Resources for Providers

From our inception, Not Putting on a Shirt has been committed to ensuring that all of the information that we provide is medically sound and consistent with the existing body of scientific evidence.

In the case of patient satisfaction with flat closure, there is a distinct lack of data. That’s why we’ve conducted our own pilot studies and are actively promoting larger-scale research with validated tools. We presented a poster with the combined results of our two pilot surveys this past December at SABCS 2019. Read our report from the first pilot, take a look at the UCLA flat closure study, or view our SABCS poster.

Women Are Happy Flat! Listen:

Resources

You may find the following to be useful. Note: you can now read about aesthetic flat closure at BreastCancer.org! Please let us know what we’re missing, too – we want to support providers as much as we want to support patients!

Informational Videos

Our esteemed advisors, Drs. Tiwari and Kocak at Midwest Breast & Aesthetic Surgery in Gahanna, Ohio, have put together a series of informational videos on technical subtopics concerning aesthetic flat closure – both explanting to flat and going flat at initial mastectomy. Take a look below. For more videos, check out MWB’s YouTube channel!

Articles about Aesthetic Flat Closure

Technical Considerations

Statistics on Aesthetic Flat Closure

How many patients are choosing aesthetic flat closure?

A 2023 study found that about 55% of patients were choosing AFC in 2019. The going flat rate plummeted after the WHCRA was passed in 1998, levelled off around 2015, and began rising again thereafter.

Why do patients choose to go flat?

A 2021 survey from UCLA indicated that the top two reasons patients choose flat closure is the lower rate of surgical complications, and avoiding implants.

How common is satisfaction with flat closure, and how common is flat denial?

The 2021 UCLA survey found that 74% of patients going flat were satisfied with the outcome of their flat closure surgery (this is in line with what NPOAS' own research has found as well.) The UCLA authors also found that 22% of patients going flat were not offered the option to go flat, experienced a lack of support from their surgeon, or had their surgeon actually leave extra skin during their surgery. NPOAS' survey found that flat denial, defined only as leaving extra skin, was prevalent at rates of 4-5% (intentional flat denial) and 7% (negligent flat denial), for a total of 11-12%. Our survey also found that roughly 1 in 4 patients going flat were dissatisfied with their surgical outcome, and that incidence of revision surgery was doubled for respondents with flat denial.

According to our survey, patient factors associated with egregiously poor expectation match (i.e., how well their expectation of their aesthetic outcome was met) are age older than 55 years and higher than “normal” BMI. Surprisingly, in our data set, larger breast cup size was NOT associated with poorer expectation match. (Note: further studies are needed to confirm and determine the specific nature of these correlations.)

There is room for improvement in patient satisfaction with their aesthetic outcome.

Coding & Reimbursement

Coding for aesthetic flat closure, whether at the initial surgery or at revision, depends on whether tissue rearrangement is involved. If yes, the CPT code is 1430X. If not, the CPT code 1310X. Other CPT codes have been used but are likely to be denied by insurance, at least initially, and especially without additional documentation. Fat grafting may also be a component of aesthetic flat closure, but not at the initial surgery (more here).

It’s also important to know that in 2024, the US Department of Labor issued guidance to insurance companies clarifying that aesthetic flat closure is covered under the Women’s Health and Cancer Rights Act (WHCRA).

Oncoplastic Training

A Note on Language

“Flat Closure” and “Aesthetic Flat Closure”

“Flat closure” is the term we use to describe the reconstruction of the chest wall contour without breast mounds after mastectomy. This procedure falls squarely under the reconstructive (not cosmetic) category of surgery as it restores a normal anatomic contour – the chest wall. Recently the National Cancer Institute added “aesthetic flat closure” to their Dictionary of Cancer Terms, defining it as:

“A type of surgery that is done to rebuild the shape of the chest wall after one or both breasts are removed. An aesthetic flat closure may also be done after removal of a breast implant that was used to restore breast shape. During an aesthetic flat closure, extra skin, fat, and other tissue in the breast area are removed. The remaining tissue is then tightened and smoothed out so that the chest wall appears flat.” (NCI Dictionary of Cancer Terms)