As Breast Cancer Awareness Month approaches, we prepare to celebrate International FLAT Day (IFD). This year, a big event will be held in Paris, France and there will be a signing ceremony for the “International Flat Manifesto.” This Manifesto delineates advocates’ vision for the future of mastectomy patient care that empowers patients going flat and honors our choice as legitimate and worthy of respect and aesthetic consideration. It was created jointly by NPOAS’ Council of International Advocates, many of whom will be in Paris for the ceremony. Individuals are encouraged to sign on to the manifesto virtually here in advance of IFD! #putflatonthemenu
International Flat Manifesto
Introduction
The purpose of this manifesto is to communicate to global stakeholders a shared vision for patients facing mastectomy. The care with respect to flat closure that mastectomy patients receive throughout the world varies by country and institution; this manifesto aims to see patients worldwide receive the same, optimal level of care.
We, the undersigned flat advocates from around the world, jointly state the following goals and principles of our advocacy work. We envision a future in which worldwide patients facing mastectomy or removal of a reconstructed breast in the context of breast cancer or genetic predisposition to breast cancer (1) are presented with ALL of their medically available reconstructive options, including flat closure, and (2) have access to flat closure, revision surgery and contralateral symmetrizing mastectomy.
Clear Language
In order to facilitate clear communication and ensure uniformity of expectations and understanding between patients, providers and other stakeholders (hospital administration, governmental agencies, medical insurance companies, etc.), the term “flat closure” shall be officially included in the lexicon of professional organizations and government and regulatory agencies as well as in national and international breast surgery guidelines. Additional terms shall also be defined to accurately characterize the experience of patients going flat after mastectomy.
“Flat closure,” or in the USA, “aesthetic flat closure,” is reconstruction of the chest wall contour. It is surgical contouring to restore a smooth chest wall, a normal anatomic structure that is disrupted by the surgery to remove the breast(s). An aesthetic flat closure implies a smooth, harmonious surface of the chest wall, with no excess skin or fat. Flat closure and revision services, therefore, fall clearly under the reconstructive umbrella (NOT cosmetic).
“Flat denial” is when a surgeon disregards a patient’s consent and fails to perform the agreed upon flat closure. Typically, flat denial results in significant excess skin and/or fat remaining on the chest wall at the mastectomy site.
“Contralateral symmetrizing mastectomy” is removal of the unaffected breast for symmetry reasons. This procedure shall be offered to all patients facing mastectomy or removal of a reconstructed breast, and covered by insurance, where applicable.
Full Disclosure & Shared Decision Making
Mastectomy patients shall be given full and accurate information about ALL of their reconstructive options, including flat closure. Patients shall be made aware of the risks and benefits of each reconstructive option in order to make an informed choice, and flat closure shall be presented on equal footing with other reconstruction options, with no bias in favor or against any particular reconstructive technique. Surgeons shall refrain from injecting their personal preferences and biases into the surgical consult. The decision making process shall consistently center the patient’s values and priorities from start to finish for optimal surgical outcomes (“shared decision making”).
Optimal Standard of Care
An optimal, evidence-based standard of care shall be developed and implemented for flat closure in order to ensure that mastectomy patients consistently receive acceptable aesthetic outcomes. This standard of care for flat closure will necessarily include:
1. Routine, well delineated full disclosure of all medically available reconstructive options, including aesthetic flat closure.
2. Individual assessment of barriers to receiving an optimal aesthetic result, and the need for a plastics closure specialist.
3. Patients choosing to “go flat” strongly prioritize a short surgical recovery period, i.e., being done in one surgery. Surgeons who are not technically skilled in flat closure surgical technique shall inform their patients of this and, when appropriate, refer them to colleagues with the skills required for an optimal result. Patients shall be advised of the possibility of engaging a plastics specialist to maximize their chances of achieving an acceptable aesthetic result at the initial mastectomy. Patients shall be advised of any specific challenges the closure surgeon will face in their specific circumstances, and the likelihood of the patient requiring revision surgery shall be individually assessed and discussed.
4. Contralateral symmetrizing mastectomy shall be offered to all patients.
5. Consensus parameters among providers for what constitutes an acceptable quality aesthetic flat closure shall be developed and implemented.
6. Whether the patient requests breast reconstruction or flat closure, at no point shall any patient be required to undergo a psychological evaluation or any other procedural hurdles simply because of their choice.
Support & Accountability
Respect for the patient’s informed consent is non-negotiable. Surgeons who intentionally disregard or override a patient’s reconstructive choice shall be held accountable as a standard practice. Systems of both support and accountability shall be improved to ensure that (1) providers consistently provide full and fair disclosure about reconstructive options to all of their mastectomy patients, and (2) all surgeons performing flat closure have the skill set to produce optimal aesthetic outcomes.
Hospital and facility administration shall review and, if needed, amend their accountability procedures to protect the interests of patients going flat and enforce consistent full and fair disclosure and respect for patient consent. All surgeons performing mastectomies shall have access to appropriate oncoplastic training, training in shared decision-making, relevant validated decision aids, and specific insurance coding support where needed.
Fair Reimbursement
Surgeons deserve to be fairly reimbursed for flat closure services, including revision services, as flat closure is a truly reconstructive, NOT cosmetic, procedure. Payment for flat closure services shall be commensurate with payment for other breast reconstruction services. This will align incentives properly to serve the interests of all mastectomy patients.
Research
Clinical care must always be evidence based. In order to directly compare patient reported outcomes for flat closure with breast reconstruction outcomes, and to support the development of a robust standard of care that serves the specific needs of patients going flat, validated research tools such as the BreastQ shall be expanded to assess flat closure at the same level and with the same accuracy as conventional reconstruction, and large scale studies shall be conducted with these tools. A scoring tool shall be developed to grade aesthetic quality of flat closures, which shall be used in these studies to explore the connection between aesthetics and patient reported outcomes.
Systemic Parity
Achieving parity for flat closure requires systematic legislative and regulatory change. Professional organizations and regulatory bodies involved in mastectomy patient care must adopt policies and protocols which clearly delineate the standard of care for flat closure, as well as remedies for victims whose choice is not respected. Relevant legislation shall be amended to ensure equitable insurance coverage and access for all to the full range of breast reconstruction surgery options, including flat closure.
In Closing
Patients facing mastectomy deserve to be presented with ALL of their medically available reconstructive options, including flat closure, and to have access to flat closure, revision surgery and contralateral symmetrizing mastectomy. We are confident that our vision for the future will be realized, and we look forward to continuing our work towards these goals with ambition and determination.
