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When you’re unhappy with your surgical result, you have options.*
Flat Denial? If you believe you have been a victim of flat denial – where your surgeon intentionally or through negligence left you with an egregiously poor cosmetic result against your will – please visit our page on Navigating the Aftermath of Flat Denial.
* most patients who are unhappy with their initial surgical result do have the option of revision surgery – but may have to wait for a period of time before pursuing revision. And some patients may have medical conditions that preclude revision. Ask your medical team about what your options are in your specific situation.
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What is Revision?
It’s not uncommon for women who have chosen to go flat after mastectomy to feel dissatisfied with their cosmetic result, even when their surgeon did their best to produce a flat contour. The appearance of a patient’s chest contour (shape) after mastectomy exists on a spectrum – all the way from nearly perfectly flat, to relatively minor imperfections, to egregiously bad results that rise to the level of flat denial. Several factors contribute to the appearance of the contour, including:
- your specific anatomy, which determines the degree of concavity you will have after your original mastectomy – concavity is very common and is a result of the removal of all breast tissue during the mastectomy, which exposes the pectoral muscles and lays bare how they are positioned relative to the ribcage and sternum
- whether you first attempted breast reconstruction before deciding to go flat – in particular, if you had tissue expanders, which can damage the pectoral muscles and underlying tissues
- the location and extent of your breast cancer – tumors close to the skin may necessitate a less than ideal or asymmetrical scar pattern, lymph node removal can cause large divots, etc.
- complicating factors such as very large breasts or obesity – excess, or “redundant,” tissue takes more time and skill to remove in a way that leaves a flat contour, and the more excess the more difficult the challenge
- your surgeon’s level of skill – general and breast surgeon’s skill (plastic surgeons as well) in flat closure technique is hugely variable. Not Putting on a Shirt and other advocates are working to remedy this by supporting efforts to train surgeons in flat closure techniques.
- your surgeon’s level of regard for your choice to go flat – a poor contour due to excess tissue left “in case you change your mind” is due to lack of regard, as are poor quality incision closures with puckers and folds
- radiation therapy can cause extensive scarring and adhesions that distort or contract the contour
- additional necessary surgeries – for example, surgical treatment for wound healing problems or persistent seroma
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 additional surgery to improve it. It’s your body, and your choice. If you choose to live with it, here are some things women have found helpful (every woman copes differently because every woman is unique):
- mitigating the unsatisfactory cosmetic result through non-surgical means – mastectomy tattoos, and/or pectoral exercises to try to build up the muscle to improve concavity
- dressing your new body for your own personal comfort and style – wearing compression garments, loose-fitting tops to camouflage the contour defects… or, conversely, embracing your chest as is and wearing clothing that doesn’t camouflage your chest at all!
- intentional emotional work, trying to make peace with your result, through mindfulness, art therapy, or other techniques
If you decide that you can’t or don’t want to live with it, you can pursue surgical repair – additional “revision” surgery to improve your result.
An unsatisfactory mastectomy result can almost always be improved, often dramatically, with revision surgery. These surgeries are most often done by a plastic surgeon who specializes in breast surgery, though some general and breast surgeons also have the skillset. 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.
It can be helpful to think of revision as less of an amputation, and more of a nip-and-tuck. Oftentimes these surgeries don’t require drains, and the healing period is typically much quicker than with the original mastectomy.
However, we must acknowledge the fact that most women who choose to go flat, do so in part in order to be “one and done.” It can be disheartening, even downright depressing, to find yourself in the position of facing additional surgery in order to achieve a result you feel you can live with. You may decide that revision surgery is not worth the risk – many women do.
You can take your time to make your decision. Revision surgery can be performed months or years after your original mastectomy. Especially if you had your mastectomy recently and are facing radiation, most surgeons will advise waiting at least a year to have any revision surgery. In the meantime, there is a lot you can do to prepare. Seek out resources and information from organizations like Flat Closure NOW. Find and interview surgeons. Speak with other women in the flat community about their experiences. Take the time to make the decision that is right for YOU.
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.
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 flat closure and the effect of revision surgery on their quality of life. However, multiple patients have shared with us that revision surgery has improved their body image as well as relieving issues of physical discomfort and inconvenience caused by dog ears and excess tissue. Ask your surgeon what you can realistically expect from revision surgery in your specific case.
How Do I Pursue Revision Surgery?
Unless you want to use your original surgical team for revision surgery (most patients do not), pursuing revision surgery will involve identifying potential surgeons and interviewing them, then proceeding with surgery only when you feel comfortable that you have been heard and respected. It is critical to use a surgeon who has a proven track record of high quality flat closure. You don’t want to be the first patient for whom the surgeon has attempted this procedure.
Finding a Surgeon
Option 1: 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. 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.
Option 2: Integrated Breast Center
Specialized integrated breast care centers that have both surgical oncologists AND plastic surgeons who specialize in breast surgery coordinating patient care will 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.
Option 3: Hospital with an Oncoplastic Surgery Program
Oncoplastic surgery is an aesthetic approach to breast cancer surgery – a surgeon who is certified in this sub-specialty will have completed training in plastic surgery techniques to produce an optimal contour after mastectomy. The focus in these training programs has historically been on lumpectomy techniques, but these surgeons are also a very good bet for flat closure.
Option 4: 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 flat closure techniques.
Option 5: 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 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 your goals clearly and specifically. For example: you want a smooth, flat contour with your dog ears completely removed, and for your chest to appear flat when you’re in an upright position. Show your surgeon photos of what you want to look like. You can find examples in the Not Putting on a Shirt brochure .
Get this information as a PDF brochure ->
Evaluate your surgeon’s response. Do they accept and respect your decision? Their response should be one of care and concern. And they should be able to to explain to you in detail how they will proceed to ensure you an acceptable flat result. 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 a flat contour in your specific case? (see the section below)
Listen to your intuition! If you feel uncertain about your surgeon’s competence or their commitment to producing an acceptable flat result, you should seek a second opinion.
Questions to Ask Your Revision Surgeon
- 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) can employ newer techniques to minimize concavity by repurposing excess tissue left over from your mastectomy to “pad” or bulk up the mastectomy site (LEARN MORE).
With a few exceptions, the Women’s Health and Cancer Rights Act (WHCRA) of 1998 requires insurance companies to cover revision surgery for mastectomy patients. However, insurance companies still sometimes initially refuse to do so. Your new surgeon’s office should know how to code for the procedure correctly and be equipped and willing to do the legwork required, including appealing denials.
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 not understand the law. Or, their office may simply not be equipped to deal with the often extensive insurance pre-authorization, billing, denial and appeal, and reimbursement processes.
Lastly, these procedures are generally not well-reimbursed and so may not be very (if at all) profitable for surgeons – for some practices, it’s a business decision not to provide flat closure and revision services.
Flat closure and revision surgeries are, in insurance coding terminology, generally considered “adjacent tissue transfers,” with the specific coding dependent on surgical field size (original breast size). Not Putting on a Shirt is working, in collaboration with other parties, to formulate guidelines to help surgeons to code properly for both flat plastics/oncoplastic closure and revision surgery.
In the meantime, if the surgeon you interview initially tells you that revision surgery isn’t covered, unfortunately you will just need to find another surgeon. Don’t give up!
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 had egregiously poor cosmetic results at their initial surgery (flat denial) but were able to finally get a result they can live with after revision surgery.
This page was authored by NPOAS Founder Kim Bowles, and an edited version was originally published at Flat Closure NOW.
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!
Tell us what you think.
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