When Shay Sharpe decided to “go flat” — to decline breast reconstruction after her mastectomy — she did so with full knowledge of what she was opting out of.
Just 36, this was Sharpe’s second bout with breast cancer. First diagnosed at 26, she had already been through a double mastectomy and reconstruction with implants. What followed was her body’s rejection of the left implant related to her radiation treatment, and the do-over of reconstruction on that side with a DIEP flap technique, using fat from Sharpe’s thigh to rebuild her breast. When her cancer reappeared in the same spot, the reconstruction was removed, and, while mulling the remaining options, Sharpe was given a prosthesis to wear.
“It was too heavy and overwhelming,” she recalls. “I was like, ‘I’m done with this, I’m not doing anything else. Instead of reconstruction, let’s just remove the right one.’ And the doctors were like, ‘What are you talking about?’ …On the day of the surgery, my doctor told me I was the only person with insurance who had ever gone flat. He asked, ‘Do you know what you’re doing?’ He looked at my mother and my ex and asked, ‘Did she discuss this with the two of you? Once she’s flat, that’s it.’ I was sitting right there! I told him this is what I want, it’s my choice. I was just over it.”
While plenty of women who opt to go flat still face a similar uphill battle from well-meaning but paternalistic doctors — not to mention a breast cancer industry, and society at large, that regularly conflates breasts with women “feeling complete” — quite a bit has changed in the years since Sharpe’s surgery. And it’s in no small part because of women like herself —advocates who have been working hard to create a movement that raises awareness and acceptance of flatness as a viable, embraceable option, complete with the fledgling International Flat Day, on Oct. 7 (falling within Breast Cancer Awareness Month), now in its second year.
“It’s gathering momentum, which is amazing,” says Kim Bowles, a Pittsburgh scientist and mother of two who has become one of the leading flat advocates after dealing with her own harrowing surgery experience: clearly telling her surgeon that she wanted to be smooth and flat after her mastectomy, but waking up from anesthesia to find that the doctor had left extra flaps of skin, just in case she were to change her mind and want reconstruction in the future.
That “flat denial,” Bowles says — and the endless, similar stories that began to pour into her from other women around the country — propelled her into activism, starting with a solo, shirtless protest in front of the hospital and, eventually, the formation of a non-profit Not Putting on a Shirt, which advocates for “optimal surgical outcomes for women who choose to go flat after mastectomy,” providing everything from a photo gallery to a flat-friendly surgeon guide, and resources for doctors, as well.
Bowles’s efforts are part of a rising movement that includes other advocacy groups such as Flat Closure Now, with a gorgeous photo gallery and the mission of “ensuring the recognition of and understanding that “‘going flat’… is a valid, beautiful, and healthy breast reconstruction option after a mastectomy or removal of breast implants.”
There’s also been a noticeable increase of proudly flat, media-savvy women, such as Shondia McFadden-Sabari of Bold and Breastless; Renee Ridgeley of Less Than Two Breasts; artist and advocate Melanie Testa; journalist Catherine Guthrie, who shared her personal story with her 2018 memoir Flat: Reclaiming My Body from Breast Cancer; and Sharpe, who founded Shay Sharpe’s Pink Wishes to support young women diagnosed with breast cancer, and who says she regularly hears from women who are encouraged by images of her flat chest — the first many have ever seen. Photographer Charise Isis, meanwhile, has spent more than a decade making empowering post-mastectomy portraits of women for The Grace Project.
Add to that the explosion of social media groups by and for women who are flat or considering going in that direction — whether because of a breast-cancer related mastectomy or of removing implants that had been the result either of reconstruction or augmentation surgery — which Ridgeley, who now runs a “Flat in the Time of COVID” Zoom support group, says have succeeded in informing more women than ever of their options.
“These women know the words to use, they know the questions to ask, they know the photos they want to bring in to their doctors,” she says of those who have joined her group. “I was impressed with them, and this was not [the way it was] three years ago.” That’s when Ridgeley received her diagnosis, opted for reconstruction after being talked out of going flat, and eventually had health issues, prompting her to get her implants removed.
“I had no support, which is why I did reconstruction first,” she says. “Now I think there’s a real awakening… and people now having the language and the knowledge to ask for themselves.”
So it’s no wonder there have also been recent victories of acknowledgment within the medical community.
The first came when the Oncoplastic Breast Consortium, an international professional organization, took advice from Bowles and added “optimal flat closure” to its mission statement alongside improved reconstruction outcomes. And then, more significantly, the National Cancer Institute in June quietly adopted a new official term that advocates had been pushing for: “aesthetic flat closure.”
The term, as defined by the NCI glossary, is “a type of surgery that is done to rebuild the shape of the chest wall after one or both breasts are removed. An aesthetic flat closure may also be done after removal of a breast implant that was used to restore breast shape. During an aesthetic flat closure, extra skin, fat, and other tissue in the breast area are removed. The remaining tissue is then tightened and smoothed out so that the chest wall appears flat.”
Regarding the NCI, says Bowles, “its sole purpose is to curate clear language in the oncology realm. They were instantly supportive — they’re a bunch of MDs and PhDs — and when you make the case, the case speaks for itself.” The addition of the term not only helps both women and physicians have a specific term at their disposal, but has the potential effect of assisting with insurance coding, allowing surgeons to be reimbursed specifically for the flat closure — something that has proved difficult, despite the extra time needed by doctors to do a smooth closure.
“People didn’t know what to ask for and we didn’t know what to offer them,” Dr. Pankaj Tiwari, plastic surgeon specializing in breast reconstruction in Gahanna, Ohio, tells Yahoo Life. “We would offer it without the vocabulary. But I think ‘aesthetic flat closure’ is a nice encapsulation of what patients should be seeking if they want flat closure.” Tiwari, who reached out to Bowles early on in her protesting after reading a story about her, says he was eager “to solicit opinions from people who spent a lot of time thinking about it,” and by doing so, has learned quite a bit about how to approach the procedure.
“We saw flat closure as just another option for patients, and never really distinguished it… but I think over the past two to three years we’ve thought of it in more of a formalized fashion, especially when we had a few patients really coming to ask for it,” says Tiwari, whose Midwest Breast & Aesthetic Surgery practice now dedicates an entire page of its website to flat closure, even noting, “Many women have begun to embrace Flat Closure as a movement and a way of life. Flat Closure is a chance for women to accept their new, post-breast cancer bodies as both beautiful and valid.”
Still, ‘flat denial’ is real
Such strong support for eschewing reconstruction, though, tends to make Tiwari an outlier, as plenty of women continue to report being pressured by surgeons to have breasts at any cost.
Just how many women are choosing it? The number of women opting for reconstruction in the U.S. has been steadily rising since 1998, which is when the Women’s Health and Cancer Rights Act was signed into federal law to ensure that insurance coverage is provided for patients who choose breast reconstruction in connection with a mastectomy — somewhere between 40 and 60 percent, according to various statistics combined with the steady rate of increase between 2009 and 2014.
And now, some would say the law has become too effective, as it’s led some surgeons to make the default assumption that reconstruction is something desired by all women.
But at least one collection of data has found that 25 percent of double mastectomy patients choose to stay flat, while about 50 percent of single mastectomy patients also make that choice — citing reasons that range from wanting to avoid additional surgery and its associated risks to not wanting a foreign object implanted. For others, it’s just not a priority, with some rejecting the notion that they need breasts to feel whole.
Still, according to results of a soon-to-be-released research survey of flat-opting women by Dr. Deanna Attai, an assistant clinical professor of surgery at the Geffen School of Medicine at UCLA, only 64 percent of respondents were initially offered the option of going flat by their doctor; 30 percent, meanwhile, felt their surgeon did not support their decision to go flat. So, what’s behind that lack of support?
“There is no data on this, and it’s actually one of the things I want to understand better,” says Bowles. “It’s a lot of different factors forming the perfect storm. At the core of it is this paternalistic notion that your opinion should supersede the patient’s decision.”
For Jenny Beaupre of Illinois, who was diagnosed with breast cancer right at the start of the coronavirus pandemic, in March, opting to go flat on one side following a unilateral mastectomy was the natural choice for her. Still, she tells Yahoo Life, she understood that “for the plastic surgeon, it’s her job to promote it, to say there are no problems with it — even though implants can leak and it brings a risk of cancer, which they kind of glossed over,” she says. “I didn’t want to have that anxiety, trying to get rid of the cancer.”
“I think a lot of people just want you to go back to what they consider being normal, which is two boobs,” Beaupre, 41, says. “But things happen in life and you have to deal with it, and for me, [reconstruction] just wasn’t the best option. Some people, that’s what they want. But I’m glad I didn’t choose it.”
She’s in the majority with others who have gone flat, according to Attai’s research, which found that 74 percent of women who made that choice “agreed or strongly agreed that they were satisfied with their surgical outcome.”
On the other side, a 2018 study by Dr. Clara Lee, a plastic surgeon specializing in breast reconstruction at the Ohio State University Comprehensive Cancer Center, found that women who chose immediate reconstruction after a mastectomy overestimated how satisfied they would be with their appearance, while women who chose not to reconstruct generally underestimated future satisfaction. Further, Attai found that one in three women who undergo reconstruction face complications.
“It is important for us to help our patients understand that breast reconstruction does restore some aspects of well-being but not all of them,” Lee noted in a release about her study. “Also, a woman’s feelings about herself, and even about her appearance, is about many things besides her breasts.”
Part of what might prevent some surgeons from being flat-supportive, notes Tiwari, is “enforced standards of beauty — standards that are societal, cultural,” along with “not really appreciating that flat closure is an option, and not a failure. Some people see it as, rather than a patient-empowered choice, a default when everything else fails. I think [the key is] reframing the problem from ‘how can we achieve reconstruction’ to ‘how can we achieve an outcome that’s most congruent with a patient’s desires and quality of life?’”
Ridgeley, who recently joined the board of the Dr. Susan Love Foundation for Breast Cancer Research, believes that the bottom line is messaging the long-buried truth: that flatness is embraceable. It’s why she’s praising the addition of “aesthetic flat closure” by the NCI.
“I think it’s phenomenal,” says Ridgeley, who released a new flat-closure PSA video with other activists on Oct. 7. “I think it’s right up there with getting breast implants recognized as a safety risk,” she adds, referring to long-awaited safety guidelines that came from the FDA in late September. “Because if you’re going to start telling women that implants are unsafe, and they think what they’ll be left with is something monstrous or deformed, then you’re setting them up for failure. But with ‘aesthetic flat closure’… you’re saying that you can wear a T-shirt, it can look smooth, you can get amazing tattoos. It’s aesthetic… So really putting that term out there is letting people know: This can look good.”
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