Aesthetic Flat Closure After Mastectomy Gains Recognition

LAS VEGAS—While the majority of breast cancer patients who undergo mastectomy opt for some form of breast mound reconstruction, many prefer to remain flat, which is a different type of reconstruction and requires skill to obtain an aesthetically desirable outcome.

“[While] many of us have spent a lot of time and effort learning how to perform nipple-sparing mastectomy, many of us have not received specific training on how to perform an aesthetic flat closure after mastectomy,” said Deanna Attai, MD, an associate clinical professor of surgery at the University of California, Los Angeles.

The results can be visually jarring, leaving patients with bumpy, droopy pockets of skin or excessive “dog ears.”

While it’s unclear whether the number of patients wanting to go flat has increased, a growing number of advocacy groups dedicated to providing education and resources to breast cancer patients, as well as raising awareness in the lay press, have succeeded in gaining recognition for those who do not want or cannot receive traditional reconstruction.

“In part due to these advocacy efforts, the National Cancer Institute now includes aesthetic flat closure in its dictionary of cancer terms. That includes any procedure done after a mastectomy to help reshape the chest wall, essentially providing a nice, neat closure,” Dr. Attai said, speaking at the 2022 meeting of the American Society of Breast Surgeons.

Understanding the Choice To Go Flat

The reasons for which a patient may choose an aesthetic flat closure are just as unique to the individual as any other choice they may make around treatment options, some of which are highly specific. In 2006, when he was a faculty member with Texas Tech, in Odessa, Leonidas Miranda, MD, saw a patient in her early 60s who required a bilateral mastectomy. She wasn’t interested in discussing reconstruction with him, and declined an opportunity to meet with the plastic surgeon.

“I think it’s important that physicians understand what patients are thinking, so I asked why she did not want to undergo reconstruction. And she said, ‘Well, I always had this dream about riding my horse without a shirt. Now I can go ahead and do that.’ So that’s what happened. She had the opportunity to become flat, and she was very happy with it,” said Dr. Miranda, a breast surgeon with Houston Elite Surgical Care.

Another patient simply didn’t want to put off a camping trip. “She showed me her calendar with all these dates and places she was planning to camp, and said, ‘I’m just going to get my mastectomy done and move on with my life.’”

According to the largest survey to date of breast cancer patients undergoing mastectomy without reconstruction (931 respondents), the primary reasons patients choose to go flat are to expedite recovery, avoid introduction of a foreign body and mitigate the risk for complications (Ann Surg Oncol 2021;28[5]:2493-2505).

“Half of the respondents noted that their breasts were not that important for their body image. The majority were satisfied with their outcomes; [the] factors most strongly associated with patient satisfaction were surgeon support and receipt of adequate information,” Dr. Attai said.

Unfortunately, 22% of respondents were not initially offered the option to go flat, were actively discouraged from going flat or were left with additional skin, and told it was in case they changed their minds. This is an ethically dubious stance, known as flat denial, given that discussing all the options—including no reconstruction—is part of informed consent, as Abhishek Chatterjee, MD, a breast surgical oncologist and plastic surgeon with Tufts Medical Center, in Boston, told General Surgery News.

“When we talk about mastectomy, I always ask the patient whether they want reconstruction or no reconstruction. Sometimes certain operations fit a patient’s disease—how it presents—much better than other options. But I think at the end of the day, it’s a shared decision between the doctor and patient on what’s safe for the patient. Going flat is a very acceptable option if the patient chooses to do so,” Dr. Chatterjee said.

Unsurprisingly, low surgeon support was the factor most strongly associated with low patient satisfaction scores in the survey. “There is some room for improvement,” Dr. Attai said.

Improving the Patient Experience

The first step in improving the patient experience for patients undergoing mastectomy is recognizing that going flat is a valid, intentional option, and it should be offered as an option, “just as we offer breast mound reconstruction,” Dr. Attai said.

Next, surgeons should know about ideal incision placement and learn a few relatively simple techniques that can result in a more aesthetic closure. “There are certainly cases where we will have to call in our plastic surgery colleagues, but techniques such as the VY [also known as] fishtail-plasty, and incision patterns including tear drop, waisted tear drop and L-shape, are certainly within the skill set of every breast surgeon,” according to Dr. Attai.

Another step in optimizing the patient experience is better understanding what truly matters to patients. “Studies using the BREAST-Q show that patients who forgo breast mound reconstruction have poorer quality of life and outcomes compared with those who undergo reconstruction. But studies using other survey tools show equivalent or improved outcomes among this patient population. Maybe it’s not the procedure; maybe it’s how we’re asking the question,” Dr. Attai said.

Finally, aesthetic flat closure techniques should be taught in general surgery fellowship programs and in postgraduate courses, “so that breast surgeons will be in a position to provide our patients with both the oncologic and aesthetic outcomes they deserve,” Dr. Attai said.

This article is from the November 2022 print issue.