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Introduction
Women going flat after mastectomy are not getting the care we need and deserve. In a recent study, fully one third of women who chose to go flat did so despite lack of information or downright resistance about this option from their surgeon. This despite the research showing no clear or significant benefit to reconstruction vs. going flat.
We believe that women need to know about all of their reconstructive options, including going flat… and that these options should be presented in an unbiased manner. That’s why we want the American College of Surgeons to update the NAPBC’s reconstructive consult protocol to include aesthetic flat closure.
Our Proposal
The National Accreditation Program for Breast Centers (NAPBC), run by the American College of Surgeons, is a program that safeguards patient care by certifying breast centers according to strict quality criteria. One of these criteria is the reconstructive consult protocol, which delineates what must be covered in a plastics consult for patients facing mastectomy. Right now, this only includes implant and flap reconstruction options.
We would like to see aesthetic flat closure added as a fourth line item in Standard 2.1.8:
More about NAPBC, its mission and the proposed update
The NAPBC is one of many quality programs run by the American College of Surgeons that ensures consistent, high standards of patient care for those facilities that meet their criteria. The College has been serving patients and providers since 1913 by providing education, resources, and support to “safeguard standards of care in an optimal and ethical practice environment.”
Our critique here aligns with this mission. This is the value of patient advocacy – patients know where the gaps are in their treatment experience. The lack of a standard of care for aesthetic flat closure is one of these gaps. Our thanks to the College for their tireless work protecting patients. And our thanks in advance for their consideration of our proposal, which is offered in a spirit of collaboration and goodwill.
The Problem
We know that plastic surgeons specializing in breast reconstruction consistently have the skillset to achieve high quality aesthetic flat closures for mastectomy patients. But too often, neither the plastic surgeon nor the oncology surgeon mentions going flat as an option, and most of the time a plastic surgeon is not involved in surgery for patients going flat. Why? Historically, going flat was not seen as an affirmative choice worthy of aesthetic consideration or plastics services.
The NAPBC’s current reconstructive consult protocol reflects this and reinforces the problematic status quo. According to the protocol, plastic surgeons are ONLY required to discuss breast mound reconstruction options (implants, flaps). The option of aesthetic flat closure is missing entirely.
But this is 2022. We now we have official recognition that flat closure is an aesthetic surgery. The National Cancer Institute recently defined “aesthetic flat closure” in its Dictionary of Cancer Terms.
Institutional protocols must be updated to reflect this development., and chief amongst these is the NAPBC reconstructive consult protocol.
The Role of the Plastic Surgeon
Particularly for patients with larger breasts and/or higher BMI’s, the involvement of a plastic surgeon at the initial mastectomy surgery can mean the difference between being “one and done,” and needing additional surgery to get their desired aesthetic flat closure. But when institutions such as NAPBC have codified that patients going flat don’t need plastics services, it reinforces a situation which de-prioritizes the needs of these patients.
Who benefits from plastics involvement at the initial mastectomy? Everyone!
- Patients. Women going flat strongly prioritize being done in one surgery. Ensuring access to a plastics closure at the initial mastectomy will reduce the need for surgical revision and thereby will serve these patients’ interests.
- Plastic Surgeons. Patient advocates are committed to improving reimbursement rates for aesthetic flat closure services. We can and will work together to ensure that all parties get what they need and deserve.
- Surgical oncologists. We don’t expect surgical oncologists to perform implant or flap reconstructions. While reconstructing a smooth chest wall contour may not require the same level of speciality, after a several hour mastectomy surgery, it can be physically taxing for the mastectomy surgeon to spend even more time to achieve an aesthetic flat closure. The option of plastics closure helps to relieve this burden and will result in better outcomes for these patients.
- Insurance Companies. As the standard of care for flat closure improves and the bias that favors breast mound reconstruction wanes, the quality of patient decision making should improve. We believe that this will translate into more women choosing to go flat. The improved reimbursement payouts to providers for flat closure and revision services will be offset by a reduced demand for expensive breast mound reconstruction.
It’s Time.
It’s time to improve the standard of care for patients going flat. The NAPBC can help facilitate this by adopting an amendment to their reconstructive protocol along the lines of what we have proposed here. We look forward to seeing NAPBC representatives at the upcoming conference in April of 2022!
How You Can Help
2. Donate to help send us to #ASBRS2022!
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