The late twentieth century has seen the widespread acceptance of the oncologic safety of immediate reconstruction after mastectomy, as well as advances in reconstructive surgical techniques.1 Federal legislation expanded insurance coverage and access, reducing disparities in the receipt of postmastectomy reconstruction based on race, ethnicity, and socioeconomic status.1,2
The increased focus on a more ‘natural’ aesthetic appearance and improved access to reconstruction has shifted attention away from the subset of patients who do not want or are unable to undergo reconstruction. Our research demonstrated that up to 74% of survey respondents who did not undergo immediate reconstruction were happy with their decision. At the same time, we identified that up to 22% of women experienced ‘flat denial’, i.e. the surgeon did not offer the option to go flat, did not support the decision to go flat, or did not perform the agreed-upon surgical procedure and intentionally left excess skin when the desire to go flat had been expressed.3 Our research highlights that for a subset of women, ‘going flat’ is a desired and intentional option, which should be supported by the treatment team and should not imply that women who forgo reconstruction are not concerned with their postoperative appearance.
The decision to undergo mastectomy with or without reconstruction is often a very personal one. Patient preference for ‘going flat’ needs to be recognized and the procedure should be offered as an option. The National Cancer Institute has recently added ‘aesthetic flat closure’ to their dictionary of cancer terms.4 As such, it is incumbent upon surgeons to become proficient in techniques that maximize the aesthetic appearance of a flat chest wall closure.
Kruper L, Holt A, Xu XX, et al. Disparities in reconstruction rates after mastectomy: patterns of care and factors associated with the use of breast reconstruction in Southern California. Ann Surg Oncol. 2011;18(8):2158-2165.
Kamali P, Ricci JA, Curiel DA, et al. Immediate breast reconstruction among patients with Medicare and private insurance: a matched cohort analysis. Plast Reconstr Surg Glob Open. 2018:6(1):e1552.
Baker JL, Dizon DS, Wenziger CM, et al. “Going Flat” after mastectomy: patient-reported outcomes by online survey. Ann Surg Oncol. In press. https://doi.org/10.1245/s10434-020-09448-9 (in press).
National Cancer Institute. Dictionary of Cancer Terms, Aesthetic Flat Closure. Available at: https://www.cancer.gov/publications/dictionaries/cancer-terms/def/aesthetic-flat-closure. Accessed 24 Nov 2020.
Jennifer L. Baker and Deanna J. Attai have no conflicts of interest/disclosures to declare.
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Baker, J.L., Attai, D.J. ASO Author Reflections: Patients Who Go Flat After Mastectomy Deserve an Aesthetic Flat Closure. Ann Surg Oncol (2021). https://doi.org/10.1245/s10434-020-09489-0