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Flat closure = post-mastectomy chest wall reconstruction
Reconstructing a smooth, breast-less chest wall contour is what flat closure is all about. 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 produce an optimal chest wall contour with a clean symmetric incision closure. This additional work can often be done at the time of the mastectomy, and most patients who choose flat closure prefer to be “one and done.”
Flat closure is reconstructive, not cosmetic
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 has since been adopted for general use by patients and providers alike.
For a more in-depth discussion about terms of art, visit the blog.
Flat closure is oncoplastic.
Surgery that combines oncologic techniques (to remove the cancer) with plastic techniques (to reconstruct a contour – a breast mound, or the chest wall) is called “oncoplastic” surgery.
The first focus of this relatively new field was improving cosmetic outcomes for lumpectomy. Complete removal of the breast (mastectomy) isn’t always required to treat breast cancer. Sometimes it’s enough to remove just the local area that contains the tumor – this is a lumpectomy.
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, resulting in better cosmetic result that patients are happier with.
Flat closure is certainly within oncoplasty’s scope, and is a 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. Patients are much happier when their surgical team spends additional time contouring the chest wall to produce a smooth result.
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:
Dr. John Williams of Breast Cancer School for Patients discusses oncoplastic surgery:
Oncoplasty: the new standard of care?
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 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 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 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 flat closure.
Read what the plastic surgeons at Midwest Breast & Aesthetic Surgery say about flat closure in their clinical practice.
Tell us what you think.
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