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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Our Message to Providers: This is Real

Most if not all medical professionals reading this page will be horrified and taken aback by not only the facts presented here, but the directness with which we present them. Most medical professionals would never consider leaving their patient with egregiously poor aesthetic results, intentionally or otherwise. Our message to you: please don’t look away. This is real. The harms are real. And we need your help to put a stop to it. Please contact us if you’d like to learn more about how you can help.

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

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

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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. (See Morrison & Karp, 2022)

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

Flat denial yields results that 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?

The paternalistic misconception that a woman’s affirmative choice to go flat does not deserve respect and consideration on par with the choice to reconstruct breast mounds translates directly into poor aesthetic outcomes for patients. An aesthetic approach to mastectomy closure is considered to be optional in this paradigm, and is not properly reimbursed.

This can lead to a skillset deficit and a casual acceptance of poor outcomes as “fixable” (with additional surgery, of course). It also leads a small subset of surgeons to intentionally override their patient’s clear directive and “leave a little extra in case you change your mind [about implants].” Flat denial can happen to a patient during her initial surgery, as well as during explant and other procedures to “deconstruct” and go flat.

Unclear language has also been a factor, historically. Patients asking to “go flat” struggled to communicate their wishes clearly in the absence of a clearly defined term. In early 2020, the National Cancer Institute defined “aesthetic flat closure” as essentially surgical reconstruction of a smooth, flat chest wall contour post-mastectomy. Moving forward, widespread adoption of this term should facilitate clear communication and reduce the prevalence of flat denial.

Lack of Flat Closure Skill Set
“Negligent Flat Denial”

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.

“Intentional Flat Denial”

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. They could refer the patient, but they don’t. Instead, they intentionally withhold this information and proceed to leave significant excess tissue remaining to facilitate implant reconstruction the patient has clearly declined. 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. This is intentional flat denial.

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.

The Costs of 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.

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

A skin-sparing mastectomy and a mastectomy with an aesthetic 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 an egregious violation of the patient’s consent – unauthorized, unethical, and illegal.

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

Financial Costs

The obvious cost associated with flat denial is the cost of the revision surgery to “fix it.” However, even when flat denial does not rise to the level of medical battery – as is the case with all intentional flat denial – it still constitutes a betrayal trauma which can have both short and long term implications for the psychological and physical health of the patient. There are significant costs associated with managing betrayal trauma:

  • Cost of switching oncology and/or surgical care away from the institution where the violation happened
  • Ongoing psychological care to manage the trauma, including potential PTSD diagnosis
  • New clothes to accommodate the egregiously poor aesthetics the patient must live with every day

The revision surgery itself involves copays, costs to manage complications, missed work, and caregiver costs. For patients with dependent children, childcare costs can be significant. And all of this does not include the immense and immeasurable cost of the pain and suffering that flat denial inflicts upon patients.

The Corrosive Effect on Providers

Intentional flat denial corrodes the integrity of both the surgeon and the institution they associate with. Ethically and legally speaking, surgeons must obtain informed consent from their patients before they operate, and consent is specific to a defined intervention. It 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.

Intentional flat denial corrodes the integrity of both the surgeon and the institution they associate with.

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 aesthetic result, one or two will suffer negligent flat denial, and one will suffer intentional flat denial. A 2021 UCLA study found that another 15-20% of patients going flat experience pushback about their choice from their surgeon, or aren’t told about flat as an option at all. 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.

Possible 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 non-specializing 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. (Note: further studies are needed to confirm and determine the specific nature of these correlations.)

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.

Help for Victims

We have developed extensive resources for victims of flat denial, all available on our Help for Victims Page.

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