My initial surgical result is not flat. Why?

One in Four Patients Are Unhappy With Their Outcome

Right now, about one in four women going flat end up with an initial surgical result that they are unhappy with. We hope this changes as patient advocacy moves the needle towards parity, but for now it’s one in four. The appearance of the chest contour after mastectomy exists on a spectrum – all the way from nearly perfectly smooth and flat, to good with minor imperfections, to egregiously poor results that rise to the level of flat denial. Why the variation? Why don’t more patients get optimal outcomes?

The first problem is the lack of clear language. It was only very recently that the National Cancer Institute defined “aesthetic flat closure” as a unique reconstructive procedure that involves an aesthetic surgical approach. So it has historically been difficult for patients to communicate exactly what they expect when they say they want to “go flat.” And there has been no clear consensus among providers as to what constitutes a “flat” mastectomy closure.

Determinants of Your Aesthetic Outcome

When you (the patient) HAVE been able to clearly communicate your affirmative choice to go flat, the quality of your initial surgical result is largely determined by three things: your specific anatomy, your medical situation and history, and the level of skill and regard on the part of your closure surgeon.

1. Your Anatomy

Your specific “body habitus” – the shape and character of your body – may make an aesthetic flat closure simple or challenging. More excess fat and skin requires more time and skill to remove and contour to produce a good aesthetic result. Whether or not you have concavity depends mostly on your bone and muscle structure – when the breast tissue is removed, the underlying topography is revealed.

2. Your Medical History

Your medical and surgical history presents constraints the surgeon must contend with, which can affect your contour. Large tumors, or tumors that are close to the chest wall or the skin, may require accommodation that impacts your contour. The incisions may be asymmetric and removal of tumors and affected lymph nodes can produce divots.

If you had tissue expanders or breast implants prior to going flat, there may be some damage to the pectoral muscles and/or the ribcage that can make any concavity more pronounced. Radiation therapy can cause extensive scarring and adhesions that distort or contract the contour.

Treatment of surgical complications (such as infection, wound healing problems, hematoma or persistent seroma) and the constraints these complications present can affect the contour as well.

3. Surgeon Skill & Regard

Surgical skill is the technical ability your surgeon brings to the operating table. Skill varies considerably among surgeons (and it can be difficult for patients to assess this in consult). Plastic surgeons are specially trained in aesthetic closure but they aren’t usually present at the initial mastectomy.

Regard is the degree of respect and consideration the surgeon has for your choice to go flat as affirmative and deserving of an aesthetic approach. A poor contour due to excess tissue left on purpose “in case you change your mind” is called intentional flat denial, and it’s a grievous and traumatic battery against the patient.

Counterclockwise: Bottom left – negligent flat denial. Bottom right – intentional flat denial. Top right – good flat result. Top left – minor defects, referred patient, bringing on a plastic surgeon

If You’re Unhappy With Your Aesthetic Outcome

Revision surgery can improve your chest wall contour both by removing excess skin (excision) and filling in areas of concavity (fat grafting). Recovery is typically easier than the mastectomy, but this varies depending on how much tissue needs to be removed and how extensive the surgery is. Typically it is a plastic surgeon who performs revision surgeries. Visit our Flat Friendly Surgeons Directory to find a revision surgeon near you!

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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