Flat Denial: In Depth

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If you’re a victim of flat denial, you’re not alone. Start here:

Flat denial is when a surgeon’s unilateral actions deny their patient a flat mastectomy result, either through negligence or intentional disregard.

What is Flat Denial?

Flat denial is when a surgeon’s unilateral actions deny their patient a flat mastectomy result, either through negligence or intentional disregard.

These results are egregiously poor, not minor defects. As we see below, the level of skill and regard a surgeon has for flat closure largely determines the quality of their patient’s mastectomy result.

The Root Cause: Paternalism

Fundamentally, the root cause underlying all instances of flat denial is the cultural misconception that a woman’s affirmative choice to go flat does not deserve to be respected on par with the choice to reconstruct breast mounds. Some surgeons unfortunately have absorbed this paternalistic attitude, and it translates into poor outcomes for their patients who choose to go flat.

These surgeons are either unwilling or unable to produce the desired result for the patient, fail to fully inform her of these facts, and in violation of their Hippocratic Oath, fail to refer her to a willing and competent colleague. Their actions leave the patient with an unacceptable result that requires additional surgery to fix. This can happen to a patient during her initial surgery, as well as during explant and autologous breast mound removal procedures to “deconstruct” and go flat.

The Expectation Gap: Patients vs. Surgeons

Choosing to go flat does NOT mean that the woman doesn’t care about the way she looks, or that she simply hasn’t decided to reconstruct yet, but will do so eventually. And yet…

This is a surprisingly common misconception among surgeons as well as the general public. In fact, patients expect a flat result when they affirmatively decide against reconstruction. They don’t anticipate their surgeon simply removing the breast and not prioritizing the creation of a truly flat contour.

But, all too often, that is exactly what happens. Since most patients going flat prioritize being “one and done,” waking up to an unexpectedly poor cosmetic result can be emotionally devastating at a time when they are especially vulnerable, grappling with the amputation of their breast(s).

“Going flat doesn’t mean just breast removal… it means being flat and having a nice chest contour.”

– Minas Chrysopoulo, Plastic Surgeon

The reality right now is that patients can be left with unsightly, uncomfortable excess tissue, folds and puckers, and other “cosmetic defects” (any part of the contour, or shape, of the mastectomy site that is not smooth and flat) even when they have clearly asked to go flat.

How does this happen?

  • gap in expectations between patient and surgeon
  • lack of training in flat closure techniques
  • paternalism – believing the patient will “change her mind”

Most general surgeons are not specifically trained in flat closure and can lack the technical skill. They can fail to recognize this limitation because they often don’t prioritize the cosmetic result in the way the patient expects. And some surgeons, unfortunately, hold the paternalistic belief that patients will change our minds about going flat – these surgeons may intentionally disregard your wishes and leave “a little extra.”

From the Protect Your Choice brochure

Right now, the onus is on the patient to not only communicate their choice to go flat, but to take measures to ensure that their choice is given the consideration they deserve.

Informed Consent

Ethically and legally speaking, surgeons must obtain informed consent from their patients before they operate. The AMA code of medical ethics is crystal clear:

“… informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention.

A surgical patient’s consent is specific to a defined intervention, and does not authorize the surgeon to take liberties unilaterally while the patient is unconscious. The only exception is emergency situations that arise during the surgery.

A skin-sparing mastectomy and a mastectomy with a flat closure, are two different procedures.

A skin-sparing mastectomy and a mastectomy with a flat closure, are two different procedures.

If a patient consents to a flat closure, and then while they are unconscious the surgeon decides to perform a skin-sparing procedure, that action is unethical and is a violation of the patient’s consent.

Flat Denial and Medical Malpractice

In some instances, flat denial rises to the level of medical malpractice.

Usually, medical malpractice is the result of negligence on the part of a medical professional. Negligence is an act or omission (failure to act) by a medical professional that deviates from the accepted standard of care – when the result is worse than what would be expected of a reasonably competent professional. Flat denial through lack of care/skill often falls into this category.

In cases of intentional disregard, where the surgeon is technically competent but intentionally denies the patient a flat result against their will in order to facilitate future reconstruction the patient has clearly decided against, a better descriptor is medical battery.

Medical battery is the intentional violation of a patient’s right to direct their own medical treatment. If medical treatment is performed without the patient’s consent or against their will, this is medical battery, and this is true even if the doctor did not intend to cause harm.

The paternalistic attitude that allows a surgeon to intentionally disregard the patient’s wishes, is usually rationalized as “surgeon knows best.” The surgeon believes that the patient will change her mind, and proceeds with the surgery that the surgeon chose, rather than the surgery chosen by the patient.

Patients Pay the Price

Gaslighting the Victim

Image: @clreid56 (Twitter)

A recurring theme from victims who have spoken out, is gaslighting. When asked or confronted, the surgeons who intentionally inflict flat denial will typically frame their decision to batter the patient in paternalistic, false, and confusing terms. This is a psychological manipulation technique known as gaslighting – presenting false information to the victim in order to make them doubt their own memory or perception.

Some surgeons will outright deny what the patient sees with their own eyes, claiming that the excess tissue is “just swelling,” or that “it’ll tighten up.” The fact is that with the exception of radiation treatment, skin stretches as it heals – it doesn’t contract. Gaslighting makes the flat denial experience extremely difficult to process and it can take weeks, months, or even years for patients to  accept the reality of what was done to them.

Shockingly, some surgeons will actually admit to battery.  They don’t call it battery, of course, but they will say things like “I left a little extra in case you change your mind,” or “I left some cleavage for you,” apparently expecting the victim to be grateful for the violation of their bodily autonomy.

Loss of Agency – An Additional Trauma

The patient experiences flat denial as dehumanizing and traumatic.  The only real matter of choice in the whole cancer treatment process is the reconstruction decision. To snatch this choice away is the height of cruelty. Cancer should be the worst part of breast cancer treatment. There’s no room for paternalism in medicine, and we must work together to put an end to flat denial once and for all.

Cancer should be the worst part of breast cancer treatment.

This page was authored by NPOAS Founder Kim Bowles, and an edited version was originally published at Flat Closure NOW.

Patients Speak on Flat Denial

I was given a skin-sparing mastectomy. I did not consent to that outcome, nor did ever imply that it was anything I wanted. I am devastated.

Anonymous victim

My surgeon told me the day after surgery, in the hospital, that she left extra skin in case i changed my mind about reconstruction. I was too out of it to respond.

Anonymous victim

When the bandages came off I was horrified to see he left extra skin in case I ever changed my mind. I never did and never will… I’ve live with it for 30 years now.

Anonymous victim

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