Clear Language: “Flat Closure”

What does the term “flat closure” mean?

Flat closure = chest wall reconstruction post-mastectomy

Flat closure is shorthand for surgery to reconstruct the chest wall contour post-mastectomy. It is a patient-friendly term that serves as a stand-in for the more cumbersome technical description. The mastectomy first removes the glandular tissue of the breast, and the subsequent closure involves surgical contouring of any remaining excess fat and skin to reconstruct a smooth, flat chest wall contour. Hence, flat closure.

Patient-FriendlyTechnical Term (Synonym)
facelift rhytidectomy
explant total capsulectomy
tummy tuckabdominoplasty
flat closurechest wall reconstruction post-mastectomy
Patient-friendly “colloquialisms” are useful as shorthand for the more cumbersome technical definitions.

Why do we need a new medical term? What’s wrong with the one we have now, “nonreconstructive mastectomy”?

As a medical term of art, nonreconstructive mastectomy is both inaccurate and overly broad. Flat closure falls squarely under the category of reconstructive (rather than cosmetic) surgery because it restores a normal anatomic contour, the chest wall. The term nonreconstructive mastectomy also fails to specify any aesthetic result. Mastectomy only defines the removal of the breast glandular tissue, and the addition of the qualifier does nothing to rectify this problem.

The reality is that patients going flat don’t just expect a mastectomy. They expect an aesthetically pleasing flat closure. And for good reason – almost all publicly available images of mastectomies without breast reconstruction, including NCI’s Visuals Online and Mayo Clinic, depict exactly that – aesthetic flat closure. It is this climate that creates the expectation among patients that an aesthetic approach is standard and that they don’t need to be more specific. But the reality they wake up to after surgery is very different. Our research shows that between 10-15% of patients going flat are left with an egregiously poor cosmetic result that they did not expect. Providers’ use of an overly broad term of art contributes to this problem of mismatched expectations.

There’s a reason patients expect aesthetic flat closure. If you expect the results on the left, and wake up to the results on the right, how would you feel? (Images at left from NCI and Mayo Clinic)

Why does it matter if flat closure is considered reconstructive or cosmetic?

This distinction is not about semantics – it is in fact critical in determining women’s access to care. Most health insurance companies do not cover cosmetic surgery. It was only with the passage of the WHCRA in 1998 that insurance companies were finally forced to cover post-mastectomy breast reconstruction. The law states that its mandate applies to “those who elect[s] breast reconstruction.” Understandably, this is often read to explicitly exclude flat closure. This outcome is in direct opposition to the intent of the WHCRA, which was to ensure mastectomy patients’ access to an aesthetic result of their choosing.

This language deficit and the problems it has produced have led patients to create their own language. The term “flat closure” entered the patient community’s lexicon in August of 2018 with NPOAS’ publication of our article about misaligned financial incentives in the mastectomy setting, “Conflict of Interest for Flat Closure”. This article was published on Facebook in August, and on the website in September shortly after our first Awareness Walk. The term has since been adopted for general use by patients and providers alike, demonstrating its utility.

The current term of art is inadequate.

By defining flat closure negatively, as essentially “the absence of breast reconstruction,” the currently accepted term of art nonreconstructive mastectomy:

  • perpetuates the myth that flat is a second class choice which does not deserve aesthetic consideration;
  • directly puts insurance coverage at risk by defining flat closure as a cosmetic procedure; and
  • is just plain inaccurate – flat closure is reconstructive, not cosmetic.

Durable change requires institutional buy-in. That’s why we have been working with the NCI (National Cancer Institute) to include “flat closure” in their official Dictionary of Cancer Terms. NCI agrees with us that “…a definitive semantic representation of the procedure is important for communication of aspects of clinical care in the patient population with a nonreconstructive mastectomy.” There really is no argument that a unique term of art is necessary for every medical procedure, nor that the existing term of art is inadequate. 

“Reconstructive” vs. “Reconstruction”

The NCI Dictionary defines reconstructive surgery as “surgery that is done to reshape or rebuild (reconstruct) a part of the body changed by previous surgery.” Flat closure clearly falls under this umbrella. So why not use the term “flat reconstruction” or something similar? The reason we do not use these terms is that they do not identify the anatomic contour being reconstructed – the chest wall. The analogous term of art, breast reconstruction, identifies the breast as the anatomic contour. By the same logic, if we are to use the term reconstruction for a flat procedure, it should similarly identify the anatomic contour. Hence, chest wall reconstruction.

Have other terms of art been used to describe flat closure?

Several other terms of art synonymous with nonreconstructive mastectomy can be found in the scientific literature, but they all have drawbacks both in terms of accuracy and specificity. These terms are:

  • oncoplastic mastectomy (link)
  • non-skin sparing mastectomy (link)
  • mastectomy without reconstruction  (link)
  • aesthetic primary closure post-mastectomy  (link)

Oncoplastic Mastectomy

A mastectomy with flat closure falls squarely under the umbrella of “oncoplastic surgery,” which combines oncologic techniques (to remove the cancer) with aesthetic techniques to reconstruct a contour such as a breast mound or chest wall. Using similar logic, flat closure could be called an “oncoplastic mastectomy” because the term specifies the intent (onco- = cancer, plastic = aesthetic). Also along these lines, “oncoplastic reduction” is a term of art currently in use that describes a breast reduction (plastics procedure) with a lumpectomy (oncologic surgery). “Transgender mastectomy” is another example of an intent qualifier – this surgery restores a masculine chest contour for patients whose breasts conflict with their gender identity (notably, this procedure does not necessarily remove all of the glandular tissue).

Non-Skin Sparing Mastectomy

This term has the advantage of clearly describing what additional tissue should be removed during the procedure. However, it suffers from the same problem posed by “nonreconstructive mastectomy,” which is it negatively defines the procedure and does not specifically describe the aesthetic outcome. Lateral (side) tissue for example could be left because it is not “extra skin.”

Mastectomy Without Reconstruction

This term suffers from the same problems as nonreconstructive mastectomy.

Aesthetic Primary Closure Post-Mastectomy

This term somewhat defines the aesthetic approach that patients expect but does not explicitly define flat closure as reconstructive, and could potentially even be interpreted to define it as cosmetic (“aesthetic”).

Flat Closure: Post-Mastectomy Chest Wall Reconstruction

This brings us full circle, to our term of choice – post-mastectomy chest wall reconstruction. It is an affirmative definition, it classifies flat closure as reconstructive, and it defines the desired aesthetic outcome as approximating a breast-free chest wall contour. Its specificity is also an advantage over oncoplastic mastectomy.

Clear language serves the interests of patients and providers alike. It’s time to #putflatonthemenu!

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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