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Our Commitment to Evidence-Based Medicine
At Not Putting on a Shirt, we stick to the facts. We are committed to ensuring that all of the information we provide or promote 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 here:
You may find the following to be useful. Please let us know what we’re missing, too – we want to support providers as much as we want to support patients!
Drs. Tiwari and Kocak at Midwest Breast & Aesthetic Surgery in Gahanna, Ohio have put together a series of informational videos on technical subtopics concerning 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 Flat Closure
The Angel Wings Incision: A novel solution for mastectomy patients with increased lateral adiposity. (Hill et. al., July 2019)
Technical considerations in nonreconstructive mastectomy patients (Djohan et. al., Oct 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)
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)
Patient-Reported Outcomes and Decision Making
Quality of Patient Decisions About Breast Reconstruction After Mastectomy. (Lee et. al., 2017)
The Functional Impact of Breast Reconstruction: An Overview and Update. (Nelson et. al., 2018)
Patient’s Education Before Mastectomy Influences the Rate of Reconstructive Surgery (Tarkowski et. al., 2017)
Statistics on 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 and Reimbursement
A Note on Language
“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.
The term “flat closure” entered the patient community’s lexicon in August of 2018 with NPOAS’ publication of our article about misaligned financial incentives in the mastectomy setting, “Conflict of Interest for Flat Closure” (published on Facebook in August, and on the website in September shortly after the first Awareness Walk). It has since been adopted for general use by patients and providers alike.
Read what the plastic surgeons at Midwest Breast & Aesthetic Surgery are saying about flat closure in their clinical practice.
Reconstructive vs. “Reconstruction”
Flat closure is reconstructive. The reason we don’t use terms like flat reconstruction or flat closure reconstruction is that these terms do not identify the anatomic contour being reconstructed (the chest wall). Since the medical community identifies the anatomic contour being restored in the term breast mound reconstruction, it would follow that if we are to use the term reconstruction for a flat procedure, it should similarly identify the anatomic contour. Hence, chest wall reconstruction.
We know that there are limitations to what patient advocates can do on their own to advance the conversation in a productive and sustainable way. That’s why we need your input!
For a more in-depth discussion about terms of art, visit the blog.
Tell us what you think about the language issue!
You can use the form below to inquire about having your listing added to our Flat Friendly Surgeons Directory, to tell us what you’re thinking about, to learn how to support our work, or to find out how to get involved. You can also email us directly at firstname.lastname@example.org
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This site contains copyrighted material. Not Putting on a Shirt’s educational materials and resources on this site are freely available for “fair use” (Title 17 U.S.C. Section 107) in accordance with our mission to advocate for optimal outcomes for those who choose to go flat after mastectomy. The copyrighted material on this site is distributed for educational purposes without profit – all donations to Not Putting on a Shirt directly fund our advocacy work. If you wish to use copyrighted material from this site for purposes that go beyond “fair use”, you must first obtain explicit permission from the copyright owner. Please direct requests or questions to email@example.com.