What Flat Denial Is, and Is Not

We would like to clear up any confusion about what flat denial is, and what it is not.  We want to directly address the conflation of minor cosmetic defects with the egregious results that constitute flat denial, as well as the conflation of women who were on the fence about reconstruction with those who made an affirmative choice to go flat.

Flat Denial Happens Without the Patient’s Consent

Flat denial is when the unilateral actions of a surgeon leave their patient with an unacceptable mastectomy result.

The key word here is unilateral.

When a patient affirmatively decides to go flat after mastectomy, expects a flat result, and then wakes up to a not-flat result, they experience this as a violation of their consent and as a loss of bodily integrity. The unacceptable result was created without their consent or participation.

We cannot fall for the no true Scotsman fallacy on this important issue. There are certainly going to be situations where there was a legitimate misunderstanding between the patient and the surgeon – whether that’s due to unclear communication, general misalignment of expectations, or some other benign reason. To be clear, even in these cases, the onus is on the surgeon to ensure that the patient is informed of the expected outcome.There will also be situations where the patient was truly undecided at the time of surgery, and ends up unhappy with their cosmetic result after the fact, or is unhappy with it for other reasons.

The cases of flat denial that Not Putting on a Shirt has published, do not fit this description. In every one of the cases we have published, the unacceptable result was produced in one of two ways:

  1. Through truly negligent behavior on the part of the surgeon. These surgeons either lacked the skill to create a flat contour and did not acknowledge their skill deficit, or they may have had the technical skill but simply did not want to expend the time or effort required to produce the result the patient agreed to.
  2. Intentionally through paternalism, by a surgeon who thought they knew better than the patient and decided, despite having the technical skill to create a flat contour, to substitute their own surgical decision for that of the patient and “leave a little extra in case you change your mind.”

The distinction between a true misunderstanding prior to surgery, and negligence or intentional disregard, seems to be easily obscured when images are not used to illustrate the problem. This is why at Not Putting on a Shirt, we routinely use images that may be shocking to some viewers, but that represent the reality that victims of flat denial are left to live with. This is why in our informational brochure, patients with similar body types whose wishes were respected, and whose wishes were not respected, are placed side by side so that the stark contrast between their results is undeniable.

Patients Experience Flat Denial as Malice

It would be easier in some ways, to believe that the victims of flat denial are somehow misrepresenting their experience. Accepting the reality is a hard pill to swallow. For patients, it is hard to accept that a medical professional would treat them with disregard or even malice.  And for surgeons, on the other side, it is hard to accept that some of their cohort would treat a patient this way.

The unavoidable fact is that there are surgeons practicing now, who are willing to behave in this manner, and inflict these unacceptable results upon some of their most vulnerable patients – who in almost all cases are cancer patients, and in all cases are facing the amputation of their breasts.

Is flat denial malicious? Our answer is that patients experience it as malicious. The specifics depend on the type of flat denial they experienced:

  1. Intentional Disregard. When the motive is paternalism – the surgeon believes the patient will change their mind and acts accordingly directly against the patient’s consent – and the flat denial is intentional, this denies the humanity and agency of the patient by definition. This is a superseding of the surgeon’s will, over that of the patient.
  2. Negligent Disregard.  If the unacceptable result is produced by either lack of technical skill or lack of care or willingness to spend the time and effort required to produce a good result… this also denies the humanity and agency of the patient, by devaluing the patient’s clearly stated priority to have a smooth flat result.

If a surgeon cannot or will not produce a result that falls within the boundaries of acceptability for the patient, it is their duty to communicate this clearly to the patient so that she can make an informed choice about her surgical care. Typically this will mean either bringing on a plastic surgeon to the team to fill the skill deficit or referring the patient to a colleague who either has the technical skill or is themselves willing to bring on a plastic surgeon.

There can be no allowance made for paternalism in medicine. There can be no excusing the misleading of a patient about their expected result, whether by affirmative statements or by omission.

Priorities and Being“One and Done”

Flat denial cannot be understood without highlighting the importance to most patients who choose to go flat, of being “one and done.” To a surgeon who sees hundreds of patients a year and is accustomed to seeing those patients lying on their operating table, revision surgery to repair an unacceptable mastectomy result may not seem to be “a big deal.”

But it is a big deal to the patients.

It is a big deal to the patients, for many reasons. These reasons can be highly personal and variable, but there are some common themes.

The population of patients that has chosen affirmatively to go flat, have different priorities from the population that chooses to reconstruct. Their valuation of the avoidance of unnecessary surgical risk, and of a quick recovery time, is relatively high. Many patients who choose to go flat simply have no interest in having reconstructed breast mounds, but there are also those who might consider reconstruction at a later date if their priorities change – and so affirmatively choose to go flat at the time of the mastectomy.

These are not patients who are on the fence.

These are patients who affirmatively decided to go flat, communicated that to their surgeon, and understood that there was mutual agreement on the expected outcome… and then woke up to another outcome entirely. This is flat denial: choosing to go flat, and then having that choice taken away from you.

The Two-Axis Spectrum of Skill and Regard

Flat denial is also not a matter of unavoidable minor cosmetic defects. Again, the no true Scotsman fallacy comes into play here. Yes, there will always be some patients who are unsatisfied with their cosmetic result despite the best efforts of a skilled surgeon or team of surgeons producing the best result they can in good faith. These are not the patients who stories we share here at Not Putting on a Shirt, and whose experiences we label “flat denial.”


Patients who have been subjected to flat denial have egregiously poor cosmetic results that were truly avoidable:

  1. Negligent flat denial typically yields poor quality closures with folds, puckers, unevenness and pronounced asymmetry.
  2. Intentional flat denial typically yields high-quality, smooth incisions devoid of folds and puckers, and carefully achieved symmetry, but with varying amounts of excess skin, some of which rise to the level of a “skin-sparing” procedure.

In this framework, the degree to which the cosmetic result is poor and avoidable exist on a two axis spectrum, the axes being (x) “skill” – technical competence in flat closure, and (y) “regard” – respect for the patients wishes:

Counterclockwise: Bottom left – negligent flat denial. Bottom right – intentional flat denial. Top right – good flat result. Top left – minor defects, referred patient, and bringing on a plastic surgeon

What Is The Solution?

In order to bring the patients on the bottom of the chart up to the top right, in one surgery – which, again, is highly valued amongst patients going flat and is one of the factors driving their decision in the first place – both regard and skill must be corrected.

Skill. Because flat mastectomy closure techniques are not routinely taught in medical school right now, general and breast surgeons often must seek out additional training if they are to acquire the skillset required to produce good flat results for their patients. Alternatively, they can bring on a plastic surgeon – who already has the skillset – for the closure. There are barriers to both of these solutions, which Not Putting on a Shirt is working on addressing in collaboration with other patient advocates and medical professionals. Stay tuned!

Regard. This is a more deeply rooted, cultural problem. Why do some surgeons lack regard for the wishes of their patients who choose to go flat? Most surgeons don’t lack regard for their patients who choose reconstruction. What’s the difference? Clearly, sexism is part of the answer – the historical, paternalistic notion that women need to appear to have breasts in order to feel or be “whole” continues to dog the women of today. The notion that women going flat will “change our minds” is also rooted in paternalism.

One of the best ways to address the regard aspect of flat denial, is the flat advocacy movement that we have seen develop over the last decade or so. Early pioneers like Melanie Testa started baring their flat chests publicly and proclaiming to the world that flat is a valid, healthy, and beautiful choice. In 2014, Flat and Fabulous picked up the banner.  And the work continues today with organizations like Flat in Canada , Flat Friends UKThe Flat Advocate, and of course, FlatClosureNOW. Publicly and happily living flat is starting to lose its stigma thanks to the tireless work of advocates like these. But clearly, we still have a long ways to go.

Not Putting on a Shirt is committed to putting an end to flat denial.

Join us!


Published by Not Putting on a Shirt

Founder of Not Putting on a Shirt, a mastectomy patients' rights organization that advocates for optimal surgical outcomes for patients going flat.

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