Revision Surgery

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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 appearance of the chest contour after mastectomy exists on a spectrum – all the way from nearly perfectly smooth and flat, to good with minor imperfections, to egregiously poor results that rise to the level of flat denial.

When you have clearly communicated your affirmative choice to go flat, the quality of your initial surgical result is largely determined by three things: your specific anatomy, your medical situation and history, and the level of skill and regard on the part of your closure surgeon.

Your Anatomy

Your specific “body habitus” – the shape and character of your body – may make an aesthetic flat closure simple or challenging. More excess fat and skin requires more time and skill to remove and contour to produce a good aesthetic result. Whether or not you have concavity depends mostly on your bone and muscle structure – when the breast tissue is removed, the underlying topography is revealed.

Your Medical History

Your medical and surgical history presents constraints the surgeon must contend with, which can affect your contour. 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 pectoral muscles and/or the ribcage that can make any concavity more pronounced. Radiation therapy can cause extensive scarring and adhesions that distort or contract the contour.

Treatment of surgical complications (such as infection, wound healing problems, hematoma or persistent seroma) and the constraints these complications present can affect the contour as well.

Surgeon Skill & Regard

Surgical skill is the technical ability your surgeon brings to the operating table. Aesthetic surgical skill varies considerably among surgeons (and it can be difficult for patients to assess this in consult). Plastic surgeons are specially trained in aesthetic closure, but they aren’t usually present at the initial mastectomy.

Regard is the degree of respect and consideration the surgeon has for your choice to go flat as affirmative and deserving of an aesthetic approach. A poor contour due to excess tissue left on purpose “in case you change your mind” is called intentional flat denial, and it’s a grievous and traumatic battery against the patient.

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. Especially if you had your mastectomy recently and are facing 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 patients may have medical conditions that preclude revision. 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 the effect of revision surgery on their 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 as well as relieving issues of physical discomfort and inconvenience 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), 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 aesthetic flat closure.

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:

1. Respected the recommending patient and their wishes to be flat,
2. Were technically competent in surgical technique to achieve a flat result, AND
3. 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: 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.

Option 4: 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 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 aesthetic flat closure. 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 competence or their commitment to producing an acceptable aesthetic flat closure, 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).

Insurance Coverage

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 can and do deny coverage, 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:

• interpret the law to exclude flat closure
• 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, in insurance coding terminology, generally considered either “adjacent tissue transfers,” with the specific coding dependent on surgical field size (original breast size, 1430X) or “scar revision” (1310X). Not Putting on a Shirt is working, in collaboration with other parties, to formulate guidelines to help surgeons to code properly for both aesthetic flat 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!

All Revision Resources

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 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.

Patients Speak on Revision

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Share your own story!

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