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

Amanda Savage Brown, PhD, LCSW

Author, Busting Free

Kimberly Bowles

President, NPOAS

In our survey in 2019, patients who reported experiencing moderate to severe preoperative pushback from their surgeon about going flat were more than three times as likely to suffer intentional flat denial and twice as likely to experience negligent flat denial compared to those who reported little to no pushback. This means you may be able to reduce your risk for flat denial by recognizing surgeon pushback. This article helps you understand what pushback looks like, why it happens, and what to do if it happens to you or someone you love.

What is flat denial? Flat denial happens when your surgeon leaves excess skin against your consent, instead of making you flat as agreed. There are two types of flat denial.

  • Intentional: Despite the surgical skills to perform an AFC, your surgeon leaves skin “in case you change your mind.” You are left with neat clean symmetric incisions atop significant excess skin and an intact inframammary fold.
  •  Negligent: The surgeon simply lacks the skill or regard to produce an AFC. You are left with sloppy, puckered asymmetric incisions with significant excess skin and “dog ears.”

How does a surgeon “pushback” on going flat? 

  • Not mentioning flat as an option along with other reconstruction options
  • Making comments like, “You won’t be happy flat,” “Women change their mind,” or “Flat can’t be beautiful.”
  • Repeatedly asking if you’re sure you don’t want reconstruction
  • Insisting you get a psychological consultation to assess your soundness of mind over going flat
  • Saying they can’t make you flat (or that you’ll need another surgery to be flat)*

*[Note: Your surgeon being honest about their skillset doesn’t necessarily constitute “pushback,” but when they tell you they can’t produce an AFC for you, you must take additional steps to avoid an unpleasant surgical outcome. If your surgeon says that they can’t get you flat in one surgery, seek a second opinion or ask them to bring on a plastic surgeon to plan the incisions or perform the closure.]

Why all the pushback? When your surgeon pushes back against your decision to go flat, it may mean they don’t understand, respect, or agree with your decision. Many surgeons believe that reconstruction offers psychological benefits and that flat patients suffer because of their choice. However, scientific literature on this matter shows mixed results and further studies are needed to explore quality of life measures among AFC patients. Surgeons also live within the same patriarchal system as the rest of us. Their minds learn the same unhelpful beliefs about women, breasts, and belonging. They may hold the sexist biases that breasts make women “whole,” are the icon of femininity, and impart societal value as sexual objects. Some surgeons may treat these biases like “rules” that must be followed or project their learned beliefs onto your body. Surgeons are, after all, only human.

What should you do if you experience pushback? Mild pushback that stops when you reiterate your decision with confidence may not be a red flag for flat denial; however, more pushback equals more risk. Pay attention to what your surgeon says and fails to say about going flat. Use your judgment. Honor your intuition. If you’re not absolutely sure that your surgeon respects your wishes, listen to that feeling and get a second opinion. You have the right to be treated with dignity and respect.

You only have one opportunity to be “one and done.” Seizing it is often important to anyone pursuing an AFC. You don’t want to miss your chance because of flat denial, whether it’s intentional or negligent. Nor do you want to “hope for the best” or blindly trust your surgeon to do no harm – especially given their socially inherited thinking about breasts may lead them to define harm differently than you. To see if there’s a recommended surgeon near you, check out the NPOAS Flat Friendly Surgeons Directory.

My initial surgical result is not flat. Why?

One in Four Patients Are Unhappy With Their Outcome

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

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

Determinants of Your Aesthetic Outcome

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

1. Your Anatomy

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

2. Your Medical History

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

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

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

3. Surgeon Skill & Regard

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

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

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

If You’re Unhappy With Your Aesthetic Outcome

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

Action Alert! Access to DIEP Reconstruction at Risk

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

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

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

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

NPOAS at Breast Surgery Conference April 2023

Critical Flat Closure Advocacy

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

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

About The ASBrS Conference

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

Why We Are Attending

The conference provides unique advocacy opportunities.

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

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



FLAT New Year’s Milestones

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

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

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

Recommend your surgeon here; find a surgeon here.


Providers: Here’s How You Can Help

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

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

NPOAS Welcomes New Board Member Mimi Frazier of Linkage Beauty Movement

Meet our newest Board member at Not Putting on a Shirt, Mimi Frazier of Linkage Beauty Movement LLC! Mimi has been a brilliant breast cancer and flat advocate since 2019, and was the winner of the Flat Retreat Flat Visibility Award this year in Chicago. The work Mimi has done and continues do to uplift and support all breast cancer survivors and thrivers, reconstructed and unreconstructed, inspires us daily. We are thrilled to have her join us at NPOAS!

“Hello, I am Mimi Frazier, from the Washington DC area, with over 12+ years of working in Housing Administration and the Human Resources field. I decided to take my career and life mission on another path after being diagnosed with Stage 3B HER2 Positive Invasive Breast Cancer in 2015. I establish a safe and supportive social media community in 2019 for women fighting, surviving, and thriving with Breast Cancer. Linkage Beauty Movement LLC has since developed into a thriving foundation, solely focused on making a positive change in the lives of women fighting cancer around the world. Showcasing survivors, conducting outreach, linking women together, sending out Linkage Care Boxes, presenting awards, promoting physical fitness awareness, providing resources, and creating 100% Natural, Homemade Essential Wellness products for women to use on our skin and hair, is just some of the work I do daily. Currently, I am studying for my Master’s degree in Human Services at Walden University, with hopes of becoming a Professional Human Services Practitioner, developing Cancer Resource Centers across the United States by 2025. I’m excited to join the NPOAS Board of Directors in hopes of bringing compassion, hope, diversity, and diplomacy to share with everyone.”

Contact Mimi by email to or

Visit the Linkage Beauty Movement WEBSITE

… and the Linkage Essentials ONLINE STORE

LBM Main Telephone: 240-602-8875

Find her on Instagram: @linkagebeautyllc  & @linkageessentials


NY Governor Signs AFC Bill Into Law

Breaking! New York Governor Kathy Hochul has just signed historic AFC legislation! AFC services are now required by law (Chapter 571) to be covered by insurance in the state of New York. This is a huge step forward for breast cancer survivors nationwide as New York state leads the way for other states to follow suit.

“‘Breast cancer survivors deserve to be treated with dignity and respect by our health care system,’ Governor Hochul said.”

Read the whole announcement here.

More about the legislation at

Thank you, Governor Hochul!




Stand Tall: AFC Campaign UPDATE!

The 2022 Stand Tall: AFC visibility campaign has been a smashing success so far this October! STAFC Teams have touched the hearts of so many across the globe, and the walks have garnered lots of media attention. We even have a big rig truck branded with the STAFC banner graphic and Dr. Sage!

STAFC in the Media!

No breasts, no regrets for Wichita breast cancer survivor

Local woman takes ‘flat’ to the streets for Breast Cancer Awareness Month

‘I’m A Breast Cancer Survivor And A Proud ‘Flattie.’ Here’s Why I Said No To Reconstructive Surgery’

Good Day Chicago! with Renee Ridgeley and Matt Selman (video)

CBS 5 Making Strides Coverage (video)

East Styrian had both breasts removed: “I felt liberated” (Dutch)

STAFC Walk Photos

These are just a few photos from the over 40 STAFC walks scheduled for the month of October! Flat hugs, solidarity, and support – it’s all part of becoming visible to one another, as Audre Lorde said.

STAFC Truck!

Trucker Brita Nowak‘s rig was decked out for FLAT visibility at Total Truck Branding in Illinois – keep your eyes peeled on the highways of the continental USA and you might spot her!

… and Stay Tuned!

Stay tuned for more updates on the Stand Tall: AFC visibility campaign. And follow STAFC on Facebook for live updates!