Frequently Asked Questions

Flat closure (or “aesthetic flat closure“) is reconstruction of a smooth chest wall contour post-mastectomy. It involves careful removal of any excess tissue remaining after excision of the glandular tissue, and can also involve contouring of the remaining tissues. The National Cancer Institute added aesthetic flat closure to their Dictionary of Cancer Terms in 2020. (Learn more.)

You can visit our Living Flat page as a starting point. If you are able, we recommend joining one of the support groups listed there, so you can ask specific questions to a group of women who have been through breast cancer diagnosis and surgery, and can offer personalized support. Be sure to watch the Flat is Beautiful video! And you can read all about going flat on our Going Flat at Mastectomy page.

Tell your surgeon you want an “aesthetic flat closure” as defined by the National Cancer Institute – and make sure it’s recorded in your medical record. A skin sparing procedure can be the best option for a patient who is undecided about reconstruction. However, if you’ve decided to go flat, skin sparing is not the right procedure for YOU. (Learn more.)

When you have clearly communicated your affirmative choice to go flat, the quality of your initial surgical result is largely determined by three things: your specific anatomy, your medical situation and history, and the level of skill and regard on the part of your closure surgeon. (Learn more here and here.)

Most people that use the term “dog ears” are referring to the excess fat and skin under the arms that can be left behind after a mastectomy if no contouring work is performed, particularly with larger breasts. This can be unsightly and uncomfortable. You may hear surgeons use the term another way, to refer to a standing cone deformity, or a “peak” of skin at the end of an incision that stands up instead of lying flat. Learn more here.

The more excess tissue you have in the breast area, the more time and specialized surgical skill is required to achieve an optimal aesthetic result. While there is no guarantee you won’t need a revision, it is absolutely possible and reasonable to ask that your cancer surgeon either do this contouring work themselves OR bring on a plastic surgeon to do it, at the initial surgery. Note that plastics closure is not standard practice right now – but we hope that will change as more patients push for better aesthetic consideration. Also, Goldilocks may be an option for you.

The short answer is maybe. Aesthetic flat closure can be done by many, but not all, cancer surgeons (general surgeons, breast surgeons & surgical oncologists) without the assistance of a plastic surgeon. Your surgeon’s specific training and skill set, their attitude about whether the flat choice is “deserving” of an aesthetic approach, your body, your medical situation, and other factors will affect your aesthetic outcome. That’s why it’s critical to ask specific questions about HOW they will get an optimal flat contour for YOU – where they’ll plan the incisions, how they will mark you up before surgery, etc. If you sense hesitation or pushback, or if they seem unsure about what you’re asking for or how they’ll do it… ask if they’ll consider bringing on a plastic surgeon!

Patients are only now beginning to ask for flat closure photos in consult. While many plastic surgeons do have such photos in their portfolio, cancer surgeons (who do the vast majority of mastectomies) may not have any such photos at all. This doesn’t necessarily mean they can’t give you a great aesthetic flat closure – but it does mean you’ll want to be very specific in your discussions with them about HOW they will achieve an optimal flat contour for you. Make sure to bring photos of what you expect AND what you want to avoid, to your consult. Learn more.

Yes, absolutely, unless medically contraindicated for some reason. For implant-based reconstruction, the skin would have to be stretched with tissue expanders first to accommodate the extra volume of an implant, and fat grafting might be called for to produce a more pleasing contour. This is a multi-stage process that can take several months. Autologous  (“flap”) reconstruction doesn’t require this “pre-stretching” with a tissue expander since the tissues are harvested from elsewhere on the patient’s body. Regardless of the reconstructive technique that’s ultimately used, delaying reconstruction until later generally also increases the amount of permanent scarring; reconstruction that’s at least started at the same time as the mastectomy (“immediate” reconstruction) usually leads to less scarring. Note: there may be other considerations in your specific case, so ask your surgeon what you can expect.

Yes. Aesthetic flat closure is reconstruction of the chest wall contour. Breast mound reconstruction restores the shape of the breast(s), while aesthetic flat closure restores the shape of the chest wall – both types of reconstruction correct the “defect” caused by the removal of the breast tissue.

After the mastectomy removes the breast glandular tissue, there will be varying amounts of extra skin and fat surrounding that location. This tissue can either be completely removed, or it can be rearranged (moved around). The end result will depend on the volume of tissue the surgeon has to work with. In a Goldilocks procedure, your surgeon will typically try to save the maximal amount of skin/fat to rearrange, with the goal of EITHER producing the largest possible breast mound or minimizing concavity to produce an aesthetic flat closure. (More)

The NCI definition states that after an aesthetic flat closure the chest wall should be “flat.” So from an aesthetic point of view, minimizing concavity is certainly a goal. But whether that goal can be achieved is a complicated question. Your specific anatomy, your medical circumstances, and the skill level of your surgeon all present constraints on the aesthetic quality of your closure.
A mastectomy for breast cancer involves complete removal of all breast tissue, and afterwards, the underlying structures that are revealed are frequently concave to some degree. This is not something the surgeon can see beforehand and plan for. Nor does the surgeon know exactly how far down they’ll have to go to remove all of the cancer. Tissue rearrangement can be used counteract initial concavity, but not all cancer surgeons are trained in tissue rearrangement (fat grafting can be done later on, but that’s a separate procedure.) All of this is to say: there are no guarantees here. Learn more about AFC aesthetics here.

Flat denial is when a surgeon’s unilateral actions deny their patient the agreed upon flat mastectomy result – either through negligence or intentional disregard. The patient is left with an egregiously poor cosmetic result with significant excess tissue that can only be remedied with additional surgery. Flat denial is a violation of the patient’s bodily autonomy. Note: flat denial has also been defined more broadly to include lack of information presented about flat closure. (Learn more.)

You’re not alone, and this is not your fault. You can read about flat denial and how to navigate the aftermath on our help for victims page, and you can join the Facebook support group I Wanted to Be FLAT to get support from a community of women who have been through flat denial. You can also contact NPOAS directly at info@notputtingonashirt.org.

You can search for a local flat closure surgeon using our Flat Friendly Surgeons Directory.

If you are not able to find a suitable flat closure surgeon using our Directory, you have options. You can search for an integrated breast center or a dual specialty (breast surgical oncology and plastics) surgeons who specializes in gender confirmation surgery. Learn more.
If you have few or no options available to you, you will want to vet your current surgeon carefully. We recommend printing out one of our publications to use for this purpose. For a general surgeon who has no experience with flat closure at all, we recommend this handout. And please contact us if you need assistance – we are here to help!

No, not if what you want is an aesthetic flat closure. This “shelf” your surgeon is referring to is the inframammary fold (where your breast meets your chest wall, under the breast) and it is completely removed for an AFC along with all other excess tissue. Anecdotally, most patients we’ve heard from who had this left behind are unhappy with it. Also, the inframammary fold is used as “scaffolding” for implant reconstruction so be aware that some surgeons will want to leave it behind “in case you change your mind,” and that’s a red flag for flat denial.

We recommend joining the Facebook support group Fierce Flat Forward so you can ask specific questions to a group of women who have been through explant surgery and can offer personalized support and direct you to additional resources. You can visit BreastCancer.org, the FDA’s website, and the Healing Breast Implant Illness and Breast Implant Illness websites to learn more about breast implant illness as well (Note: NPOAS is not affiliated with HBII or BII). You can also visit our webpage for explant resources and details about going flat after explant.

You can recommend your flat closure surgeon by using our easy online form or by contacting us by email to info@notputtingonashirt.org.

You can now share your story with NPOAS by using our easy online form or by contacting us by email to info@notputtingonashirt.org.

You can download the printable PDFs of all of our publications, or order brochures mailed free of charge, at our Publications Page.

Nope. This myth probably originates from the (correct) observation that some women develop a hunch after their mastectomy. Posture and other related functional problems flow from the amputation itself (and other treatments such as radiation). They generally aren’t related to whether you have reconstruction or not. Flat closure does not cause functional impairment beyond that of the mastectomy itself.

Gender confirmation mastectomy is performed solely with aesthetics in mind without any oncological constraints, so the goal is not to completely remove breast tissue but rather to use existing tissue to contour a masculine chest. With AFC, all breast tissue is removed. Also, nipples are typically preserved with top surgery, whereas with AFC they’re typically removed.

We are here to help! Please ask your question directly by emailing us at info@notputtingonashirt.org or by using our contact form.