What is Aesthetic Flat Closure?

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Aesthetic flat closure = post-mastectomy chest wall reconstruction

Mastectomy with no additional contouring – patient was very dissatisfied with this poor aesthetic result. Read her story here.
AESTHETIC FLAT CLOSURE. The same patient, after revision surgery to restore the chest wall contour. The patient was highly satisfied with this result.

Aesthetic flat closure (or “flat closure”) is post-mastectomy chest wall reconstruction. After the mastectomy to remove the breast tissue, additional work is often required to smooth out any lumps and bumps and trim any excess skin to restore an optimal chest wall contour with a clean symmetric incision closure. This can often be done at the time of the mastectomy, and most patients who choose flat closure prefer to be “one and done.”

The National Cancer Institute (NCI) defines “aesthetic flat closure” as follows:

“A type of surgery that is done to rebuild the shape of the chest wall after one or both breasts are removed. An aesthetic flat closure may also be done after removal of a breast implant that was used to restore breast shape. During an aesthetic flat closure, extra skin, fat, and other tissue in the breast area are removed. The remaining tissue is then tightened and smoothed out so that the chest wall appears flat.” (NCI)

Aesthetic flat closure is reconstructive, not cosmetic.

Aesthetic flat closure falls squarely under the reconstructive (not cosmetic) category of surgery as it restores a normal anatomic contour – the chest wall. The NCI defines “aesthetic flat closure” as a rebuilding of the shape of the chest wall after the breast(s) are removed, and includes the following elements:

  • aesthetic flat closure is reconstructive (“rebuilding” the shape of the chest wall)
  • aesthetic flat closure requires an aesthetic surgical approach
  • aesthetic flat closure may be performed at the initial mastectomy or at explant
  • excess tissue removal and contouring are involved
  • the goal of aesthetic flat closure is to create a smooth, flat chest wall contour

The term “flat closure” entered the patient community’s lexicon in 2018 with NPOAS’ publication of our article about misaligned financial incentives in the mastectomy setting, “Conflict of Interest for Flat Closure.” It was since been adopted for general use by patients and providers alike. In June 2020, the NCI adopted “aesthetic flat closure” as the officially defined term. For a more in-depth discussion about terms of art, visit the blog.

Aesthetic flat closure is oncoplastic.

Flat closure is a valid reconstructive choice deserving of an aesthetic surgical approach. Increasingly, institutions are recognizing this fact.

The Oncoplastic Breast Consortium (OPBC), an independent, international nonprofit organization working to bring safe and effective oncoplastic breast surgery to routine patient care, recently added “optimal flat closure” to their mission statement, recognizing flat closure as an oncoplastic procedure alongside breast preservation and reconstruction.

Oncoplastic surgery combines oncologic techniques (to remove the cancer) with plastic techniques (to reconstruct a contour – a breast mound, or the chest wall). The initial focus of this field was improving cosmetic outcomes for lumpectomy (also known as breast conserving surgery). A traditional lumpectomy excises the lump and closes the incision without any additional contouring, which can leave behind a permanent “dent.” Oncoplastic techniques contour the remaining tissues to avoid leaving dents (often paired with a symmetry operation on the healthy breast), resulting in better cosmetic result that patients are happier with. (Image: Kronowitz SJ et. al.)

Flat closure is the natural next step for oncoplastic focus. Simply removing the breast tissue often does not produce an optimal flat result, especially for patients with larger bodies and/or breasts (see right). Patients going flat are much happier when their surgical team takes an aesthetic approach, planning the excision and spending additional time contouring to produce a smooth, flat chest wall.

Cleveland Clinic researchers recently partnered with the University of Toledo to produce a paper on a specific oncoplastic flat closure technique. Read all about it here.

Patients expect aesthetic flat closure.

Our research shows that of every 20 patients who choose flat closure, 5 will end up with cosmetic results they are dissatisfied with. Of these 5 patients, two will have egregiously poor results, and one will suffer intentional denial of their choice.

Clearly, patients need an improved aesthetic standard of care for flat closure. We believe that oncoplastic training for surgical oncologists will play a significant role in improving flat closure quality for those 4 in 5 dissatisfied patients, and the 2017 ASBrS-COS study supports this.

“Oncoplastic surgery is integral to all breast cancer surgeries. The use of an aesthetic approach to breast conservation or mastectomy greatly enhances the range of options that can be offered to women with breast cancer and facilitates better outomes from it. It should be the standard of care.

– R. Douglas MacMillan, Nottingham Breast Institute

Who performs aesthetic flat closures?

A surgical oncologist always performs the mastectomy (breast tissue removal) itself. If the surgical oncologist has the skill set to reconstruct the chest wall contour themselves, they can elect to spend some additional operating room time for their patients who choose aesthetic flat closure. If they prefer a plastic surgeon to do the closure instead, a co-surgery may be an option – the plastic surgeon can take over after the mastectomy.

According to Dr. Patricia Clark at Ironwood Breast, oncoplastic techniques have been used by surgical oncologists in Europe since the 1980’s:

Surgeons are talking about aesthetic flat closure.

Read what the plastic surgeons at Midwest Breast & Aesthetic Surgery say about flat closure in their clinical practice.

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