Just published! A new, excellent journal article on AFC out of the Indiana University School of Medicine, by authors Bhaskara et. al. This is a scoping review article, which is a type of evidence synthesis that maps the existing research on a topic to determine the scope, range, and nature of the literature, identify knowledge gaps, and clarify concepts. The article describes the various surgical techniques used to produce AFC in good detail, as well as patient motivation and satisfaction with choosing AFC.
The authors specifically acknowledge that AFC is distinct from “flat closure” and is in fact, chest wall reconstruction: “AFC is distinct from a flat closure following mastectomy without reconstruction. Patients may have a specific expectation of aesthetic outcomes, making AFC a new type of reconstruction. As a chest wall reconstruction, AFC differs from breast reconstruction by the lack of intention to recreate the appearance of breast tissue.”
The review found that, in total, there were 89.9% (328/365) of patients who were satisfied in choosing a flat closure but that only 58.2% (689/1183) (a “glaring disparity” according to the authors) were satisfied with their aesthetic outcome, and concluded that “optimization of aesthetic results can be achieved by implementing chest wall reconstruction techniques with the specific goal of obtaining an AFC. ” In other words, when more surgeons performing non-reconstructive mastectomies are trained in and are able to implement AFC surgical techniques, their patients will be happier with their outcomes!
The review affirmed that patients’ primary motivations for choosing flat closure were to achieve a shorter recovery time and to avoid implants. Additionally, reconstructed breasts were perceived as “unnatural,” or “other,” and some patients were also influenced by the experiences of people they knew who had either positive experiences with flat closure or negative experiences with breast reconstruction. Characteristics of people who tend to choose flat closure included being of a non-white race, being of older age, having comorbidities, having government insurance or no insurance, having a later stage of breast cancer, having had radiation or chemotherapy, and having had treatment at a community institution (vs. an academic institution).
Five AFC surgical technique studies were included in the review, and the covered techniques were categorized as either incision placement (ex. at the inframammary fold instead of the standard placement, and joined vs. separate incisions) or chest contour optimization (avoidance/removal of lateral, or underarm, “dog ears” was extensively addressed, as well as obliteration of the inframammary fold and strategies to minimize concavity). WISE pattern incisions and Goldilocks type techniques were also discussed in the context of aesthetic flat closure.
The authors specifically state that, “Patient habitus [body type] should be considered in surgical planning.” Under the status quo, where there is no widely accepted aesthetic standard of care for patients going flat, this consideration is frequently omitted, leaving larger bodied patients in particular with egregiously poor aesthetic outcomes and in need of additional, corrective surgery. So, this statement is very important. Since 2020, NPOAS has been advocating for the involvement of plastic surgeons at the initial mastectomy for larger bodied patients when the oncologic surgeon does not feel confident that they can produce a good AFC for the patient in one surgery by themselves. A plastic surgeon can either help plan the incisions, or they can perform the closure themselves in the operating room. Patients reconstructing their breasts routinely receive plastics care – patients going flat should receive no less.
The authors suggest that surgeons should counsel patients pre-operatively to understand the patient’s values, goals, and expectations, and that realistic expectations should be discussed, including the potential for concavity and the potential need for revision surgery. The authors further suggest that surgeons should specifically take into account how patients want their flat closure to look:”During surgical consultation, it is important to ask about patient goals, particularly about how they envision their flat closure.” We couldn’t agree more!
Limitations of the review were discussed, including the fact that the included studies did not use formal validated tools to evaluate patient satisfaction with their decisions and their outcomes. NPOAS is happy to report that we are currently working with researchers at Harvard University to develop such a validated PRO tool! In addition, we are working with researchers at Georgetown University to develop an aesthetic scoring tool for AFC, which will be able to be used in tandem with the validated PRO tool to produce future research to advance the standard of care in the near future.
A big THANK YOU to all of the authors of this excellent paper: Meghana Bhaskara, Luci Hulsman, Shahnur Ahmed, Angad S. Sidhu, Chelsea Fathauer, Ethan Rinne, Kandice K. Ludwig, Mary E. Lester, Ivan Hadad, Carla S. Fisher, and Aladdin H. Hassanein.
This is a great article and should be put into circulation around the world! Lots of very appropriate information here and valuable to all cancer patients and physicians and their staff.
Thank You,
Carol Rheault,RN
BREAST CANCER PATIENT