by Marie-Claude Belzile
The Importance of Having a Plastic Surgeon at the Initial Mastectomy for Women Who Choose Flat Closure
Editor’s Comment: Routine plastics closure for women going flat is a logical extension of the practice of “immediate breast reconstruction” (reconstruction performed at the time of mastectomy.) If a surgical oncologist identifies that their patient’s situation calls for significant extra aesthetic skill and/or time and the patient prioritizes being done in one surgery, that should be an automatic trigger for bringing on a plastic surgeon.
Women going flat prioritize fewer surgeries, just like women who choose immediate breast reconstruction. Both choices are equally valid and deserve the fairly compensated services of a specialist. We know that aesthetic outcomes are worse for women with higher BMI’s. This disparity is not a reason to resign these patients to multiple surgeries – it’s a reason to provide a plastics closure. Marie-Claude Belzile makes the case here.
Many times, when a woman chooses to have a flat closure (i.e., chest wall reconstruction) after a mastectomy, it’s only a breast surgeon, or even a general surgeon, who performs the surgery, without any help from a plastic surgeon. Breast surgeons and general surgeons are not always properly trained in how to perform a proper aesthetic flat closure. As a result, women may wake up from their surgery with an uneven scar, with lumps on her chest or excess skin and rolls on her sides under the armpits. These poor results are not what any woman wants. And they could be avoided if surgical oncologists had the skillset (through specific, routine training). Another solution would be to have a plastic surgeon – an aesthetic specialist – present for the closure during the initial surgery.
Sometimes, women with larger bodies or who have more excess tissue on the chest wall are denied a proper flat closure because, as some surgeons say, they are “too fat to avoid dog ears” (dog ears are excess skin on the sides of the chest or under armpits). This excuse is unacceptable. There are techniques to avoid the excess skin, like the D-shaped incision, and many larger bodied women have had a nicely done and aesthetic flat closure. We can compare, while acknowledging that it’s not exactly the same surgery, larger bodied women having a mastectomy because of breast cancer to transgender men who had a mastectomy for gender confirmation. Larger bodied trans men routinely receive pleasing aesthetic flat closures, regardless of their body size. The reason why it is routine for them and not for all women having breast cancer surgery, is that the former always have a plastic surgeon for their mastectomy closure at the initial surgery.
Women facing breast cancer surgery should similarly have routine access to a plastic surgeon when opting for a flat closure. It must be covered by insurance and included in the options discussed with the patient in consultation. Aesthetic flat closure is reconstructive, not cosmetic, and it should be offered to patients in the same way we offer traditional reconstruction to any woman having a mastectomy. The multiple surgeries that traditional reconstruction entails are far more expensive and time consuming than an aesthetic flat closure. So there is no argument about cost to be made against routine plastics flat closure. Also, when a woman is denied the nice flat closure she asked for and expected, she must undergo another surgery, which she wanted to avoid, to repair the poor aesthetic result. There should be no ”poor” results, ever. They are entirely avoidable with routine plastics closure. And if, because of the lack of will or skill on the part of her surgeon, a woman has to do a revision surgery to correct a poor result, it should be paid for by insurance just like the numerous revisions so often required for traditional breast reconstruction.
In Canada, in 2015, Cancer Care Ontario (CCO) released a Breast Cancer Treatment Pathway Map which mandated that all women diagnosed with operable breast cancer requiring mastectomy be referred to a plastic surgeon to discuss reconstructive options before their scheduled mastectomies. This means that all women in Canada have the right to an appointment with a plastic surgeon before their surgery. The goal of our efforts in flat closure advocacy is to change the medical lexicon used by surgeons (plastic or oncologic) to include flat closure in the category of ”reconstruction”. This paradigm shift would result in less revision surgeries for patients who choose flat closure, and less psychological distress and physical repercussions for patients associated with a poor aesthetic outcome.
It is still a mystery to me why breast or general surgeons are not routinely and specifically trained in how to do a smooth flat closure without leaving excess skin. It should be a basic requirement for being a breast or general surgeon. Flat closure is – especially compared to traditional reconstruction – a fairly straightforward procedure that should be done in a couple of hours with perhaps an hour of extra operating time devoted to achieving proper aesthetics. This is what I experienced for my own surgery – and it should be the same for every woman facing mastectomy.
Marie-Claude Belzile of Quebec, Canada began her advocacy work in 2017 after being diagnosed with stage IV breast cancer, undergoing a double mastectomy, and noticing that medical professionals and the public at large seemed uncomfortable with her new body.
You can find her work on her Facebook page Tout aussi femme. Marie-Claude recently published a book in which she deconstructs the cultural narrative about breast reconstruction, Penser le Sein Feministe. She also founded a French-speaking flat support group called Les Platines.
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