Your one stop shop for all things aesthetic flat closure.
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Our Commitment to Evidence-Based Medicine
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:
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!
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!
What is a flat closure after mastectomy?
Do you consider a flat closure to be a reconstruction?
Should a plastic surgeon always be involved with a flat closure?
What are the 3 reconstruction options after mastectomy?
How to address shape and form vs. scar
Can large breasted patients expect to have a good flat closure?
How to address concavity after a flat closure?
Is fat grafting possible to address concavity after a flat closure?
Muscle repair after explant
Why is it important to take out the entire capsule?
Articles about Aesthetic Flat Closure
Not Just a Linear Closure: Aesthetic Flat Closure after Mastectomy (Morrison & Karp, May 2022)
The Modified M-plasty Approach to Mastectomy: Avoiding the Lateral Dog-ear. (Meybodi et. al., Feb 2022)
The double S technique to achieve aesthetic flat closure after conventional mastectomy (Steffens et. al., February 2022)
Technical considerations in nonreconstructive mastectomy patients (Djohan et. al., Oct 2019)
The Angel Wings Incision: A novel solution for mastectomy patients with increased lateral adiposity. (Hill et. al., July 2019)
Mastectomy flap design: the ‘waisted teardrop’ and a method to reduce the lateral fold. (Thomas et. al., 2012)
Y-V oncoplastic wound repair of mastectomy dog-ear deformity. (Gittleman, 2012)
Oncoplastic technique for the elimination of the lateral “dog ear” during mastectomy. (Clough et. al., 2011)
The Lateral Chest Wall” A Separate Aesthetic Unit in Breast Surgery. (Bar-Meir et. al., 2011)
Mastectomy approach with Y-shaped incision: a technique designed for women with obesity. (Szynglarewicz et. al., 2009)
An oncoplastic technique to reduce the formation of lateral ‘dog-ears’ after mastectomy (Haresh et. al., 2007)
Eliminating the dog-ear in modified radical mastectomy (Farrar et. al., 1988)
Other – PRO’s, Decision Factors, Prevalence, Etc.
“‘Going Flat’ After Mastectomy: Patient Reported Outcomes by Online Survey” (Attai et. al., 2021)
The Functional Impact of Breast Reconstruction: An Overview and Update. (Nelson et. al., 2018)
Quality of Patient Decisions About Breast Reconstruction After Mastectomy. (Lee et. al., 2017)
Patient’s Education Before Mastectomy Influences the Rate of Reconstructive Surgery (Tarkowski et. al., 2016)
Statistics on Aesthetic Flat Closure
Patients going flat have unique values and priorities.
Multiple studies have confirmed that the population of patients who choose to go flat from the outset has distinctly different values and priorities that lead them to this path, vs. the population who chooses breast mound reconstruction (BMR).
Patients who choose FLAT
About 45% of patients.
- want to avoid additional surgery
- do not consider a breasted appearance to be important
- worry about health impact of implants
- tend to be older (over age 60, 4/5 choose flat)
Patients who choose BMR
About 55% of patients.
- accept the possibility of additional surgery
- want to maintain a breasted appearance to “feel whole”
- do not want to use prosthetics
- tend to be younger
Patients expect aesthetic flat closure.
According to our research, patient factors associated with egregiously poor expectation match 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.
Of all mastectomy patients choose to go flat.
Three of every four patients going flat are satisfied with their aesthetic outcome.
1 in 20
About 1 in 20 patients going flat – that’s a 5% risk for each woman who chooses flat closure – are subjected to INTENTIONAL flat denial at the hands of an unethical provider.
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).
A Note on Language
“Flat Closure” and “Aesthetic Flat Closure”
“Flat closure” is the term we are using 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)
For a more in-depth discussion about terms of art, visit the blog.
Tell us what you think about the language issue!
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