Going Flat at Mastectomy

SOURCE: International FLAT Day‘s “Flat is Beautiful” brochure [Chiara D’Agostino for Oprah Magazine, Ms. Rosewater, and Jersi Baker for The Grace Project]

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Why Choose Aesthetic Flat Closure?

There are many reasons a woman may choose to opt out of breast mound reconstruction, or “go flat,” following mastectomy.

Often, the reason is to avoid additional surgeries – and additional pain, risk, expense, and time lost to medical treatment and recovery. Some women have other risk factors like diabetes or heart problems. Some initially chose to reconstruct, were unhappy with the results due to complications such as chronic pain, and/or a poor aesthetic result, and want to remove the reconstruction. For many women, the prospect of living with reconstructed breasts simply holds no interest at all – they do not view the loss of their breasts as making them any less “whole.”

Is there any harm in going flat? No. Quality of life studies have shown mixed results. There is no question that the reconstruction decision is a highly individual one – this is your body, your life, and your decision. Aesthetic flat closure is a valid, healthy and beautiful reconstructive choice!

The Expectation Gap

Choosing to go flat does NOT mean that you don’t care about the way you look, or that you simply haven’t decided to reconstruct yet, but will do so eventually.
flat denial photos comparison chart acceptable unacceptable aesthetic flat closure after mastectomy Not Putting on a Shirt advocacy pictures of bad mastectomy results full color

This is a surprisingly common misconception among surgeons as well as the general public. In fact, women expect aesthetic flat closure. They don’t anticipate their surgeon simply removing the breast tissue and not prioritizing the creation of a truly flat contour.

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

Right now, between 1 in 10 and 1 in 15 women who choose to go flat are left with egregiously unsightly, uncomfortable excess tissue, folds and puckers, and other “defects” (any part of the contour, or shape, of the mastectomy site that is not smooth and flat) even when they clearly asked to go flat.

The onus is on YOU, the patient, to not only communicate your choice to go flat, but to take measures to ensure that your choice is given the consideration you deserve.

How to Ask for FLAT

It is critical to use a surgeon who has a proven track record of high quality aesthetic flat closure – ask to see photos of their work. Use the correct term so there is no ambiguity: “aesthetic flat closure.If you feel uncertain about your surgeon’s commitment or competence, you should seek a second opinion. Listen to your intuition!

Steps to Take to Protect Your Choice:

  1. Communicate Your Decision: “Aesthetic Flat Closure”

    Communicate your decision and your expectations to your surgeon. Use the term “aesthetic flat closure,” which is defined by the National Cancer Institute. Ask to see photos of their work. Print out or order our “Flat is Beautiful” brochure so you can show your surgeon pictures of what you want AND what you are hoping to avoid. Be very specific in your discussion – ask the questions listed in the brochure (also listed below on this page).

  2. Evaluate Your Surgeon’s Response

    Do they seem to accept and respect your decision? Or do they try to talk you out of it, or make statements about “leaving a little extra in case you change your mind”? If there’s pushback, it may be time to consider a new surgeon. Pre-operative pushback is strongly associated with flat denial. Your surgeon should have a detailed plan for how they will achieve an aesthetic flat closure for you.

  3. Consider Plastics

    If your surgeon seems unsure if they can give you an aesthetic flat closure in a single surgery, ask if they will consider bringing on a plastic surgeon. Plastic surgeons are specially trained to create aesthetically pleasing results. Ask these same questions of the plastic surgeon as well.

  4. Can’t Get a Second Opinion?

    If you aren’t confident that your surgeon can do what you want, and you are unable to access either a plastic surgeon or another cancer surgeon for a second opinion, print out our “Asking for Flat” handout to assist you in communicating your wishes clearly to your surgeon, who may have little or no familiarity with aesthetic flat closure techniques.

  5. Document Your Wishes

    Bring a support person to your surgical consults who can confirm your wishes. Bring photos of the results you want, and of what you are trying to avoid, and ask that they be included in your medical record. Our “Flat is Beautiful” brochure has these photos, and our online Gallery has many more to choose from. Have your surgeon confirm your wishes in writing – email a summary of your discussion to your surgeon and ask them to confirm that this is correct. Be sure to use the NCI term, “aesthetic flat closure.” This will alert you both to any misalignment in expectations. And ask if your surgical consent form can include “aesthetic flat closure.”

  6. Trust Your Intuition

    If at any point, you suspect that your surgeon may not produce your desired result, you can find a new surgeon. It may not be easy to do this when you’re in the midst of cancer treatment – but remember, this is your body, and your choice. You deserve an optimal aesthetic outcome.

If you have breast cancer, you will always need a breast surgeon or surgical oncologist to perform the mastectomy.  But you may also need a plastic surgeon on your team to ensure a good flat result. Some plastic and oncoplastic surgeons can employ newer techniques to minimize concavity by repurposing excess tissue to “pad” or bulk up the mastectomy site.

Questions to Ask Your Surgeon

Be very specific in your discussion so there is no room for miscommunication.

Questions to Ask Your Surgeon

1. Have they performed aesthetic flat closures for previous patients? Ask to see photos of their work.

Plastic surgeons usually have photos readily available; general and breast surgeons may not.

2. Will your surgeon(s) be able to complete the job in one surgery, or is it likely that you will face additional surgery?

If it is important for you to be done in one surgery, be sure you find a surgeon who is confident this can be achieved.

3. How will your surgeon(s) address any special challenges in your case – for example, very large breasts or obesity?

The surgeon should have a specific, constructive plan to address any special challenges that respects your values and priorities and gives you an optimal surgical outcome. For example, if you have a high BMI and it is important to you to be done in one surgery, your surgeon should have a plan to achieve that for you. If not, it may be time for a second opinion.

4. Should you expect concavity, and how will this be addressed?

Concavity is largely a result of your anatomy and medical history, but your surgeon may be able to employ surgical techniques to minimize it.

5. How will they avoid “dog ears”? How far will the incisions extend on the lateral chest in order to achieve a flat contour?

For example, for patients with a higher BMI, your surgeon may need to extend your incisions farther around towards your back in order to achieve an aesthetic flat closure.

6. A simple incision may be insufficient to create a flat contour. What type of incision will your surgeon use, and why?

Your surgeon may consider using a more complex incision pattern (see diagram below).

7. How will they account for gravity? Will they mark you up in a sitting position either before or during the surgery?

Your surgeon should mark you up pre-operatively in a sitting or standing position so that after they close you up, the tissues will lie flat against your chest wall.

Scar Patterns: There are many ways to produce an aesthetic flat closure.

“Women have to live with this outcome for the rest of their lives… the burden is on the surgeons to make it a good one.”

Dr. Patricia Clark, Breast Surgeon

Finding a Surgeon

Use Our Flat Friendly Surgeons Directory

Our online directory lists surgeons, both general/breast and plastics, that have been recommended by patients in the flat community (and as of 2021, those who have applied and met our criteria).

Integrated Breast Center

Specialized integrated breast care centers that have both surgical oncologists AND plastic surgeons who specialize in breast surgery coordinating patient care will have more experience with insurance than general practice plastic surgeons, and so are more likely to accept patients seeking aesthetic flat closure. They will also likely have more experience with aesthetic breast surgery techniques.

Use a Surgeon Trained in Oncoplasty

Oncoplastic surgery is an aesthetic approach to breast cancer surgery – a surgeon who is certified in this sub-specialty will have completed training in plastic surgery techniques to produce an optimal contour after mastectomy. The focus in these training programs has historically been on lumpectomy techniques, but these surgeons are also a very good bet for aesthetic flat closure.

Use a Dual Specialty or Gender Confirmation Surgeon

Some women going flat have had success using a dual-specialty surgeon (certified in both general surgery and plastic surgery).  Surgeons specializing in gender confirmation surgery, in particular, are harder to come by but are a great bet for getting a good aesthetic flat closure in a single surgery. They typically have more experience with insurance processes than general practice plastic surgeons and are generally highly skilled in flat closure techniques.

Local Referrals from Trusted Sources

You can also ask your local medical providers and cancer community centers or support groups for recommendations – but make sure you specify that you want a surgeon who has experience with aesthetic flat closure.

Insurance Coverage

With a few exceptions, the Women’s Health and Cancer Rights Act (WHCRA) of 1998 requires insurance companies to cover breast cancer related surgery for mastectomy patients.  This should include plastics closure and/or additional operating time for the surgical oncologist to contour the chest wall after removing the breast tissue. However, insurance companies still sometimes initially refuse to do so.

Aesthetic flat closure was only defined as reconstructive in mid-2020 and institutions have yet to catch up. Your surgeon’s office should know how to code for the procedure correctly and be equipped and willing to do the legwork required, including appealing denials.

Aesthetic flat closure and revision surgeries are, in insurance coding terminology, generally considered either “adjacent tissue transfers,” or “scar revisions” with the specific coding (1430X or 1310X, respectively) dependent on surgical field size (original breast size). Not Putting on a Shirt is working, in collaboration with other parties, to formulate guidelines to help surgeons to code properly for aesthetic flat closure surgeries.

In the meantime, if the surgeon you interview initially tells you that aesthetic flat closure isn’t covered, unfortunately, you may just need to find another surgeon. Don’t give up!

Going Flat Resources

NPOAS’ Flat Friendly Surgeons Directory

Find a patient-recommended surgeon with a proven track record of flat closure for your mastectomy.
Flat is Beautiful Brochure
Order or print this out to take with you to your surgical consult. It has the questions for your surgeon listed.
Preparing for Your Surgery - Mastectomy with Aesthetic Flat Closure
Preparing for Surgery

What you need to know to prepare for your mastectomy with aesthetic flat closure
Living Flat

Everything you need to know about living flat: how to find community support, fashion, body images, tattoos, and more.

Fierce, FLAT, Forward

… is a Facebook support group for women at different points of their breast cancer journey who are either flat, going flat, or wanting to research/explore “living the FLAT life”—whether or not they choose to present as such in their daily lives. (LEARN MORE)

Patients Speak on Flat Closure

“I was one of the lucky ones…I had a surgeon that cared about the cosmetic results. My chest is flat and my scar barely visible. She was a breast cancer surgeon…that’s all she does.”

– Lonnie (Read her story.)

”I knew immediately I wanted the whole breast gone, and it was then that I began to Google images of mastectomies.  I remember my wife and I looking at image after image as I said, “That’s not too bad”. And that’s why I’m sharing my story.  I was able to make an informed decision because other people were brave enough to show their mastectomies on the internet.”

– Deborah (Read her story.)

”I first saw my chest two days after surgery, when I was allowed to take a shower. I took the bandages off, looked, and my first thought was, “I look like a fucking badass!” It was flat! The mermaid [tattoo] would look great there.”

– Wanda (Read her story.)

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