Kim Bowles wanted to go flat after a mastectomy, but she says her doctor didn't listen. Stephanie Strasburg

When Kim Bowles woke up in the hospital recovery room, a thick white gauze blanketed her chest. She knew she shouldn’t disturb the surgical dressing, but she had to see. She tugged at the edges of the bandages until they were loose enough that she could steal a glimpse of the results of her hours-long surgery. But underneath, where she hoped to see nothing, there was definitely something—two sagging pockets of empty skin on her chest, like a set of worn pillows that someone had pulled the stuffing out of.

That’s when she got mad—“set-the-world-on-fire levels of mad.”

Bowles, a stage 3 breast cancer survivor, had just undergone double mastectomy surgery and had told her surgeon to make her “flat”—that is, do not reconstruct her breasts. No implants. No molding of a boob from excess skin. Nothing. But as the fuzzy haze of anesthesia began to wear off, she realized he had completely disregarded what they had agreed upon—her body reshaped by a doctor while she was unconscious.

“My surgeon unilaterally decided to go against what I had consented to while I was on the operating room table. Motherfucker.”

This year, 266,000 new cases of invasive breast cancer will be diagnosed, as estimated by the American Cancer Society, and more than 100,000 women will undergo a mastectomy to treat or prevent cancer. Although women traditionally have chosen to reconstruct their breasts—either through implants or a breast formed from excess skin and tissue—now more women than ever are feeling empowered to go flat.



Roughly 25 percent of double-mastectomy patients and 50 percent of single-mastectomy patients opt out of reconstruction, according to a study published in the Journal of Clinical Oncology. “Many women do it for comfort, others are athletes, and many women simply don’t want implants—they want to stay as simple and true to nature as possible,” says Patricia Clark, M.D., a breast cancer surgeon in Scottsdale, Arizona.

But while women have begun to reject reconstruction, the only thing doctors seem to be rejecting is their patients' wishes.

“In my research I've found that many women are completely surprised at the outcomes when they come out of surgery,” says Gayle Sulik, Ph.D., founder of the Breast Cancer Consortium and author of .

Not only have doctors reportedly urged patients to reconstruct without even discussing the option of going flat, some women say that they’ve woken up to find that their surgeon left them with extra skin in case they change their minds and want to build a breast later (commonly referred to as a “skin-sparing mastectomy”). If confronted post-surgery, doctors often lean on the excuse that they had to it for medical reasons, such as making sure the patient has proper range of motion.

Bowles had always had a complicated relationship with her breasts. She grew up trying to hide her “ginormous” size 36HH boobs, uncomfortable with the attention they brought her, especially from men. And as a natural athlete who loved to run and swim, she always felt they held her back.

“Everything was harder with boobs that size,” she says. “When I swam, I had to wear an expensive underwire bikini top under my racing suit—otherwise my breasts would fall out of the sides of my Speedo. You need industrial-strength scaffolding to hold up 10 pounds of boob.”

To go from that to flat may seem extreme. But not for Bowles.

Five months after her diagnosis, in 2016, chemotherapy had melted the golf-ball-size lump in her right breast, and after doing substantial research, she decided she wanted to go flat. She believed that without her big breasts she’d be able to move more freely, run and swim with ease.



“I was ready to let my breasts go and was actually happy at the prospect of having them gone,” she says. Cancer had torn her apart, but now she was putting herself back together—on her terms.

Becky Fitz and what she calls her "pit tits." courtesy of becky fitz

After she made her decision, Bowles felt relief. She went online to find support, but also found something else. Women in Facebook groups, like Young Survival Coalition and Flat & Fabulous, described being pushed toward boobs, or worse, waking up expecting a smooth chest but discovering “droopy” pockets of skin.

The evidence was there for her viewing. Photos of women with “empty bags of flesh” where a flat chest should have been filled her feed, she says. “I used to work at a veterinarian’s office and our vets wouldn’t have done that to a dog,” Bowles says. “I couldn’t believe surgeons had left women looking like that.”



Becky Fitz was one of them. She says she told her doctor she wanted to go flat and he agreed to her request. But when she woke up from her double mastectomy, the result was not at all what she had asked for. Instead, on her chest were two pointy peaks of tissue, and the excess skin left behind dangled under her arms like stretched-out dough. “I call them my pit tits,” she says.

She estimates the tissue under her right arm could fill an A-cup and the left side could fill closer to a B. It’s so bad that she can’t sleep on her side or even lower her arms completely. “I have a funny shape to me that makes people stare,” she says, her voicing trailing off.

According to Fitz, when she asked her surgeon what happened, he explained that he was worried she would change her mind and want to reconstruct later. “I’m told that I’m lucky to be alive—but this isn’t living,” Fitz says. But because she has an autoimmune disease, she’s decided she’ll have to live with the outcome. “Surgery is incredibly hard on my body,” she says. “I just can’t go through a revision.”

Bowles shows the results of her surgery.

After reading stories like Fitz’s, Bowles was determined to make sure her doctor respected her wishes to go flat. She messaged women, listened to their experiences, and took their advice. They told her to clearly state her desire to go flat (she did), to put it in writing (she drafted a letter), to take a witness (she took her husband), and to provide photos of the smooth, flat chest she was hoping for (she provided six).

“When I met with my surgeon, I told him that I had seen other women left with skin to facilitate reconstruction and that I couldn’t live like that,” Bowles says. “I didn’t want to be reminded of what I’d lost. I told him I needed to be completely flat with no extra skin at all.”

She chuckles at the memory of her husband pulling her aside and telling her, Enough already. I think he gets it. But she stops laughing when she describes what happened next.

To state what should be obvious, you do not have to have boobs to be a woman. But experts say there are long-held beliefs around femininity and sexuality that are in direct conflict with the request to go flat. The surgical world is very paternalistic, says Clara Lee, M.D., an associate professor of plastic surgery at Ohio State University. “Many surgeons don’t know how to deal with a woman who’s deeply engaged in her own decision making.”

And they’re not always subtle about it either. Women who have stated their intention to go flat report that doctors can be pretty explicit in their anti-flat bias. In one case, a woman's surgeon called her at home the night before her surgery begging her to change her mind, saying she was too young to live without breasts. Another said her doctor implied she'd never be able to get married if she didn't opt for faux-boobs over going flat.



There’s a notion that “surgeons know best,” Sulik says. And many of those surgeons happen to be men. A report by the American College of Surgeons found that women make up only 15 percent of general surgeons and 13 percent of plastic surgeons.

But it’s not just misogyny bleeding into medicine: The majority of breast cancer surgery in the United States is done by general surgeons with no specialty training on how to handle breast disease, according to a study in the Journal of Clinical Oncology. The study pointed out that when breast cancer patients were treated by a surgeon that lacked specialization, they reported a lower level of satisfaction with their care compared to those who were tended to by a specialized surgeon.

"Breast cancer is still considered a true general surgery procedure,” says Julie Margenthaler, M.D. the director of breast surgical services at Washington University School of Medicine and a spokesperson for the American Society of Breast Surgeons. “But achieving a cosmetically pleasing outcome requires nuance that is hard to learn if you’re only doing a couple of mastectomies a month.”

Even surgeons who see a high-volume of breast cancer patients in need of mastectomies (more than 30 a month) may struggle to get a beautiful, flat result, Clark says. That's because when it comes to perfecting technique, breast surgeons focus on the surgeries they perform the most, which is still breast reconstruction, she says.

So in some cases, it’s not that a doctor left a pouch of skin to stuff an implant into later, but that they just weren’t able to pull off an unobtrusive scar. Instead, there’s a puckering of skin that hangs, drapes, bulges, sweats, and chafes.

Bowles at her home in Pittsburgh, Pennsylvania. Stephanie Strasburg

Bowles was on the operating room table seconds away from going under anesthesia when, she says, she heard her surgeon tell her, “I’m just going to leave a little extra skin in case you change your mind.

Bowles knew the sedative was “dripping into her veins” and that at any second she would cede control to a surgeon who had just revealed his intention to do something she’d explicitly asked him not to do. She felt panicked, but her body was unable to move. She recalls saying no twice, repeating that she wanted to be flat.

Then everything went black.

When her eyes blinked open after the procedure, she was devastated by what she saw under her bandages. “Every time I looked at my chest I'd get sick to my stomach,” she says. “There was nothing I could do. The deed was done.”

Reached for comment, the hospital provided the following statement: “Taking care of patients is our top priority. In this instance, Ms. Bowles chose to have a double mastectomy after having chemotherapy for her tumor. Per her wishes, she opted not to have further surgical revisions that are common for patients who have had mastectomies. The physicians involved in her care have outstanding reputations and are highly skilled. We conducted three thorough reviews relating to her concerns and shared with her that it was determined every aspect of her care was done optimally to give her the safest amount of extra skin to prevent jeopardizing her arm movement.”

But Deanna Attai, M.D., a breast surgeon and assistant clinical professor of surgery at the David Geffen School of Medicine at the University of California, Los Angeles, refutes that notion: "That’s bullshit. Leaving the excess skin—it’s no easier to move the arms either way.”

Previously easy-going and confident, Bowles was overcome with grief and disbelief for months after the surgery. “I couldn’t stand to take a shower because whenever I saw my chest I was reminded of the violation—it still makes me nauseous,” she says. When her young son was invited to a friend’s pool party, she declined because she was too humiliated to put on a swimsuit. She wore tank tops on top of tank tops on top of tank tops to conceal what remains of her breasts. “Often I’d have on three layers of clothes,” she says. “I was always overheated, but I was too embarrassed to take anything off.”

Bowles' experience is one that BethAnne King is all too familiar with. After being told in 2015 that she had breast cancer, she knew she wanted to go flat—the same option her grandmother had made after her double mastectomy. "I wanted to be like her and not have reconstruction," King says. But when she woke up from her surgery, there it was—extra tissue. "I looked messed up," she says, choking back tears. "There was a twisted part of skin that was lumpy. I felt so embarrassed, and stupid—I trusted that the surgeon would do what I had asked. It was bad enough that I had cancer—I certainly didn't want to look at the leftovers of it every damn day."

She never confronted her doctor or filed a formal complaint—many women don't. Some worry it may impact their treatment going forward. And historically, women have struggled to get doctors to take their complaints seriously. The stigma prevents many women from speaking up in the first place or compels them to quickly back down if their concerns are dismissed.

“Surgeons need to honor a patient’s request to go flat just as they would for a patient who wants to reconstruct,” Attai says. “Not all breast cancer patients want to reconstruct, but all people want to feel good in their bodies.”

BethAnne King after her double mastectomy. Shawna Lobmiller

And it’s not just about listening to what women want—there are serious health ramifications for women who undergo reconstructive surgery, too. Many women choose to go flat because it’s an easier procedure to recoup from and they want to minimize their recovery time. Breast cancer reconstruction often involves multiple surgeries and a new study published by JAMA Surgery found that one in three women who reconstruct after breast cancer suffer a major complication, such as infection.

Now Bowles is faced with another decision about her body. Does she want to correct the extra skin she was left with? “I’m torn,” she says. “On the one hand, I don’t want to because it’s a purely cosmetic surgery and I don’t want to risk my life for a cosmetic result. On the other hand, whenever I see my chest I’m reminded of the surgeon violating me. It’s unwinnable.”

But that doesn't mean she's done fighting.

Two weeks after her surgery, Bowles filed a complaint with the hospital, but about two months later, administrators closed the case, saying their investigation didn’t find that the doctor had done anything wrong.

In June of this year, she conducted a one-woman, topless sit-in outside the hospital CEO’s office. She walked in, sat down, briefly introduced herself, and whipped off her shirt. Security forced her to leave within minutes. But she was back at the end of the month to deliver a petition demanding the hospital put systems in place to hold surgeons accountable for poor mastectomy outcomes (it has nearly 37,000 signatures, mostly from breast cancer patients and their families and friends).

And she isn’t stopping there in her role as the de facto leader of the reconstruction resistance. On September 8 she’s organizing the first Not Putting On A Shirt Nationwide Walk in Cleveland, Ohio, in which women will join her to march topless and raise awareness around the issue. A sister march will be held in Los Angeles in the same day.

Others are trying to shift breast cancer culture from inside the medical establishment. Clark is committed to training surgeons in the art of the flat mastectomy. She travels to surgical conferences, such as those sponsored by the American Society of Breast Surgeons, and teaches a workshop called “Oncoplastics for Dummies” (oncoplasty means bringing some principles of plastic surgery to cancer surgery).

Bowles hopes by speaking up, this won't happen to other women. Stephanie Strasburg

“Women have to live with this outcome for the rest of their lives,” Clark says. “The burden is on surgeons to make it a good one.” She notes that more recently trained surgeons are more interested in learning techniques that make a woman truly flat, which she says is a hopeful sign. But she predicts it will take five to 10 years for the new class of doctors to fill the pipeline.

It's progress, sure, but that's a lot of years and a lot of women will go under the knife during that time. Rather than waiting for the surgical profession to catch up, Bowles has a better idea: Why don't we just treat women and their bodies better now?



“Everything about cancer is out of your control,” Bowles says. “The one thing I could control was what my chest looked like and to have someone casually snatch that away is insulting, demoralizing, and traumatizing. This can’t keep happening to women—it’s got to stop.”

Catherine Guthrie's debut memoir will be published this month.

