Media Kit

Website: www.NotPuttingonaShirt.org

IG: @notputtingonashirt

Twitter: @not_shirt

Email: info@notputtingonashirt.org

Phone: (412) 407-5997‪

Mailing Address: Not Putting on a Shirt, Inc.
PO Box #111215
Pittsburgh, PA 15238

Charity ID#: 84-3021062

Not Putting on a Shirt (NPOAS) is a patient-led, all-volunteer 501(c)(3) nonprofit organization advocating for optimal surgical outcomes (aesthetic flat closure) 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 aesthetic 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:

• AFC Surgical Photo Database
• SABCS Research Poster
• State Legislation for Revision Coverage
• Literature Distribution
• NY Legislation
• WHCRA Amendment
• Surgeon Directory Validation/Expansion
• Coding for Flat Closure
• NAPBC Protocol Amendment
• NCI “Aesthetic Flat Closure” Campaign

Kimberly Bowles, President

Christy Avila, Vice President

Devorah Anne Vester Borenstein, Secretary

Shana Whitehead, Treasurer

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.

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.)

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.

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.

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.

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.

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)

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.

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.

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?

• 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.

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)

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)

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.

Word is spreading in the medical community, and surgeons are beginning to discuss and offer aesthetic flat closure (or, “flat closure”) by name:

• Midwest Breast & Aesthetic Surgery (view the awareness video)
• NYBRA Plastic Surgery
• Dr. Susan Love Foundation for Breast Cancer Research
• Oncoplastic Breast Consortium

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)

Reasons to choose aesthetic flat closure are as varied as the women themselves, including (sourced from BreastCancer.org and Dr. Deanna Attai):

• 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)

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.

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

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.

• 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)

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)

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.