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Aesthetic flat closure = post-mastectomy chest wall reconstruction
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Aesthetic flat closure (or “flat closure“) is post-mastectomy chest wall reconstruction (from BreastCancer.org). 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)
Surgical Work Involved. Aesthetic flat closure involves careful removal of all redundant lateral (side) tissue (to avoid “dog ears”), obliteration of the inframammary fold (where the breast meets the chest wall), and the production of smooth, symmetric incision closures (Karp et. al., 2022).
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 has 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. Both the American Society of Breast Surgeons and the Society for Oncoplastic Surgery‘s oncoplastic training courses include aesthetic flat closure technique.
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. And the National Comprehensive Cancer Network (NCCN) recently updated its Patient Guidelines to include specific information on flat closure!
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.
Multiple flat closure technique articles have been published in the medical literature in recent years, by both breast and plastic surgeons (library here.)
BreastCancer.org has a page about aesthetic flat closure 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. A study out of UCLA recently published in the Annals of Surgical Oncology found similar results.
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. The 2017 ASBrS-COS study supports this, and the UCLA study’s lead authors concluded much the same.
“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 outcomes from it. It should be the standard of care.“
– R. Douglas MacMillan, Nottingham Breast Institute
Who performs aesthetic flat closures?
A cancer surgeon (general, breast, surgical oncologist) always performs the mastectomy (breast tissue removal) itself. If the cancer surgeon 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. A third option is for the breast surgeon to request the plastic surgeon help plan the incisions, but not perform the surgery itself – this is a small time commitment for the plastic surgeon and may improve the aesthetic outcome considerably.
Surgeons are talking about aesthetic flat closure.
“Aesthetic flat closure IS a type of reconstruction and is a very powerful choice that deserves just as much care and respect as any other reconstructive surgery.”
Dr. Ron Israeli
Plastic & Reconstructive Surgeon, NYBRA Plastic Surgery
“We believe patients should be fully informed of all their breast reconstruction options, as well as the option of aesthetic flat closure (no reconstruction with a nicely-contoured, truly flat result). It is only once all the options are fully discussed, that patients can take part in a shared-decision-making conversation with their surgical team.”
Minas Chrysopoulo MD, PRMA Plastic Surgery
“Many women have begun to embrace Flat Closure as a movement and a way of life. Flat Closure is a chance for women to accept their new, post-breast cancer bodies as both beautiful and valid.”
Midwest Breast & Aesthetic Surgery
“I think ‘going flat’ just refers to removal of the breast and no reconstruction, and what it should refer to is removal of the breast, no reconstruction, and the surgeon doing everything they can to make it look nice and neat.”
Dr. Deanna J. Attai for the Breastcancer.org podcast
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