Empowering Patients with a Bill of Rights

Bill Of Rights by Nick Youngson CC BY-SA 3.0 Alpha Stock Images

The Goal: Optimal Patient Care

A cancer diagnosis is a harrowing experience. The patient must process a deluge of information and trust their medical providers to help them make the right treatment choices.

But not every patient gets the best guidance, or the best care. Disparities exist, and oftentimes, the patients most in need of informational and community support to help them advocate for themselves, are the very patients who can’t access it.

Because breast cancer afflicts one in eight women, the scale of the impact of even small improvements in breast cancer care can be enormous. Providers, patient advocates and other stakeholders have been working on this for decades. Their work continues today.

Europe Sets the Example in 2014

In February of 2014, on World Cancer Day, the European Cancer Patient’s Bill of Rights was unveiled. The initiative was spearheaded by the European Cancer Concord, a coalition of patients and providers in the EU. It aimed to address disparities in cancer care to ensure optimal patient outcomes across Europe, and was based on three principles:

  1. Patients should receive the most accurate information and should be proactively involved their care (i.e., shared decision making)
  2. Patients should have optimal and timely access to evidence-based, appropriate, specialised care
  3. Health systems should ensure all patients receive the best possible cancer care from diagnosis through survivorship, and should focus on continuous innovation and improvement

For patients facing mastectomy in particular, these principles should guide not just their oncology care but also their reconstructive surgical care – to ensure that every patient enjoys full and fair disclosure of all of their options, has their values and priorities factored into their treatment plan, is able to access appropriate and evidence based specialized (oncoplastic or plastic) care, and receives optimal surgical outcomes to ensure they enjoy the best possible quality of life moving forward. To recap:

  • Full and fair disclosure
  • Shared decision making
  • Access to plastics
  • Optimal surgical outcomes

… sounds like something flat advocates can (and should) get behind!

Oncologists in the U.S. Lead the Way in 2020

Providers in the US are now following Europe’s example. A coalition of leading oncologists and researchers recently published their own proposal for a Cancer Patient’s Bill of Rights based on similar principles, in JCO Oncology Practice (Feb 2020):

Proposing a Bill of Rights for Patients With Cancer,” JCO Oncology Practice (Feb 2020) – Dr, Joseph O. Jacobson, Prof. Leonard L. Berry, Patricia A. Spears, Dr. Karina Dahl Steffensen, and Dr. Deanna J. Attai

Of particular interest to patients facing mastectomy and considering their reconstructive options is the proposal’s principle of equitable treatment – including “the right to balanced information about treatment options, provided in understandable language, that takes into account their priorities and values.” These three components – balanced information, clear language, and shared decision making – are critical to achieving parity for flat closure.

Balanced information in the mastectomy setting means that surgical options are presented in a fair and unbiased manner, without the provider’s personal opinions unduly influencing the communication. Comments such as “you’re too young to go flat,” “you’ll change your mind,” and “you’ll look deformed” have no place in this paradigm. Nor does omission of flat closure as an affirmative choice.

Providers must offer the option to go flat as an aesthetic option. Clear language is fundamental in medicine, and that’s why we believe that the term “flat closure” should be adopted by providers – to ensure patients understand that going flat is an affirmative, viable, aesthetic choice worthy of the same respect and consideration as other reconstructive options.

Lastly, treatment decisions must take into account the patient’s priorities and values – this is another way to describe shared decision making. If the patient prioritizes being “one and done,” this should be a factor determining how the surgery is planned. To this end, plastics closure should be considered when indicated.

Empowering Patients

The proposed Bill of Rights aligns perfectly with our core values, in particular, full disclosure, shared decision making, and evidence-based medicine. It will be a tool to empower patients to demand a better standard of care as well as a means to for that standard of care to be broadly and uniformly implemented.

Thank you to Dr. Jacobson, Prof. Berry, Ms. Spears, Dr. Steffensen, and Dr. Attai for being a voice for patients!

Dr. Joseph O. Jacobson
Dana Farber
Prof. Leonard L. Berry
Harvard
Patricia A. Spears
Dr. Karina Dahl Steffensen
University of Southern Denmark
Dr. Deanna J. Attai
UCLA

“We believe that every patient has the right to receive the best possible care that aims to achieve the best possible outcome.” (Jacobson, et. al.)

We couldn’t agree more.


Share This.

Tell us what you think.

Pioneers in Flat Advocacy: Beth Fairchild


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.


Beth Fairchild

Beth Fairchild is a mother, tattoo artist, and strong advocate for both reconstructive choice and metastatic breast cancer (MBC). She has been living with MBC since her de novo diagnosis in 2014. Beth initially decided to go flat after her mastectomy to protect her treatment timeline and options. After three years with stable disease, she decided to pursue implant reconstruction.

Beth served as the President of Metavivor for three years, continuing to serve on the Board today. She is the creator and producer of Metavivor’s #ThisIsMBC initiative, and is also a Director of #Cancerland. Beth was the first MBC patient to be featured in Glamour, and has also been featured in Oprah Magazine, the Today Show, A Story Half Told, Third Love’s #TheUnderneathProject, and more.


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

“I chose to go flat, as a de novo MBC patient, due to the risk of complications that could arise from reconstructive surgery, and the implications that any complication could lead to prolonged discontinuation of treatment, thus leading to progression or recurrence of my metastatic disease.

After three years of living with my flat chest, and 5 years of completely stable and quiet disease, I chose to reconstruct my chest. I was frustrated with clothing options, especially when trying to buy lingerie, and having to have everything altered. My DD breasts had been a huge part of who Beth was before cancer, and I wanted to feel what that was like again, even though I chose much smaller breasts for reconstruction.”

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

“I had to advocate for my mastectomy, and when I got it I was thrilled. I traded up once the first time I saw my flat chest after removing the bandages and never looked back. I was happy. I felt just as sexy and feline as ever without bulky breasts weighing me down. Most of all, I felt free of any BC that could have been lurking in that tissue, feeding distant metastasis. 

Now, with my new breasts, I feel equally as sexy and feminine, AND I can buy a bikini, shirt, or any dress I want off the rack and wear it with confidence. I enjoy buying sexy lingerie and looking at my curves in the mirror. 

The bottom line, I think, is that you have to feel good about whatever choice you make, and that feeling good is critical for having and maintaining quality of life.”

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

“I’m not sure I decided to be an advocate as much as advocacy found me. I just started sharing my experiences and people listened, they were intrigued, and it just started snowballing there. I think once I realized how great it felt to help others I was hooked. It’s a wonderful thing to be able to say to someone who’s frightened and assure, “I’ve been where you are now and it’s going to be ok.” There were so many women who were that for me when I was first diagnosed and now I get to be that guiding light for others. “

What is your proudest accomplishment as an advocate?

“My proudest accomplishment as an advocate is probably my work at METAvivor as part of #Cancerland, walking the runway at NYFW without breasts. Being able to carry forward my friends Champaign Joy’s legacy and know how proud she would be of all us. “

What has been your biggest challenge as an advocate?

“The biggest challenge for me honestly is the infighting. Women can be mean and catty and judgmental, and it seems even more severe when they’re hurting, ie after a BC diagnoses. It’s sad to me that my lifestyle, my tattoos, my choices to go flat/reconstruct have been examined under a lens clouded by others people’s personal experiences and that I have been included or excluded based on those opinions. And it’s not just me,  UT I see it happen with lots of other women and men and advocates in this space. This is a time, especially during cancer and treatment, when we should be rallying for another, cheering one another on, not being divisive.”

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

“I’d like other advocates to know that your story is just as important as anyone’s. If you can learn to share that story in a positive and impactful way, by doing so, you can change the life of others, an entire community, an entire industry. Never underestimate the power of the spoken word.”

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

“First, I would like to say, just because I ultimately chose to have reconstruction, I am still very much an advocate for the flat movement. While I want to educate people about my experiences, I’m not advocating for women to choose implants, but for them to make more informed decisions about reconstruction.

I wish women were offered flat as an option. It’s like once you’re diagnosed with early stage BC, you’re placed in an assembly line and you’re bouncing from doctor to doctor and just trusting them to make the right choices for you. Most breast surgeons don’t offer all the options for reconstruction, just implants. Remaining flat should be viewed as normal as implants, DEIP, TRAM, etc. I’ve learned so much after being flat and now having reconstructed breasts, and the only thing I know for a fact, is that there is no right or wrong when making the choice about reconstruction, there just IS. The key is realizing that you have options and the choice is YOURS, and that patients have the right to be informed of every single option available and be free to make that choice.”


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!

Share This.

Tell us what you think.


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.


Pioneers in Flat Advocacy: Barbara Kriss


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.


Barbara Kriss

When Barbara Kriss needed a bilateral mastectomy in 2006, she realized that she didn’t want reconstruction but couldn’t find information or support for women who felt like she did. In 2007, she founded BreastFree.org, a non-profit website that presents non-reconstruction as a positive alternative to reconstruction. BreastFree.org has information about living breast-free with and without prosthetics, as well as a flat closure image gallery and stories from women who chose to go flat. Barbara has been featured in the Chicago Tribune, Cure Magazine, Paint it All Pink Magazine, and BreastCancer.org.


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

“I didn’t think I wanted reconstruction, but I went for a consult with a plastic surgeon. That convinced me it wasn’t right for me. I loved my breasts, but they didn’t define me. I didn’t want any more surgery than absolutely necessary. I actually felt that if I had reconstruction and the two reconstructed ‘breasts’ didn’t match, that would be much more upsetting to me than being flat.”

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

“I was very fortunate that my breast surgeon gave me the cosmetically pleasing result that I requested before surgery. My chest is flat and smooth, with symmetrical incisions. My surgery was in 2006 and the thin incision lines are now almost invisible. When I first saw my chest after surgery, I felt relieved. I thought I looked fine, even beautiful. Although I choose to wear breast forms when I’m out and about, I feel totally comfortable with my breast-free self.”

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

“After my diagnosis, I struggled to find information online about mastectomy without reconstruction. Other than a discussion forum on Breastcancer.org, which provided some support, I found virtually nothing. I felt that, building on my own experience, I could create a website that would cover everything from making the decision not to have reconstruction, to preparing for surgery, to recovery and learning to live breast-free.”

What is your proudest accomplishment as an advocate?

“I founded BreastFree.org in 2007. At that time, many breast surgeons didn’t even mention non-reconstruction as an option. I believe that BreastFree.org helped enable women to advocate for themselves and thereby helped swing the pendulum toward a more balanced approach, in which doctors no longer automatically assume that women want reconstruction. And I’m proud that I paved the way for sites such as yours, which have brought even greater visibility to the flat option.”

What has been your biggest challenge as an advocate?

“My approach has always been that each woman should choose what feels best for her. I’ve never been against reconstruction. Rather, my advocacy has been about making sure women have equal access to information about the option of not reconstructing. I also believe that once a woman decides not to have reconstruction, wearing breast forms or going flat are equally viable options. These views may not be quite in sync with the current flat movement. As the photos of me show, I choose to wear breast forms (unweighted foam forms, very comfortable!). At times, I feel I have to defend this choice.”

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

“Over the years, I’ve received hundreds of questions and comments from women who visit BreastFree.org. I’m constantly amazed that women keep coming up with questions and perspectives I hadn’t considered. It’s a reminder that we all bring different ideas and backgrounds to our experience of mastectomy and of living breast-free. Advocacy has taught me to listen better and not to assume that other women have the same needs and expectations as me.”

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

“My vision is the same as it has always been – the choice of having reconstruction or not should be viewed (by the medical community and the world) as equally valid options for women facing mastectomy surgery. I’d like the future to be one where women can feel beautiful and whole without breasts.”


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!

Share This.

Tell us what you think.


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.


#ASBRS2020 Will Be Postponed Due to the COVID-19 Pandemic

As our nation and the rest of the world prepare to weather this pandemic, our thoughts are with all women and their loved ones, in the hope that everyone stays safe and comes through this global health crisis well. Our thoughts are also with the medical providers and first responders who put their lives on the line every day to protect us. Let’s all follow their example and commit to doing our part to protect the most vulnerable among us.

Late yesterday, the CDC issued new recommendations (no mass gatherings for eight weeks) that indicate that #ASBRS2020, originally scheduled for April 28th – May 3rd, will be postponed. Shortly afterwards, the corporate venue (MGM) took the initiative to close down their facility. Our many thanks to the CDC, other agencies, and MGM for their leadership in taking the right steps to protect the public health.

We will be pausing our conference fundraising efforts until we have more information, but our work to protect the interests of women going flat will continue unabated. Thank you for your support, and stay safe out there.

For updates in real time, please follow us on social media.

Share This.

Tell us what you think.

Demand Parity for Flat Closure – Amend the NAPBC’s Reconstructive Consult Protocol

Women reconstructing their chest wall should be able to access a services of a plastics specialist.

The vast majority of mastectomy closures are performed by surgical oncologists, who may or may not have any training in plastic surgery techniques. This is certainly a contributing factor to the 25% dissatisfaction rate for women going flat. Therefore, until oncoplastic training becomes standard for surgical oncologists, women should be able to access a plastics specialist for their initial surgical closure to ensure they get the best possible aesthetic outcome.

Right now, all too often, when a woman tells her surgical oncologist that she wants to be flat, she is cut off from the option of a plastics closure. She may not be referred to speak with a plastic surgeon at all, and if she is, the plastic surgeon most often does not discuss flat closure as an aesthetic option.

The message is clear: if you don’t want breast reconstruction, you must not care about how you look. This harmful myth is reflected in the way that institutions manage our care. Flat advocates want a culture shift. To accomplish that, we must break down the institutional barriers that reinforce the status quo.

That brings us to the NAPBC – the National Accreditation Program for Breast Centers. Run by the American College of Surgeons, this program safeguards patient care by certifying breast centers according to strict quality criteria. Their reconstructive consult protocol delineates what must be covered in a plastics consult for patients facing mastectomy. Entirely missing? Flat closure.

This is why, along with legislative action and improved reimbursement, we are targeting this protocol for amendment. It’s as simple as adding a fourth line item, flat closure, to the existing reconstructive options. It won’t instantly solve the problem… but ensuring that flat closure is framed as reconstructive – and therefore deserving of an aesthetic approach – is a big step in the right direction.

Learn more & sign the petition.

Pioneers in Flat Advocacy: Ms. Rosewater


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.


Ms. Rosewater

Ms. Rosewater (Regina Matthews) is a musician, visual artist, dancer and model with a powerful presence and voice. She had a double mastectomy in 2019 and chose to go flat to protect her health and well-being. She started sharing her experience on social media as affirmation and to take ownership of the struggle. Ms. Rosewater has modeled for Ana Ono + #Cancerland‘s 2020 NYFW show benefiting Metavivor. She holds an annual not-for-profit event with live music, art, food, yoga and more in Los Angeles, California – the “Fuck Cancer Kickback + Jam.” You can find Ms. Rosewater’s work on Youtube, Facebook, Instagram and online at ThisIsMsRosewater.com.


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

“I ended up with flat closure as an option because I did not like the idea of reconstructive surgery.  My reconstructive surgery would have included lifting my chest wall and I did not want to endure such pain. Also I had a fear of the possibility of developing breast implant infections, sickness or failure from my body rejecting them. In addition, after finding out that implants last approximately 10 years before having to be revisited… I did not want to deal with any future surgeries 10 years later.”

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

“I feel I had a wonderful surgeon who understood flat closure. My scars are symmetrical and my chest is flat. Radiation therapy has caused some slight issues across one scar. Otherwise,  I feel grateful to not need any revision surgeries and it has made my healing process a little easier, mentally.”

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

“Honestly, I feel the advocacy found me. I began posting my mental health and breast cancer journeys on social media as a way for me to be able to face my battles head on; sort of like proof that this is real life, to myself. Many people began following my journey and I appreciate it.”

What is your proudest accomplishment as an advocate?

“I tend to remain humble with things. I’m just very grateful to be able to reach out and help when and wherever I can.”

What has been your biggest challenge as an advocate?

“Hmmm… I think a big personal challenge with all of this is accepting when people call me a badass lol. Because I’m not in anyway trying to be a badass, I’m just sharing things that are meaningful to me in the best way that I know how.”

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

“I would advise other advocates to make sure they are being themselves. Share because it’s pertinent and not for clout.”

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

“My vision is to see more normalization of flat closure; in the media and even in the streets. I’m so tired of being stared down in confusion. I would also like to see more celebratory events alongside the research based events. As much as we are longing for a cure we need to remember that we have made it this far… and that’s worth celebrating.”


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.


New Project! Amend the NAPBC’s Reconstructive Protocol

Patients going flat deserve access to plastics closure. NAPBC can help.

Women going flat after mastectomy are not getting the care we need and deserve, in part because most of us cannot access a plastic surgeon for our closure. Women reconstructing their chest wall should be able to access a specialist just like women who are reconstructing their breasts. That’s why we want the American College of Surgeons to amend the NAPBC’s reconstructive consult protocol to include flat closure. 

The National Accreditation Program for Breast Centers (NAPBC), run by the American College of Surgeons, is a program that safeguards patient care by certifying breast centers according to strict quality criteria. One of these criteria is the reconstructive consult protocol, which delineates what must be covered in a plastics consult for patients facing mastectomy. The current version of NAPBC’s reconstructive consult protocol only requires plastic surgeons to discuss breast mound reconstruction options (implants, flaps). The option of aesthetic flat closure is missing entirely.

This protocol, while well intentioned and certainly helpful to women who choose to reconstruct their breasts, has unfortunately had the unintended effect of reinforcing this myth that women going flat don’t care how we look. The protocol formally embodies the status quo: breast mound reconstruction deserves an aesthetic specialist, and flat closure does not. This is why, along with legislative action and improved reimbursement, we are targeting this protocol for amendment. It’s quite simple: we would like to see flat closure added as a fourth line item in Standard 2.1.8:

It’s time to improve the standard of care for patients going flat. The NAPBC can help facilitate this by adopting an amendment to their reconstructive protocol along the lines of what we have proposed here. We look forward to seeing NAPBC representatives at the upcoming conference in April!

Support this project by signing the petition!

Learn more at the project page!

Share This.

Tell us what you think.

REGISTERED CHARITY ID# 84-3021062

New Explant Brochure

Women Going Flat Need Support to Advocate for Their Choice.

Those who are facing explant post-mastectomy are particularly in need of solid, concise and comprehensive information that they can use during their consult to ensure their decision is respected. That’s 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 patient’s expectations.

Explanting and Mismatched Expectations

Explant can be technically complex and there is significant variability in what surgeons hear when their patient requests explant surgery. This makes it much harder for patients to advocate for themselves, and exacerbates the risk of mismatched expectations which can present significant additional hardship for the patient.

Specifically, some surgeons consider implant removal with capsulotomy (making a cut through the scar tissue to release the implant) to be sufficient. But explant activists, along with many explant-specializing surgeons, maintain that the entire scar capsule must be removed along with the implant because it has been in direct contact with the implant and may therefore harbor harmful contaminants. This is a more invasive and costly procedure called “total capsulectomy.” Removing the capsule and implant in one piece (en bloc) minimizes the risk that a potentially ruptured implant and any associated contaminants will spill out into the chest cavity during the surgery.

There is also variability in the type of testing surgeons will order on the excised materials. Most non-specializing surgeons don’t routinely send for the battery of tests that explant specializing tend to recommend. As a result, patients may need to be very specific when discussing their expectations for pathology, documentation, and – if the patient desires – post-testing implant return.

A Tool to Support Both Patients and Providers

Our new brochure “Going Flat After Implant Reconstruction: Your Body, Your Decision” was created to address this problem. It was produced by a collaboration of multiple stakeholders including explant activists, explant and flat closure specializing surgeons, and others. Much of the information on explant was sourced from Nicole Daruda’s HealingBreastImplantIllness.org, and the information on flat closure was sourced from other NPOAS publications. This brochure includes:

  • 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

Having all of this information centralized in one easy to read brochure will help women seeking explant of their implant reconstruction to advocate for themselves and to get the surgical outcome that they expect. Patients can print the brochure out at home and take it with them to use in their surgical consult.

It’s all part of our mission to help women going flat ensure their wishes are respected. Find the brochure on our Publications Page or directly here:

Pioneers in Flat Advocacy: Jersi Baker


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.


Jersi Baker

Angela “Jersi” Baker of North Carolina was just 32 years old at her original diagnosis (stage 0). She had a single mastectomy with implant reconstruction. Eight years later she progressed to stage IV. Jersi founded her nonprofit, Angel In Disguise Inc., in 2015, to provide transportation assistance and support for local residents in who are undergoing cancer treatment. Jersi is active with several organizations that advocate, promote awareness, and provide support for women of color facing breast cancer, including TigerLily Foundation, SISTA Survivor, and BreastofUs. In 2016, Jersi decided to explant and go flat. She has modeled for the AnaOno and #Cancerland in their annual fashion show benefiting Metavivor.


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

“When I was making my decision I actually didn’t really think about being flat, as much as I was thinking about explanting. Once I decided to explant, I realized that wow, now I am going to only have one breast. But I didn’t care, I just knew I wanted that implant out and I would deal with the rest later.”

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

“The healing process was easy, although my skin is thin. It was the best decision that I made for my body and eliminated all of the discomfort from previously having an implant.”

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

“Once I decided to apply for disability, sitting at home and doing nothing wasn’t an option, and I knew there were people who needed my help. I began to get involved by starting my own nonprofit organization, Angel in Disguise Inc., and started attending more conferences to become more involved. That is when I saw all the opportunities to get involved.”

What is your proudest accomplishment as an advocate?

“Starting my nonprofit organization, and although we have never received a grant and operate on donations I understand the importance of this work and will NOT STOP! My voice is being heard.”

What has been your biggest challenge as an advocate?

“Funding for my nonprofit. Getting a seat at the table.”

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

“That using your voice whenever you get the opportunity is key and don’t worry how others perceive you, if you speak loud and proud you will be heard. #avoiceforthevoiceless”

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

“To let others know that it is an option. Being flat is not taboo. Being flat as an option should be included in all reconstruction conversations with your oncology team, as well as options available for when someone doesn’t want to appear flat in their clothing.”


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.


Pioneers in Flat Advocacy: Juliet Fitzpatrick


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.


Juliet Fitzpatrick

Juliet Fitzpatrick of the U.K. became an advocate after struggling to have her own surgical choice respected in 2017. She was never offered flat as an option, and was initially denied a prophylactic contralateral mastectomy (to remove the healthy breast). She has a blog about life after cancer, Blooming Cancer, and her visibility work has been widely featured both publicly in the U.K. and online.


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

“I was told that I needed a single mastectomy in February 2016, and at the same time it was assumed that I would have a DIEP reconstruction. I agreed and over the next few days, realized that I didn’t want reconstruction because of the length of surgery and the look of the end result. I asked my surgeon to do a bilateral mastectomy but he refused, so I ended up as a uniboober with a remaining GG cup breast. I kept asking for a second mastectomy for symmetry and finally my surgeon agreed eighteen months later.”

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

“I’m mostly happy with both of my surgical results. I do have excess skin under both arms, but I can live with this. I had a small revision surgery on my left scar to remove a tissue flap in the middle of my chest. The fact that both of my scars are flat and smooth has really helped me to move forward both physically and psychologically.”

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

“I became a flat advocate in February 2018 after I’d had my second mastectomy and I’d done my first topless flat photo shoot. I started my blog with those photos and my first post was about my journey to living as a flat woman.

“I never planned to become an advocate, but I was alarmed that my medical team assumed that I wanted to have reconstructive surgery. The alternative – to remain flat – was never given to me as an option. I believe strongly that all treatment options should be offered to patients at the time of their mastectomy. I had to fight hard to be “allowed” to have my remaining breast removed and I wanted to highlight that these two situations happened to me.

“I want to let other women know that they don’t have to go with what their medical team says they should do if it’s not what they want. We need to know all of the options if we are to make an informed choice. My friend took some topless photos of me and I started a blog. The positive response that I got to my first post encouraged me to do more to break down the taboo around living flat and to highlight some of the medical professionals’ attitudes to a woman’s right to choose.”

What is your proudest accomplishment as an advocate?

“Being featured in the Dove #ShowUs project this year. My flat topless image was used all over the world in press and advertising billboards including Times Square and Piccadilly Circus. I was proud to be getting flat representation out across the world.”

What has been your biggest challenge as an advocate?

“Keeping the momentum going as someone working solo.”

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

“That it’s hard work and you must be prepared to put yourself in situations that may be uncomfortable. You will receive positive feedback most of the time but you should be prepared to receive criticism from unexpected sources.”

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

“My vision is for all flat advocates worldwide to collaborate with each other so that our message can be strong and united. The more we speak out together, the further our message will get and the more we can influence the medical professionals in so many ways. To listen to women, to respect our choices, to understand that we have agency over our bodies, to know that we know what we want to happen to our bodies. It’s important that flat advocates get disseminated the message that women are more than their breasts and that many of us don’t want to have surgery to restore our bodies to what they were before mastectomy – it’s an impossible solution.

“In the future I would like women to be listened to. Whether that’s to hear when women say that they don’t want reconstruction or when they say that they want a totally flat surgical outcome. No woman should be left with pockets of skin ‘in case they change their minds about reconstruction’.”


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.