💬 Why I Chose to Go Flat: A Conversation About Aesthetic Flat Closure and Advocacy

After completing six cycles of chemotherapy and three cycles of monoclonal antibody therapy for the treatment of HER2-positive breast cancer, I was faced with the next phase of treatment, which was surgery.  The post-treatment MRI showed resolution of the masses that had been seen initially. 

Early in my diagnosis, I had already decided that I wanted to undergo a bilateral mastectomy just to be done with it all.  My breast surgeon made me aware of the fact that there was little difference in recurrence rate between a lumpectomy with radiation versus a mastectomy with radiation.  In my case, I would still need radiation as there had been a spread to an axillary lymph node. 

My breast surgeon could see I was conflicted between the two options.  I mean, was it a rational decision to cut off a perfectly healthy breast simply because I didn't want to go through the emotional rollercoaster of frequent surveillance examinations and testing?  

She recommended that I consult with a plastic surgeon who worked out of her office so that I could explore all my options. 

During my research, I had heard of the term 'aesthetic flat closure'.  I was intrigued by this.  But I had never encountered any woman who had gone through this.  I bought some books and perused some websites. 

When I met with the plastic surgeon, he took the time to outline all the reconstructive options that were feasible.  I must admit I was pretty surprised that the longer our conversation went, the more I realized that I could not recall some of the options that he shared.  Call it chemo-brain or simple overwhelm.  Some of the options seemed time-intensive with a long period of recovery.  I needed to be as close to full recovery as possible in the shortest time.  I live alone, and my family was going to be coming into the country to help with my post-op recovery, and I did not like the idea of depending on others for longer than was needed. 

Feeling that a bilateral mastectomy may be overkill given that I had achieved resolution on MRI, I finally settled on a lumpectomy on the right side with an oncoplastic reduction to the left breast. 

My surgery was scheduled for May 21, 2024.  Post-op op I was able to go home with drains in my side.  By the next morning, I was up and about, measuring the fluid in my drains, wearing my compression wear, and even ready to walk my dog 🐶.  I was even able to attend a friend's wedding service (drains and all) a few days later. 

Well, all that would change a week later when I went in for my post-op check-up.  My plastic surgeon came into the room and asked me, "Which do you want to hear first.  The good news?  Or the bad news?"  "Bad news?" I asked in bewilderment.  I had informed my family that I was going for a quick check-up to have the drains removed.  The hospital was a mere four blocks from my home.  I had not anticipated anything out of the ordinary.  After all, I was buoyed by the assurance of the MRI.  So what was the bad news?

"Well, the surgical sample from the left breast that I sent for pathology came back showing a 4 mm invasive lobular carcinoma," he said.  I looked at him, dumbstruck, and burst into a torrent of tears.  I have never felt so alone, knowing I could have had my brother or my daughter there with me.  I wept uncontrollably.  How could this be happening?  Another cancer??  He went on to share some statistics with me that this happens in 1:1000 women who are having plastic surgery and are found to have an incidental cancer.  Why was I that 1 in 1000!!  There was another caveat, however; one of the markers that had been implanted into the area that had a mass pre-surgery on the right breast hadn't been located during the prior surgery. So they would need to go back in to retrieve it to ensure that there was resolution of the cancer under the microscope (what is called a complete pathologic resolution). 

So I had to go under surgery again anyway.  And I had a lobular cancer on the left side.  That's when I said to myself, you should have stuck with your initial intuition—a bilateral mastectomy with an aesthetic flat closure. 

👙 What Is Aesthetic Flat Closure?

Aesthetic flat closure is a surgical procedure performed after mastectomy to create a smooth, flat chest wall without reconstructive implants or flaps.  This isn't the same as simply leaving the area "untreated." It's a surgical approach designed to produce a clean contour with symmetry and intention.  In 2019, the National Cancer Institute officially recognized "aesthetic flat closure" as a legitimate reconstructive option.  Yet, many people still don't hear about it from their medical teams.

I also read of cases where women wake up from surgery with unexpected results, such as leftover hanging skin or contour irregularities, because their choice to go flat wasn't fully honored.  That's why flat advocacy matters.

 Why I Chose to Go Flat

As I shared after discovering another cancer on the left side, I decided that flat closure was the option for me.  I weighed the physical, emotional, and financial costs of reconstruction, and for me, it didn't make sense.  I didn't want additional surgeries, potential complications, or long recovery times.  I love working out.  I needed to heal from surgery and move forward to the next phase of treatment, which was radiation therapy.  It took a lot of time getting used to my flat chest.  But I have come to accept myself -I am enough, just as I am. 

🗣️ How to Talk With Your Surgeon About Flat Closure 

If you're considering going flat, it's essential to have a clear, confident conversation with your surgical team.  Here are some strategies that helped me and others in the flat advocacy community:
✔️ Use the exact term "aesthetic flat closure" so there's no confusion.
✔️ Bring photos or examples of the outcome you hope for.
✔️ Ask your surgeon directly: "Have you performed aesthetic flat closures before?"✔️ Make sure your wishes are documented clearly in your medical record or surgical consent.
✔️ If your decision is being dismissed or minimized, it's okay to seek a second opinion.  This is your body and your future.  Your preferences matter.

🛑 Dealing With "Flat Denial"

Sadly, some women experience what's called "flat denial"—when a surgeon intentionally leaves excess skin or contours without consent, in case the woman "changes her mind" and wants implants later.  This practice is unethical.  You have the legal and moral right to choose the surgical outcome that aligns with your values and lifestyle.  If this happens, it's not your fault.  You deserve respectful care and informed consent every step of the way.  And it's not too late to have corrective surgery.

💪 Choosing Flat Is a Valid Choice. 

There is no "one size fits all" when it comes to breast cancer surgery.  Some women choose reconstruction, others opt for prosthetics, and some—like me—decide to go flat.  All of these paths are valid.  What's essential is that you feel empowered in your decision and supported by your care team.  But more women are becoming aware of the option to go flat.  

🌱 Closing Thoughts

If you're navigating life after breast cancer and wondering what comes next, I want you to know you're not alone.  The decision to go flat or reconstruct is yours to make, and it should be respected without question.  I'm here to support you—through education, advocacy, and community.  This is one of the many topics we explore inside my upcoming cancer survivorship program, where I help women like you build a post-treatment life that feels empowered, intentional, and supported.

🔗 Are you having a challenge deciding your surgical options?

This is where an independent health advocate like me can help you navigate office appointments with your surgeon and provide a summary of all your surgical options.  I can also be a sounding board, offering you a safe space to reflect on your decision without the pressure, and then ensure that your wishes are communicated clearly to your surgical team. Schedule a free 30-minute call to see how I may be able to help you during this critical time.  You do not have to do this alone.