Book Launch for “Flat & Happy” This Thursday

Join us for a virtual book launch event this Thursday, June 9th at 8pm ET!

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Topic: Flat & Happy Virtual Book Launch
Time: Jun 9, 2022 08:00 PM Eastern Time (US and Canada)

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Meeting ID: 875 8687 2177
Passcode: 160524

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“The weeks leading up to mastectomy surgery or the removal of an implant are often filled with scary statistics and bewildering medical jargon. For a woman navigating this tumultuous time, Flat and Happy is like a conversation with a good friend who’s been there and done all the research: informative, personal and brimming with humor and heart. Written in consultation with experienced breast cancer specialists, this comprehensive guide is hailed as a “unique and invaluable resource for any woman faced with a diagnosis of breast cancer.” Flat and Happy gives women who are seeking an alternative to breast reconstruction the information and tools they need to make informed decisions and to advocate for themselves before and after surgery.”

Flat & Happy – Book Description,






Update on NPOAS Oncology Nursing Conference Exhibit

NPOAS represented FLAT the last week of April 2022 at the Oncology Nursing Society ‘s 2022 Congress! Huge thanks to lead volunteer Renee Ridgeley (@LessThanTwoBreasts & the voice of Dr. Wendy Sage, the first openly single breasted TV character) for organizing and staffing our exhibit, and to all of our volunteers who staffed the booth. Here’s a report from Renee!

Not Putting On A Shirt took aesthetic flat closure (AFC) awareness and education to the Oncology Nurses Society (ONC) 2022 conference. Following their success at the American Society of Breast Surgeons (ASBrS) conference earlier this year, NPOAS was encouraged by ASBrS attendees to have a presence at ONS where over 2,600 oncology nurses, patient navigators and other medical providers gathered for the in-person conference in Anaheim, California, April 28 to May 1. 

Six breast cancer patient advocates and one patient caregiver volunteered to work at the NPOAS booth which was located in the nonprofit Advocates corridor of Exhibitors Hall. These seven women engaged over 300 medical professionals over the course of three days. Conference attendees engaging with the NPOAS booth were able to:

  • learn about NPOAS’s work with breast and plastic surgeons to ensure optimal surgical outcomes for women who choose to go flat after mastectomy
  • view testimonial videos of patients who chose AFC
  • talk with advocates who shared their experiences
  • submit their practice for the NPOAS Surgeons Directory for AFC and Goldilocks mastectomy
  • register their breast clinics to receive My Choice AFC educational brochures for patient distribution (offered free of charge in English and Spanish by NPOAS)

NPOAS advocates distributed over 300 NPOAS brochures (with information and links to the NPOAS website) and over 400 My Choice AFC educational brochures (a literary supplement to a patient’s surgical consultation). Several nurses and navigators requested 20-30 patient brochures for immediate use at their clinics. NPOAS continues to ship orders from attendees of both American Society of Breast Surgeons and ONS conferences.

Many nurses who had experienced breast cancer themselves shared personal stories of breast cancer surgery with the NPOAS advocates. Nurses with implants, tissue-based reconstruction and flat closure were candid about their experiences. Several nurses with reconstruction reported decision regret due to lack of information about collateral damage of reconstruction. Other nurses reported that AFC would be their choice if ever faced with a breast cancer diagnosis.

A few patient/nurses reported being shamed by surgeons for choosing not to reconstruct breast mounds. One young nurse, in her 20s at the time, went against her doctor’s wishes and demanded that her expanders be removed permanently, and that she be closed flat after being admitted to the hospital for life-threatening infections. Another oncology nurse in her 30s was repeatedly questioned for choosing not to reconstruct. In the hospital just before mastectomy, her surgeon again challenged her decision to go flat “with an eyeball roll”, then warned her that she would have long scars. The woman (of average BMI with B-cup native breasts) woke from anesthesia to find her incisions extended from the top of her biceps through the axilla, across her chest and then down to her waist. The nurse reported that this was not an optimal outcome.

Nurses and patient navigators shared with advocates their enthusiasm for AFC awareness, with many noting their practice was supportive and competent in providing AFC. Some attendees expressed frustration with the lack of institutional patient education material available for women choosing flat. Some nurses reported that the surgeons they work with do not support flat and actively dissuade women from their option to go flat. Many took NPOAS and My Choice AFC brochures back to these surgeons.

These stories as well as the warm reception from all the attendees who engaged with the NPOAS booth, were confirmation of the important and necessary work provided by NPOAS.

NY AFC Bill Passes in Senate!

This Just In… NY Bill has PASSED in the Senate!

As of May 31st, the New York AFC bill has passed in the Senate, and should be signed into law by the governor later this year! Women in New York State will no longer have to fight their insurance companies to get coverage for their AFC (Aesthetic Flat Closure) surgeries.

Huge thanks to Senator Toby Ann Stavisky for sponsoring the bill, to Representative Stacey Pheffer Amato for her leadership in the Assembly, to all the members of the NY Congress who voted in support of the bill, to the American Society of Plastic Surgeons (ASPS) for their support, and to all the many folks who worked tirelessly over the past seven months to get this done!

How was this accomplished?

Based on connections made in Flat Retreat Community in October of 2021, advocates including Jo Amato , Melissa Eppard, Christy Avila and Kimberly Bowles joined forces with Assemblywoman Stacey Pheffer Amato to compose an amendment to NY state law to rectify a loophole which allowed insurance companies to deny coverage for AFC services. Thanks to the hard work and dedication of the bill’s sponsors in the Assembly, their staff, advocates and volunteers from NY state, the bill passed unopposed in both houses. As of May 31, 2022, the bill is on its way to the governor’s desk to be signed into law.

What does it mean?

When the bill is signed into law, it will ensure that insurance companies cannot deny coverage for AFC surgeries, including a plastic surgeon at the initial mastectomy, as well as subsequent revision surgeries, in New York State. The bill also serves as a template for amending the federal law (WHCRA, Women’s Health & Cancer Rights Act) which will not only protect patients nationwide, but will also be foundational to an improved standard of care for women going flat. 

Learn more about the bill at

New Flat Closure Technique Article!

Just published in Plastic & Reconstructive Surgery (PRS) Global Open, a fantastic technique article “Not Just a Linear Closure: Aesthetic Flat Closure after Mastectomy” by Drs. Kerry Morrison and Nolan Karp.

The article’s major takeaways for surgeons include:

  • listen to the patient, and to fully understand the patient’s concerns, wishes, and particular aesthetic desired
  • sit the patient up to account for gravity’s effects on the tissues
  • completely remove the inframammary fold
  • excise any dog ears (side or center of chest)

“With the increasing demand for flat closures after mastectomy, plastic surgeons need to utilize modified surgical techniques for aesthetic flat closure reconstructions, as these are not simply linear closures.”

NEW! Guide Book for Going Flat, on Amazon!

Big news! A new comprehensive guide book on going flat, “Flat and Happy: Mastectomy and Flat Closure – A Personal, Practical Guide,” was just published and is now available for purchase on! Authored by the one and only Katrin van Dam… and do we spy a review from Tig Notaro on the cover?! 👊

Full disclosure, our NPOAS founder did the illustrations! 🙌

“The weeks leading up to mastectomy surgery or the removal of an implant are often filled with scary statistics and bewildering medical jargon. For a woman navigating this tumultuous time, Flat and Happy is like a conversation with a good friend who’s been there and done all the research: informative, personal and brimming with humor and heart. Written in consultation with experienced breast cancer specialists, this comprehensive guide is hailed as a “unique and invaluable resource for any woman faced with a diagnosis of breast cancer.” Flat and Happy gives women who are seeking an alternative to breast reconstruction the information and tools they need to make informed decisions and to advocate for themselves before and after surgery.”

Flat & Happy – Book Description,






NCCN’s 2022 Guidelines for Patients Updated to Include “Flat Closure”

A Huge WIN for Patient Education!

Groundbreaking News! Absolutely stellar news from flat advocates Robyn Towt (GPAC) and Andrea Citarelli Ottaiano (Silver Lining Holistic Health)! These amazing women worked with the National Comprehensive Cancer Network (NCCN) on the 2022 updates of the breast cancer patient guidelines to include flat closure as an explicit, valid reconstructive choice. Way to put FLAT on the menu, ladies!

About NCCN. NCCN’s mission statement: “The National Comprehensive Cancer Network® (NCCN®) is a not-for-profit alliance of 32 leading cancer centers devoted to patient care, research, and education. NCCN is dedicated to improving and facilitating quality, effective, equitable, and accessible cancer care so all patients can live better lives.” NCCN Guidelines are used by clinicians and patients as a reference for best practices and comprehensive patient educational resources. Visit the NCCN Guidelines for Patients page to see the new editions!

“Flat Closure

In a total mastectomy with a flat closure, the entire breast, including nipple, extra skin, fat, and other tissue in the breast area are removed. The remaining skin is tightened and sewn together. No breast mound is created and no implant is added. The scar will be slightly raised and differ in color than the surrounding skin. A flat closure is not completely flat or smooth. The end result varies from person to person. Ask to look at “after” pictures from flat closures so you know what to expect.

You might decide to have a flat closure procedure at a later time or after having breast implants removed. Talk to your care team to learn more.”

NCCN Guidelines for Patients – 2022 Breast Cancer Guidelines

About the Advocates. Robyn and Andrea became advocates after multiple breast cancer diagnoses and explanting their initial implant reconstruction due to systemic symptoms (breast implant illness (BII) ). They work tirelessly to spread awareness about both the risks of breast implants and the option of going flat after mastectomy as a healthy, beautiful alternative to breast mound reconstruction.

Thanks to Robyn & Andrea, and the folks at NCCN for including the FLAT choice alongside breast reconstruction in their patient education materials!

The Middle Way? SWIM

Reconstructing a normal anatomic chest contour post-mastectomy using a new plastic surgery technique without implants or distant tissue donor sites

As patient demand grows for high quality, aesthetically pleasing flat mastectomy closures, cutting edge surgical techniques will be part of the conversation. Today we discuss a new technique called the “Goldilocks mastectomy,” or SWIM. This option, while not currently available to most patients, focuses specifically on maximizing cosmesis for patients having mastectomies without traditional reconstruction.

It’s important to note that because this is a new procedure, there is no long term data on its safety from an oncology perspective. The surgeons who offer it say that its risks are similar to that of a skin-sparing mastectomy. We look forward to seeing data on this.

Why Not Use Traditional Breast Reconstruction?

Traditional breast reconstruction involves additional risk beyond simple mastectomy and can impair function. Patients who reject traditional breast reconstruction are often motivated by wanting to preserve form and function for the rest of their bodies.


Rejection of autologous flap reconstruction, for example, avoids a second surgical wound that may compromise recovery time and/or function – especially in the case of muscle tissue transfer, i.e., LD (Figure 1) and TRAM flaps (Figure 2). Rejection of submuscular implant reconstruction avoids damage to the pectoral muscle that can impair function (this muscle is partially detached from the ribs to accommodate the device) (Figure 3).

These patients are also motivated by minimizing their exposure to additional surgeries beyond the original mastectomy, and traditional reconstruction almost always involves multiple surgeries.

Flat IS Reconstructive – Not Cosmetic

ALL patients care about their cosmetic result. But cosmesis for patients going flat has historically been devalued or outright ignored. A common misconception about these patients is that they “don’t care about how their body looks.” This notion is rooted in historical sexism and sexual objectification of the female body.

The truth is that these patients have made an affirmative, informed decision. They have weighed their options and are simply not willing to shoulder the risk burden presented by traditional breast reconstruction in order to achieve an artificial breast mound. So, they proceed with the default reconstructive option: no reconstruction, or going flat.

In terms of cosmesis, patients going flat report desiring a smooth, flat (not concave) result with the original breast contour removed to the greatest extent possible. The ideal resulting contour would approximate that of the prepubescent female chest – a reconstruction of a normal anatomical structure that falls squarely into “reconstructive surgery” territory… not cosmetic.

Figure 4  Mastectomy patients who asked for a flat result

Unfortunately, many patients going flat are left with results that are nowhere near smooth or flat – concavity (which is largely unavoidable with traditional techniques), lumps, sagging excess skin (“in case you change your mind” about implant reconstruction (Figure 6)), redundant fatty tissue, dog ears, wrinkled/puckered incisions, and asymmetry (Figure 4).

It seems that until very recently, no one has thought to ask the patients making this choice the simple question, “what DO you want your chest to look like post-mastectomy?”

Traditional surgical techniques to remove all redundant (excess) tissue and create a smooth contour go a long way to producing results patients can live with. But even with a dedicated and highly skilled oncoplastic surgeon, and/or plastic surgeon using traditional techniques, patients can be left with significant concavity – the appearance of being “scooped out.” Concavity is currently addressed with fat grafting, which means additional surgeries, pain and bruising at the donor site, uncertain cosmetic results, and sometimes produces hard lumps (fat necrosis) which can be distressing to patients.

The New Middle Way? Using Local Tissues to Contour

What if there was a “middle way”? What if patients could choose reconstruction of a flat/convex structure or very small breast mound, with a moderately longer anesthesia burden, but without comprising any other part of their body – and without the need for multiple surgeries?

Plastic surgery techniques for breast mound reconstruction have advanced in recent years, and many of these techniques can be adapted to improve cosmesis for patients who choose to forgo traditional reconstruction. Thanks to the pioneering work of Dr. Grace Ma, Dr. Heather Richardson, and Dr. Lisa Cassileth, some patients* can now choose this “middle way” – it’s called the SWIM, or “Goldilocks mastectomy.” In this procedure, excess fat and skin adjacent to the breast tissue that has historically been discarded is instead repurposed to contour – or reshape – the mastectomy site. And it can be done in one surgery.

Figure 5 (left) SWIM resulting in a slightly convex, smooth contour for an explant patient – note: patient reports some flattening of the contour at 4 months post op. Figure 6 (right) traditional mastectomy resulting in normal concavity surrounded by redundant tissue (in this case, intentional flat denial)

In the SWIM (Skin-sparing Wise-pattern Internal Mammary Perforator) procedure, a skin-sparing mastectomy is first performed to remove the breast tissue. Then, excess healthy skin and fat in the local area are processed (de-epithelialized) and arranged to create “padding.” The mastectomy flap is then closed around the padding to create varying sizes of reconstructed convex structures.

The size of the resulting structure will depend on the amount of healthy tissue that was available. Larger breasted patients may be able to achieve a mound that is easily recognizable as a female breast (Figures 7 and 8 represent patients who elected SWIM at their initial mastectomy surgery). Smaller breasted patients or patients pursuing revision surgery (after a poor initial cosmetic result, or during/after explant – so may not have had the nipple preserved) may end up with a flat or only slightly convex contour (Figure 5). You can find more Goldilocks images at Dr. Grace Ma’s site.

FIGURE 7 SWIM flap results from Dr. Cassileth (SOURCE: Cassileth Plastic Surgery)
FIGURE 8 “Goldilocks mastectomy” results from Dr. Richardson (SOURCE: Bedford Breast Center)

Consider the time, risk and expense of traditional breast mound reconstruction: up to six to twelve hours under anesthesia at the initial procedure, up to 9 (or more) surgeries over a period of a year or so, upwards of a 30% complication rate, and hundreds of thousands of dollars expended.** This burden has clearly been deemed acceptable by surgeons, patients, and the insurance companies who are footing the vast majority of the bill. In this framework, is it unreasonable to consider that patients going flat should be able to access surgical procedures involving a fraction of these outlays, in order to achieve a cosmetic result that they can live with?

Patients going flat deserve equal care and consideration for reconstruction of an anatomically normal chest contour.

The goal is not perfection – the goal is parity. It’s time to ensure that all mastectomy patients receive the respect, care and consideration they deserve, to achieve a surgical result that they can live with – regardless of their surgical preferences.

See below for references, glossary, a list of surgeons who currently offer SWIM, and suggestions for further reading.

Questions or comments?


* it should be noted that not all patients will be good candidates for a given surgical procedure

**The Number of Operations The Number of Operations Required for Completing Breast Reconstruction , Eom, J.S., Plast Reconstr Surg Glob Open. 2014 Oct; 2(10): e242

Comparison of 2-Year Complication Rates Among Common Techniques for Postmastectomy Breast Reconstruction  , Bennett, K.G., JAMA Surg. 2018;153(10):901-908

Financial Impact of Breast Reconstruction an Academic Surgical Practice, Alderman, A.K., Plast Reconstr Surg. 2009 May; 123(5): 1408–1413


autologous flap reconstruction = use of the patient’s own tissues to recreate a breast mound

cosmesis = aesthetic appearance

chest contour = topography or three-dimensional shape of the chest

de-epithelialization = removal of the epidermis without compromising the vascularity of the dermis, to allow the rearranged tissue to heal properly

Goldilocks mastectomy = SWIM flap (below)

oncoplastic reduction = a procedure which combines lumpectomy with rearrangement of the remaining tissues to create a breast mound – similar to Goldilocks mastectomy but doesn’t remove all the breast tissue

SWIM Flap = Skin-sparing Wise-pattern Internal Mammary perforator. A new plastic surgery technique in which the extra local skin and fat of the original breast contour left over after mastectomy is folded to create a smaller, reduced breast mound. Also called “Goldilocks mastectomy.” Skin sparing is employed when possible at the original mastectomy to preserve the nipple and/or maximize cosmesis.

Who performs these procedures?

At present, only a small number of surgeons advertise that they offer these services, including but not limited to:

Dr. Marguerite Barnett
Sarasota Institute of Plastic Surgery
Sarasota, FL
https://drmbarnett.comDr. Lisa Cassileth
Cassileth Plastic Surgery
Beverly Hills, CA
https://www.drcassileth.comDr. Lisa Jewell
Surgery Center of South Bay
Torrance, CA


Dr. Sendia Kim
Kaiser Permanente
Woodland Hills, CA

Dr. Grace Ma
Peachtree Plastic Surgery
Atlanta, GA
http://www.peachtreeplasticsurgery.comDr. Heather Richardson
Bedford Breast Center
Beverly Hills, CA
https://www.bedfordbreastcenter.comDr. Shannon Tierney
Swedish Hospital
Seattle, WA

Further Reading:

SWIM Flap Breast Reconstruction – Cassileth Plastic Surgery

Goldilocks Mastectomy – The Bedford Breast Center

Goldilocks Mastectomy with Bilateral In Situ Nipple Preservation Via Dermal Pedicle, Richardson, H. et. al., Plast Reconstr Surg Glob Open. 2018 Apr; 6(4)

The Goldilocks Mastectomy, Richardson, H., Ma., G., Int J Surg. 2012;10(9):522-6

Outcomes Analysis of Goldilocks Mastectomy and Breast Reconstruction: The Mayo Clinic Experience, Oliver, J. et. al., Plast Reconstr Surg Glob Open. 2018 Apr; 6(4 Suppl): 61-62

NY Bill A8537 Marching Forward!

Big news on the legislative advocacy front! NY Bill A8537 – Insurance Coverage for AFC has just cleared a major hurdle. The bill has passed in the Assembly, and is on its way to the Senate! Next, it’ll go to the governor’s desk to be signed into law… and that will mean no more denials of coverage for women going flat in New York!

Congratulations to Assemblywoman Stacey Pheffer Amato, Jo Amato, Melissa Eppard, Christy Avila and the NPOAS legislative team members, for their hard work and dedication to the FLAT cause!

And a huge thank you to all of the bill’s co-sponsors and those who voted YES to support breast cancer patients going flat!