Breaking! Aesthetic Flat Closure Research Just Published in Annals of Surgical Oncology

A Critical Step Forward

An historic study on patient satisfaction with aesthetic flat closure out of UCLA was just published in the Annals of Surgical Oncology, an official journal of The Society of Surgical Oncology (SSO) and the American Society of Breast Surgeons (ASBRS). This research represents a critical step forward to parity for flat closure, by characterizing the patient experience going flat and factors contributing to satisfaction with aesthetic outcome.

View Abstract (PubMed)

Takeaways from this Research

How Bad is It? Prevalence of Flat Denial

22% experienced “flat denial” – they were not initially offered the option to go flat, their surgeon was not supportive of their decision or tried to talk them out of the procedure, or extra skin was intentionally left in case the patient changed her mind. (Dr. Attai)

This figure is higher than what NPOAS’ pilot studies found, likely because the term “flat denial” was defined more broadly in the UCLA study. Our pilots found 10-15% of women going flat received unacceptable aesthetic outcomes either through negligence or intentional disregard, but this was only looking at surgical outcome and did not include the patient’s experience in consult. The UCLA finding confirms that there is a lot of room for improvement in the way the flat option is presented and executed.

If 2-3 in 20 patients going flat are denied a flat closure and another 1-2 experience disregard or disrespect for their decision in consult, improving the situation is a challenge we can, and must, rise to.

Protect Yourself: Know the “Risk Factors”

Factors most associated with flat denial include low level of surgeon support, high flat denial score, higher BMI (body mass index), and those undergoing unilateral (one side) versus bilateral (both sides) mastectomy… [and] patients who reported that their surgeon had an exclusive breast surgery practice were less likely to be dissatisfied.(Dr. Attai)

These findings confirm that patients going flat who choose a breast specialist (vs. a general surgeon) and who have lower BMIs are more likely to receive an aesthetic outcome they are satisfied with – and that pre-operative pushback is associated with flat denial. Additionally, the UCLA study found that patients having a single mastectomy had higher rates of dissatisfaction.

For patients going flat to advocate for and protect their choice, these findings are critical. What does this mean for individual patients? While there is no iron-clad protocol for ensuring your choice is respected, a patient with a high BMI having a unilateral mastectomy and using a general surgeon could reasonably consider their situation to be “high risk” for flat denial, and would therefore be wise to consider having a plastic surgeon involved at their initial surgery.

Overall Satisfaction with Aesthetics

74% agreed or strongly agreed that they were satisfied with their surgical outcome.(Dr. Attai)

This confirms the rate from our pilots as well. This is our “starting point.”

The Goal: An Improved Standard of Care

The UCLA study confirmed that three in four patients going flat are satisfied with their aesthetic flat closure. This figure can be improved upon by improving the standard of care for this population. According to Dr. Attai, this may involve:

  • further research;
  • better education for surgeons about the flat option and about the potential for partnering with a plastic surgeon for mastectomy with flat closure; and
  • improved access to training in aesthetic flat closure technique for cancer surgeons.

“Our findings reveal a a need for additional research into factors that impact patient satisfaction as well as for surgeon education on how to optimally support women who are not interested in breast mound reconstruction. In addition, surgeons should be trained in techniques to perform an aesthetic flat closure, or partner with their plastic and reconstructive surgical colleagues so that they can provide optimal results for their patients.

Dr. Deanna Attai

We couldn’t agree more! These steps are integral to our strategic plan at NPOAS. As we enter the new year, we look forward to further collaborations with researchers, and to continuing to provide support for patients and providers who are interested in aesthetic flat closure.

Our Thanks

Our sincere thanks to the entire research team – Dr. Jennifer Baker (the principal investigator at UCLA), Dr. Deanna Attai (UCLA), Dr. Don Dizon (Lifespan Cancer Institute of RI), Cachet M. Wenziger, Elani Streja, Dr. Carlie K. Thompson, Dr. Minna K. Lee, and Dr. Maggie L. DiNome. And to all who contributed and participated in this important research!

To read more about the study’s findings or to request a copy of the article, visit Dr. Attai’s website.

Before Your Surgery: Memorializing Your Breasts

Woman making plaster cast of breasts before mastectomy Image Credit: Patricia Chambers
A plaster cast can be used to create a keepsake.
Photo Credit: Patricia Chambers (SELF Magazine, 2015)
Young woman pre-mastectomy boudoir Photo Credit Claire Burnett
A boudoir session is an option for remembering your pre-surgery body.
Photo Credit: Claire Burnett (Smithsonian Magazine)

More about preparing for your mastectomy with aesthetic flat closure at the Preparing for Surgery page.

Memorializing Your Breasts: Options to Consider

You may want to consider memorializing your breasts before your surgery. Then after your mastectomy, you will have something tangible with which to remember and honor your previous breasted body. Here are a few ideas, sourced from breast cancer survivor-created lingerie company AnaOno and life coach and breast cancer survivor Melissa Eppard:

  • Photos. Photos of your breasts can help you remember them after they’re gone and play a role in supporting you through your grief and healing process. You can take intimate photos either by yourself or with a partner. Or, you can have professional photos taken – there are many photographers who specialize in boudoir, with options for all different styles and preferences. Peruse Instagram or Pinterest to gather some “inspiration” photos that you like to show to your photographer.
  • Write a letter or journal/poetry about your breasts. Or, address your letter TO your breasts – some people find a sense of peace in thanking their breasts for what they’ve done for them and “letting them go.”
  • Hold a farewell ceremony or celebration with friends and/or family. It can be as lighthearted as making a silly cake and enjoying the company and support of loved ones, or as solemn as you prefer. Some people have a special spiritual or religious practice, or meditation routine, that helps them process their feelings.
  • Make a paper mâché or plaster cast of your breasts or torso, or have one professionally made, that can be turned into a sculpture you can keep.

Some women don’t feel inclined to do any of these things, and that’s ok too – preparing emotionally for your mastectomy is a very individual process and you know what’s right for you.

Some articles and inspiration:

New Resource! Preparing for Surgery

New resource at NPOAS for women facing surgery! Preparing for your mastectomy with aesthetic flat closure can be an undertaking – it helps to know what to expect. This illustrated resource includes a pre-surgery checklist, supply list, recovery tips from patients who have been there, FAQ, and more! Visit the Preparing for Surgery and please share for women in your life who are facing mastectomy surgery.

INCLUDES:

What is a Mastectomy with Aesthetic Flat Closure?

A Note About Revision Surgery

Single or Double?

Before Your Surgery: What You Should Know

  • Pre-Surgery Checklist & Supply List
  • Personal Assistance: You Will Likely Need Help for 1-2 Weeks
  • Considerations for Caregivers
  • Sleep Environment
  • What to Wear
  • Things to Discuss with Your Surgeon
  • Emotional Support
  • Memorializing your Breasts

After your Surgery: What to Expect

  • Pain Management
  • Surgical Drains
  • Things You May Notice As You Heal
  • Stretching to Regain Your Range of Motion
  • Staying Active
  • Showering & Dressing

Moving Forward: Now What?

  • Physical Rehabilitation & Exercise
  • Scar Massage
  • Lymphedema Risk Reduction
  • Managing Chronic Pain & Functional Problems
  • Adjusting to Living Flat:
  • Body Image, Sexuality, Fashion, Tattoos, Prosthetics & More

Frequently Asked Questions (FAQ)

Glossary (A-Z)

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Meet Our Advisors: Minas Chrysopoulo, MD, FACS

Meet Our Advisors

Our Advisory Council consists of leaders in the professional community who have generously donated their time and expertise to advise the “Not Putting on a Shirt” Board of Directors. We sat down with them to talk about who they are and why they support aesthetic flat closure.


Minas Chrysopoulo, MD, FACS

Advisor, Plastic & Reconstructive Surgery, Shared Decision Making

Dr Chrysopoulo (“Dr C”) is a board certified plastic surgeon, breast reconstruction surgeon and microsurgeon, and President of PRMA Plastic Surgery in San Antonio, TX.   He specializes in state-of-the-art breast reconstruction with a particular focus on perforator flap breast reconstruction, nipple-sparing mastectomy, techniques to maximize aesthetic outcomes, and restoring sensation after mastectomy.

Dr C is certified by the American Board of Plastic Surgery, is an active member of several professional societies including the American Society for Reconstructive Microsurgery (ASRM), and the American Society of Plastic Surgeons (ASPS) for which he serves on several educational committees.  He has authored and co-authored several book chapters and scientific articles in peer-reviewed journals, and is routinely an expert speaker at regional, national and international academic meetings.

Dr C has dedicated his professional life to advocating for breast cancer patients.  He strongly believes that shared decision-making between the physician and patient is crucial in achieving the best outcomes and has built his practice on this philosophy.  To empower as many patients as possible to advocate for themselves, Dr C created the Breast Advocate® App, a free app that provides anyone with a breast cancer diagnosis, or at increased risk of developing breast cancer, a much needed voice in their breast cancer treatment planning.


Dr. Chrysopoulo is a board certified plastic surgeon specializing in autologous breast reconstruction. He is the President of PRMA Plastic Surgery, and has authored and coauthored several articles and book chapters. Dr. C is also the founder of the Breast Advocate, which is a great tool to help for patients facing breast cancer surgery understand their reconstructive options.

Learn more about Dr. C and why he supports aesthetic flat closure by watching the interview:


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.


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Meet Our Advisors: Corine de Boer, MD, PhD

Meet Our Advisors

Our Advisory Council consists of leaders in the professional community who have generously donated their time and expertise to advise the “Not Putting on a Shirt” Board of Directors. We sat down with them to talk about who they are and why they support aesthetic flat closure.


Corine de Boer, MD, PhD

Advisor, Medical & Research

Corine de Boer is a physician, wife and principal of her own consulting company. She was diagnosed with breast cancer in 2015 and opted for a double mastectomy. Her female breast surgeon in Seattle was very supportive of her flat choice and did a great job but Corine has since learned, to her dismay, that this is not the case in other parts of the country. She fully supports the mission of Not Putting on a Shirt so every woman who chooses to go flat after mastectomy has a satisfactory outcome.


Dr. de Boer’s assistance was invaluable in getting our 2018 and 2019 Survey data presented at the San Antonio Breast Cancer Symposium in December 2019, and she has also assisted in reviewing information we provide on this website. Thank you, Dr. dr Boer, for your help as we work together to #putflatonthemenu!

Tell us about your work and how aesthetic flat closure came on your radar screen.

“I am the Chief Medical Officer of MAPS PBC, a Public Benefit Corporation that is working on healing and well-being through psychedelic drug development and therapist training programs. We are currently developing MDMA-assisted psychotherapy for PTSD. Flat closure came on my radar screen in 2015 when I was diagnosed with early stage breast cancer and chose that option. My female surgeon honored that decision but it came to my attention through social media and the work that Kim is doing that is not the case in other parts of the country.”

What do you think patients facing breast cancer surgery should know about “going flat”?

“Patients facing breast cancer surgery should know that “going flat” is a valid option that should be given to each and every person. If the provider seems hesitant to discuss that option, it is best to go for a second opinion. After the surgery, the chest could feel a bit tight (the “iron bra”) and that could improve over time and there are options such as self massage with Bio-Oil. The chest area could be less sensitive to touch but that is not always the case (e.g. I personally never lost sensitivity).

“Lastly, and that’s not discussed often, losing your breast may have an effect on your sex life; however, that also takes time and overall the relief of being done with any surgeries and having faced the diagnosis of breast cancer is with a good outcome, at least in my personal opinion takes the big positive prize. A friend in a same sex relationship told me that prior and I still think it is good to at least mention. Of course, one’s sex life is very personal and I don’t want to open the can of worms that women are not female without our breast as that is not the case and I feel very comfortable being flat (and preferable to DD physically).”

What do you think providers should know about aesthetic flat closure?

“Providers should discuss the pros and cons of each option for breast cancer surgery clearly and without any bias. If a provider personally favors one option over the other, they should refer that patient to a colleague who may not have that bias. I also think it would be great if there is  e.g. a folder with all the options included that a patient can take home. Such a folder should have all options included (with pictures) and preferably a phone number where a patient could talk with breast cancer survivors who choose the option mentioned. I am thinking of a phone number for NPOAS where someone could talk to a patient who went flat and shares his/her experience and answers questions. You already do that and to avoid bias, preferably there would be a phone number for a patient to talk to representatives who choose any of the other options.

“Patient need to have time to digest the information and then make an informed decision about their choice.”

In your view, what are the most important barriers to parity for aesthetic flat closure and how should we address them?

“The most important barriers to parity for aesthetic flat closure is the fact that not all providers are aware of that option; plastic surgeons are generally more into “beautifying” their patients and unless they have heard the stories of patients like yourself and others in the community, are not aware of the problem. So getting out the information, as early as possible in medical school and residency training, and providing all clinics who are seeing breast cancer surgery patients with a folder explaining what aesthetic flat closure is from both the technical perspective and the patient perspective would be great.

“More scientific papers about the topic would be helpful, e.g. setting up a study where patients would fill out questionnaires prior and after their surgery and Patient Reported Outcomes (PRO) about satisfaction with the results using a Likert scale may be an option.”


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.


#aestheticflatclosure
#putflatonthemenu
#notputtingonashirt

Action Alert! Flat Closure Study Recruiting Participants

If you chose to go flat after mastectomy, YOU can help support the research effort to improve the standard of care for aesthetic flat closure!

Investigators at Hofstra University are conducting a qualitative study looking at how going flat affects quality of life. It’s easy to participate – just schedule a 30-60 minute Zoom interview to speak with investigators about your experience. Contact Kellie Cronley (kelliecronley3@gmail.com) to sign up, or for more information.

#putflatonthemenu
#aestheticflatclosure

Meet Our Advisors: Yara Robertson, MD, FACS

Meet Our Advisors

Our Advisory Council consists of leaders in the professional community who have generously donated their time and expertise to advise the “Not Putting on a Shirt” Board of Directors. We sat down with them to talk about who they are and why they support aesthetic flat closure.


Yara V. Robertson, MD, FACS

Advisor, Breast Surgical Oncology

Yara V. Robertson, MD, FACS, is a board-certified general surgeon and fellowship-trained breast surgical oncologist. Dr. Robertson has been in Atlanta, GA since 2011 providing quality breast cancer care and has been passionate about eliminating disparities in breast cancer treatment, especially in the African American community. She lectures on breast health and participates in numerous health fairs providing free clinical breast exams. She has previously served as Vice-Chairman of Sisters by Choice, a non-profit organization that provides education and free breast health screenings to uninsured women as well as support for women diagnosed with breast cancer.

As a kidney cancer survivor herself, Dr. Robertson is fully aware of the importance of the patient’s role in shared decision making and advocates for patient centered care.  Dr. Robertson believes that women who choose to go flat after a mastectomy deserve a surgical result that is aesthetically pleasing to them and fully supports the mission of Not Putting on a Shirt.


Dr. Robertson is a breast surgical oncologist who has been practicing in Atlanta, GA since 2011. She is passionate about eliminating disparities in breast cancer treatment, especially in the African American community. She has also served as Vice-Chair of Sisters by Choice and is a kidney cancer survivor herself. She’s a strong advocate for patient choice and shared decision making as well.

Learn more about Dr. Robertson and why she supports aesthetic flat closure by watching the interview:


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.


#aestheticflatclosure
#putflatonthemenu
#notputtingonashirt

Louise: My Surgeon Refused to Even See Me

Editor: Louise had to fight her surgeon to get the single mastectomy she wanted, instead of the lumpectomy her surgeon wanted. She suffered a serious complication, a persistent seroma, which affected her aesthetic result. Later, when she inquired of her surgeon about revision, instead of referring her to a plastic surgeon… he simply refused to see her. Louise was crushed because she was so unhappy with her aesthetic result and was now, essentially, being told there was nothing to do about it. Then she came across NotPuttingonaShirt.org and realized that she deserved better. Louise is currently awaiting her revision surgery with a new doctor.


I had a single mastectomy in 2018. I knew I didn’t want reconstruction but had fought so hard with my surgeon who wanted to do a lumpectomy, I didn’t have the strength to argue any more. I was just grateful he had, in the end, agreed.

When I woke I was horrified with what I could see. I wasn’t flat at all, in fact I was almost the same size as I had been. It turned out to be a huge seroma which, so I’m told, stretched the skin so much and with radiotherapy following, was never going to lie flat. It is a mess, even 2 years later.

Louise suffered a severe and persistent post-operative seroma at the mastectomy site.
Louise’s result after the seroma healed and post-radiation therapy.

Recently I enquired of the same surgeon what options I had for further surgery. Without seeing me, he has refused to do anything. Disappointed is putting it mildly.

I then found NPOAS and cried! I had no idea my mess could be sorted, or that I could ask for a second mastectomy[sic] for symmetry. I sought recommendations of other surgeons at the same hospital, and was lucky to have an appointment very quickly. I haven’t had to fight, beg or seek counselling. I was listened to with compassion and understanding. My options for revision and symmetry were discussed, it was a 2 way conversation. She – I decided a woman maybe be more sympathetic to my request – agreed she would perform the surgery. I signed the consent forms and I am waiting for a date for surgery.

“I haven’t had to fight, beg or seek counselling. I was listened to with compassion and understanding.”

I am so grateful to the ladies on NPOAS for sharing their stories, and to Kim for giving me the confidence to seek another opinion.


A note on mastectomy vs. lumpectony: While it’s often true that mastectomy does not provide additional survival benefit to the patient… survival is not the only endpoint that matters. Many women choose mastectomy over lumpectomy not only for the somewhat nebulous “peace of mind,” but to reduce their risk of local recurrence (albeit a typically small reduction), which could mean additional surgery/radiation/chemotherapy in addition to the psychological trauma of a second diagnosis. This is why shared decision making (SDM) is so critical. Listen to Dr. Ted James, head of Breast Surgical Oncology at Beth Israel Deaconess in Boston, on SDM:

“Survival is not the only endpoint of significance… if we inform the patients, if we engage in a process of shared decision-making and then support them in a decision that’s really tailored for their preferences and priorities, that is ideal,” said James. “As long as that process is being adhered to, I think the right things are being done for the patient.”

Dr. Ted James (BIDMC) Forbes

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.


Meet Our Advisors: Rep. Charen Fegard (D-VT)

Meet Our Advisors

Our Advisory Council consists of leaders in the professional community who have generously donated their time and expertise to advise the “Not Putting on a Shirt” Board of Directors. We sat down with them to talk about who they are and why they support aesthetic flat closure.


Rep. Charen Fegard (D-VT)

Advisor, Legislative

Charen Fegard of Berkshire, Franklin County, Democrat, was born on Howard Air Force Base in Panama. She lived in many states and countries growing up and through her twenties. Charen earned a Bachelors degree in Biology from the University of NC at Wilmington. She has worked in the Civil Service in Hazardous Materials/ Environmental Compliance on overseas military bases, and has owned and operated a registered home daycare as well as landscaping and cleaning businesses.

Charen worked for a variety of non-profits in Vermont over the years. Before starting the legislative session, she volunteered on the Richford Restorative Justice Panel. Currently, she consults for non-profits and waste municipalities throughout Vermont regarding recycling, composting, and Indoor Air Quality related to cleaning chemicals. She raises meat birds, sheep, laying hens, a lot of vegetables, and enjoys deer hunting with her husband, Russ Ford. They have 4 children in their blended family.

Legislative Website


Rep. Fegard is a long-time strong supporter and strategist in her work with NPOAS. She spearheaded the 2019 legislation in Vermont that would require stakeholders to convene and ensure insurance coverage for revision surgery. Thank you, Rep. Fegard, for your help as we work together to #putflatonthemenu!

Tell us about your work and how aesthetic flat closure came on your radar screen.

“I have so many different types of jobs, from Civil Service work in Haz-Mat/Environmental Compliance on overseas military bases, administrative work, registered childcare, professional landscaping and cleaning, outreach and education and technical assistance to schools and businesses around Indoor Air Quality and waste diversion. But 2019-2020 I have been a House Representative in Vermont’s Legislature. I was diagnosed BRCA-1 positive and had a prophylactic bilateral mastectomy in 2016. I knew from the moment of my test results that I was committed to limiting surgical injury and risk of complication and infection by not having reconstruction. I was lucky. My breast surgeon was skilled in patient education and surgery. My results were excellent. Later, I learned of other women choosing flat and that many were not as lucky as I was.”

What do you think patients facing breast cancer surgery should know about “going flat”?

“Breast cancer patients deserve to know all their options in unbiased, full disclosure. Patients should be made aware of the stark differences in surgery time, in-patient hospitalization time, pain medication expectations and general recovery time between the different reconstructions and aesthetic flat closure. Their surgeon should also be upfront about their skill in flat closure.”

What do you think providers should know about aesthetic flat closure?

“Providers need to know that AFC is a valuable medical treatment that, when done well, allows women to minimize their surgical injury, feel authentic and quickly get back to living their lives with dignity in a body that is fully functional.”

In your view, what are the most important barriers to parity for aesthetic flat closure and how should we address them?

“Lack of patient education, lack of support by medical staff play roles in dissuading patients from choosing AFC. This is true for women facing mastectomy as well as women who want to explant their breast implants from problematic reconstruction. After the initial surgery, if the surgical outcome is unsatisfactory, providers need to educate patients about clean-up options. Sometimes insurers may balk at the clean up procedure and miscode it as ‘cosmetic’ instead of reconstructive.”


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.


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Progress: Marie-Claude Belzile’s Petition Gets Traction in Québec’s National Assembly

Thanks to the pioneering work of Québec advocate Marie-Claude Belzile of Tout aussi femme (who is also a member of our Council of International Advocates), the main online French-English translation database for Québec, Grand dictionnaire terminologique, has included “mastectomie à fini plat” (the French analogue of aesthetic flat closure) since mid-2020. And now, her petition (sponsored by Assembly member Christine Labrie of Québec solidaire) to ensure women in the province receive full information about all of their reconstructive options is getting major traction in the Québec National Assembly!

In Marie-Claude’s words, she created the petition last Spring to ensure women facing breast cancer surgery in Québec province:

“… who choose flat reconstruction after a mastectomy and the transparency of the information given to women to make a free choice and enlightened about post mastectomy surgery”

Marie-Claude Belzile (Québec), Tout aussi femme

The Ministry of Social & Health Services wrote a letter of support for Marie-Claude’s petition, agreeing that full disclosure of all reconstructive options including aesthetic flat closure is a critical component of informed consent for breast cancer patients facing surgery. The letter will be forwarded to the Québec College of Medicine a (the main professional society of physicians in the province) and to the Breast Cancer Committee of the Québec Oncology Program (the government agency which guides, coordinates and evaluates government action aimed at reducing the burden of cancer in Québec).

#aestheticflatclosure

#mastectomieafiniplat

#putflatonthemenu

#toutaussifemme