A Critical Step Forward
An historic study on patient satisfaction with aesthetic flat closure out of UCLA was just published in the Annals of Surgical Oncology, an official journal of The Society of Surgical Oncology (SSO) and the American Society of Breast Surgeons (ASBRS). This research represents a critical step forward to parity for flat closure, by characterizing the patient experience going flat and factors contributing to satisfaction with aesthetic outcome.
Takeaways from this Research
How Bad is It? Prevalence of Flat Denial
“22% experienced “flat denial” – they were not initially offered the option to go flat, their surgeon was not supportive of their decision or tried to talk them out of the procedure, or extra skin was intentionally left in case the patient changed her mind.“ (Dr. Attai)
This figure is higher than what NPOAS’ pilot studies found, likely because the term “flat denial” was defined more broadly in the UCLA study. Our pilots found 10-15% of women going flat received unacceptable aesthetic outcomes either through negligence or intentional disregard, but this was only looking at surgical outcome and did not include the patient’s experience in consult. The UCLA finding confirms that there is a lot of room for improvement in the way the flat option is presented and executed.
If 2-3 in 20 patients going flat are denied a flat closure and another 1-2 experience disregard or disrespect for their decision in consult, improving the situation is a challenge we can, and must, rise to.
Protect Yourself: Know the “Risk Factors”
“Factors most associated with flat denial include low level of surgeon support, high flat denial score, higher BMI (body mass index), and those undergoing unilateral (one side) versus bilateral (both sides) mastectomy… [and] patients who reported that their surgeon had an exclusive breast surgery practice were less likely to be dissatisfied.” (Dr. Attai)
These findings confirm that patients going flat who choose a breast specialist (vs. a general surgeon) and who have lower BMIs are more likely to receive an aesthetic outcome they are satisfied with – and that pre-operative pushback is associated with flat denial. Additionally, the UCLA study found that patients having a single mastectomy had higher rates of dissatisfaction.
For patients going flat to advocate for and protect their choice, these findings are critical. What does this mean for individual patients? While there is no iron-clad protocol for ensuring your choice is respected, a patient with a high BMI having a unilateral mastectomy and using a general surgeon could reasonably consider their situation to be “high risk” for flat denial, and would therefore be wise to consider having a plastic surgeon involved at their initial surgery.
Overall Satisfaction with Aesthetics
“74% agreed or strongly agreed that they were satisfied with their surgical outcome.“(Dr. Attai)
This confirms the rate from our pilots as well. This is our “starting point.”
The Goal: An Improved Standard of Care
The UCLA study confirmed that three in four patients going flat are satisfied with their aesthetic flat closure. This figure can be improved upon by improving the standard of care for this population. According to Dr. Attai, this may involve:
- further research;
- better education for surgeons about the flat option and about the potential for partnering with a plastic surgeon for mastectomy with flat closure; and
- improved access to training in aesthetic flat closure technique for cancer surgeons.
“Our findings reveal a a need for additional research into factors that impact patient satisfaction as well as for surgeon education on how to optimally support women who are not interested in breast mound reconstruction. In addition, surgeons should be trained in techniques to perform an aesthetic flat closure, or partner with their plastic and reconstructive surgical colleagues so that they can provide optimal results for their patients.
Dr. Deanna Attai
We couldn’t agree more! These steps are integral to our strategic plan at NPOAS. As we enter the new year, we look forward to further collaborations with researchers, and to continuing to provide support for patients and providers who are interested in aesthetic flat closure.
Our Thanks
Our sincere thanks to the entire research team – Dr. Jennifer Baker (the principal investigator at UCLA), Dr. Deanna Attai (UCLA), Dr. Don Dizon (Lifespan Cancer Institute of RI), Cachet M. Wenziger, Elani Streja, Dr. Carlie K. Thompson, Dr. Minna K. Lee, and Dr. Maggie L. DiNome. And to all who contributed and participated in this important research!
To read more about the study’s findings or to request a copy of the article, visit Dr. Attai’s website.