Guest Blog: At the Intersection of My Flat Chest and an Antiquated System of Care

by Melissa Eppard

Melissa Eppard is a certified Life Coach, writer, and breast cancer thriver. Today she’s speaking with us about women’s health, women’s autonomy, explant, and flat closure.


Women everywhere are calling for the standard of surgical breast cancer options to shift and include flat closure. We’re finally positioned culturally and historically to demand autonomy over our health care choices, and how we express our ideas of what is truly healthy and beautiful for ourselves.

Melissa after her explant (removal of breast implants and scar capsules) and flat closure with the technique described here.

Breast cancer has become ground zero, where the intersection of popular culture—music, media and fashion, meets medical device manufacturing, the health and beauty industry, the world of plastics, and what women want for themselves in terms of comfort, health and functionality. We are taking ownership in self-determination, both in our surgical outcomes and self-image, redefining the currency of what makes a woman beautiful. 

We are now poised at this powerful juncture with more women in leadership roles in business and politics than ever before, in the wake of the #MeToo movement, with the surge of the collective feminine voice reaching into every cultural corner. We are gymnasts and yoga teachers, nurses and gardeners, congresswomen and doctors. We are carpenters and professors, actors and MMA fighters, engineers and activists, and so much more. 

“We’re finally positioned culturally and historically to demand autonomy over our health care choices.”

Melissa Eppard

We want the least amount of surgical down time, no extra revisions required, and none of the complications or harmful side effects from breast implants. We want surgeons who make us flat when we ask them to, without scare tactics or chauvinistic comments, wondering how we’ll manage to fill out a swimsuit. We want the truth about breast implants, in plain language, and flat closure to be offered as a valid option from the time of that very first consult. 

We want to be visible to each other and to the world. We are not broken. We are beautiful and strong and whole, and a force to be reckoned with. It is time our health care policies and patient care reflected the evolving needs and demands of 21st century women. 


Melissa Eppard is a certified Life Coach, writer, and breast cancer thriver. She uses her personal and professional experiences to help women get their sexy back after cancer so they can move forward with less fear, make peace with their bodies and reclaim the fullness of life. She uses guided visualization, mindfulness tools, embodiment practices, and EFT Tapping to empower her clients. She lives and works in Kingston, NY and offers long distance sessions as well. 


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.


NPOAS Exhibit at 2019 Pittsburgh SABCS Review

Not Putting on a Shirt will be exhibiting at the 2019 San Antonio Breast Cancer Symposium Review at the Pittsburgh Mariott this Friday January 24th.

This important annual event provides for medical professionals who could not attend the San Antonio conference to learn about the cutting edge research presented there and to discuss the implications for clinical practice with their colleagues.

Engaging local providers and educating them about flat closure as a valid option, is critical to our mission to #putflatonthemenu. We will be showcasing our original research, distributing publications, and answering provider’s questions about flat closure.

Thanks to Allegheny Health Network for organizing the Review, and for their generous support of nonprofit exhibitors like NPOAS.

Stop by and see us!


Share Your Experience: Revision Surgery

Did you need revision surgery after going flat? We want to hear from you!

Help us ensure women’s access to care by filling out our short online survey. Your participation in the survey will take only a minute or two of your time, and will help us understand how we can solve the problem of insurance denials for women seeking flat closure and revision services.

Visit the website to learn more about our work on insurance coding and federal and state legislation.



REGISTERED CHARITY ID# 84-3021062


Recommend Your Flat Closure Surgeon!

Happy with your flat closure – whether at initial mastectomy, explant, or revision – and want to help other women going flat? Now you can recommend your surgeon for our Flat Friendly Surgeons Directory, with our easy online form!

Our Directory helps women protect their choice by connecting them with a proven flat closure surgeon in their local area who:

– respects their patients and their wishes to be flat
– are technically competent in surgical technique to achieve a flat result, AND
– do their best to give their patients their desired result

As of January 2020, the Directory has over 180 surgeons specializing in flat closure, including 133 surgical oncologists and 59 plastic surgeons (11 dual specialty). Of interest to women looking to explant, thirteen of our Directory surgeons also appear on the HBII explant list. (Note: NPOAS is not affiliated with HBII).

Tina – Flat Has Been Freeing


Editor: It’s been some months since we published our last personal story of going flat. Today we hear from Tina Rattunde, a woman who tested positive for the BRCA2 mutation after watching multiple family members deal with breast cancer. She chose to go flat in July of 2016. Her surgical oncologist wanted her to see a plastic surgeon “in case she changed her mind” about reconstruction, but Tina declined. She had made her decision: she wanted to be flat, and to be done with surgery.

Reading Tina’s story, it’s clear that she is happy with her decision and with her surgical result. She didn’t expect perfection – no one does. And Tina’s confidence had a profound effect on her surgical oncologist. She now offers flat as a viable option to her patients, because through Tina she learned that flat is a healthy, legitimate, safe reconstructive choice that women are happy with. Nice work, Tina! And bravo for her surgeon keeping an open mind.

Tina’s daughter Nat wrote a letter of support for her mother’s choice as well, and had some powerful words both for women facing mastectomy and for the providers who care for these women.


Tina Rattunde chose to go flat in 2016 after testing positive for the BRCA2 mutation. Her pre-op imaging uncovered DCIS.

My name is Tina Rattunde. This is a brief accounting of my journey to become flat and why I advocate for flat closure.

In October 2015, my 1st cousin was diagnosed with breast cancer. This sparked the desire to have a mammogram by my sister and myself.

We were both called back for another mammogram the same day. These tests lead to MRI’s for both of us. My sister’s tests observed multiple crystallizations in both breasts and mine showed nothing. We geared up for the possibility that hers were cancerous in nature. After her biopsy, she learned that she, in fact, did not have cancer. She chose a bilateral mastectomy with DIEP flap reconstruction in early 2016. She has since had another procedure to correct some of the fat deposits.

Effect of BRCA mutations on cancer risk
CREDIT: Cancer.gov

Why do I tell you all about my sister? Because, this is where her story ends and mine begins. As of January 2016, I thought I was good. I still chose to have a preventative bilateral mastectomy because of the family history. You see, during my sister and my ordeal, we chose to be genetically tested for the BRCA mutation. We both tested positive for BRCA2.

I arranged to meet with a breast surgeon to set up my surgery. She was a fantastic surgeon who listened to me and my want to be flat. She felt it was important to have me see a plastic surgeon “in case I changed my mind later on”. This was heartily declined. I did not want any future surgeries. I saw firsthand my sister’s 13-hour surgery and how much it took out of her to heal. I knew my cousin had expanders put in and they were so uncomfortable. (By the way, she did pass away due to complications with sepsis after her implants were placed.) With being 43 years old, having a young, active son, and knowing reconstruction would be a lifelong, repetitive issue, and not wanting multiple surgeries,  I chose to be flat.

When going in for my pre-op MRI in late June 2016, the MRI specialist found cancer. Yes, I was clear in January but now had DCIS (ductal carcinoma in situ) in my right breast. My surgeon and I decided it was best to move quickly. Surgery was scheduled for two weeks later.

So, on July 8th, 2016 I was given my flat closure as I requested. My scars were very nicely done. I did have a deep tissue infection caused by the surgery but it was taken care of without causing more dramatic scars in the surgeon’s office, thankfully. I have not had any other surgeries to adjust my breast area. I do have “dog ears” but they are minimal. I am overweight so this does affect other areas of my body’s image without my breasts, but I would never make a different choice. My surgeon did confess that after being part of my choice in going flat, she too would do her best to offer “flat” as a viable option for others. She witnessed that my choice was a healthy (both mentally and physically) choice made with great reflection and a well-informed education.

Flat has been a freeing of sorts to me. I no longer have to have yearly mammograms. I can easily check for any lumps or suspicious issues on my chest wall. I don’t miss the heaviness of my natural breasts. I can choose prosthetics if I do want to have the look of breasts. And, most importantly, I’m alive, well, and happy.  

This story of my sister and I shows how, just in one family, cancer and reconstruction can differ greatly. Neither is wrong. Neither makes us less of or more of a woman. We are both very comfortable with our outcomes and our choices. We both support one another on our choice. This should be the “norm” of every decision when it comes to reconstruction. When I state reconstruction, I mean the following choices: flat, unilateral mastectomy, unilateral mastectomy with reconstruction, bilateral mastectomy, bilateral mastectomy with reconstruction, lumpectomy, lumpectomy with reconstruction.

Thank you for taking the time to read this. Please consider every option when having to make these tough decisions in life. Be YOUR best advocate! No one wants cancer. Let’s do all we can to promote healthy choices for those who may be cancer’s next victim. Whether it is the option of PREVENTATIVE or LIFESAVING measures, let’s not think of just the here and now. Let’s think ahead to the future generations looking at us, waiting for us to do our best for them, no matter what that looks like!


Tina’s daughter Nat writes:

“I am a 26 year old woman. I may very well have to face [the situation my mother and aunt faced] in the future. I also know that just because it is currently the accepted course of action to recommend reconstruction and ignore (at best), or actively discourage, remaining flat after the mastectomy, women do not need to silently accept this treatment.

This line of thinking is indicative of our societal frame of mind that women are sexual objects and without breasts, are not acceptable. My mother is no less of an attractive woman without her breasts. My aunt is no more of an attractive woman after reconstruction. I am no more attractive than both with natural breasts.

Breasts, or a lack of them, do not define our value or who we are. Whether anyone chooses to have flat closure, they are entitled to a safe, unbiased, and aesthetically pleasing surgery.” – Nat Rattunde 

Breasts, or a lack of them, do not define our value or who we are. Whether anyone chooses to have flat closure, they are entitled to a safe, unbiased, and aesthetically pleasing surgery. 

I am incredibly blessed to be in a family that supports our right to choose what is best for our own body. I have watched how horrifying the choice is to make, yet because of the support we have for one another, this choosing was completed without guilt or shame. There is no universal right choice for what to do with your body after cancer or to prevent it... I fully, and without any semblance of hesitation, support the reformation of legislature and societal norms to reflect women having true autonomy over their bodies and flat closure for those who want it.

And whether that includes me or not, I will continue to support a woman’s choice to have medical procedures that are healthy, unbiased, and a reflection of their best interest.”


Editor: Well said, Nat! We thank you, and we support you!


Vermont Rep. Fegard Introduces Revision Bill

Breaking news!

Vermont State Representative Charen Fegard has just introduced an historic bill requiring insurance coverage for revision surgery!

Charen Fegard VT State Representative has just introduced a bill that will require healthcare stakeholders to decide on a clear coding and billing protocol for revision surgery for women who have chosen flat closure after mastectomy. Working across the aisle with Rep. Lynn Batchelder (R), herself a medical coding specialist, the good Rep. Fegard has 77 cosigners (of 150 house members) for the bill. Rep. Fegard explains:

“I have submitted one bill that affects a very small percentage of the population but I hope can make a difference for them and be used as a model in other states. When a woman undergoes mastectomy surgery, she may choose to have breast mound reconstruction or have chest wall reconstruction (also known as flat closure). Each of the two choices has advantages and drawbacks and the decision is a very personal one. Regardless, sometimes the initial surgery needs a follow up revision surgery to make corrections. The coding is pretty clear for women who need revision for breast mound reconstruction, but is less clear for those who have chest wall reconstruction. My bill requires state healthcare stakeholders to decide on clear coding and billing protocol so that no woman recovering from the devastation of mastectomy surgery must deal with incorrect coding and denial of revision surgery. Representative Lynn Batchelder (R), who has long worked as an insurance coder, was a strong ally, reaching across the aisle to help me gather 77 co-sponsors for the bill, which hopefully prompts the bill off the wall in committee.

Introducing a bill or signing on as a co-sponsor is a bit of a gamble and is not a guarantee to vote for it in the end. One reason for this is that bills are often modified in some way before passing out of their committee of jurisdiction and then the Senate committee of jurisdiction makes changes, too. While the topics of a bill generally hold, it can have a very different affect after it gets through two committees. “

Charen Fegard VT State Representative (Facebook post, January 09, 2020)

This is an historic moment for the flat community. Women have had to fight their insurance companies to get revision surgery covered for far too long. It’s way past time to #putflatonthemenu.

A heartfelt thank you to Rep. Fegard and to all of the good Vermont Representatives who have co-signed to this historic bill to protect the interests of women who choose flat closure. This bill will serve as a template for other states to pass similar legislation, and eventually this momentum will carry over to amending our federal target legislation, the WHCRA.

Visit our Contact Your Legislators project page to learn more and to see what you can do in your state.

Stay tuned for updates!


NEW – International Translations of the "Flat is Beautiful" Brochure

We are happy to announce nine new international translations of the Flat is Beautiful brochure, available now for download. Spanish, French, German, Arabic, Swahili, Russian, Chinese (simplified), Hindi, and Portuguese are the languages now available.

We extend a heartfelt thank you to Global Wordsmiths for providing translation services for this project.

Global Wordsmiths is a Social Enterprise that provides language translation and interpretation services, as well as language access consulting and training. Every dollar of profit is used to finance their innovative Social Impact Initiatives: providing free translation and interpretation to selected nonprofits, providing quality jobs and growth opportunities for their staff, and helping service providers to build or improve their language access policies and procedures. Their goal is to create and advance a culture of language access awareness, so that translations and interpreters will become more widely available for individuals who need them in order to access services, to integrate and to thrive. [Learn More]

To download a translated brochure, select your language below, or visit our Publications page.




Our Poster at SABCS 2019

NPOAS founder Kim Bowles presenting a research poster on flat closure at SABCS 2019

We had a successful poster session at the San Antonio Breast Cancer Symposium (SABCS) this past month, presenting a poster with the results of our original research, “Flat closure after mastectomy: are your patients satisfied with the results?”

This research explored the patient experience going flat, including decision factors, satisfaction with cosmesis, provider pushback, and more. Stay tuned for the full report.

The SABCS19 poster presenting NPOAS’ original research on flat closure

The response from providers attending the conference was overwhelmingly supportive, and several surgeons made some great suggestions for avenues to pursue parity which we will be exploring in the coming weeks.

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!

We look forward to continuing our work to promote and protect the interests of women going flat in 2020 and beyond.

Want to support our work? Spread the word on social media, volunteer, or donate.

#SABCS19
#putflatonthemenu
#notputtingonashirt
#stagefourneedsmore
#thegraceproject

Flat is Beautiful (Video)

A new resource is up on the website – the Flat is Beautiful video presentation, featuring many amazing flat advocates and advocacy projects. This 6 minute video is an introduction to going flat as a valid, beautiful mastectomy choice. Narrated by Kim Bowles of NPOAS. Transcript below the video.


Transcript:

Hi, this is Kim Bowles, founder of Not Putting on a Shirt. I’m here to talk to you all about going flat – a legitimate and beautiful reconstructive option for women facing mastectomy.

Losing your breasts isn’t fun. And it’s not really a choice for most women – cancer made that call for us. I myself faced this situation in 2016 – I’ll talk about my own story a little later.

For women facing mastectomy, the only choice is… do I try to reconstruct my breasts, or not? It’s a very personal choice. Women consider:

  • Is it important to me to maintain a breasted appearance?
  • How much surgery am I willing to undergo to achieve breast mounds?
  • Are the risks of implants or autologous reconstruction, worth it in my case?

Before the 1990’s, breast reconstruction was largely considered to be “cosmetic” – not necessary. Many women who wanted reconstruction could not afford it because it was not covered by health insurance. For these women, going flat was not their first choice – it was just what they had to live with.

Patient advocates changed this situation by partnering with provider organizations and lobbying to pass the Women’s Health and Cancer Rights Act of 1998. This legislation required most insurance companies to cover the cost of breast reconstruction.

Reconstruction rates skyrocketed in the decades following. Yes, it’s been decades since the 90’s.

Other things have changed since the 90’s as well. Women’s perception of our own worth and of how we define “beauty” is changing… and with it, so is the way we view breast reconstruction.

The WHCRA advocates’ goal was to ensure women could access ALL reconstructive options.

Now we have come full circle.

For many woman today, flat is where it’s at. We have looked at all of our options, and flat is our affirmative choice.

All reconstructive choices are valid.

And they are all beautiful in their own way.

A woman’s aesthetic choice after mastectomy represents her new body moving forward in her life. This is who she is now.

This is her body and her choice.

For some women, reconstructing their breasts does help them to feel whole again. Living flat does not appeal to them at all. That’s their perspective, and that’s ok. That’s the beauty of choice. Women who choose to go flat, on the other hand, have a different perspective – we feel that we are already whole. Many of us simply don’t desire the appearance of breasts, and for others, the price of reconstructing our breasts – to our time, and to our health – is just too high. Many women who initially choose implant reconstruction later decide to explant and go flat for this reason.

For some of us who were diagnosed at a young age, our priority is to get back to life with our kids. We feel that cancer treatment has taken us away for too long already. And we also want to show our daughters that we are not defined by our breasts. This is who we are. It’s ok to be breastless. It’s ok to have scars. We are whole!

Going flat can be a way to take back ownership over your new body after breast cancer. For some of us, it’s reminiscent of when we were kids – we were breastless then too. Breast reconstruction doesn’t give us back what we lost. Facsimiles of breasts may be important to other women, but not to us. Our breasts are gone… but WE are still here.

And we are proud of our scars!

There are many ways to reclaim our bodies after mastectomy. Reconstructing breast mounds is one way… but a smooth, flat chest can be a great blank canvas for individual artistic expression. Mastectomy tattoos play a big role in some women’s healing process. We’ve even heard from women who knew exactly what they wanted their chest tattoo to look like immediately after learning they needed the surgery!

Over the last decade, patient advocates have developed extensive resources for women considering going flat.

From online support groups, to photography projects to magazine articles, to podcasts, to full length memoirs. And there are nonprofit advocacy organizations as well – in the US and the United Kingdom as well – that are working to promote flat as a legitimate reconstructive choice.

It’s all freely available online.

FLAT resources online continue to grow and expand as women learn more about the benefits of this reconstructive choice. There’s even an annual day of celebration every October 7th – “International FLAT Day”. You can find the Flat is Beautiful brochure at InternationalFLATDay.com. It has a list of resources as well as detailed information about going flat and questions to ask your surgeon.

So we’re coming back now to my personal story.

It’s an unfortunate reality that not everyone believes that women can be whole without breasts. And surgeons are no exception.

I’m here today because my surgeon intentionally disregarded my clear directive and left “pockets for implants” remaining on my chest. He thought I would “change my mind” about getting implants. You can visit my website to see my whole story.

To ensure that women recieve full and fair disclosure of ALL of our reconstructive options, and to ensure that our informed consent respected, EVERY TIME, women must speak out. That’s why I’m here talking to you. Education is a big part of the solution, but it’s not the whole picture.

You can learn more about my work at Not Putting on a Shirt.org

I’ll leave you with this lovely photograph that we saw earlier – this is from a photography project called The Breast and the Sea. It’s a collaboration between Miana Jun, a photographer, and patient advocates.

Whether you choose flat, breast reconstruction, whether you’re a unicorn (that’s half flat)… all reconstructive choices are valid, and all are beautiful in their own way.

Thanks for listening.


Coding for Flat Closure

Interested in helping us break down barriers that women going flat face when trying to achieve an aesthetic result they can live with? Coding for flat closure is one of those barriers, and Not Putting on a Shirt is on the case with our Coding for Flat Closure project.

The problem: there’s no clear pathway to code for for flat closure and revision services. As a result, quite often providers will simply tell the patient they can’t or won’t do the procedure at all. So women are denied services and left with “mangled” chest walls while they’re dealing with breast cancer treatment.

Legislative action is one piece of the puzzle, but that will take some time… we need to support providers who offer these services, right now.

That’s why we are working to facilitate the development of a standard protocol, or pathway, for providers to seek reimbursement for flat closure and revision services… and that involves clearing up the confusion about CPT codes.

Background: what are CPT codes?

Current Procedural Terminology (CPT) is a medical code set maintained by the American Medical Association. It’s a common language for those who work in the medical field – each code is a unique string of numbers that indicates a service or procedure. In the breast surgery setting, CPT codes are used by providers to request reimbursement from insurance companies for the services they provide to their patients – lumpectomy, mastectomy, conventional breast reconstruction procedures, etc.

Here’s the catch: there are no CPT codes specific to flat closure or revision.

Without the proper coding, many insurance claims are denied… as too many women seeking revision surgery have discovered.

One solution to this problem might be to lobby for a new, unique CPT code. However, this becomes complicated very quickly. When you add a new CPT code to the mix, by definition any value assigned to it has to be taken away from an existing code – and that means that we might inadvertently worsen reimbursement for mastectomy itself. Not good!

So we are left with selecting a code from the existing list – but which one?

Reviewing the candidates

Our review has determined the following short list of options for coding for flat revision (note: “modifier -22” can be appended to the initial mastectomy code (19303) if the contouring work is done during the initial surgery.)

CPT Coding for Flat Closure Revision Surgery

CodeCode DescriptorNotes (current RVU)
19499Unlisted procedure, breast.chest wall may or may not qualify as “breast” (variable RVU)
15839Excision, excessive skin and subcutaneous tissue (including lipectomy); other area.most revision involves removing excess tissue
(10.5 RVU)
13101/
13102
Repair, unusual, complicated, over 7.5 cm, any area / each additional 5cm or less complex incision type wound repair (3.50 RVU)
14301/
14302
adjacent tissue transfer (example: V-Y plasty)exact code depends on surgical field size  (6.37 RVU)

Other considerations are procedure specifics, code valuation, and the status of a code as “unlisted”:

Procedure Specifics. The choice of code for any given revision procedure may depend on the details of exactly how the procedure was performed.

Valuation. Each CPT code is assigned a value by the AMA, called an “RVU” (Relative Value Unit). A higher RVU means a better reimbursement rate.

A note on “unlisted” procedure codes. Because these codes are non-specific, providers must submit supporting documentation so that billing can determine coverage and payment. This presents an additional burden on providers.

Learn more at the Coding for Flat Closure project page:

Not Putting on a Shirt will continue to work with stakeholders to produce a workable protocol for CPT coding for flat closure and revision services.

Want to help? Contact us below, or donate to support this project.

We welcome your input! If you’ve experienced (or struggled with) coding for flat closure or revision services, or if you have expertise in medical coding and want to share your insight, please send us a message. We’d love to talk to you.