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!


NPOAS at Oncology Nursing Society Conference

NPOAS is representing FLAT this week 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!

(Yes, this is the second conference this month!)



#ASBRS2022 Conference Update

We were so happy to be able to exhibit at the annual meeting of the The American Society of Breast Surgeons representing the FLAT patient voice! Here’s an update on how the conference went and what we learned to help focus our future advocacy efforts.

We were too busy talking with the surgeons to get very many photos!

What We Learned. We had a really great turnout and response from the surgeons attending the conference. Most of the surgeons who stop at our booth were interested in in-depth discussion about the topic, and many requested CME training resources so they can learn more about aesthetic flat closure technique. We also learned that last year, ASBRS added AFC technique to their annual pre-meeting oncoplastic training course! That means that surgeons attending the meeting can access that training there!

Thanks to our friend Jessica Pearce (@sobercancerwarrior on Instagram), we had a handy QR code linked to a form so attendees were able to simply scan the code and then fill out a quick form so we have information about who visited our booth and who we can follow up with (sending brochures, updates, etc.) We were surprised how many surgeons were already familiar with the term aesthetic flat closure – we would say it was over 75%. And the majority also reported that they have seen an increase in the number of patients going flat in their practice.

Interestingly, there was a research poster presented at the conference which looked at the rate of going flat over time *since the FLAT movement kicked off in earnest in 2016*, and it looks like after two decades of increasing, reconstruction rates have plateaued. So there’s a chance that was in part due to flat advocacy! Fascinating!

Dr. Attai’s Talk on AFC. Dr. Deanna Attai knocked it out of the park with her talk on aesthetic flat closure entitled, “Going Flat: Aesthetic Closures.” She covered her researched published last year, discussed flat denial, and gave an overview of AFC surgical technique. Thanks to Dr. Sangeetha Kolluri for the photos of the talk!

My Choice Brochures. We got some great feedback about the new My Choice brochure, which was specifically designed for clinics. Almost all of the surgeons visiting our booth took brochures back to their clinic to give to their patients who are considering going flat, and many signed up to receive additional brochures.

Directory Surgeons. We met dozens of surgeons listed on our Flat Friendly Surgeons Directory, many of whom were also presenting their research at the conference.

AFC Testimonials VIDEO. The beautiful, powerful video put together by videographer Cassi Glisper and producer/editor Stacey Sigman (Flat Retreat Community) was an invaluable tool for engagement throughout the conference. It really made our booth stand out, and drew attendees to the booth so we could talk them about the issue in depth.

Renee Ridgeley / Dr. Wendy Sage. Actor, writer and flat advocate Renee Ridgley was at the booth with NPOAS leadership as well, and was interviewed on local television and on a local podcast about her one breasted Simpson’s character Dr. Wendy Sage!

Flat Retreat – Las Vegas. The amazing women at organized an in-person retreat for women in the flat community to attend at a host house in Las Vegas near by the convention, and hosted a dinner for NPOAS to update on the conference. Community is healing, and NPOAS is grateful to Flat Retreat for their unwavering support!

All in all, we were overwhelmed by how fruitful our attendance at #ASBRS2022 was and we look forward to exhibiting again at future meetings!

AFC Testimonials (Video)

Great news! The conference video we premiered at the ASBRS conference earlier this month is now available for public viewing! This video was made specifically for surgeons and sends the message that women are happy flat. Huge thanks to videographer and flat friend Cassi Glisper, and producer/editor Flat Retreat ‘s Stacey Sigman for their excellent creative work. Watch:

You can also find the video at our Provider Resources page at

NY Bill Co-Sponsors Sign On & RALLY!

Great news! NY Bill A8537 – Insurance Coverage for Aesthetic Flat Closure – now has SIX additional sponsors in the Assembly! Assemblywomen Alicia Hyndman, Rebecca A. Seawright, and Judy Griffin, and Assemblymen Peter J. Abbate, John T. McDonald III, and Jeffrion L. Aubry have all signed on as co-sponsors to support the bill.

A virtual RALLY will be held on Zoom this coming Tuesday, April 26th, at 7pm ET with Rep. Amato. She will be updating us on the bill’s progress and answering questions. NPOAS will be attending… we hope to see you there! Zoom info:

Topic: Rally for NYS Aesthetic Flat Closure Bill (A8537/S7881)

Time: Apr 26, 2022 07:00 PM Eastern Time (US and Canada)

Join Zoom Meeting

Meeting ID: 820 4754 9028

Passcode: 933309

Legislative Sponsors

ASPS Supports NY Bill

HUGE NEWS! The American Society of Plastic Surgeons (ASPS) and the New York State Society of Plastic Surgeons are supporting the NY Bill to ensure insurance coverage for aesthetic flat closure (i.e., chest wall reconstruction)! Learn more about the bill and sign the petition at



NPOAS Welcomes New Psycho-Oncology Advisor Hester Hill Schnipper

We are privileged and thrilled to announce our new Advisory Council member, Hester Hill Schnipper, LICSW, OSW-C. Hester is an oncology specializing counselor and social worker and has numerous other accomplishments under her belt that you can read about at the Council webpage. Follow her blog  for Beth Israel Deaconess Medical Center, “Living with Cancer” for invaluable information and insights into the world of breast cancer treatment and survivorship. Welcome to the team, Hester!

NPOAS Welcomes New Oncology Physical Therapist Advisor Dr. Leslie J. Waltke

We are so happy to announce the newest member of the NPOAS Advisory Council, oncology physical therapist Dr. Leslie J. Waltke, PT, DPT, founder of the Waltke Cancer Rehabilitation Academy. Dr. Waltke has generously lent her time and expertise to NPOAS, and we appreciate it so much. Welcome to the team, Dr. Waltke! Read more about her at the Council webpage.