My Body, My Choice: Aesthetic Flat Closure after Mastectomy

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

By Kim Bowles — July 21, 2020

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.

logo for aesthetic flat closureIt 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.

logo for the organization Not Putting on a Shirt


9 responses to “My Body, My Choice: Aesthetic Flat Closure after Mastectomy”

  1. Thank you for what you have done for women! You could have sulked away but you didn’t. Thank you for sharing your story and using your experience to change the world.

  2. I only wished I had seen this website 12 weeks ago before having my surgery. Now I will have to undergo another surgery that I told my surgeon I did not want any more surgeries and asked to be flat and no dog ears. Instead he did what he wanted, extra skin and dog ears.

  3. Complaint- nowhere on the notputtingonashirt website are their surgical guidance papers to help surgeons who are unfamiliar with the term and are not in the USA.

  4. Both the Not Putting On a Shirt and Flat Closure Now sites were invaluable to me when learning how to communicate with my doctors for my bilateral mastectomy. They gave me the confidence to advocate for myself and the language to use to ensure my surgery’s results were what I wanted. The generosity of the women who share their photos and stories is so appreciated. Thank you.

  5. I’m so thankful for finding this page. I decided to “go flat” and the Information you provide on here helps to provide clear language on what we are asking for! Bravo to you!!

  6. Wow – I’m so glad my surgeon didn’t di this to me! Today (4 years after my mastectomy) is the first time I’ve ever heard of such a thing. I’m completely flat on the left, and reduced (in the same op – two surgeons working in parallel) from DD to B on the right. I proudly wear a knitted knocker on the left!
    If I could have it over, I would have both completely flat, and would be able to choose when to wear, or not wear, what.
    Thanks for what you are doing!

  7. I told my surgeon I wanted everything flat. He did that for me – but still, I ended up with bubbles under my arms afterward. I had to appeal against my medical aid’s decision when they declined to pay for plastic surgery to remove the bubbles. I won the appeal. They said what I wanted was not reconstruction and my opinion was it’s my body and I may choose what type of reconstruction I want. So they were prepared to pay R300 000 for reconstruction and not R7000 to remove the bubbles.

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