Editorial in Annals of Surgical Oncology: “The Era of Flat Closure Mastectomy”

A fantastic new editorial on flat closure was just published in the Annals of Surgical Oncology, authored by Dr. Jennifer Baker of UCLA, who also co-authored this flat closure study.

In the editorial, Dr. Baker addresses her fellow breast surgeons. Her message is that success in mastectomy patient care should no longer be measured by how high we can push reconstruction rates (as a surrogate for access to care), but rather by how high we can manage to push patient satisfaction regardless of surgical choice. And she says that, “Patients deserve information about [AFC]… and access to these procedures, just as they deserve information about and access to PMBR [post-mastectomy breast reconstruction].”

We thank Dr. Baker for this great and informative editorial, and we hope it becomes widely read in the surgical professional community! It’s now archived on our Provider Resources page.

New Flat Closure Study in Body Image Journal

A stellar new study on patients’ flat closure experiences by lead author Dr. Tracy Tyner has just been published in the prestigious journal Body Image!

This was a qualitative study, which means nothing was measured specifically, but rather interviews were conducted with patients who had gone flat and those interviews were analyzed for themes and contextualized within what we already know based on existing research. It’s a wonderful deep dive into the diversity of the patient experience, from flat denial to optimal aesthetic flat closure, and from the decision making process to post-operative adjustment to living flat.

Some highlights from the study include:

  • Aesthetic Flat Closure (AFC) should be offered as a valid surgical option for women undergoing mastectomy, on equal footing with breast reconstruction.
  • Patients need access to flat closure education and photo galleries prior to their surgeries, as well as psychological support after their surgeries (particularly peer support).
  • Suboptimal flat closures resulted in patient disempowerment and led to psychological distress and body image disturbances.
  • Body comfort/acceptance was variable from day to day and from individual to individual, but improved over time and with flat closure revision surgery for those with suboptimal outcomes.

The entire article is available free of charge at the Elsevier website until the beginning of October. Here’s the official abstract (summary):

This qualitative study aimed to describe and explore the pre and post-mastectomy experiences of women choosing flat closure after a breast cancer diagnosis. Aesthetic flat closure creates a flat contoured chest wall after a mastectomy. There is limited research on women’s flat closure experiences. To fill this gap, we interviewed 19 women (Mage = 53, range 31–72) with breast cancer who underwent a bilateral mastectomy with flat closure, examining decision-making, mirror-viewing, and flat closure experiences. Using a hermeneutic phenomenological design, we generated seven themes. Broadly, women choosing flat closure experienced pressure from their clinicians to undergo breast reconstruction. We found flat closure information to be consistently lacking. Mirror-viewing experiences of women obtaining suboptimal flat closure outcomes led to shattered expectations, mirror avoidance, psychological distress, and body image disturbances. Women negotiated their new reality by discovering ways to feel comfortable with their flat bodies. Regardless of surgical outcome, decision satisfaction was high. These findings illustrate the importance of bodily autonomy and supportive healthcare environments for women making flat closure decisions. Providing comprehensive information on all surgical options and addressing post-operative expectations can improve women’s decision-making and mirror-viewing experiences and assist women in adapting to their new body image.

Tyner et. al., 2023

We couldn’t be happier to read this excellent study, and we hope every surgeon working with mastectomy patients gets the chance to read it as well! It’s now archived on our Provider Resources page.

Flat Memoir: “To Boob or Not to Boob”

NPOAS sat down with “To Boob or Not to Boob” author Liza Hernandez to learn more about her and her book.

Following a breast cancer diagnosis and bilateral mastectomy, I learned to look at life differently. I chose reconstructive surgery with implants, and my new boobs lasted 16 happy years. Then the point came when I had to replace the implants after they became hard and painful. I researched my options for removing the implants and learned about an aesthetic flat closure procedure. If I chose this option, I wouldn’t have to have any more surgeries in the future. While deciding what to do, I read a quote from the Mary Poppins movie: “Open different doors, you may find a different you there that you never knew was yours. Anything can happen.” The quote resonated with me, so I followed my heart and said, “Off with the implants!” With this book, I created a guide with practical suggestions for before and after surgery and the first year of healing. I share how I found the right look for me and my new figure, and how I dealt mentally and emotionally with the changes. I still have boobs, just in my unique way.

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

I decided to write the book because I could not find much information about women who had breast reconstruction and breast implants for numerous years and needed to explant. Also, a lot has changed, and aesthetic flat closure has become an option that I knew nothing about. I could not find much on the healing process for women like me. I walked into my boss’s office and told him I needed to remove my implants and planned to take two weeks off to recover. That was a joke; I was off for six weeks.

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

Writing the book felt like I was living Ground Hog Day, the 1993 movie with Bill Murray, for a year and a half. It was difficult to relive the worst part of my life over and over. I have dyslexia which only compounded the problem, but as time passed, I also relived all the beautiful things that happened to me. Ultimately, it has become a part of my life, not the worst. I have no worst part because I am alive.

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

 I want to make the experience of others easier and help them know how to plan for healing and what to expect. I want them to know they are not alone and can receive help from many unexpected places. Also, there are helpful things to know, like choices of scar patterns and essential questions to discuss with your physician before surgery. Letting people know there are websites with lots of information and support is essential.

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

My favorite part of the book is realizing I can wear lightweight breast forms and achieve the same look without further surgeries. Rigo’s reference that they are like a pair of heels, and I can throw them off when I want to, is a great way to think of them because being flat feels great too.

Any parting thoughts?

My parting thoughts are we are never alone. Even when we think we are, a stranger will give us a kind gesture. People from all walks of life still have kind hearts and care about others. Lastly, illnesses have a way of teaching us to love ourselves.

Order To Boob or Not to Boob on Amazon here.

New Study Looks at Trends in Going Flat After Mastectomy

A new study from the Medical College of Wisconsin, co-authored by Flat Friendly Directory surgeon Amanda Kong, was just published in the prestigious Annals of Surgical Oncology and looks at trends in rates of reconstruction vs. going flat from 2004-2019. We’ve been waiting for this analysis for some time! Previously, data on these rates was only available through 2014 which did not encompass the modern “flat movement” and its potential effects.

Figure 1. National trends in going flat from 2004 to 2019, all age groups (Kong et. al., 2023)

Figure 2. National trends in going flat from 2004 to 2019, by age group. (Kong et. al., 2023)

The authors discussed some potential (not definitive) explanations for the trends. They acknowledge that the literature shows no clear or significant psychosocial benefit to reconstruction, and that women are aware of the potential complications of reconstruction:

“Women who undergo PMBR may report dissatisfaction with their breast outcome due to asymmetry, cup size, lack of sensation, chest pain and weakness, changes in abdominal strength, and unexpected appearance. These issues may affect long-term quality of life, are particularly relevant to younger breast cancer patients, and may also contribute to the stabilizing rates in PMBR. Additional reasons for changes in PMBR rates may be rising concerns regarding the risks of complications with PMBR which have been reported to be as high as 33% in some series.”

The influence of information found online and through social media was discussed:

“Information found online and through social media can significantly influence patients’ decision-making processes, with one survey finding 23% of patients reported that the internet affected their reconstruction decision and 16% were influenced by social
media. Another survey study found that in patients who went flat, many reported learning about this option through their own independent research and 40% expressed they
would like physicians to provide more information on options following mastectomy.”

Rising awareness about the specific risks of implant-based reconstruction, including BIA-ALCL (67.6 times increased risk with implants relative to the general population) was also mentioned as a potential contributing factor.

Thanks to Dr. Kong and her colleagues for this important study!

Conference Update #ASBRS23

A quick update on the 2023 American Society of Breast Surgeon’s conference which the NPOAS Board attended this past week in Boston, MA!

At the conference, we learned about sensation preserving mastectomies and that they are performed with aesthetic flat closure in addition to reconstructions. We also attended a talk by Flat Friendly Directory Surgeon Dr. Sharon Lum on “Unreconstructed Mastectomy” which featured NPOAS.

We actually met multiple surgeons who are using NPOAS as a resource to develop talks on aesthetic flat closure, which is fantastic and we encourage anyone and everyone to use our resources and information this way!

Surgeons were enthusiastic about the surgical photo database at AestheticFlatClosure.com which is filterable by characteristics like BMI, age, race, etc. and can be used by patients to see similar photos to their body type to see what they might be able to expect for their own flat closure. We hope to see the database populated soon!

We gave away 20 copies of Kat van Dam’s great technical guide to going flat, “Flat & Happy: Mastectomy and Flat Closure, a Personal & Practical Guide.” They went like hotcakes! We expect these to be included in the surgeon’s patient resource libraries, which will be very useful for their patients facing mastectomy. A few surgeons even mentioned that their patients had brought the book in to their consultations!

Notably, we are hearing more and more surgeons say that patients are coming in asking for aesthetic flat closure by name! The word is getting out!

“I think people who go flat have accepted the way that cancer has changed their bodies in a fundamental way and that leads to satisfaction with their decision.”

ASBRS Attendee

We signed up quite a few surgeons to receive brochures for their clinic and our newsletter, and we had lots of productive conversations about new resources to develop for both patients and surgeons.

All around, it was a successful conference and we look forward to attending again next year!


Flat Memoir: “Last Cut”

NPOAS sat down with “Last Cut” author Sam Paige to learn more about her and her book.

LAST CUT… outlines my own explant process and more broadly offers a 7-step framework for the many moments in life when we are given the opportunity to make choices that line up who we are on the inside with how we are moving through the world. These moments are the last cuts. When we openly acknowledge a disconnect—such as living with implants was for me, then we can move through a process of self-inquiry to find a solution and greater personal freedom.”

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

When I decided to have an explant in 2016, there were very few people sharing their stories of choosing to be flat, especially in a pre- or post-cancer context. Vonn Jensen of Flattopper Pride was one of the trailblazers in this work, and they deeply impacted me. In the weeks leading up to my own explant surgery, I recalled the conversations and decisions made around my preventive double mastectomy in 2008. Going flat only offered as an option with bias. I was told that going flat rarely makes people happy. The very word “flat” almost seemed taboo. What nonsense! 

So, as I stepped into my own embodiment, I documented my experiences through Last Cut Project, tracing my own reclamation for us all. This body of work became LAST CUT, the book that outlines my own explant process and more broadly offers a 7-step framework for the many moments in life when we are given the opportunity to make choices that line up who we are on the inside with how we are moving through the world. These moments are the last cuts. When we openly acknowledge a disconnect—such as living with implants was for me, then we can move through a process of self-inquiry to find a solution and greater personal freedom. We can stand behind our choices. 

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

Writing this book was empowering and cathartic. The whole explant process offered a metaphor and lens for myriad ways I had allowed for external forces to impact my internal decision-making processes. We all want to feel our worth. We all want to fit in and be seen. However, prioritizing what the outside world thinks of us can lead us down a path of making decisions that make us feel like strangers in our own lives. In my book, I wrote, “I write the story to right the story.” Writing is such a powerful tool for remembering who we are, and when we share that process, we invite others to do the same in their own way.  I found it so empowering and affirming to share and create community around owning my body, choices and growth. I have met amazing people along the way and had incredible experiences come forth [the Equinox campaign in 2017 that showed my flat chest for one] too! I teach writing workshops to model to others the transformative power of putting words to our internal landscapes. Inner inquiry is edgy, and it is also liberating.

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

I want people to read LAST CUT and walk away with the remembrance that we are whole (scars and all). Period. I offer a mirror that reflects back to people that our truest beauty shines through when we take ownership of our inner knowing and when we take action to live a life that embodies this truth. The most gorgeous iteration of self is one that resonates with you. Empowerment is stunning!

We each know more about our bodies and minds than anyone else. So why outsource fundamental decisions to the beliefs of others? [There obviously is a time and place for professional and medical advice and consultation. I am speaking to the day-to-day and the heart and soul decisions that can so easily be swayed by societal ideals.] 

The book also features quotes taken from Last Cut Conversations podcast interviews that I did with phenomenal humans who have made bold last cuts in their lives. My intention is that we are emboldened in each other’s company to show up more authentically and bravely for ourselves. I want to remind people that we can cultivate a deeper connection to self that supports us in navigating all experiences, medical, physical and otherwise. We can face even the most dizzying moments and decisions with grace and greater ease when we take the time in the quiet to find clarity within ourselves. We then have a map with which to navigate. Asking informed questions begins as an internal process. 

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

My favorite part of the book is the TRUST chapter. This chapter speaks to the moment in the Last Cut framework during which things can feel messier before they get better. We can make decisions with clarity and still undergo some moments along the way that may feel rocky. My creative partner on Last Cut Project, photographer Lisa Field, and I came up with this idea to have me sit in a bathtub filled with charcoal water. She had me stay there for a long time while she photographed me. This visual metaphor expresses how sometimes we must sit with the challenges, messiness, cleanup before we find our way to the other side. Clarity comes. We simply have to have the patience to be still, to be present, to trust in the process. I wrote, “Being in it is beautiful.” “Being in it” is the one where the most precious alchemy happens. The TRUST phase is also where we learn to sit with ourselves, to hold ourselves, to be our own best friend and advocate. From this place, we emerge transformed, stronger, bolder, more beautiful. 

Any parting thoughts?

Looking back, I believe I wrote this book to remind a younger me that only I know what will make me happy. This book is a manifesto for authentic, participatory living! Writing this became a love letter to self to say, “Your voice is the one to honor as you make big life decisions.” So, remember to listen to yourself and value what you hear.

My current project, My Beautiful Alien, furthers this work by inviting us all into shared conversation around the things we have been told to hide. I am currently answering 99 questions people have asked of me. Join us!

I would love to gift LAST CUT to you. You can use the code STUNNING for the book (not including shipping).

Order Last Cut here with code STUNNING to receive the book at no cost to you (you pay only shipping).

Webinar on AFC – May 3rd

UPDATE! The recorded webinar is now available on YouTube here.

On May 3rd, 2023 from 12-1 PM ET, join the Program for Breast Cancer in Young Adults and Not Putting on a Shirt to learn more about the option of Going Flat After Mastectomy! In this 1-hour webinar, you will hear from a panel of survivors who went flat, learn about aesthetic flat closures, research on mastectomies, and the psychosocial aspects of going flat. Nursing and Social Work CE credit approval for this event is pending. Register HERE.

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.