Talking to Your Surgical Team About Going Flat
If you’re having a mastectomy to treat breast cancer, your surgical team can include:
a general surgeon who performs many types of surgery
a breast surgeon who specializes in breast procedures
a plastic surgeon who specializes in reconstruction options
The primary concern of both general and breast surgeons is to remove the cancer and all the breast tissue and to check nearby lymph nodes for cancer cells. The plastic surgeon can advise you about reconstruction options, including aesthetic flat closure, and perform the specific type of reconstruction you choose — either at the time of mastectomy or later. It’s important to know that your surgical team may not necessarily include a plastic surgeon. Suppose you are interested in going flat, and the surgeon doesn’t have experience performing aesthetic flat closures. In that case, you may want to ask whether bringing in a plastic surgeon with expertise in the procedure is possible.
Some surgeons strongly favor breast reconstruction with tissue flaps or implants. Surgeons with this bias may not necessarily bring up aesthetic flat closure when discussing reconstruction options or frame it as less desirable. 1 If you’re interested in aesthetic flat closure, it may be necessary to start the discussion yourself. According to current research, some women who have chosen to go flat felt like their surgeons didn’t support their decision.
If you decide to go flat, finding a surgeon who listens to and respects your choice is essential.
Asking for a plastic surgeon
Whether you have questions about going flat or already know you want aesthetic flat closure, it’s a good idea to ask that a plastic surgeon join even early conversations. A plastic surgeon can potentially:
consult with you and your cancer surgeon before surgery
be present at the time of mastectomy to perform the flat closure
be prepared to perform flat closure after the affected area has had a few months to heal
Plastic surgeons have a skill set that cancer surgeons may not necessarily have and can offer advice about advanced reconstruction techniques that cancer surgeons might not even know about. Additionally, not all general surgeons or even all breast surgeons have experience in performing aesthetic flat closure. Having a plastic surgeon present when you have a mastectomy can improve your chances of getting an optimal flat closure and help you avoid additional surgery.
Physical features — such as breast size, body mass index (BMI), degree of sagging (also called ptosis), amount of skin under the arms, and position of the breasts relative to the rib cage — can make it more challenging to achieve an excellent flat closure. 2 Scarring from radiation therapy also can present challenges during an aesthetic flat closure. In these more complex situations, having a plastic surgeon present is a good idea.
Finding a local breast surgeon or plastic surgeon with experience in aesthetic flat closure can be challenging. Going flat advocates are working to improve this situation. For example, the organization Not Putting on a Shirt offers a directory of flat-friendly surgeons that may be useful. It’s not a comprehensive directory, so you may likely have to do some research.
If you can’t find a flat closure surgeon near you, you and your breast cancer surgeon may benefit from a video consultation before the mastectomy. A plastic surgeon specializing in flat closure can recommend where to make the mastectomy incisions to ensure an optimal flat closure later.
Any pushback from your surgeon is a red flag. If you feel that your surgeon isn’t listening to you or taking your choice seriously, finding another surgeon who is on board with your decision and qualified to help you is essential.
What to ask your surgical team before going flat
You must better understand and feel comfortable with the surgical team, so asking many questions during your consultation is a good idea. These early discussions can help you assess their experience with aesthetic flat closure and give you a better idea of what to expect.
Here are some questions you may want to consider asking:
What percentage of your practice focuses on mastectomy? How many procedures do you perform on average in a month?
Have you received any surgical training focused on giving women excellent cosmetic results after mastectomy without reconstruction?
Do you have experience with aesthetic flat closures? How many of these procedures have you performed?
If you have little to no experience with aesthetic flat closure, are you willing to bring in a plastic surgeon to perform the procedure?
How many in your practice have chosen to go flat?
Is it possible to show me pictures of patients who’ve had aesthetic flat closure?
Can you put me in touch with some of your patients with aesthetic flat closure?
Can you make sure the mastectomy scars lay flat against my chest? Can you tell me how you plan to avoid bulges or bumps at the ends of the scars, as well as dog ears (extra tissue under the arms)?
What type of incision pattern do you plan on using? Can you tell how far the excisions might extend across the chest and under the arms toward my back?
Is there anything about my anatomy (large breasts, weight, or body type) that makes an excellent flat closure challenging? How do you plan to address those challenges?
Should I expect a scooped-out appearance? Do you have a plan to minimize a scooped-out appearance?
What can I expect during my recovery? What results are realistic for me?
Is it normal for the chest to feel numb after mastectomy with flat closure?
Should I expect any tightness or changes in range of motion? Do you recommend physical therapy for me?
How long after surgery should I wait to judge the appearance of my chest? Do you expect any significant changes in contour over time?
Will I need a second procedure to refine my aesthetic flat closure? What can I expect if I need a second procedure?
What are my options if I decide to rebuild my breasts after going flat?
Several weeks may pass between your first consultation and the surgery, so it’s essential to go over your expectations with your surgical team again right before you have surgery.
The organization Not Putting on a Shirt offers the following tips:
If possible, take a trusted relative or friend to your first visit for extra support and to help take notes as you express your wishes.
Give your surgeon pictures of flat closure results that appeal to you, and ask if they are realistic. Try to find before and after photos of people with similar body types and breast sizes, and ask that a copy be placed in your file.
Ask if your surgical consent form can specify aesthetic flat closure, as defined by the National Cancer Institute. Some surgeons prefer the term flat closure reconstruction and leave out the word aesthetic, so it’s clear that the surgery is reconstructive and not cosmetic. Ask your surgical team what they recommend.
Ask your surgeon to confirm your wishes in writing. It may be easier to write a summary of your expectations — specifying that you want mastectomy with aesthetic flat closure — and ask your surgeon to sign it. You can share the write-up in person, email, or upload it to your electronic medical record.
Flat advocates also recommend you document your wishes as clearly as possible from your first visit. According to the organization Not Putting on a Shirt, flat denial is when a surgeon leaves behind some skin to accommodate a future breast reconstruction with tissue flaps or implants despite having agreed to perform aesthetic flat closure.
A surgeon should only leave skin behind if that’s what you’ve requested so you can choose between aesthetic flat closure and breast reconstruction with tissue flaps or implants later. Still, as time passes, the extra skin can harden, and the scarred areas can be mistaken for a breast cancer recurrence, or the skin may not be helpful if you’ve received radiation treatment in the area. Extra skin also can make it challenging to wear breast forms.
It’s not necessary to make your choice right away. And once you choose, it’s possible to change your mind. Just as it’s possible to have breast reconstruction with tissue flaps or implants after going flat for some time, it’s possible to go flat after breast reconstruction with tissue flaps or implants.
Baker JL, Dizon DS, Wenziger CM, et. al. “Going Flat” After Mastectomy: Patient-Reported Outcomes by Online Survey. Annals of Surgical Oncology. 2021. 28(5): 2493-2505. Available at: https://link.springer.com/article/10.1245/s10434-020-09448-9
Djohan M, Knackstedt R, Leavitt T, et al. Technical considerations in nonreconstructive mastectomy patients. The Breast Journal. 2020. 26(4): 702-704. Available at: https://onlinelibrary.wiley.com/doi/10.1111/tbj.13641
— Last updated on September 14, 2023 at 1:48 PM