Amend the NAPBC’s Reconstructive Protocol

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NAPBC Protocol Amendment infographic

Women going flat after mastectomy are not getting the care we need and deserve, in part because most of us cannot access a plastic surgeon for our closure. Women reconstructing their chest wall should be able to access a specialist just like women who are reconstructing their breasts. That’s why we want the American College of Surgeons to amend the NAPBC’s reconstructive consult protocol to include aesthetic flat closure

What is the NAPBC?

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.

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 flat closures for their patients. And we know that one quarter of patients are dissatisfied with the quality of their surgical oncologist’s flat closures. Women going flat after mastectomy are not getting the care we need and deserve.

The current version of NAPBC’s reconstructive consult protocol only requires plastic surgeons to discuss breast mound reconstruction options (implants, flaps). The option of aesthetic flat closure is missing entirely.

How Did We Get Here?

Why aren’t plastics services already widely available to patients going flat?

The bottom line is that going flat has historically not been seen as a choice deserving of aesthetic consideration. But the myth that women who choose to go flat “don’t care how we look” couldn’t be farther from the truth. Women who wake up to poor aesthetic closures are dismayed not only because we DO care about how we look, but because we know we will need another surgery if we want to get it fixed. And women going flat strongly prioritize regaining normal function as quickly as possible – we really don’t want multiple surgeries.

The Role NAPBC’s Protocol Plays

The NAPBC’s reconstructive consult protocol, while well-intentioned and certainly helpful to women who choose to reconstruct their breasts, has unfortunately had the unintended effect of reinforcing this myth that women going flat don’t care how we look. The protocol formally embodies the status quo: breast mound reconstruction deserves an aesthetic specialist, and flat closure does not.

But 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, and its definition including the following critical elements:

  • flat closure is reconstructive
  • flat closure requires an aesthetic surgical approach
  • excess tissue removal and contouring are involved
  • the goal of flat closure is to create a smooth, flat chest wall contour
Infographic - Thank you, NCI for adding "aesthetic flat closure" to the Dictionary of Cancer Terms #putflatonthemenu

This is why, along with legislative action and improved reimbursement, we are targeting this protocol for amendment. It’s quite simple: we would like to see aesthetic flat closure added as a fourth line item in Standard 2.1.8:

Aesthetic Flat Closure Requires a Plastics Skillset

Contouring the tissues to reconstruct a smooth chest wall contour post-mastectomy is an aesthetic surgical approach that requires a plastics skillset. Therefore, until oncoplastic training is the standard for all surgeons who perform mastectomies, patients going flat deserve to be able to access the services of a plastic surgeon.

Oftentimes, a plastics closure won’t be necessary. But there will be many times where a high-quality aesthetic flat closure at the initial surgery can only realistically be achieved by bringing on a specialist, particularly for patients who are larger-bodied or have very large breasts.

Access to Plastics Closure Helps 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 flat closure (and revision) 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 2021!

Stay tuned for project updates!

June 20, 2020 – National Cancer Institute defines “aesthetic flat closure” as a unique reconstructive procedure.

April 19, 2020 – The Oncoplastic Breast Consortium adds “optimal flat closure” to its mission.

How You Can Help

2. Donate to help send us to #ASBRS2021!


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