Welcome to my Flat Forum!

When you write a book, you have to make so many decisions about what to include and what to cut. For “Flat and Happy,” I interviewed dozens of patients about their experiences, but not all of those interviews made it into the final edit. And since publishing the book, I’ve heard so many important stories that deserve a wider audience. So I decided to create this blog as a place to keep the conversation going.

In the book’s introduction I list some reasons why I felt compelled to write it:

…because I thought losing my breasts would be hard, and it’s turned out to be surprisingly easy. Because women confronting mastectomy need to be aware that choosing to go flat could potentially save them a lot of pain and difficulty. Because I want to help women understand that a doctor’s opinion about reconstruction is only that: an opinion. And because I now know that all too many women have reconstruction because they don’t realize there’s an alternative.

Even though I knew the truth of that last statement when I wrote it, I continue to be gobsmacked when I see it play out in patients’ interactions with their surgeons. Recently I spoke with a friend of a friend who was trying to decide between undergoing a third lumpectomy or a bilateral mastectomy. Having already had radiation on both breasts, this woman is not a candidate for expander-implant reconstruction, and she had no interest in undergoing a flap procedure that would require her to recover from multiple surgeries at once. Having been given a copy of my book, she asked her doctor about aesthetic flat closure (AFC) only to be told that she “didn’t know what she was asking for” and that she would be miserable with the results. “You’ll be concave. Your ribs will show. You’ll hate it,” her surgeon told her. “There are studies that show that women who go flat are unhappy.”

Fortunately, this woman is a total badass who didn’t just take her surgeon’s word for it. She did her own research, confirmed her instinct that reconstruction definitely wasn’t for her, and ultimately persuaded her breast surgeon to work with a plastic surgeon to close her up flat. As I write this post, her mastectomy surgery has been scheduled, and I hope that she’ll get a beautiful flat closure and will quickly adapt to living without breasts. But I’m troubled that things could so easily have gone another way for her. And I can’t help thinking about all the other patients who are relying on their doctors’ advice and are being confronted with a wall of bias and misinformation.

For the record, I believe this surgeon was well intentioned. She has taken good care of this woman through her two previous lumpectomy surgeries. But everything that she has read seems to have fed her pro-reconstruction bias. It’s unfortunate that she doesn’t know that there is a rowdy cohort of women who are living happily and unapologetically flat. Nor is she aware that the studies she’s citing suffered from badly flawed methodology. As more recent studies have proven, when bias is removed from the questions, it turns out that women who go flat are just as satisfied with their closures as women who have reconstruction are with their rebuilt breast mounds.

And the single biggest factor that determines whether they’re satisfied? Their surgeon’s support. A 2021 study found that “low level of surgeon support for the decision to go flat was the strongest predictor of a [low] satisfaction score.” On the other hand, “Greater satisfaction was associated with receiving adequate information about surgical options.”

I’ll let that sink in for a second. Just by offering the option of flat closure and supporting their patient’s decision to pursue it, doctors can increase the likelihood that the patient will be satisfied with the outcome. So why is it still so common for breast surgeons to advise their patients to get reconstruction, to fail to mention the option of going flat, to question their patients’ judgment if they express interest in aesthetic flat closure?

Like most complex questions, this one doesn’t yield to a simple answer. I believe there are a lot of factors that contribute to the medical profession’s pro-reconstruction bias. These include financial incentives, a history of paternalism towards patients and a whole lot of societal obsession with boobs (If you want to learn more about this, the final chapter of my book provides an analysis of all these interwoven factors).

So maybe a better question to ask is, “How do we change this?” The antidote to ignorance, clearly, is education. And there are so many flat advocates who are working to raise visibility for this choice. But you don’t have to be a full-time activist to make a difference. If you need to have mastectomy surgery, either because of an active cancer or for prophylactic purposes, you can help raise awareness just by asking your surgeon to tell you about aesthetic flat closure. If you choose to undergo AFC, you can tell everyone you know about the choice you made, and why. Things won’t change overnight, but eventually the ripples will spread far and wide.

My new friend had to work unreasonably hard to get her surgeon to agree to her wishes. But my hope is, the experience will persuade her surgeon (who is, after all, a decent person who wants what’s best for her patients) that there is more to the story than she previously recognized. Maybe, because of my friend’s courage, this surgeon will think twice before telling a patient that she’ll regret going flat. Maybe next time a patient of hers needs a mastectomy, she will begin the conversation by saying, “With a mastectomy, you have a few choices to make. The first is whether or not you want to have reconstruction. There are various approaches to reconstruction that you might consider, and you can have an in-depth conversation with a plastic surgeon about that. But many patients find that they don’t want to have additional surgery, and just want a clean, flat closure. If you opt for aesthetic flat closure, after the breast tissue is removed we would cut away any excess skin and close you up nice and smooth. Your recovery time would be shorter, and the risk of complications is also significantly lower. But this is a deeply personal choice, and only you can decide what’s best for you…”

A girl can dream, right?


BUT WAIT! This story has an incredible twist ending. As I was getting ready to post this blog, I got another text from my friend. I’ll let her tell it in her own words:

“The most amazing thing happened today at my pre op appointment! [My surgeon] said that since she had now learned so much from me on this whole flat movement– and has started doing some reading– she asked if she and the plastic surgeon could begin using my pre and post surgical photos in what they hope is a new approach to offering patients the choice to “go flat” in mastectomy discussions–so they can include them in their portfolio of surgical options. And she asked if I would be a spokesperson for the two practices if women considering the same wanted to connect with me. I literally started crying on the spot…. If this helps one other woman anywhere, it will all have been worth it!!”

So there you have it. We really can change the world, one mind at a time!