Scar Patterns
If you’ve decided to pursue aesthetic flat closure for your mastectomy, you may be wondering what incision or scar pattern is right for you. This is an important discussion to have with your surgeon, and it can help to think through your options ahead of time. Note: your surgeon may have specific incision patterns that they routinely use that they are comfortable with, and your preference may not be the determining factor. If having a particular scar pattern is very important to you, you can request a plastic surgeon be brought onto the team.
Ideally, your surgeon will be able to plan the incisions to achieve your aesthetic goals, taking into consideration your preferences, your anatomy, and any oncologic or other constraints.
Think about which scar patterns look good to you:
Considering the Pros and Cons of Patterns
- Curved or Straight? While the default seems to be straight scars, many patients prefer curved scars because of the more “natural” look. Additionally, a curved scar can sometimes produce a flatter contour than a straight scar. The U-shaped pattern follows the natural curve of the breast, and the gull wing is another option which some people find preferable aesthetically.
- Horizontal, Diagonal, or Vertical? If you will have straight scars, they can be oriented in different ways on your chest. Do you have a preference?
- High or Low? Do you want your scars to lie high on your chest closer to your armpits, or lower down near the natural curve of your breast? The default seems to be “in the middle,” but there can be advantages to placing the scars lower, in particular - it allows you to wear low-cut tops without exposing your scars (if that’s a concern for you).
- (For larger breasts) Anchor or Y-shaped? Particularly if you have significant excess tissue in your breasts or on your chest wall, a type of procedure called “tissue rearrangement” may be called for to ensure you receive an optimal flat outcome. You don’t want to end up with dog ears under your arms - this can be uncomfortable as well as unsightly. Two main types of scar patterns result from this rearrangement: y-shaped and anchor. You’ll notice that with y-shaped scars, the extra “line” is under your arm (at the side of your chest), while with anchor scars the extra “line” is over your breast area (on top of your chest).
- Joined or Separate? To smooth out the center of your chest, some surgeons will join together the two incisions to create one long scar that goes from armpit to armpit.
"Dog Ears"
What are "dog ears"? These are masses of excess tissue (skin and fat) left over after the removal of the breast tissue at the end of an incision, usually under the arm. Dog ears protrude out from the chest wall and can be very uncomfortable, especially when your arms are down. Your surgeon must take special care to avoid creating dog ears during your mastectomy. They must carefully remove all the excess tissue to leave a smooth flat surface under your arm.
To the left, we see a dog ear before revision surgery, and to the right, the result after the dog ear was removed. Much better!
Another area of potential excess tissue being left behind is the fold underneath the breast itself, known as the "inframammary fold" (IMF). Again here, your surgeon must take special care to ensure the IMF is removed during your mastectomy, otherwise your result will look like the picture to the left here (after revision to the right).
A Note on Larger Bodies. For patients with larger bodies (higher BMIs) or even just very large breasts, it takes more time in the operating room and a higher level of surgical skill to produce an aesthetic flat closure. And an aesthetic flat closure will look different on different body types - for example, scars may be longer and extend further under the arm towards the back. Below are some examples of larger bodies with aesthetic flat closure.
Managing Concavity
Concavity = a “scooped out” or sunken-in appearance
Most mastectomy patients going flat desire a smooth, flat contour with no extra skin and no concavity. Unfortunately, that’s not always what we get. Areas of concavity result from both your unique anatomy and from the surgeon’s technique. Concavity may also be more pronounced at explant. How can concavity be minimized? There are two approaches. A procedure called tissue rearrangement with “de-epithelialization” can be used to avoid concavity during the mastectomy, and fat grafting can be used after the fact also.
De-epithelialization is a straightforward procedure used during the initial mastectomy. It repurposes some of the extra skin (which would otherwise be removed) as padding to “fill in” the concave site. When the incision is then closed over the area, the result is an optimal contour. When the maximum amount of skin/fat is repurposed this way, the result can even be a small breast mound (that’s called a “Goldilocks mastectomy.”)
Fat grafting is performed at a later date. It is essentially a type of liposuction, i.e. removing fat from a donor site, but instead of discarding the fat, it is then injected into the breast area to bulk up and smooth out the contour. With multiple rounds of fat grafting, some people may even be able to achieve a small mound (if that's their goal).
Nipples
If you’re considering preserving your nipples and/or your areolas at the time of your mastectomy with aesthetic flat closure, you’re not alone. While it’s not a common choice, it is a valid one - but most surgeons won’t bring it up at all if you’ve decided to go flat. That’s because historically, nipple preservation was only considered as part of a skin-sparing procedure to facilitate breast reconstruction and produce a “natural looking” breast mound. You can ask your surgeon if you're a candidate for nipple and/or areola preservation.
You Should Know
- It’s Not Always an Option. Not all women are candidates for nipple preservation, from a medical perspective. Nipple preservation may also constrain the incision patterns that will work for your situation.
- Areola vs. Nipple Preservation. Even if you're not a candidate for nipple preservation, you may be able to preserve some or all of your areolas. That's because the areola doesn't contain breast tissue like the nipple does.
- Loss of Sensation. Even if your surgeon is able to preserve your nipples and/or areolas, you likely will not retain much if any sensation in the area. That’s because when the underlying breast tissue is removed, the nerves that produce sensation are severed.
- Alternatives. There are alternatives available. If the look of a nipple is important to you but you’re unable to preserve your natural nipples and/or areolas, nipple reconstruction may be an option. This is where a nipple shape is surgically created out of your own breast skin. The look of a nipple and areola can also be created with restorative tattooing (more below in the following section). Tattooing has come a long way in the last several years and can look photo realistic with the right artist. And there are the options of temporary tattoos and removable prosthetic nipples as well.
Talk to Your Surgeon
Speak to your surgeon about which surgical approach is best for you. There can be oncologic, anatomic, or other constraints to consider, so it's important to speak to your surgeon about your specific situation and your preferences. Not all oncology surgeons are versed in every technique either. If that’s the case with your surgeon, it may be an option to bring on a plastic surgeon to the team. Don't be afraid to seek a second opinion if you feel you are not being listened to, or if you feel you're not being presented with all of your options. This is your body, your life, and your choice.
After Surgery: Mastectomy Tattoos
Mastectomy Tattoo: a tattoo that is drawn on top of the mastectomy site, usually to cover mastectomy scars – includes both restorative tattoos (restoring the nipple/areola) and decorative pieces (non-anatomic).
Another aesthetic consideration when going flat is the option of eventually getting tattooed. Tattoos can be an important component of healing for many women following their surgery. This is true for both those who chose to reconstruct their breasts AND those who chose to go flat. Most surgeons recommend waiting 6-12 months after your surgery to get tattoos.
For some, tattoos can restore the appearance of their lost nipple/areola (restorative, or reconstructive tattoos). Others choose decorative mastectomy tattoos (also called artistic, or “scar covering”) rather than anatomic, and that hold special meaning for them. Women going flat typically choose decorative tattoos rather than restorative tattoos, but both are an option.