Research is Making the Case for Aesthetic Flat Closure

Improving the Standard of Care Must Be Based on Evidence.

The historic study on patient satisfaction with aesthetic flat closure out of UCLA published earlier this year in the Annals of Surgical Oncology was a critical step forward to parity for flat closure. It established a solid baseline characterization of the patient experience going flat and factors contributing to satisfaction with aesthetic outcome, confirming NPOAS’ own research.

Clearly, according to the data we now have, 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.

Lead authors Dr. Deanna Attai & Dr. Jennifer Baker also wrote this important Author Reflections Commentary contextualizing their research. And Tracy Tyner’s thorough literature review , which was published just before the UCLA study, showed just how little data there is on this important issue, further illustrating the need for more investment in flat closure research.

Visual Abstract by @DrAttai for @AnnSurgOncol

Extensive News Coverage

In the months since the UCLA study’s publication, multiple media outlets picked up the story to discuss both the study itself and the larger issue of parity for this reconstructive choice. The paradigm shift in considering flat closure as a valid choice worthy of an aesthetic approach is picking up steam! Read:

The Progressive Magazine - Article on Aesthetic Flat Closure
BreastCancer.org - Article on Aesthetic Flat Closure
Cure Today - Article on Aesthetic Flat Closure
US News - Article on Aesthetic Flat Closure
VeryWell Health - Article on Aesthetic Flat Closure
Cancer Health Magazine - Article on Aesthetic Flat Closure

Fact: This Affects a Lot of Women.

The number of women affected by the current suboptimal standard of care for aesthetic flat closure is significant. Around 70,000 women going flat every year, not including those who explant their initial reconstruction. A 2014 analysis of data from 1998-2007 found that over that time period, 44% of women in the US who have a mastectomy go flat. That figure includes both those who chose to go flat and those who were not candidates for reconstruction and decreased from 54% in 1998 (when the Women’s Health and Cancer Rights Act was enacted) to 37% in 2007. Unfortunately, we are not aware of any similar analysis using more recent data. Note that the above figures don’t include the significant minority (perhaps 5-15% or even higher) of women who initially reconstructed with implants that ended up removing them for one reason or another and going flat.

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.

Breaking! Aesthetic Flat Closure Research Just Published in Annals of Surgical Oncology

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.

View Abstract (PubMed)

Visual Abstract by @DrAttai for @AnnSurgOncol

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.

Before Your Surgery: Memorializing Your Breasts

Woman making plaster cast of breasts before mastectomy Image Credit: Patricia Chambers
A plaster cast can be used to create a keepsake.
Photo Credit: Patricia Chambers (SELF Magazine, 2015)
Young woman pre-mastectomy boudoir Photo Credit Claire Burnett
A boudoir session is an option for remembering your pre-surgery body.
Photo Credit: Claire Burnett (Smithsonian Magazine)

More about preparing for your mastectomy with aesthetic flat closure at the Preparing for Surgery page.

Memorializing Your Breasts: Options to Consider

You may want to consider memorializing your breasts before your surgery. Then after your mastectomy, you will have something tangible with which to remember and honor your previous breasted body. Here are a few ideas, sourced from breast cancer survivor-created lingerie company AnaOno and life coach and breast cancer survivor Melissa Eppard:

  • Photos. Photos of your breasts can help you remember them after they’re gone and play a role in supporting you through your grief and healing process. You can take intimate photos either by yourself or with a partner. Or, you can have professional photos taken – there are many photographers who specialize in boudoir, with options for all different styles and preferences. Peruse Instagram or Pinterest to gather some “inspiration” photos that you like to show to your photographer.
  • Write a letter or journal/poetry about your breasts. Or, address your letter TO your breasts – some people find a sense of peace in thanking their breasts for what they’ve done for them and “letting them go.”
  • Hold a farewell ceremony or celebration with friends and/or family. It can be as lighthearted as making a silly cake and enjoying the company and support of loved ones, or as solemn as you prefer. Some people have a special spiritual or religious practice, or meditation routine, that helps them process their feelings.
  • Make a paper mâché or plaster cast of your breasts or torso, or have one professionally made, that can be turned into a sculpture you can keep.

Some women don’t feel inclined to do any of these things, and that’s ok too – preparing emotionally for your mastectomy is a very individual process and you know what’s right for you.

Some articles and inspiration:

New Resource! Preparing for Surgery

New resource at NPOAS for women facing surgery! Preparing for your mastectomy with aesthetic flat closure can be an undertaking – it helps to know what to expect. This illustrated resource includes a pre-surgery checklist, supply list, recovery tips from patients who have been there, FAQ, and more! Visit the Preparing for Surgery and please share for women in your life who are facing mastectomy surgery.

INCLUDES:

What is a Mastectomy with Aesthetic Flat Closure?

A Note About Revision Surgery

Single or Double?

Before Your Surgery: What You Should Know

  • Pre-Surgery Checklist & Supply List
  • Personal Assistance: You Will Likely Need Help for 1-2 Weeks
  • Considerations for Caregivers
  • Sleep Environment
  • What to Wear
  • Things to Discuss with Your Surgeon
  • Emotional Support
  • Memorializing your Breasts

After your Surgery: What to Expect

  • Pain Management
  • Surgical Drains
  • Things You May Notice As You Heal
  • Stretching to Regain Your Range of Motion
  • Staying Active
  • Showering & Dressing

Moving Forward: Now What?

  • Physical Rehabilitation & Exercise
  • Scar Massage
  • Lymphedema Risk Reduction
  • Managing Chronic Pain & Functional Problems
  • Adjusting to Living Flat:
  • Body Image, Sexuality, Fashion, Tattoos, Prosthetics & More

Frequently Asked Questions (FAQ)

Glossary (A-Z)

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Meet Our Advisors: Minas Chrysopoulo, MD, FACS

Meet Our Advisors

Our Advisory Council consists of leaders in the professional community who have generously donated their time and expertise to advise the “Not Putting on a Shirt” Board of Directors. We sat down with them to talk about who they are and why they support aesthetic flat closure.

Minas Chrysopoulo, MD, FACS

Advisor, Plastic & Reconstructive Surgery, Shared Decision Making

Dr Chrysopoulo (“Dr C”) is a board certified plastic surgeon, breast reconstruction surgeon and microsurgeon, and President of PRMA Plastic Surgery in San Antonio, TX.   He specializes in state-of-the-art breast reconstruction with a particular focus on perforator flap breast reconstruction, nipple-sparing mastectomy, techniques to maximize aesthetic outcomes, and restoring sensation after mastectomy.

Dr C is certified by the American Board of Plastic Surgery, is an active member of several professional societies including the American Society for Reconstructive Microsurgery (ASRM), and the American Society of Plastic Surgeons (ASPS) for which he serves on several educational committees.  He has authored and co-authored several book chapters and scientific articles in peer-reviewed journals, and is routinely an expert speaker at regional, national and international academic meetings.

Dr C has dedicated his professional life to advocating for breast cancer patients.  He strongly believes that shared decision-making between the physician and patient is crucial in achieving the best outcomes and has built his practice on this philosophy.  To empower as many patients as possible to advocate for themselves, Dr C created the Breast Advocate® App, a free app that provides anyone with a breast cancer diagnosis, or at increased risk of developing breast cancer, a much needed voice in their breast cancer treatment planning.

Dr. Chrysopoulo is a board certified plastic surgeon specializing in autologous breast reconstruction. He is the President of PRMA Plastic Surgery, and has authored and coauthored several articles and book chapters. Dr. C is also the founder of the Breast Advocate, which is a great tool to help for patients facing breast cancer surgery understand their reconstructive options.

Learn more about Dr. C and why he supports aesthetic flat closure by watching the interview:

Disclaimer: Any and all information published by Not Putting on a Shirt (NPOAS) on behalf of a third party is for informational purposes only and should not be taken as a substitute for medical or legal advice from a licensed professional. Views expressed and claims made by third parties do not necessarily represent the views of NPOAS.

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#putflatonthemenu
#notputtingonashirt