What is Flat Denial?

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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 contour.

But, all too often, that is exactly what happens. Since most patients going flat prioritize being “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).

Flat denial is when a surgeon’s unilateral actions deny their patient a flat mastectomy result – either through negligence or intentional disregard.

Mastectomy patients who asked for a flat result

These 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.

Why is This Happening?


Fundamentally, the root cause underlying most instances of flat denial is the cultural misconception that a woman’s affirmative choice to go flat does not deserve to be respected on par with the choice to reconstruct breast mounds. Some surgeons unfortunately have absorbed this paternalistic attitude, and it translates into poor outcomes for their patients who choose to go flat.

These surgeons are either unwilling or unable to produce the desired result for the patient, fail to fully inform her of these facts, and leave the patient with an unacceptable result that requires additional surgery to fix. This can happen to a patient during her initial surgery, as well as during explant and autologous breast mound removal procedures to “deconstruct” and go flat.

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) even when they have clearly asked to go flat.

Denial of Informed Consent

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.

Loss of Agency – An Additional Trauma

The patient experiences flat denial as dehumanizing and traumatic.  The only real matter of choice in the whole cancer treatment process is the reconstruction decision. To snatch this choice away is the height of cruelty. Cancer should be the worst part of breast cancer treatment. There’s no room for paternalism in medicine, and we must work together to put an end to flat denial once and for all.

Read more:

This page was authored by NPOAS Founder Kim Bowles, and 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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