Aesthetic Flat Closure
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Press Releases – Aesthetic Flat Closure
Not Putting on a Shirt (NPOAS) is a patient-led, all-volunteer 501(c)(3) nonprofit organization advocating for optimal surgical outcomes for women who choose to go flat after mastectomy. NPOAS was founded in July 2018 and incorporated in 2019.
Our mission is to advocate for satisfactory aesthetic outcomes – as agreed upon by the mastectomy patient and surgeon(s) – for those who choose to go flat. We inform and support patients, demand increased accountability for medical professionals and institutions, and collaborate with patients and the surgeons who care for them to establish resources and protocols that will make a difference.
NPOAS curates extensive resources available online and free of charge for both patients and providers interested in aesthetic flat closure, including:
- comprehensive, medically reviewed information on going flat at initial mastectomy, revision surgery, going flat at explant, and flat denial
- printable publications to assist patients in surgical consult, and for outreach
- the Flat Friendly Surgeons Directory, a searchable database of flat closure surgeons
- a gallery of flat closure photos
- an online support group for victims of flat denial
- an archive of patient stories about their experience going flat
- provider resources including a literature library, statistics, videos and more
Our grassroots initiatives include stakeholder and public outreach, legislative and regulatory actions, and original research in order to effect cultural and institutional change to protect the interests of women going flat. Our current/recent projects are:
Officers & Directors
Kimberly Bowles, President
Christy Avila, Vice President
Devorah Anne Vester Borenstein, Secretary
Shana Whitehead, Treasurer
Statistics & Fact Sheets
Patients going flat have unique values and priorities.
Patients who choose FLAT
… about 45% of patients
- want to avoid additional surgery
- do not consider a breasted appearance to be important
- worry about health impact of implants and losing muscular strength from breast reconstruction
- tend to be older (over age 60, 4/5 choose flat
Patients who choose PMBR
… about 55% of patients
- accept the possibility of needing additional surgery
- prioritize maintaining a breasted appearance
- do not want to use prosthetics
- tend to be younger
There is room for improvement in aesthetic outcomes.
44% of all mastectomy patients choose to go flat.
75% patients going flat are satisfied with their aesthetic outcome.
1 in 20 patients going flat are subjected to intentional flat denial.
Certain factors are associated with flat denial and poor aesthetic outcomes.
Factors associated with flat denial:
- age over 55 years
- BMI over “normal”
- use of a general surgeon (vs. breast specialist)
- presence of pre-operative pushback
Patient factors associated with egregiously poor expectation match include age older than 55 years (left) and higher than “normal” BMI (right). In these figures, red = poor expectation match, green = excellent expectation match.
Note: further studies are needed to confirm and determine the specific nature of these correlations.)
What Is Aesthetic Flat Closure?
Aesthetic flat closure = post-mastectomy chest wall reconstruction
An Alternative to Breast Mound Reconstruction
Aesthetic flat closure is a beautiful, healthy oncoplastic alternative to conventional reconstruction (i.e., implants and autologous flaps) that restores a smooth, flat chest wall contour instead of breast mounds.
Recognized by National Cancer Institute
The mastectomy first removes the glandular tissue of the breast, and the subsequent aesthetic flat closure removes and/or contours any remaining excess fat and skin to restore a smooth, flat chest wall. According to the National Cancer Institute’s definition:
- aesthetic flat closure is reconstructive (“rebuilding”)
- aesthetic flat closure requires an aesthetic, or oncoplastic, surgical approach
- excess tissue removal & contouring are involved
- aesthetic flat closure may be performed either at the initial mastectomy or at explant (implant removal)
History & Significance
For years, women going flat struggled to be clear with their surgeons, because we didn’t have the language to ask for aesthetic flat closure by name. As a result, surgeons sometimes skip the contouring altogether, leaving a “mess” that required additional surgery to fix. And sometimes, a surgeon will override the patient’s consent and leave extra skin to facilitate implant reconstruction. Our research suggests that 25% of women going flat end up with cosmetic results they are dissatisfied with, and about 5% suffer intentional denial of their choice by a surgeon who thinks they’ll change their mind.
The term “flat closure” entered the patient community’s lexicon only a couple of years ago with the publication of our article about misaligned financial incentives in the mastectomy setting. It was then adopted for general use by patients and providers alike, and in early 2020, the NCI added “aesthetic flat closure” to their Dictionary of Cancer Terms. Now, the ambiguity is gone. And as cancer surgeons’ understanding of their patients’ expectations evolves, it should become commonplace for them to bring on a plastic surgeon to perform aesthetic flat closure – just as they do for breast mound reconstruction.
Frequently Asked Questions
What’s the story here?
Women who choose to go flat after mastectomy deserve a surgical result they can live with, in one surgery whenever possible. But that’s not always what we get. Right now, flat is seen as a second class choice and poor aesthetic outcomes happen far too often, even when patients take steps to protect their choice. Some women are even given a skin-sparing mastectomy against their consent.
Flat advocates are making the case that going flat is a valid, beautiful and healthy reconstructive choice, and the recent adoption of “aesthetic flat closure” by the National Cancer Institute is a historic step forward.
- We reject sexism in breast cancer care. We reject the notion that women need breasts to be whole, feminine, sexy, or happy. Going flat is just as valid a choice as breast mound reconstruction.
- All reconstructive choices are valid. Flat advocates are not anti- breast reconstruction. We believe that there is no right or wrong choice when it comes to reconstruction, only informed choice – and we believe that aesthetic flat closure is a valid, beautiful and healthy choice.
- We reject paternalism in breast cancer care. We reject the notion that a woman’s reconstructive decision belongs to anyone other than the woman herself. There can be no allowance for paternalism in medicine – overriding patient consent (“flat denial”) is never acceptable. This is about our health and our bodily autonomy and integrity.
- Informed consent matters. Women facing mastectomy deserve full disclosure of all of their reconstructive options, including all risks and benefits of each option. Going flat is the lowest risk and least expensive reconstructive choice – that’s a fact.
- All patients deserve optimal aesthetic results. Women who choose flat deserve optimal aesthetic results and should be able to access the services of a plastic surgeon just like women reconstructing their breasts do.
Who will this story appeal to?
Anyone with a family member or friend with breast cancer or at a high risk of getting breast cancer, breast cancer patients themselves (250K new diagnoses per year in the US alone), general/breast/plastic surgeons and others involved in breast cancer care, and those interested in bodily autonomy and related feminist issues.
Why is it important to tell this story now?
The National Cancer Institute recently added the term “aesthetic flat closure” to their Dictionary of Cancer Terms, defining it as a reconstructive procedure involving an aesthetic approach. Women have long struggled to communicate their wishes to their surgeons – and that ambiguity has been weaponized by a few surgeons to impose skin-sparing procedures on women against their will (to facilitate implant reconstruction they expressly rejected.) Now, women have clear language with the weight of the NCI behind it. This ensures providers understand exactly what patients want and also provides a mechanism for accountability.
What is “flat denial“?
Flat denial is when a surgeon decides to leave their patient with significant excess skin instead of the agreed upon flat closure. It is a violation of the patient’s consent. According to our research, about 1 in 20 women going flat are intentionally denied a flat closure by a surgeon who believes they will change their mind about implants, and another 2-3 in 20 are left with egregiously poor aesthetic results due to lack of skill or care. There’s a lot of room for improvement here.(More here)
What’s at stake?
Women’s health, bodily autonomy and dignity are at stake. No woman should wake up from her mastectomy to see a violation of her consent – this is an avoidable trauma that breast cancer patients do not need to be dealing with on top of losing their breasts. An optimal aesthetic result sets the stage for healing.
Who are the players?
The one in eight women who face a breast cancer diagnosis in their lifetime, plastic surgeons, general and breast surgeons, insurance companies, hospital administration, healthcare researchers, attorneys, public health officials, women’s health activists, and oncology social workers and others who care for the emotional health of breast cancer survivors.
What’s the big question?
Do women going flat deserve the same respect given to women who choose to reconstruct breast mounds? YES! The question is, how do we get there?
Why does this story matter?
- The scale of women affected is enormous. Every year sees another 268,000 new breast cancer diagnoses in the United States alone. One in eight women will face a breast cancer diagnosis in their lifetime. Of those women, 35% will undergo mastectomy – and 40-45% of mastectomy patients go flat. That is a lot of women going flat.
- Sexism and paternalism in breast cancer care harms patients and erodes the public’s confidence in medical providers. We must reject the notion that women need breasts to be whole, feminine, sexy, or happy. And we must reject the notion that a woman’s reconstructive decision belongs to anyone other than the woman herself. A woman’s decision to go flat must command respect on par with conventional reconstruction. Overriding patient consent – leaving pockets of skin “in case you change your mind” instead of a flat closure – is never acceptable. Flat denial is a serious trauma and interferes with the patient’s healing process.
- Informed consent is a human rights issue. Women facing mastectomy deserve full disclosure of all of their reconstructive options, including all risks and benefits of each option, and to have our decision respected. Going flat is the lowest risk and least expensive reconstructive choice – that’s a fact.
- All patients deserve optimal aesthetic results. Women who choose flat deserve optimal aesthetic results and should be able to access the services of a plastic surgeon just like women reconstructing their breasts do.
What is an “aesthetic flat closure?”
Aesthetic flat closure (or “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 recently added aesthetic flat closure to its Dictionary of Cancer Terms. (More here)
How is aesthetic flat closure different from a nonreconstructive mastectomy?
Aesthetic flat closure refers specifically to the contouring work that is performed after removal of the breast tissue, whether at the initial surgery or at a later time point (i.e., revision or explant), to restore a smooth, flat chest wall contour. Patients who choose to go flat almost universally desire aesthetic flat closure. The previously used term for going flat, “nonreconstructive mastectomy,” did not specify an aesthetic outcome and was therefore overly broad and inadequate to ensure clear patient-provider communication. (More here)
Can’t a plastic surgeon do the aesthetic work at a later date?
Yes, but most patients going flat strongly prioritize being “one and done.” For this reason, if they do not feel they can provide the result the patient expects, some surgical oncologists may elect to bring on a plastic surgeon to perform an aesthetic flat closure after they perform the mastectomy/ies.
Do medical professionals accept this new term?
Word is spreading in the medical community, and surgeons are beginning to discuss and offer aesthetic flat closure (or, “flat closure”) by name:
Why was it necessary or important to have this entered into the official NIH glossary?
In the absence of a clearly defined term, women struggled to communicate their wishes to their surgeons. Our research has shown that the ambiguity has been weaponized against 1 in 20 women going flat to intentionally deny them a flat closure and push them towards breast reconstruction, and another 2-3 in 20 received egregiously poor aesthetic results as a result of lack of skill or care. But now, with the NCI’s definition of “aesthetic flat closure” on the books, women have clear language with the weight of the NCI behind it. This ensures providers understand exactly what patients want. And clarity is a vehicle for accountability as well. (More here)
What are some reasons that women would opt for flat closure?
- they want to avoid additional surgery
- they prioritize a short surgical recovery period because of an active lifestyle or athletics
- they prioritize a short surgical recovery period because of caregiving responsibilities
- maintaining a breasted appearance is not a priority for them
- they do not feel they need breast mounds in order to “feel whole”
- if they want the look of breasts, they prefer external prostheses that don’t require surgery
- they do not want foreign bodies implanted
- they do not want a second surgical site for flap reconstruction
- they have concerns about the potential health and/or functional risks presented by breast mound reconstruction
- they want to avoid potentially anxiety-inducing annual mammograms or other screening
Also, some women are not candidates for breast reconstruction because of medical issues, and some face financial and/or logistical barriers to access breast reconstruction (lack of access to a plastic surgeon, etc.) (Read more at BreastCancer.org)
About what percentage of women who have mastectomies opt to go flat?
A 2014 analysis of data from 1998-2007 found that over that time period, 44% of women in the US who have a mastectomy go flat. That figure includes both those who chose to go flat and those who were not candidates for reconstruction, and decreased from 54% in 1998 (when the Women’s Health and Cancer Rights Act was enacted) to 37% in 2007. Unfortunately, we are not aware of any similar analysis using more recent data. Note that the above figures don’t include the significant minority (perhaps 5-15%) of women who initially reconstructed with implants that ended up removing them for one reason or another and going flat.
Do women face pressure to do the reconstruction — particularly from the medical community — and if so, why?
Absolutely. Recent research out of UCLA found that 36% of women surveyed were not even offered flat as an option, and 30% report that their surgeon did not support their decision to go flat. Our own research found that for 1 in 20 women who choose to go flat are intentionally denied a flat closure by a surgeon who believes they will change their mind about implants. Women’s health journalist Catherine Guthrie wrote about this phenomenon for Cosmopolitan Magazine in 2018. A New Jersey woman, Deb Smalley, recently spoke out about her surgeon’s flat out refusal in 2015 to perform her bilateral mastectomy unless she agreed to reconstruct. The pressure to reconstruct was explored in depth from a sociological perspective in this well-referenced 2020 article by Abigail Bakan. Some articles cited:
- “A Matter of Choice: Mastectomies Without Reconstruction.” CBS New, 12 Mar. 2017
- “Why More Breast Cancer Survivors Are Going Flat.” Oprah, 20 Sep. 2017
- Newman, Amie. “To Have or Have Not: Breast Reconstruction and ‘Going Flat.’” Our Bodies Our Selves, 3 Nov. 2016
- “‘Going Flat’ After Breast Cancer.” The New York Times, 31 Oct. 2016
What are possible complications of reconstruction? What about going flat?
Going flat presents no additional risks beyond those of the mastectomy (breast tissue removal) itself. If significant contouring work or extension of the incisions is called for to produce an aesthetic flat closure, this may present proportionally higher risks relating to all surgery. Reconstruction with implants or autologous flaps does present significant additional risks, including proportionally higher risks relating to all surgery, and specifically loss of sensation or wound healing issues at the donor site, the mastectomy site, or both, and implant rupture or capsular contracture with implants. Implant reconstruction is also associated with an increased risk of a type of lymphoma (cancer) and of certain autoimmune disorders.
Why would surgeons possibly leave extra skin for a patient who has expressed a desire to go flat, and is there any way to hold a doctor accountable?
- Unclear language was (and will continue to be until “aesthetic flat closure” is universally adopted), a big contributing factor to surgeons leaving excess skin. What does it mean to “go flat” in the context of mastectomy? If it simply means “no reconstruction,” the aesthetic goal is not defined and is therefore entirely at the discretion of the surgeon and might even be construed to include skin sparing procedures.
- Historically, paternalism has played a role. If a surgeon believes the patient will change her mind, they might decide to override her decision and leave skin to facilitate future reconstruction. That is a clear violation of her bodily autonomy encouraged by paternalism.
- Sexist objectification and notions of traditional femininity can come into play. Surgeons are subject to the same cultural biases as the rest of us, including seeing women as sexual objects with breasts being a defining feature of femininity. Under this paradigm, the affirmative choice to remain breast-free might be considered anywhere from aberrant to pathological. In Australia, for example, a psychiatric assessment is routine for women who want a contralateral prophylactic mastectomy, and some women going flat have reported this treatment as we..
- And there’s the business/logistics side as well – aesthetic flat closure involves “extra” contouring work, which takes more time in the operating room (about 30 to 60 minutes). This work may not be reimbursed well, if at all – the insurance coding situation is still in flux.
- Lack of a clear standard of care plays a role, and some surgeons may downplay the patient’s priority of being done in one surgery, believing that it’s acceptable to have a plastic surgeon “fix it later.”
- Surgical training in breast cancer care has a hyper-focus on restoring the breast mound which engenders a pervasive anti-flat bias that the individual surgeon must overcome when trying to present flat closure as a legitimate reconstructive option. (More here)
What is shared decision making?
Shared decision making (SDM) is a collaborative model of clinical decision-making that ensures the patient’s values and priorities are centered during the decision making process. It represents a philosophy of clinical practice that restores and protects patient autonomy and informed consent. and it is one of the avenues by which clinicians can achieve their goal of providing patient-centered care. For mastectomy patients, SDM is critical to improving patient outcomes. A 2017 study out of Ohio State University found that less than half of patients undergoing mastectomy made a “high-quality” reconstructive decision that was consistent with their values and priorities – and one of the contributing factors was that patients were not adequately informed about their options. (More here)
What should a woman do if she needs support at her consultation?
It’s a good idea to bring a support person with you to your surgical consult(s) – a spouse, partner, or friend. Many cancer centers also have nurse navigators and/or oncology social workers who can assist you in finding the support you need. You can also contact a patient advocacy organization such as SHARE, NBCF, or ACS to be connected with resources. If you’re considering going flat, you can print out (or order mailed) one of our brochures to take with you to your consult.
Board of Directors
Kim Bowles is a scientist, artist, mother of two, and founder of Not Putting on a Shirt. She decided to go flat in 2017 as part of her breast cancer treatment plan, but her plastic surgeon intentionally left her with excess tissue to facilitate reconstruction. Kim went public with her story, and upon realizing that flat denial is a systemic problem requiring institutional change, decided to invest in pursuing parity for flat closure and helping women protect their choice. Kim has been featured in Cosmopolitan magazine, Women and the World, on the Today Show, and more.
Christy Avila is a career educator, mother, and explant and flat closure advocate. She founded Fierce, Flat, Forward, a support and advocacy group that encourages, guides, and educates other breast cancer survivors and previvors on going flat—whether at the time of initial mastectomy or post-explant. She herself chose to “go flat” after discovering breast implant illness (BII) and choosing to explant based on her subsequent research on breast implants as medical devices.
Christy co-founded “International FLAT Day,” (Oct. 7th), an annual event that celebrates FLAT and promotes flat closure and breast reconstruction awareness. In 2019, she testified before the US FDA at their Hearing on Breast Implant Safety in Washington DC, advocating for proper informed consent for breast cancer survivors. Christy serves on the faculty of the Communication Studies Department at San Jose City College where she has taught for over a decade. She looks forward to continuing her advocacy work to promote flat closure, explant, and informed consent.
Devorah Vester Borenstein
Devorah Vester Borenstein is an appellate attorney in Boston who helps persons with mental illness regain their agency, liberty and dignity. In July 2019, she had a double mastectomy after a local recurrence. Devorah always knew she did not want breast reconstruction, and feels fortunate that her breast surgeon – who told her about the flat movement – honored her choice. Devorah’s closely held values of integrity, transparency and individual autonomy make her an incredible asset to the NPOAS Board. Her goal at NPOAS is to bring all parties to the table – doctors, legislators, health insurers and patients – to make certain that in every state a woman’s right to full disclosure and informed consent is protected, and her decision to go flat is respected.
Shana Whitehead is a wife, mother of four, and VP of Property Management Operations with DLP Real Estate Management. Shana was diagnosed with Breast Cancer in January 2018. As a part of the treatment plan, Shana had a double mastectomy with tissue expanders placed in July of 2018. After one year with tissue expanders and suffering from BII symptoms, Shana made the decision to have them removed and decided on a flat closure. Shana was denied a flat result and moved forward with a revision in September 2019. As a result of her experience, she decided to make it her mission to advocate for women and their right to be fully informed about flat closure and acceptable outcomes.
Hi, I am BethAnne King. My interest in this movement is personal. I was denied the flat surgery I wanted and was inspired to establish Breastless and Beautiful, a social support group for mastectomy survivors. This group’s focus is body acceptance, regardless of surgical results. Members talk about adjusting to their changed bodies and new normal, since breast cancer. The validation and sisterhood there is healing and helpful.
I proudly advocate for informed consent for women who are facing mastectomy due to breast cancer (or risk of). My advocacy work is focused on helping to change laws that increase patient’s opportunities for informed consent so that they receive the surgical outcomes they expect.
My goal is to make changes so that no one else has to suffer this experience. We need to update the policies that restrict insurance coverage of revision procedures for those whose wishes were disregarded, and for those who, with more information, have decided they want to go flat.
Pankaj Tiwari, MD
Advisor, Plastic & Reconstructive Surgery
Dr. Pankaj Tiwari is a board-certified plastic surgeon who has fellowship training in microvascular surgery and focuses his practice on breast reconstruction after mastectomy. After completing medical school at New York University, plastic surgery residency at the Baylor College of Medicine and fellowship at The MD Anderson Cancer Center, Dr. Tiwari went on to accept a faculty teaching position at The James Cancer Center and The Ohio State University, Wexner Medical Center. While a full time faculty member for seven years, he co-authored numerous publications and book chapters, was awarded the “Microsurgery Case of the Year”, Resident Teaching Award and Best Doctors’ Award and was selected as one of Columbus’ top 40 under 40 professionals. In 2014 he co-founded Midwest Breast and Aesthetic surgery and in 2018 Onyx and Pearl Surgical Suites to provide advanced techniques for reconstructive breast surgery. Beyond microsurgery, Dr. Tiwari has a keen interest in developing practice patterns and standards to help lower the costs of healthcare while providing outstanding quality and safety outcomes. He enjoys spending time with his lovely wife and two daughters, traveling on surgical mission trips and playing the Tabla (Indian Drums).
Ergun Kocak, MD
Advisor, Plastic & Reconstructive Surgery
Dr. Ergun Kocak is a board-certified plastic surgeon specializing in advanced aesthetic and reconstructive surgeries of the breast and body. He is fellowship-trained in microvascular reconstruction and performs over 200 DIEP and other microvascular free flap breast reconstructions yearly. He also specializes in aesthetic operations of the breast including breast reduction, and breast lift (mastopexy). After graduating from the University of Michigan with Honors, Dr. Kocak went on to complete medical school at The Ohio State University College of Medicine. Dr. Kocak continued his training by completing his plastic surgery residency at The Ohio State University Medical Center in Columbus, Ohio. During this time, he completed a Research Fellowship and earned a Masters of Sciences degree in Medical Sciences from The Ohio State University’s Graduate School. After residency, he further specialized by completing a fellowship in reconstructive microsurgery and cancer reconstruction at the esteemed M.D. Anderson Cancer Center in Houston, Texas.
Yara V. Robertson, MD, FACS
Advisor, Breast Surgical Oncology
Yara V. Robertson, MD, FACS, is a board-certified general surgeon and fellowship-trained breast surgical oncologist. Dr. Robertson has been in Atlanta, GA since 2011 providing quality breast cancer care and has been passionate about eliminating disparities in breast cancer treatment, especially in the African American community. She lectures on breast health and participates in numerous health fairs providing free clinical breast exams. She has previously served as Vice-Chairman of Sisters by Choice, a non-profit organization that provides education and free breast health screenings to uninsured women as well as support for women diagnosed with breast cancer.
As a kidney cancer survivor herself, Dr. Robertson is fully aware of the importance of the patient’s role in shared decision making and advocates for patient centered care. Dr. Robertson believes that women who choose to go flat after a mastectomy deserve a surgical result that is aesthetically pleasing to them and fully supports the mission of Not Putting on a Shirt.
Minas Chrysopoulo, MD FACS
Advisor, Plastic & Reconstructive Surgery, Shared Decision Making
Dr Chrysopoulo (“Dr C”) is a board certified plastic surgeon, breast reconstruction surgeon and microsurgeon, and President of PRMA Plastic Surgery in San Antonio, TX. He specializes in state-of-the-art breast reconstruction with a particular focus on perforator flap breast reconstruction, nipple-sparing mastectomy, techniques to maximize aesthetic outcomes, and restoring sensation after mastectomy.
Dr C is certified by the American Board of Plastic Surgery, is an active member of several professional societies including the American Society for Reconstructive Microsurgery (ASRM), and the American Society of Plastic Surgeons (ASPS) for which he serves on several educational committees. He has authored and co-authored several book chapters and scientific articles in peer-reviewed journals, and is routinely an expert speaker at regional, national and international academic meetings.
Dr C has dedicated his professional life to advocating for breast cancer patients. He strongly believes that shared decision-making between the physician and patient is crucial in achieving the best outcomes and has built his practice on this philosophy. To empower as many patients as possible to advocate for themselves, Dr C created the Breast Advocate® App, a free app that provides anyone with a breast cancer diagnosis, or at increased risk of developing breast cancer, a much needed voice in their breast cancer treatment planning.
Jennifer Montes, MD, MPH
Advisor, Breast Surgical Oncology
Dr. Montes knew very early in her medical career that the treatment of breast disease was her true calling. She is a board-certified general surgeon specializing in diseases of the breast. She received her undergraduate education at Cornell University and went on to receive a Masters degree in Public Health from Columbia University. She earned her medical doctorate from Temple University and completed her surgical training at Lenox Hill Hospital. During her residency, she completed externships at Memorial Sloan Kettering, Columbia University and St. Luke’s Roosevelt Hospital. She received her fellowship in breast surgery from NYU Medical Center.
Dr. Montes understands that the scars left behind from a breast cancer diagnosis go much further than skin deep. She believes in the power of holistic modalities to help heal these wounds left on the mind, body and spirit. Through her years of training she has created a unique treatment approach incorporating these modalities with traditional medicine and her goal is to make these modalities accessible to all women fighting breast cancer.
Rep. Charen Fegard (D-VT)
Charen Fegard of Berkshire, Franklin County, Democrat, was born on Howard Air Force Base in Panama. She lived in many states and countries growing up and through her twenties. Charen earned a Bachelors degree in Biology from the University of NC at Wilmington. She has worked in the Civil Service in Hazardous Materials/ Environmental Compliance on overseas military bases, and has owned and operated a registered home daycare as well as landscaping and cleaning businesses.
Charen worked for a variety of non-profits in Vermont over the years. Before starting the legislative session, she volunteered on the Richford Restorative Justice Panel. Currently, she consults for non-profits and waste municipalities throughout Vermont regarding recycling, composting, and Indoor Air Quality related to cleaning chemicals. She raises meat birds, sheep, laying hens, a lot of vegetables, and enjoys deer hunting with her husband, Russ Ford. They have 4 children in their blended family.
Corine de Boer, MD, PhD
Advisor, Medical & Research
Corine de Boer is a physician, wife and principal of her own consulting company. She was diagnosed with breast cancer in 2015 and opted for a double mastectomy. Her female breast surgeon in Seattle was very supportive of her flat choice and did a great job but Corine has since learned, to her dismay, that this is not the case in other parts of the country. She fully supports the mission of Not Putting on a Shirt so every woman who chooses to go flat after mastectomy has a satisfactory outcome.
Council of International Advocates
Juliet has worked as a librarian, researcher, in sports development, is a mother of two adult children and has been married for 30 years. Right now she’s a writer, campaigner, flower grower and flat topless model. She was diagnosed with breast cancer in January 2016 at the age of 54, and had a left mastectomy, chemotherapy and targeted drug therapy. She decided against breast reconstructive surgery despite this being the only post mastectomy treatment option offered to her, and was left with a GG cup right breast. She was very unhappy being a “uniboober” and asked her surgeon over 18 months to remove her right breast so that she could be symmetrical and aesthetically flat. He finally agreed and she’s now very happy living flat, without breasts.
Juliet started to campaign for women to be given all the options post mastectomy so that they can make informed treatment choices. As part of this she did a series of topless photo shoots to increase the visibility of women living flat. This culminated with her working with Dove and her flat topless image being shown globally including on billboards in Times Square & Piccadilly Circus as part of the #ShowUs campaign, and in a prime time television commercial which aired in North America and Europe. She’s also appeared in the national press, on UK TV and radio, and on numerous podcasts.
Marie-Claude Belzile is a 33 year old writer, poet and advocate living with her wife and partner of eight years in Montréal (Québec, Canada). She earned her degree in anthropology from the Université de Montréal in 2014 and has written many socio-political articles for the independent journal L’Esprit libre. Her book, Penser le sein féministe, published in 2019, explores the experience of going flat after mastectomy from a feminist perspective. In it, she discusses how pervasive sexist bias affects women throughout their cancer journey, including the pressure to reconstruct their breasts.
Marie-Claude was first diagnosed with early stage breast cancer in 2016, followed by a metastatic diagnosis in 2018. When her ongoing chemotherapy treatment made work untenable, she started to advocate from home under Tout aussi femme (“not less of a woman”) on Facebook. In her spare time, Marie-Claude cares for her extended animal family, draws, and reads to satisfy her lifelong intellectual curiosity.
University of Toronto
Abigail B. Bakan is Professor in the Department of Social Justice in Education (SJE), at the Ontario Institute for Studies in Education (OISE), University of Toronto, Canada. Her research is in the area of anti-oppression politics, with a focus on intersections of gender, race, class, political economy and citizenship. Her experience with breast cancer, and flat denial, led her to share her story in “Going Flat: Breast Cancer, Mastectomy and the Politics of Choice”, Imaginations: Journal of Cross-Cultural Image Studies, vol. 11, no. 1, May 2020: 39-63. Other publications include: Israel, Palestine and the Politics of Race: Exploring Identity and Power in a Global Context (2020) (with Yasmeen Abu-Laban); Theorizing Anti-Racism: Linkages in Marxism and Critical Race Theories (co-edited with Enakshi Dua); and Negotiating Citizenship: Migrant Women in Canada and the Global System (with Daiva Stasiulis).
Pascale Contrino was born in 1972 in Marseille, France. She earned her degree in conservation & restoration of painted works in 1997, and then worked as a painting restorer and artist. In 2017 Pascale was diagnosed with breast cancer, and in 2018 she had a partial mastectomy. She was in treatment until March 2019 – chemotherapy, immunotherapy, hormone therapy, radiotherapy. In April 2019, Pascale created the Facebook page Complètement FEMME – l’audace d’être entière après une mastectomie (“Completely Woman – the audacity to be whole after a mastectomy”).
In June 2019, in partnership with Valerie Blondeau, she founded the nonprofit organization Complètement FEMME to support Amazons and enhance their image. In July 2019, the organization created the first prototypes of Amazon swimwear. The following year, the organization marketed the first sports shirts and bras for Amazons to wear without prosthesis. Pascale is now dedicated to both her artistic work and to the work of Complètement FEMME = find her work online and on social media. Her paintings of Amazons have been featured in art exhibits throughout the world (Tahiti, Switzerland) and are helping transform the narrative about women with mastectomies to one of beauty and positivity.
Kerstin learned she had the BRCA1 gene mutation when she was just 28 years old after a genetic test prompted by her extensive family history of cancer. She first decided to have routine MRI scans with the idea that early detection could spare her from unnecessary surgery, but the stress of the testing made her change course. Then she came across Catherine Guthrie’s memoir, “FLAT: reclaiming my body from breast cancer” and made her final decision. Now she’s flat, happy, and living her life free from fear of cancer.
Grit was diagnosed with triple negative breast cancer in January 2016 and shortly after learned she had the BRCA1 gene mutation, putting her at very high risk for recurrence. During neoadjuvant chemo, her surgeon offered reconstruction as the default and her only choice was what KIND of reconstruction. Her instinct was to reject reconstruction, but everyone around her seemed to expect her to reconstruct. Finally, she had a moment of clarity: “It’s my breasts or NOTHING!” She began searching online for support but found nothing. When she told her surgeon she’d decided to go flat, the surgeon’s response was “You want me to mutilate you?” Luckily, Grit met a flat woman in a BRCA support group who gave her the confidence to stick to her guns, and she has been flat and happy with her decision ever since.
Heike’s mother and sister were both diagnosed with breast cancer. Her mother wore prostheses religiously, and her sister opted for implant reconstruction before passing away shortly after from metastatic breast cancer. They never spoke about their experience nor showed their scars. Two years after her sister passed away, Heike was diagnosed and discovered she had the BRCA2 gene mutation. As a single mother of a ten year old, she wanted to heal as quickly as possible. And she didn’t want a foreign body inside of her. Heike has never once regretted her decision and accepts her new body. She wears her flat chest proudly to show other women that there is no shame in breast cancer and to honor those whose lives have been taken by the disease.
Ngozi is a lawyer turned entrepreneur and breast cancer advocate. Her journey down this path started after her Stage 3 breast cancer diagnosis in 2016 when she found a lump and went on to have a modified radical mastectomy. She was given the option of reconstruction, but wasn’t in the mood for more surgeries.
She went online and discovered that there was no support for Nigerian Women living with Breast Cancer. She started sharing on her personal page and progressed to starting @whatcancernaija, her mission control tower on Instagram where she educates women on the need to be breast aware, proactive about their health and take charge of their bodies as knowledge is power.
Ngozi is on a mission to demystify breast cancer in Nigeria and passionate about changing the narrative behind the disease by getting women to understand the need to face breast cancer head on armed with the necessary information without fear or stigma, as well as championing the cause for patient experience in the management of breast cancer.
She enjoys traveling and taking pictures to show that breast cancer is not a death sentence and her own way of showing gratitude to God. She has decided to soar after her breast cancer experience. She is married with 3 kids.
She runs The Judah Foundation for Breast Cancer where main focus is on Survivorship and Life after breast cancer.
Her end goal is a world standard breast cancer center across regions in Nigeria. Confession: She loved her scar and didn’t understand that aesthetic closure was a thing. All she knew was that her surgeon did a fantastic job and that is the story behind how she started talking about what she calls clean lines after surgery. She is glad that it is now a cause for advocacy.
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