Focus on Flat Closure Techniques

Awareness Continues to Spread

Word continues to spread among the surgical community that patients going flat after mastectomy expect their choice to be given the care and consideration it deserves – the same level that is afforded to the choice to reconstruct. Patients going flat expect a high-quality flat closure in one surgery whenever possible.

 


Article on Flat Denial Published in Clinical Oncology News, December 2018

Catherine Guthrie‘s scathing exposé of flat denial in September 2018 confronted surgeons with the reality of what many patients have been subjected to, and how serious the negative impact on their quality of life has been as a result of their choice being devalued, disregarded, or overridden. The article made clear that action was required on their part to address the problem.

And surgeons are taking action. Three months after Guthrie’s article came out, Clinical Oncology News, an online news and analysis resource for oncologists, published Monica J. Smith‘s article “Managing Patient Expectations Key for Mastectomy Without Reconstruction: Surgeons Discuss Techniques That Can Help With Women Who Decide Against Reconstruction”. Two surgical oncologists specializing in oncoplasty were kind enough to provide their professional perspectives on the problem. From the article:

Earlier this year, an article in Cosmopolitan magazine suggested surgeons leave excess skin behind just in case patients change their minds about reconstruction, despite their patients’ decisions to go flat. Accompanying photos document the poor cosmetic outcome…

“Those photographs are all real, but the reason excess skin was present was due to the surgeon not repairing the dog ears that naturally occur with a simple mastectomy,” said Juliann Reiland, MD, a surgeon with the Avera Medical Group in Sioux Falls, S.D. “This is a common problem among most all surgeons, and it is very distressing to the patient.” [our bold]

Not Putting on a Shirt would like to thank Dr. Reiland for explicitly acknowledging the distress that a poor cosmetic result causes the patient. This is a big step forward. Women have been suffering in silence for far too long. Another surgical oncologist and professor of surgery, Dr. Julie Margenthaler, then describes several surgical techniques that can be used at the time of the mastectomy to produce a better quality flat closure (illustrations included from the article):

There are some techniques that surgeons can use to get patients close to what they want with the initial procedure. One of the most common is the V-Y plasty, a hockey stick–shaped incision that most general surgeons learn in general training, Dr. Margenthaler said. “It takes a bit more time, but it can address some of those issues.”

… Instead of going straight across the chest, the V-Y plasty runs straight and curves up, eliminating most, if not all, of the pucker of skin that would otherwise be a dog ear… Other approaches include the M-plasty and the angel wing.

 


A Huge Step Forward: Developing Educational Courses and Videos on Flat Closure Techniques

The article goes on to say that Guthrie’s exposé has prompted much discussion among breast surgeons. Patients are reportedly coming into their surgical consults well prepared, knowing about flat denial, and advocating for themselves and their choice to go flat. Mission accomplished! Just a reminder: patients can use our brochure to help them advocate for a good flat result.

The [Cosmopolitan] article prompted a conference call among members of the American Society of Breast Surgeons (ASBrS), some of whom reported several patients in their office demanding perfect mastectomies, unlike the ones depicted in the article.

“Demanding perfect mastectomies” is perhaps an exaggeration and an understandable response to patient advocacy. Women now know about flat denial… and want to avoid it!

The article goes on to state that the American Society of Breast Surgeons (ASBrS) is developing educational courses on techniques to help surgeons achieve better outcomes in breast surgery, as well as a series of online videos that will show surgeons step-by-step how to repair defects (dog ears, etc.). The “priority video list” on the ASBrS 20th (May 2019) Annual Meeting agenda includes “MEDIAL AND LATERAL Dog-ear repair techniques.”

The ASBrS’s oncoplastic committee is developing courses on techniques to help surgeons achieve better outcomes in breast surgery; they’re also working on a series of online videos that will show surgeons step-by-step how to repair these defects. Dr. Reiland encouraged general surgeons to learn from colleagues who perform a high volume of mastectomies. She also urged them to be up front with patients about why their initial outcomes might be less than optimal.

This is a huge step forward. Training general surgeons in flat closure techniques will be critical in ensuring that women receive results they can live with following mastectomy. It’s in our mission statement at Not Putting on a Shirt. And it’s in the mission statement at our sister advocacy organization Flat Closure NOW as well.

One thing that was not mentioned in the article as a way to address the lack of skillset among general surgeons, is the prospect of bringing on a plastic surgeon to perform a high-quality flat closure. Plastic surgeons already have the skillset. There are barriers to this in some cases. However, as a tool in the arsenal, it’s important to keep in mind.

In terms of expected outcomes and communicating realistic expectations to patients – this is critical. Patients who are obese or have very large breasts do indeed present more of a technical challenge than thin, small breasted patients, in achieving a truly flat contour. If these challenges are present, they should be addressed clearly, honestly, and effectively, so the patient can make informed decisions.


“We need to respect her wishes”

Normally when a plastic surgeon agrees to perform a flat closure, the result will be high-quality. In NPoaS founder Kim Bowles’ case, her plastic surgeon intentionally failed to repair her dog ears, leaving the excess tissue behind to facilitate future reconstruction “in case you change your mind.” But this is a highly unusual situation. Most instances of flat denial do not involve a plastic surgeon at all.

Dr. Reiland goes on to address intentional flat denial:

“It really bothered me that surgeons in the Cosmopolitan article said they left the extra skin in case the patient changes her mind about reconstruction. If the patient states she wants to be flat, we need to respect her wishes and do the best we can to achieve that in the first operation. Regardless of whether a woman voices a desire to be flat, we should all do our best to employ the surgical techniques required to remove the excess skin medially and laterally* to give our patients the best results.” – Dr. Juliann Reiland (our bold)

*medially = on the front of the chest; laterally = at the sides (under the arms)

Most surgeons are ethical individuals who acknowledge the limitations of their skillset. That’s why flat denial has gone under the radar for so long… it doesn’t happen often enough to produce an obvious pattern.  And of course, women have been ashamed to talk about it. But flat denial is not under the radar anymore, thanks to the brave women who have come forward with their stories, and to the brave surgeons who have spoken out in support of these women.

Thank you, Dr. Reiland, for being a voice for women!

Thank you to the American Society of Breast Surgeons, especially their esteemed oncoplastic committee members, for taking action to improve outcomes for patients going flat!

And thanks to Clinical Oncology News for publishing this important article.

Change is happening. Together, we are putting an end to flat denial.

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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