Tracy Tyner, NP, is an acute care nurse practitioner with 25 years of nursing experience. She was diagnosed with breast cancer in 2017 and had a double mastectomy with flat closure in 2018. After her surgery, she decided to go back to school for a nursing PhD so she could learn to conduct research that will hopefully help other people who are considering or choosing mastectomy with flat closure.

When I found out I had ductal carcinoma in situ (DCIS), an early-stage breast cancer, I knew immediately that I wanted to undergo a double mastectomy due to my family history of breast cancer. Next, I needed to decide whether I wanted to have breast reconstruction or remain flat, a procedure defined as “aesthetic flat closure” or “flat closure.” When a person has a mastectomy with flat closure, the extra fat, skin, and other tissue are removed in the breast area and the remaining tissue is tightened and smoothed out to flatten the chest wall. Deciding whether to “go flat” was probably one of the hardest decisions I have ever had to make in my life.

As a nurse practitioner, I had cared for people undergoing breast reconstruction and had a good idea of what these procedures involved. However, I knew nothing about flat closure. I reached out to others who had gone flat through online support groups to find out what it was like to undergo a mastectomy with flat closure and to live flat.

Through these online groups, I heard various stories and saw lots of pictures of flat chests. It was pretty eye-opening. Most people seemed happy with their results and their decision to go flat. Some had amazing results with a smooth, flat chest wall, but I was shocked to see others with excess sagging skin or skin pockets that looked like they were designed to hold a breast implant. Many of those who were left with excess skin after requesting flat closure were devastated by their results. Some were told that the excess skin was left behind in case they changed their minds and wanted future breast reconstruction. Others may have been due to poor surgical technique or lack of surgeon experience with flat closure.

A recent study found that most women were satisfied with their flat closure results. However, 34% of women reported not receiving adequate information about their surgical options, and 20% did not feel their decision to go flat was supported by their surgeon. Some women even experienced flat denial, which is when a surgeon denies their patient an agreed-upon flat closure either through negligence or disregard.

Although many people in my online support groups reported good surgical outcomes, the pictures of those being left with excess skin gave me pause. As I was leaning toward flat closure, I needed to make sure that my surgeon and I were on the same page and that she knew exactly what I wanted and expected for my results. I needed to find that balance between autonomy, which is respecting the right of a patient to make their own decisions, and paternalism, which is when an authority figure makes decisions for a patient that is deemed within their best interest and can be a factor in flat denial.

I knew I could not make an informed decision independently, as I did not have the comprehensive knowledge about all aspects of my surgical options. I also did not want a surgeon who would override my decision to go flat because they thought I would be happier with breast reconstruction or that reconstruction would better align with societal expectations of women. I wanted a surgeon who respected my views in conversations about my body and who listened and supported me while making this difficult choice.

Doing my homework before deciding to go flat

In preparing for my surgical appointment, I did lots of research online about both flat closure and breast reconstruction. I reached out to others who had undergone flat closure. I found pictures of nice flat closures to show my surgeon so she knew what I expected. I also wrote down a long list of questions to ask. I even saw a plastic surgeon to make sure I understood all my reconstructive surgical options. 

On the day of my appointment, my breast surgeon described all my surgical options in detail without pressuring me one way or the other. She listened to my concerns and provided unbiased, non-judgmental answers to my questions. She showed me photos of other people that she had done flat closures on to reassure me of her skill level. She supported me throughout the decision-making process, even when I knew some of my questions might seem silly or trivial.

Even as a health care professional, hearing that you have cancer can fill your head with emotions and thoughts that may cloud your thinking. My surgeon helped ground me and offered guidance based on the available information and research about my surgical options, while still considering my personal preferences and the rationale for my decision. She and I experienced “shared decision-making,” a collaboration between a patient and their doctor that offers a balance between autonomy and paternalism. She provided me with the information and support I needed to make a healthy, informed decision about my body that aligned with my values and priorities. I left that appointment knowing she heard me, knew what I wanted, and respected my decision.

The big reveal

When I awoke from my mastectomy with flat closure and looked at my chest for the first time, I was filled with emotion due to the loss of my breasts. But I was also able to breathe a huge sigh of relief. I got the flat closure I was seeking. I am so glad I took the initiative to do my own research, get information from others who had undergone flat closure, and had a supportive surgeon who took the time to listen to me. Taking an active role in the decision-making process and having the right breast surgeon allowed me to get the surgical result I wanted.

It has been almost 4 years since my surgery, and I am still pleased with my decision to undergo mastectomy with flat closure.

The author has no relationships relevant to this content to disclose.