What’s the Plan?

Driving home from the 2018 NPOAS Awareness Walk in Cleveland, OH

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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.

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Not Putting on a Shirt is solving the flat denial puzzle by empowering patients and working with stakeholders to effect institutional change.


Barriers We Face:


When a woman says “I want to be flat,” some surgeons hear “I don’t care about how I look.” This is an outdated and paternalistic attitude that we must confront. We must work to ensure medical professionals understand that going flat is an affirmative, legitimate, healthy, and beautiful reconstructive choice.


In most other medical settings, outright disregard for a woman’s informed consent by a provider would be grounds for disciplinary action. In cases of flat denial, there has never been a recorded instance of a surgeon being held accountable. Hospital systems of accountability are failing these patients. Protecting the “bad apple” surgeons is not the right thing to do, and administrators know it – but until patients demand accountability, nothing will change.


Update! As of June 2020, “aesthetic flat closure” has been officially recognized as reconstructive by the National Cancer Institute! (Learn More)

Many surgeons see flat closure and revision as “cosmetic” procedures, rather than reconstructive. And who can blame them, when the legislation is unclear and there is no official way to request reimbursement for these procedures? We are building a coalition of plastic surgeons, general and breast surgeons, insurance companies, researchers, attorneys, public health officials and patient advocates that is working together to make the case that flat closure is reconstructive, NOT cosmetic.


We routinely bring on a plastic surgery specialist to perform implant and autologous breast mound reconstructions after mastectomy. We should do the same for chest wall reconstruction. But there is no standard of care for aesthetic flat closure, as there is for other reconstructive options. There is no clear protocol of “best practices” for a surgeon to follow when their patient makes the choice to go flat. We must support research on flat closure that will support the development of an evidence-based standard of care that serves women’s needs.


Right now, surgeons often do not receive appropriate reimbursement for flat closure and revision services. And we cannot expect medical professionals to want to pursue work they know will be drastically underpaid. When legislation was passed in 1998 requiring insurance companies to cover breast mound reconstruction, implant rates skyrocketed and surgeons honed their skill sets – we can expect the same to happen when flat closure is fairly reimbursed.

Not Putting on a Shirt’s strategic initiatives address these barriers directly, and provide women with tools to protect their choice to go flat NOW.

On the Road to Parity

Our Two Year Strategic Plan: 2020-2021

Here’s our detailed roadmap for the next two years, give or take, broken down by category. Join our mailing list, or follow us on social media to stay in the loop. Contact us with questions, comments, or ideas – we’d love to hear from you!

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Target: WHCRA (Women’s Health & Cancer Rights Act)
Improved Standard of Care
  • Outreach to the National Accreditation Program for Breast Centers (NAPBC) about their protocol and the case for an amendment to include aesthetic flat closure, ahead of the 2021 ASBRS Meeting.
  • Continued consultation and collaboration with breast surgeons and the OPBC to encourage the widespread adoption of an oncoplastic approach to mastectomy. Identify barriers, stakeholders, and steps necessary to achieve this goal.
  • Encourage research on insurance coverage denials for flat closure and revision services (and use those statistics – along with the new NCI definition of aesthetic flat closure – to support our case for amending the WHCRA).
  • Encourage research on the prevalence of common post-surgical adverse conditions (“iron bra,” restricted shoulder range of motion, truncal lymphedema) and determine whether these conditions have any association with aesthetic flat closure vs. mastectomy without additional contouring.
Coalition Building
  • Work towards the formation of a Young Professionals Advisory Board – in tandem with outreach to medical students and residents.
  • Finalize our Council of International Advocates, to amplify the work of flat advocates worldwide and present a unified message to stakeholders, and facilitate connecting advocates with local OPBC leadership.
  • Work to characterize the barriers to parity in each country and determine how NPOAS can maximize the translation of our work in the US to other countries (and vice versa).
Organizational Leadership and Inclusivity
  • Continue to expand our Advisory Council to include at least one: breast surgeon, oncoplastic breast surgeon, general surgeon, oncology social worker, oncology physical therapist.
  • Nominate additional Board members with the explicit goal of ensuring representation of concerns specific to BIPOC and LGBTQ communities.
Medical Coding
  • Encourage the American Society of Breast Surgeons (ASBRS) to survey their membership to determine what codes are currently being used for aesthetic flat closure surgical work.
  • Continue to interface with stakeholders including ASBRS, the American Society of Plastic Surgeons (ASPS), health insurance companies, and others to finalize a mutually agreed upon coding protocol for aesthetic flat closure at initial mastectomy, explant, and revision.
  • Initiate lobbying effort to improve reimbursement by increasing the valuation of the agreed-upon insurance code(s).
  • Continue to provide support to victims electing to pursue legal action.
  • Continue outreach to advocates in related fields, including obstetric violence and institutional betrayal trauma, in order to identify areas of potential translation with the goal of speeding up the timeline to establishing legal precedent and discouraging intentional flat denial.

Current Projects Page

All Initiatives:

Education & Awareness

Knowledge is power.

Our informational website and media outreach efforts inform women about flat closure as a valid reconstructive option.

We provide resources and tools to empower women to protect their choice.

We also attend patient-centered conferences to conduct outreach and networking.

Standard of Care

We advocate for the development of a robust standard of care that serves the interests of women going flat.

NPOAS conducts novel research on flat closure in order to promote larger scale research by epidemiologists.

We also attend medical conferences, both to present our research and to conduct outreach to professional researchers.

Surgeons Directory

Women going flat need to be connected with surgeons who have a proven track record of flat closure.

Our growing database of Flat Friendly Surgeons is now available online, with over 230 listed surgeons recommended for flat closure at initial mastectomy, explant and revision. Easy to use and cross referenced with the two primary patient-compiled explant lists.

Community Support

Social media provides a forum for patients to find community and support. Several Facebook support groups exist for women considering their options.

If you need assistance, please contact us at info@notputtingonashirt or use the contact form here.

We also run a moderated private support group for victims of flat denial.

Literature Distribution

Our literature distribution campaign reaches women facing mastectomy right where they are NOW: local hospitals, imaging centers, community centers, and public events.

We are always working to produce new publications that serve the needs of patients and providers.

Legislative & Regulatory

Flat closure is reconstructive, not cosmetic. But our system is behind the times. To achieve parity, we must amend key legislation and agency definitions and protocols to explicitly include flat closure in the WHCRA. We are lobbying to have flat closure included in:

  1. The NCI (National Cancer Institute) Dictionary of Cancer Terms UPDATE! It’s DONE!
  2. The WHCRA (Women’s Health and Cancer Rights Act) of 1998
  3. The NAPBC‘s “Reconstructive Surgery Consult” protocol

Oncoplastic Training

We believe that improving access to oncoplastic training (i.e., for an aesthetic approach to mastectomy) for surgical oncologists will play a significant role in improving flat closure quality for their patients.

Oncoplastic training programs are currently provided through the ASBrS and the School of Oncoplastic Surgery, among others.

Our membership with the American Society of Breast Surgeons supports their training programs.

Improved Reimbursement

Insurance reimbursement rates for flat closure and revision services are too low right now. Providers deserve to be paid fairly.

Improved reimbursement will translate into better outcomes for patients, as surgical oncologists improve their oncoplastic skill set and/or bring on plastic surgeons for the closure.

In collaboration with other stakeholders, we are working to promote standardized insurance coding for flat closure and revision.

Outreach to Med Schools

Medical students are some of the smartest, hardest working, empathetic, and most highly ethical people in our society. And they are training to become the surgeons of tomorrow.

Our outreach campaign for medical students aims to promote awareness of flat closure as a valid reconstructive option, and also ensure they understand what they can do to protect their future patients.

Ready to take action?

You can support our work by spreading the word, volunteering, or donating. NPOAS is an all volunteer organization and all donations directly fund our advocacy work.

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This site contains copyrighted material. Not Putting on a Shirt’s educational materials and resources on this site are freely available for “fair use” (Title 17 U.S.C. Section 107) in accordance with our mission to advocate for optimal outcomes for those who choose to go flat after mastectomy.  The copyrighted material on this site is distributed for educational purposes without profit – all donations to Not Putting on a Shirt directly fund our advocacy work. If you wish to use copyrighted material from this site for purposes that go beyond “fair use”, you must first obtain explicit permission from the copyright owner. Please direct requests or questions to info@notputtingonashirt.org.