the public spotlight. She quickly characterized the problem (intentional vs negligent flat denial, flat denial as medical battery, the various conflicts of interest involved, etc.) and developed extensive resources to empower women to protect their choice to go flat. These are the resources Kim wished she had when she was facing surgery. They include:

  • a flat closure surgeons directory, searchable online and cross-referenced with the popular explant lists
  • illustrated brochures to help women ensure their choice is respected – tailored to the needs of those facing initial mastectomy and revision, explant, and for those without the ability to choose their surgeon
  • comprehensive information on mastectomy, explant and revision
  • informational, community, and one-on-one support for victims of flat denial using social media

As the movement grew, thanks to support from thousands of women across the world, Kim expanded her focus from empowering individual patients – to building a coalition of stakeholders to effect institutional change. She developed extensive resources for providers interested in flat closure, including:

At the close of 2019, less than two years after her first protest, Kim flew to San Antonio, Texas to present NPOAS’ research poster at the world’s premier breast cancer research conference – the research yielded important information to inform patients and providers about the prevalence of flat denial and how to direct future research efforts.

Our Current Work (2020)

Corporate Leadership and 501(c)(3) Status

In January 2020, NPOAS announced its new Board of Directors and status as a 501(c)(3) nonprofit organization. This was the result of months of work setting up a durable yet nimble organizational structure and governance framework. Learn about our new Board on our Leadership Page. Our growing Advisory Council includes plastic reconstructive surgeons, a legislator, and an M.D. researcher – we have several more exemplary candidates in the wings.

The process of recruiting Board members and Advisors involves building trust relationships with stakeholders in the field by producing consistent, high quality work and adhering to the highest standards of integrity and transparency. Identifying candidates who have demonstrated a consistent commitment to the organization’s mission takes years to do correctly, and it is absolutely critical to build the right team to get the job done. The same principles apply to building relationships with other advocacy organizations – and our network is strong and growing.

Flat Friendly Surgeons Directory – a Trusted Resource Since 2018

As of May 2020, we have over 200 surgeons on the Directory recommended for flat closure at initial mastectomy, explant and revision. The listings are searchable and are cross-referenced with the popular explant lists online. The initial database validation was completed with the help of NPOAS volunteers (we now validate new listings monthly), and each Directory surgeon receives an orientation packet with a welcome letter and several Flat is Beautiful brochures (they can order more, free of charge, on the website).

The Directory is a critical tool for patients, both as a stopgap to empower women to protect their choice in the absence of a reliable standard of care for aesthetic flat closure, and as a tool to organize and recognize leading medical professionals who work tirelessly to provide women with surgical results. We are grateful to each and every surgeon on the Directory for their diligence and to each and every woman who recommended them.

Vermont Revision Bill H.686

In January 2020, we saw historic buy-in in Vermont from legislators, BCBS-VT, and the financial regulation department, on ensuring insurance coverage for flat revision surgery. The proposed legislation was spearheaded by our stellar legislative advisor Rep. Charen Fegard.

We worked closely together for months to help refine and support Rep. Fegard’s vision for the bill, gather input from stakeholders, and produce visual and informational aids to garner support within the legislature. NPOAS published a “Contact Your Legislators” project page to empower members of the public to take legislative action in their state – simply click to download the materials, use the online tool to contact your legislators, and get rolling!

WHCRA Amendment Initiative

We launched our WHCRA petition and project page to lay the groundwork for the national push that’s on the horizon, and provide a resource for interested parties so that we can build a strong, effective coalition. Many of our initiatives have a timescale of several years, and this is one of them. Getting the ball rolling early is critical.

Explant Brochure

Those who are facing explant post-mastectomy are particularly in need of solid, concise, and comprehensive information which they can use during their consult to ensure that their decision is respected. This is because these women are really looking at two procedures: explant AND flat closure, neither of which have a robust standard of care in place that aligns with a patient’s expectations. In collaboration with multiple stakeholders including explant activists and surgeons specializing in explant and flat closure, NPOAS produced this valuable resource that covers:

  • reasons women decide to explant
  • clear & concise information about total capsulectomy, pectoral muscle repair, pathology, documentation and implant return
  • how to interview your surgeon
  • images of flat (acceptable) vs. unacceptable flat closures for reference
  • a checklist of questions to ask your surgeon
  • concrete steps to take to ensure your decision is respected
  • links for further information
Breast Surgery Conference Exhibitors

Due to the COVID-19 pandemic, our attendance as exhibitors at the 2020 American Society of Breast Surgeons (ASBRS) Annual Meeting was rolled over, along with all donated funds, to 2021.  Thanks to our generous donors, we were able to raise over $1,500 – and our plan remains in place. Attending this conference is critically important and allows us to:

  • Engage providers in one-on-one discussion about 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 the debate
  • Engage with researchers to promote further studies to support an improved, evidence-based standard of care for flat closure
OPBC Includes “Optimal Flat Closure” in Mission Statement

In an important step forward, in April 2020, the Oncoplastic Breast Consortium (OPBC) added “optimal flat closure” to its mission statement, recognizing flat closure as an oncoplastic procedure deserving of an aesthetic surgical approach. NPOAS first reached out to OPBC in February 2020 by joining the organization’s patient advocacy group and entering into discussions about potential mission overlap. We discovered very quickly that OPBC and NPOAS share the same goal – to see oncoplasty become routine in breast cancer care by means of advocacy, research, and promotion of improved, evidence-based standards of care.

We were overwhelmed with gratitude when OPBC amended its mission statement to be inclusive of aesthetic flat closure. And we look forward to continuing working with them to promote oncoplastic breast surgery worldwide!

NCI Adds “Aesthetic Flat Closure” to Dictionary

In another important step forward, just this month, the National Cancer Institute (NCI) added “aesthetic flat closure” to its Dictionary of Cancer Terms, defined as “A type of surgery that is done to rebuild the shape of the chest wall after one or both breasts are removed…” and also describes what the procedure generally entails – removal of excess tissue and contouring to produce a smooth, flat chest wall.

When NPOAS reached out to NCI in January 2020, we had no idea that they’d generate change this quickly. This is a great example of our organization’s approach to getting the job done – one step at a time, reaching out to all possible stakeholders and making the case to each of them in a clear and effective manner. For the NCI Dictionary folks, clear language is their job. They recognized a glaring deficit: there was no term describing this procedure. We made this case plainly to NCI, and were bowled over with their positive and supportive response.

Looking Ahead: 2020 and Beyond

So what does NPOAS have in store for the rest of 2020 and beyond? Plenty. Let’s break it down by category.

Target: WHCRA (Women’s Health & Cancer Rights Act)
  • Organize research into nationwide prevalence of insurance denials for flat closure and revision services to quantify how widespread the problem is.
  • Use those statistics, the NCI definition of aesthetic flat closure, the support of the OPBC’s mission statement, and data from Dr. Attai’s flat closure research to make the case to federal legislators that the WHCRA should be amended to include aesthetic flat closure (aka chest wall reconstruction).
  • Investigate possible collaboration with established legislative advocacy organizations.
Improved Standard of Care
  • Outreach to NAPBC about their protocol and the case for amendment to include aesthetic flat closure, ahead of the 2021 ASBRS Meeting.
  • Continued consultation and collaboration with breast surgeons and the OPBC to encourage the widespread adoption of an oncoplastic approach to mastectomy. Identify barriers, stakeholders, and steps necessary to achieve this goal.
  • Encourage research on insurance coverage denials for flat closure and revision services (and use those statistics – along with the new NCI definition of aesthetic flat closure – to support our case for amending the WHCRA).
  • Encourage research on prevalence of common post-surgical adverse conditions (“iron bra,” restricted shoulder range of motion, truncal lymphedema) and determine whether these conditions have any association with aesthetic flat closure vs. mastectomy without additional contouring.
Coalition Building
  • Work towards the formation of a Young Professionals Advisory Board – in tandem with outreach to medical students and residents.
  • Finalize our Council of International Advocates, to amplify the work of flat advocates worldwide and present a unified message to stakeholders, and facilitate connecting advocates with local OPBC leadership.
  • Work to characterize the barriers to parity in each country and determine how NPOAS can maximize the translation of our work in the US to other countries (and vice versa).
Organizational Leadership and Inclusivity
  • Continue to expand our Advisory Council to include at least one: breast surgeon, oncoplastic breast surgeon, general surgeon, oncology social worker, oncology physical therapist.
  • Nominate additional Board members with the explicit goal of ensuring representation of concerns specific to BIPOC and LGBTQ communities.
Medical Coding
  • Encourage the ASBRS to survey their membership to determine what codes are currently being used for aesthetic flat closure surgical work (Kim is an ASBRS member, representing NPOAS).
  • Continue to interface with stakeholders including ASBRS, the American Society of Plastic Surgeons (ASPS), health insurance companies, and others to finalize a mutually agreed upon coding protocol for aesthetic flat closure at initial mastectomy, explant, and revision.
  • Initiate lobbying effort to improve reimbursement by increasing the valuation of the agreed-upon insurance code(s).
Legal Precedent
  • Continue to provide support to victims  electing to pursue legal action.
  • Continue outreach to advocates in related fields, including obstetric violence and institutional betrayal trauma, in order to identify areas of potential translation with the goal of speeding up the timeline to establishing legal precedent and discouraging intentional flat denial.

How Do We Do It?

We Keep Going.

Progress certainly doesn’t always happen as quickly as it did with the OPBC and NCI. Sometimes when we reach out, we get no response, a stock response that goes nowhere, or even a negative response every once in a while. But we keep going. And step-by-step, piece by piece, we are getting closer to our goal: parity for flat closure.


Want to support our work?

We welcome financial support to help us continue our push forward our legislative and other institutional initiatives, but we also understand how many folks might be suffering due to the pandemic-induced financial crisis. If you want to help but are unable to donate at this time, there’s a lot you can do! Share our work on social media, apply to join our volunteer force, or contact us to recommend your surgeon or share your story. We’d love to hear from you!