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 Flat?

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.

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.

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).

Aesthetic Flat Closure (Left) vs. No Contouring (Right)

All of these women asked to be flat.

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.

Right now, 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.

Listen to Terri Coutee, patient advocate and founder of DiepCFoundation, speak with Drs. Minas Chrysopoulo and Ramon Garza III of PRMA Plastic Surgery about the importance of discussing expectations with your surgeon in detail prior to your surgery:

How to Ensure You Get an Aesthetic FLAT Closure

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!
Communicate Your Decision: “Aesthetic Flat Closure

Communicate your decision and your expectations to your surgeon. Use the term “aesthetic flat closure,” which is now defined by the National Cancer Institute. Write down your rationale for going flat. That way your surgeon can review it and include it in your medical record. Show your surgeon pictures of what you want AND what you are hoping to avoid (above).

Evaluate Your Surgeon’s Response

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 hedging your bets, “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.

Consider Plastics

If your surgeon seems unsure if they can give you an aesthetic flat closure in a single surgery, ask them if they’d 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.

If your surgeon doesn’t seem confident in their ability to produce an aesthetic flat closure for you, and they don’t want to bring on a plastic surgeon to correct the skill deficit, consider a second opinion.

If for any reason you cannot pursue a second opinion despite wishing to do so based on your interview with your initial surgeon, you may wish to print out our handout “Asking for FLAT” to assist you in clearly communicating your wishes to a surgeon who may not have much if any experience with aesthetic flat closure techniques.

Incision patterns for aesthetic flat closure

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 (LEARN MORE).

Specific Questions to Ask Your Surgeon

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

  • Have they performed aesthetic flat closures for previous patients? Ask to see photos of their work (note: plastic surgeons should have these readily available; general and breast surgeons may not)
  • Will your surgeon(s) be able to complete the job in one surgery, or is it likely that you will face additional surgery?
  • How will your surgeon(s) address any special challenges in your case – for example, very large breasts or obesity?
  • Should you expect concavity, and how will this be addressed?
  • How will they avoid “dog ears”? How far will the incisions extend on the lateral chest in order to achieve a flat contour?
  • A single incision may be insufficient to create a flat contour. What type of incision will your surgeon use, and why?
  • How will they account for gravity? Will they mark you up in a sitting position either before or during the surgery?
Get this information as a PDF brochure ->

Protect Yourself:  Documenting Your Wishes

“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

While the responsibility for the aesthetic outcome ultimately lies with the surgeon(s), it’s your body – protect yourself.  Evaluate your surgeon’s commitment and competence as described in this brochure – and make sure that your choice, “aesthetic flat closure,” is documented in your medical record.

We recommend the following steps:

  1. Bring a support person to your surgical consults – ex. spouse, partner, family member, or friend.
  2. Provide your surgeon with pictures that represent your desired aesthetic result and ask they be included in your medical record for reference prior to surgery. Our brochures have pictures like this, or you can source your own.
  3. Have your surgeon confirm your wishes in writing. Write up a summary of what was discussed in consult and email it to your surgeon.  Use the term “aesthetic flat closure.” Ask that they respond confirming that this is correct. This will alert you both to any misalignment in expectations.
  4. Ask if your surgical consent form can specify “aesthetic flat closure
  5. Trust your intuition.  If at any point, you suspect that your surgeon may not produce your desired result, find a new surgeon.  It is not easy to do this when you are dealing with ongoing cancer treatment. But it’s worth it to ensure that your wishes are respected and that you get a result you can live with. Remember: this is your body and your choice.
Get this information as a PDF brochure ->

Finding a Surgeon

Option 1: 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. These surgeons:

  1. Respected the recommending patient and their wishes to be flat,
  2. Were technically competent in surgical technique to achieve an aesthetic flat closure, AND
  3. Did the best they could do give the patient the desired result.
Option 2: 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.

Option 3: Hospital with an Oncoplastic Surgery Program

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.

Option 4: Use a Dual Specialty or Gender Confirmation Surgeon

Some women going flat have had success using a dual-specialty surgeon (certified in both surgical oncology and plastic surgery).  Surgeons specializing in gender confirmation surgery who are also certified in surgical oncology, in particular, are rare 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.

Option 5: 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 “adjacent tissue transfers,” with the specific coding (143XX) 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 both aesthetic flat closure and revision surgery.

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.
Protect Your Choice Brochure

Print this out to take with you to your surgical consult.

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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