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Unhappy with your surgical result? You’re not alone.
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What is Revision?
Revision is additional surgery to improve the aesthetic appearance of the chest wall contour. An unsatisfactory mastectomy closure can almost always be improved with revision, often dramatically. The goal of revision surgery is to remove all remaining excess (“redundant”) tissue and “clean up” the surgical site to create the best possible smooth, flat contour. Sometimes fat grafting or tissue transfer is also used to try to fill in areas of concavity.
These surgeries are most often done by a plastic surgeon who specializes in breast surgery, though some general and breast surgeons also have the skill set. Oftentimes these surgeries don’t require drains, and the healing period can be much quicker than with the original mastectomy.
My initial surgical result is not flat. Why?
About one in four women going flat ends up with an initial surgical result that they are unhappy with. We hope to see this improve now that we have established clear language – “aesthetic flat closure” – for women to communicate their choice to their surgeons.
The look of the chest after a mastectomy can vary a lot – from almost completely smooth and flat, to mostly smooth with small flaws, to very poor results that fail to honor the choice for a flat chest.
When you have clearly communicated your choice to go flat, the quality of your initial surgical result mostly depends on three things: your body’s shape, your medical situation and history, and the skill and care of your surgeon.
Your Anatomy
Your specific “body habitus” – the shape and character of your body – may make an aesthetic flat closure simple or challenging. Having more fat and skin means the surgeon needs extra time and skill to remove and shape it for a smooth result. Whether or not you have concavity depends mostly on your bone and muscle structure – as the underlying shape of your body becomes visible once the breast tissue is removed.
Your Medical History
Your medical and surgical history can create challenges for the surgeon, which may affect the shape of your chest after surgery. Large tumors, or tumors that are close to the chest wall or the skin, may require accommodation that impacts your contour. The incisions may be asymmetric and removal of tumors and affected lymph nodes can produce divots.
If you had tissue expanders or breast implants prior to going flat, there may be some damage to the chest muscles and/or the ribcage that can make any concavity more pronounced. Radiation therapy can also cause significant scarring and tightness, which can change or pull on the chest shape.
Surgical complications (such as infection, wound healing problems, hematoma or persistent seroma) can affect the shape of the chest as well.
Surgeon Skill & Regard
Surgical skill is the technical ability your surgeon brings to the operating table. Aesthetic surgical skill varies among surgeons (and it can be difficult for patients to evaluate this during consultation.) Plastic surgeons are specially trained in aesthetic closure, but they aren’t usually present at the initial mastectomy.
Regard refers to how much respect and consideration the surgeon has for your choice to go flat, treating it as valid and worthy of an aesthetic approach. If excess tissue is left intentionally “in case you change your mind,” it’s called intentional flat denial. This can be deeply harmful and is considered a serious violation of the patient’s trust and autonomy.
Live With It, or Get It “Fixed”?
In any case, if you’re not satisfied with your result, there are really only two options: live with it, or get it fixed surgically. Women going flat usually want to be “one and done,” and for many women an additional surgery is too high of a price to pay for a smoother chest contour. For these women, mastectomy tattoos and/or physical therapy to build up the chest wall muscles can be helpful. This is your body, and your choice.
You can take your time to make your decision. Revision surgery can be performed months or years after your original mastectomy. If your mastectomy was recent and you are undergoing radiation, most surgeons will advise waiting at least six months to a year to have any revision surgery. In the meantime, there is a lot you can do to prepare. Find and interview surgeons about your options, and speak with other women in the flat community about their experiences. Take the time to make the decision that is right for YOU.
Is Anyone Not Eligible for Revision?
Most patients who are unhappy with their initial surgical result do have the option of revision surgery. Some medical conditions may make revision surgery not an option.. Every patient’s medical situation is unique. Ask your medical team about what your options are in your specific situation.
Risks and Benefits
Your Health ALWAYS Comes First! Never delay radiation or other cancer treatments in the hopes of getting a revision first – it’s not worth the risk.
Risks
Revision surgery has the same risks as most operations, including infection, tissue death, and blood clots. As with a mastectomy, revision surgery may also cause changes in sensation that may change over time. Generally, revision surgery is a quicker procedure with a faster, easier recovery than mastectomy. Ask your surgeon about the medical risks in your specific situation.
Benefits of Revision Surgery
Unfortunately, there is not much scientific data on patient satisfaction with aesthetic flat closure and how revision surgery affects quality of life. But the data we do have suggests drastic improvement in satisfaction with chest wall aesthetics, and many patients have shared with us that revision surgery has improved their body image and relieved physical discomfort caused by dog ears and excess tissue.
Steps to Take
Unless you want to use your original surgical team for revision surgery (most patients do not), you’ll need to find and interview potential surgeons. Only proceed when you feel confident that your surgeon understands and respects your choice. It is critical to use a surgeon who has a proven track record of high quality aesthetic flat closure.
Finding a Surgeon
Use Our Flat Friendly Surgeons Directory
Our online directory lists surgeons, both general/breast and plastics, that have been recommended by patients in the flat community (surgeons may also apply subject to approval by NPOAS). These surgeons:
- Respected the recommending patient and their wishes to be flat,
- Were technically competent in surgical technique to achieve a flat result, AND
- Did the best they could do give the patient the desired result.
Other Options for Finding a Surgeon
Integrated Breast Center
Specialized integrated breast care centers where surgical oncologists and plastic surgeons specializing in breast surgery work together often have more experience with insurance than general practice plastic surgeons, and so are more likely to accept patients seeking revision. They will also likely have more experience with cosmetic breast surgery techniques.
Use a Dual Specialty or Gender Confirmation Surgeon
Some women going flat have had success using a surgeon specializing in gender confirmation surgery. These surgeons typically have more experience with insurance processes than general practice plastic surgeons and are generally highly skilled in aesthetic flat closure techniques.
Local Referrals from Trusted Sources
You can also ask your local medical providers and cancer community centers or support groups for recommendations – but make sure you specify that you want a surgeon who has experience with aesthetic flat closure.
Interviewing Your Surgeon
As with going flat at the time of mastectomy, patients seeking revision surgery need to take steps to ensure they get the best possible cosmetic result in as few surgeries as possible. Communicate, evaluate, ask questions, and listen to your intuition!
- Communicate your goals clearly and specifically. Use the term “aesthetic flat closure” – it’s now defined in the National Cancer Institute’s Dictionary of Cancer Terms. You want all excess tissue removed to create a smooth, flat chest contour with no dog ears. Show your surgeon photos of what you want to look like. You can find examples in many of our publications.
- Evaluate your surgeon’s response. Do they accept and respect your decision? Their response should show care and concern. And they should be able to explain to you in detail how they plan to achieve an aesthetic flat closure that meets your needs. If you detect hesitation, pushback about reconstruction, body-shaming language, or anything that makes you feel uncomfortable, listen to your intuition – find a different surgeon.
- Ask specific questions about technique. How they will achieve an aesthetic flat closure in your specific case? (see Questions to Ask Your Revision Surgeon)
- Listen to your intuition! If you feel uncertain about your surgeon’s skills or their commitment to producing an acceptable aesthetic flat closure, it’s a good idea to get a second opinion.
Questions to Ask Your Revision Surgeon
Get this information as a PDF brochure ->
- Have they performed revision surgery for previous mastectomy patients who went flat? Ask to see photos of their work.
- Will they be able to produce the result you want in one surgery? How likely is it that you will face additional surgery?
- How will they address any special challenges in your case? For example, dog ears, puckering of the scar, excess tissue, concavity, etc.
- Will they extend the incisions further on the lateral chest (under your arms) or use additional incisions in order to achieve a flat contour? Will this produce a different scar pattern?
- How will they ensure the closure is tight enough to present a flat contour when you are upright, not just when you’re lying down?
- What can you expect in terms of your recovery period? For example, what is the likelihood of drains and what will the postoperative activity restrictions be?
Some plastic surgeons (even some breast surgeons also have this skillset) use newer techniques to minimize concavity by repurposing excess tissue left over from your mastectomy to “pad” or bulk up the mastectomy site (LEARN MORE).
Insurance Coverage
The Women’s Health and Cancer Rights Act (WHCRA) of 1998 generally requires insurance companies to cover revision surgery for mastectomy patients. However, insurance companies can and do deny coverage for aesthetic flat closure surgery, so it’s essential that your new surgeon’s office knows how to code for the procedure correctly and be equipped and willing to do the legwork required, including appealing denials. In 2024, the US Department of Labor issued guidance to insurance companies that states that aesthetic flat closure is a covered procedure under the WHCRA. Your surgeon may need to bring this guidance to the attention of the insurance company on appeal.
Unfortunately, many general practice plastic surgery offices will not accept patients seeking revision surgery, or will say that the procedure “is not covered.” This happens for several reasons. Most plastic surgery practices are fee for service – they don’t go through insurance, because elective cosmetic surgery typically is not covered by insurance. So the surgeon and/or office staff may:
- interpret the law to exclude flat closure (note that the 2024 DOL guidance is new and they may not be aware of it)
- not be equipped to deal with the often extensive insurance pre-authorization, billing, denial and appeal, and reimbursement processes
- may not desire to offer revision surgery because it isn’t well reimbursed
Aesthetic flat closure and revision surgeries are usually coded as either “adjacent tissue transfers,” with the specific coding dependent on surgical field size (original breast size, 1430X) or “scar revision” (1310X) (MORE).
All Revision Resources
Find a patient-recommended surgeon with a proven track record of flat closure for your revision surgery.
Print this out to take with you to your surgical consult to ensure your revision surgeon can give you a good flat closure.
A primer on preparing yourself mentally, physically and emotionally, and tips on what to expect after surgery.
Everything you need to know about living flat: how to find community support, fashion, body images, tattoos, and more.
Further Reading
If you would like to read personal accounts of women who have undergone revision, some are sharing their “Finally Flat” stories publicly at the blog. These women initially had
poor cosmetic results (flat denial) but were able to finally get a result they can live with after revision surgery.
Patients Speak on Revision
“My message to other women who were left with excess skin is: You do NOT have to settle and just ‘live with it’!”
– Suzie
“I am so happy with how they left me. I feel confident and strong. “
– Stephanie
Share your own story!
Find out more!
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