My Body, My Choice: Aesthetic Flat Closure after Mastectomy

In 2016, I was diagnosed with breast cancer and underwent a double mastectomy. After careful consideration and lots of research, I decided against getting breast implants or other conventional reconstructive surgery, because I wanted to get back to my normal life as quickly as possible. I told my surgeon that I wanted to “go flat” and put my request in writing, providing him photos of the kind of flat chest I was hoping for.

When I woke up from surgery, I was horrified to discover that I was nowhere near flat as agreed. Instead, my surgeon had left “a little extra” skin, likely because he believed I would change my mind and choose later to get implants. (The extra skin makes implant reconstruction faster and easier.)

What happened to me — my surgeon intentionally and against my consent leaving extra skin — is not unusual. It happens to one in twenty women who choose to go flat.  When we look at our chests, instead of seeing our choice reflected back to us, we see violation. We are forced to live with the results of our surgeons’ negligence or intentional disregard, or to undergo another surgery to fix it.

It doesn’t have to be this way. A procedure called flat closure (aesthetic flat closure), which creates a smooth, flat chest wall by smoothing out any lumps and bumps and trimming any excess skin, can be done when the breasts are removed.

For the past three years, ever since my surgery, I have been working to make things better for women who choose to go flat. I founded an organization, Not Putting on a Shirt, to make one message clear: women facing mastectomy deserve full disclosure of all of their reconstructive options, including aesthetic flat closure, and to have their informed consent respected.

One of the questions we ask is “Why?” Why do so many women end up looking far different than they expected?

We believe these outcomes are the direct result of decades of unclear language, unchecked paternalism and protectionism, and medical training which reinforces the myth that women cannot be “whole” without breasts.

One problem is that “flat” is an ambiguous term. To address this, flat advocates have been fighting to get official recognition of flat closure as a reconstructive choice deserving of the same respect and consideration as breast mound reconstruction.

Finally, institutions are starting to listen. Recently, as a result of our efforts at Not Putting on a Shirt, the National Cancer Institute added the term “aesthetic flat closure” to its official Dictionary of Cancer Terms, defining it as a reconstructive and aesthetic surgical procedure. And just like that, women have the clear language we’ve been needing so desperately for so long, to tell our surgeons exactly what we want.

I was lucky to have a great response to my treatments for stage 3 breast cancer. The main trauma I’ve had to heal from since was not from the cancer itself – it was from the experience of waking up and realizing that my consent had been intentionally violated.

With the support of my family, friends, and advocacy colleagues, I have been able to take this trauma and use it to ensure this never happens to another woman. For the sake of our daughters, we cannot allow the status quo to persist unchallenged.

At Not Putting on a Shirt, we provide patients  with tools and resources to help them advocate for their choice. We also provide support for victims whose wishes were disregarded.  Equally important, we are building a coalition of institutional stakeholders who will work together to bring aesthetic flat closure to routine patient care once and for all. Surgical oncologists and plastic surgeons, researchers, insurance companies, policymakers – all must have a seat at the table.

As we look to the future, we anticipate the day when every woman is duly informed of her option for aesthetic flat closure alongside conventional reconstruction. The day when insurance covers all aesthetic flat closure and revision services without question. The day when every patient’s informed consent is respected without exception. We do this work now so that our daughters will have a better future. We can make that happen – and we will.

Kim Bowles is a scientist, artist, mother of two, and founder of Not Putting on a Shirt, a 501(c)(3) nonprofit advocating for optimal surgical outcomes for women going flat after mastectomy.