What is Flat Denial?

Flat denial is when a surgeon’s unilateral actions deny their patient the agreed-upon flat closure, either through negligence or intentional disregard.

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Patients Expect Aesthetic Flat Closure

Patients expect a flat result when they affirmatively decide against breast mound reconstruction. They don’t anticipate their surgeon simply removing the breast and not prioritizing the creation of a truly flat chest wall contour.

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

LEFT: Flat closure RIGHT: Flat denial
Excess or “redundant” tissue may remain after the mastectomy and produce discomfort and an unpleasantly lumpy contour, unless the surgeon takes special care to remove it.

Flat denial yields results are egregiously poor, not minor defects. The level of skill and regard a surgeon has for flat closure largely determines the quality of their patient’s mastectomy result. Factors outside the control of either party include the patient’s body type, breast size, surgical history, and existing medical complications.

Patients who want to go flat have made a affirmative and viable choice and deserve to have their wishes respected. Flat denial is always unacceptable.


Why Does Flat Denial Happen?

Fundamentally, underlying most instances of flat denial is the cultural misconception that a woman’s affirmative choice to go flat does not command respect and consideration on par with the choice to reconstruct breast mounds. When a surgeon has absorbed this paternalistic attitude, it can translate into poor aesthetic outcomes for their patients who choose to go flat. Flat denial can happen to a patient during her initial surgery, as well as during explant and other procedures to “deconstruct” and go flat. Sometimes flat denial is a result of lack of skill, but it can also be intentional in spite of skillset.

Paternalism

Most surgeons respect their patient’s reconstructive decisions… but there are exceptions to every rule. A small subset of surgeons are unwilling to produce the patient’s desired flat closure. It is the intentional withholding of this information that results in intentional flat denial. The unwitting patient is then left with an unacceptable result that requires additional surgery to fix. Enough excess tissue can be left to qualify as a “skin sparing mastectomy” – a procedure to which the patient who wants to be flat did not consent.

Intentional flat denial is characterized by carefully closed symmetric incisions with an intact inframammary fold and varying amounts of excess tissue which may even qualify as a “skin-sparing” mastectomy.

Lack of Flat Closure Skill Set

Most general surgeons are not specifically trained in flat closure and can lack the technical skill. They can fail to recognize this limitation because they often don’t prioritize the cosmetic result in the way the patient expects. The reality right now is that patients can be left with unsightly, uncomfortable excess tissue, folds and puckers, and other “cosmetic defects” (any part of the contour, or shape, of the mastectomy site that is not smooth and flat).

Negligent flat denial is characterized by poor quality, uneven, asymmetric incisions with folds and puckers and varying amounts of excess skin.

Denial of Informed Consent

Ethically and legally speaking, surgeons must obtain informed consent from their patients before they operate. The AMA code of medical ethics is crystal clear: surgical patient’s consent is specific to a defined intervention, and does not authorize the surgeon to take liberties unilaterally while the patient is unconscious. The only exception is emergency situations that arise during the surgery.

A skin-sparing mastectomy and a mastectomy with a flat closure, are two different procedures.

A skin-sparing mastectomy and a mastectomy with a flat closure, are two different procedures. If a patient consents to a flat closure, and then while they are unconscious the surgeon decides to perform a skin-sparing procedure, that action is a violation of the patient’s consent – unauthorized, unethical, and illegal. This is intentional flat denial.


Additional, Avoidable Trauma

The patient experiences both intentional and negligent flat denial as dehumanizing and traumatic.  The only real matter of choice in the whole cancer treatment process is the reconstruction decision, and to take this choice away is cruel… and avoidable. Cancer should be the worst part of breast cancer treatment.

There is no room for paternalism in medicine, and no allowance should be made for anything other than full respect for patient consent.


How Common is Flat Denial?

According to our research, the prevalence of flat denial is about 10-15% of all patients going flat. For every twenty women that choose flat closure, five will receive an unsatisfactory cosmetic result, one or two will suffer negligent flat denial, and one will suffer intentional flat denial. There is a lot of room for improvement here.

NPOAS’ poster at the 2019 San Antonio Breast Cancer Symposium summarized our original research on patient experience with flat closure.

Risk Factors for Flat Denial

According to our research, factors associated with an increased prevalence of flat denial are age older than 55 years, higher than “normal” BMI, presence of pre-operative pushback from the surgeon, and use of a general surgeon rather than a breast specialist (breast surgeon). Overall, breast surgeons were more likely to meet their patient’s aesthetic expectations, and three times LESS likely to deny their patients a flat closure, than were general surgeons (7% vs 24%). The data is less clear for plastics closure because of the small sample size. Surprisingly, in our data set, larger breast cup size was NOT associated with poorer expectation match.

Fig. 1 Expectation match by age group (red = poor, green = excellent)
Fig. 2 Expectation match by BMI category (red = poor, green = excellent)
Fig. 3 Pre-operative pushback for patient category (intentional flat denial, negligent flat denial, no flat denial) (red = extreme pushback, green = no pushback)
Fig. 4 Prevalence of flat denial by surgeon type.

This page was authored by NPOAS Founder Kim Bowles. An edited version was originally published at Flat Closure NOW.


Patients Speak on Flat Denial

I was given a skin-sparing mastectomy. I did not consent to that outcome, nor did ever imply that it was anything I wanted. I am devastated.

Anonymous victim

My surgeon told me the day after surgery, in the hospital, that she left extra skin in case i changed my mind about reconstruction. I was too out of it to respond.

Anonymous victim

When the bandages came off I was horrified to see he left extra skin in case I ever changed my mind. I never did and never will… I’ve live with it for 30 years now.

Anonymous victim

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