What is Aesthetic Flat Closure?

Following a single or double mastectomy, some people may choose not to get breast reconstruction and decide to ‘go flat’. What that means is that they will not have a breast mound and can avoid having traditional forms of reconstruction, including breast implant placement or flap surgery.

The surgeon performing the mastectomy (breast surgeon or surgical oncologist) may be comfortable and sufficiently experienced to offer this. However, it is very important that you clarify with the mastectomy surgeon what is the expected cosmetic outcome. This way you will not be surprised when you wake up after surgery. Sadly, Dr Li has met many unhappy patients who opted for ‘no reconstruction’ but did not expect to be deformed and disfigured after mastectomy without reconstruction. 

Here in Los Angeles, typically it is the plastic surgeon who will perform this aspect of the surgery. Plastic surgeons are trained in making scars look as pleasing to the eye as possible. Telling your mastectomy surgeon that you ‘don’t want breast reconstruction’ may end in disappointment because that surgeon may just ‘close you up’ and not consider the extra tissue or the appearance after the mastectomy has been done.

Who is a good candidate for Aesthetic Flat Closure?

Anyone can choose to get ‘flat closure’ after mastectomy. However, patients that are heavier, (body mass index, or BMI,> 30) especially those with a large bra cup size, tend to be more difficult to get a flat appearance after mastectomy (see Image 1). These patients should discuss with their mastectomy surgeon about the realistic expectation after mastectomy and whether they feel a plastic surgeon is needed to give the best result.

On the other hand, very slim people (BMI<20) may have an opposite problem. Instead of having too much tissue, they can have too little and end up looking ‘caved in’. There are techniques that plastic surgeons are trained it that can often prevent this from happening.

What are ‘dog ears’ after going flat?

When removing tissue around a circular structure, (like the skin around the breast), it is important to remove the extra tissue along the sides, making it more like an ellipse shape. Think of the pupil of the eye vs the entire eye shape. If this is not performed well, patients may end up with extra redundant tissue on the side (especially close to the axilla, or armpit,) which can hang, known as ‘dog ears’ due to their resemblance to the ears of a dog (see video 1). Not only is this unattractive, (some patients refer to this as a ‘side boob’), but it makes it hard to wear clothing and sometimes may make hygiene difficult if the scar is also uneven and puckered. Heavier patients with large breasts are most at risk of this happening.

You can see Dr. Li’s YouTube video on going flat after a mastectomy for further reference.

Not only is this unattractive, (some patients refer to this as a ‘side boob’), but it makes it hard to wear clothing and sometimes may make hygiene difficult if the scar is also uneven and puckered. Heavier patients with large breasts are most at risk of this happening.

What are the benefits of Aesthetic Flat Closure?

• By not getting breast reconstruction, you avoid the risks and long-term maintenance of breast reconstruction. These include the short-term risks of implant infection, longer term risks of capsular contraction, silicone leak and rare implant-associated malignancy, anaplastic large cell lymphoma. For autologous (or ‘flap’ surgery) such as DIEP (deep inferior epigastric perforator) flap, you avoid the long surgery time (6-8 hours), early risks of surgery, such as complete vs partial flap loss (due to disrupted blood supply), having to deal with another surgical site (such as the abdomen in DIEP flap, which can result in a permanent bulge or hernia), long surgery time and extended recovery period. Also, in both forms of reconstruction, often patients need more than one surgery to improve the reconstruction.
• Shorter surgery time: depending on your preop cup size (the larger the breast size, the longer the surgery), aesthetic flat closure by an experienced plastic surgeon is usually a quicker surgery – ranging from 1-2 hours depending on the complexity of the case
• Less pain and easier recovery: generally speaking, because we are not placing an implant or flap, the tissues are under less tension and this translates to less pain. After surgery, patients usually make a much quicker recovery compared to traditional forms of reconstruction. 
• May improve symptoms of neck, shoulder and back pain in patient with very large breasts. This is a condition known as ‘symptomatic macromastia’. By removing the weight of the large breast(s), some patients have breasts that weigh up to 1500g, patients will notice a big difference in terms of these symptoms. If we were to replace the breasts with large implants (largest is 800cc), these would also be very heavy after surgery.
• Peace of mind: some patients like the idea of as much breast tissue and overlying skin to be removed as possible. After aesthetic flat closure, surveillance of disease recurrence is straightforward as any new lumps can be felt easily.
• Appearance: some patients prefer the clean look of no breast mound.

When is the best time to get Aesthetic Flat Closure?

This depends on several factors including: whether there is concern of getting clear margins i.e. removing all the tissue that is needed; the availability of a plastic surgeon, the ideal length of surgery time for you.

Immediate = same day as the mastectomy

Aesthetic flat closure can be performed the same day as your mastectomy. This is known as ‘immediate aesthetic flat closure’. This does have advantages because the patient’s surgery is completed in the same procedure and does not require a second general anesthesia. Patient’s wake up and their cancer is out and they are flat; they can immediately begin to focus on healing. It also tends to give better outcomes and appearance.

Dr Li previously conducted a study where we compared immediate vs delayed flat closure, giving an aesthetic score. The immediate aesthetic flat closure patients all scored higher than the delayed reconstruction patients (References 1 and 2).

Delayed-immediate= 2-3 weeks after the mastectomy

Delayed-immediate is the next best timing, after immediate reconstruction. This means that the mastectomy is performed first and then 2-3 weeks later, the aesthetic flat closure is performed.

The advantages of this timing include:

1. Instead of getting one long general anesthesia, you will only need two shorter general anesthesia. This may be important for patients with pre-existing heart or lung conditions and needs to be discussed with your surgeon and/or anesthesiologist at the pre-op anesthesia evaluation visit, during the planning of your surgery.
2. By adding in this break between mastectomy and reconstruction allows time for the removed tissues (breast, and in some cases, the lymph nodes from the axilla, or armpit) to be studied in-depth by the pathologist, before any tissue is rearranged. This may be important if your mastectomy surgeon is unsure if all the diseased tissue is removed or they can achieve ‘clear margins’. Very occasionally, after the mastectomy is performed, the pathology result may show close or ‘positive margins and more tissue may need to be removed to achieve ‘clear margins’ and reduce the risk of disease coming back (‘local recurrence’).
3. Allows patients to think about ‘going flat’ before fully committing to it. When a patient has undergone mastectomy, with a scheduled flat closure within a couple of weeks, they have a chance to ‘try’ out the idea of not getting a full breast mound’. After flat closure it is still possible to get breast reconstruction in the future but, typically, we need to perform autologous reconstruction, to replace all the removed skin. This scenario is not common but has happened with one of my patients, who changed her mind after a few years of being flat, see figure 2.

Delayed = more than 3 months after mastectomy

This is also known as ‘revision flat closure’. In this situation, the patient has lived with the aftermath of a single or double mastectomy without reconstruction and is unhappy with the scar (see figure 3 image A and image B). This may be related to the uneven appearance of the scar including orientation or lumpiness. A common problem are the dreaded ‘dog ears’, where women are left with extra tissue along the side of the chest, especially near the axilla. While these patients can be noticeably improved, because we have to work with the original scars, it is more limiting. The results tend to be not as good as immediate or immediate-delayed reconstruction but still better for the patient. All my patients who have undergone this delayed procedure have been very satisfied with the revision surgery.  

What are the goals of aesthetic flat closure surgery?

The main goals of esthetic flat closure include:

1. Esthetic and symmetric appearance in double mastectomy cases
2. Long-term comfort for the patient, this includes avoiding making patients so tight that they have limited arm movement and feel in constant tightness with pain within the chest region
3. Avoiding redundant tissue
4. Avoiding a ‘sunken in’ appearance in the chest region, especially in thin people.
5. Improved patient’s body images and self-esteem. 

What are the Risks of an Aesthetic Flat Closure Surgery?

The risks of aesthetic flat closure include those of any other surgery of the chest, including the risk of general anesthesia, bleeding, infection, scarring, asymmetry, limited arm movements. The biggest risk is seroma formation, where the body is making a lot of fluid after the surgery. This is why Dr. Li always recommend placing drains and Dr. Li restricts post-surgery movements and activities for a few weeks.

What are the different Aesthetic Flat Closure Surgery Types

In most cases, esthetic flat closure involves some form of local tissue rearrangement. In thin patients, we may need to bring up some of the lower breast skin (mastectomy flap) and bury it to provide some ‘padding’ over the ribs. This avoids the chest looking ‘sunken in’ after mastectomy. We always tidy the scars to give a symmetric and pleasing appearance. In some patients, simply removing enough skin and soft tissue will be enough and local tissue rearrangement is not necessary.

Will There Be Any Scars After an Aesthetic Flat Closure Surgery?

Yes. There will be scars after flat closure. These can be the width of the breast or even longer, in order to remove the extra tissue along the sides. In some cases, the scars can be kept low, so that when patients wear a blouse or top that has a low or V-neckline, these scars are not visible. There are different shapes and appearances that you should be aware of.  

Your Aesthetic Flat Closure Consultation 

When you meet with your surgeon (mastectomy or plastic surgeon) it is important to discuss the surgical procedures, risks and benefits of surgery and the expected outcome. I recommend bringing your partner or friend who you trust, not just for support, but they may think of questions that you may not have.

Usually if it is a plastic surgeon who has not met you before, they perform a history and physical and ask you general questions related to your health, medications and whether you’ve had previous surgeries. You should gauge the experience of that surgeon in performing flat closure and that surgeon should be able to show you before and after pictures. I encourage my patients to bring in pictures or a scar chart of their desired outcome. This is a link to a very useful website on esthetic flat closure’ that has a ‘scar chart’ that you may print and bring to the consultation (Reference).

What Can You Expect and Recovery After an Aesthetic Flat Closure Surgery?

Day of surgery

The same day after surgery, you may feel some tightness of the chest wall. There may be some discomfort along the incisions and the drain sites. This is completely normal. You should not feel a lot of pain after surgery, and this is usually well-controlled by oral pain medication. Some patients, especially if only one side surgery, may be well enough to go home the same day and some patients prefer to stay overnight.

Between 2-7 days

You may have slight increase of pain during this period especially if, like Dr. Li, your surgeon has used local ‘nerve blocks’. The pain should be well controlled by oral pain medication. Most patients complain of pain at the drain sites but minimal pain over the chest. The day after surgery, Dr Li encourages her patients to remove the dressings and shower. Dressings should be replaced. The chest should remain flat but mild post-surgery swelling, edema, is common. I encourage my patients to wear compressive garments. You can use your arms to move up to 5 pounds, but I do request patients do not lift their arms above 90 degrees. My patients will come back for follow up at this point, during which time we check the wounds, and in some cases if two drains were placed on one side, we may remove one of the drains.

Days 8- 21

You should notice that the pain is gradually improving. The drain output fluid volume should slowly decrease, the color will change from pink/bloody to a straw color. You will be seeing your plastic surgeon at this point and the drains will be removed. I usually wait a week after all drains have been removed before starting patients on occupational and physical therapy.

2 Months

Most patients are back to normal at this point and patients may resume driving and their work. I recommend seeing your plastic surgeon beforehand for a check of your wound and making sure your arm movements are back to normal.

How to Choose the Best Plastic Surgeon for an Aesthetic Flat Closure

There are several ways to find the best plastic surgeon to perform any surgery (see Dr Li’s Youtube video on ‘how to choose the best plastic surgeon’ below) including for esthetic flat closure.

1. Referrals: Your oncologic surgeon may recommend a plastic surgeon they have worked with. Make sure if they do, that this recommendation is based on the skills and outcome of that plastic surgeon and not merely convenience. Friends and family may recommend a plastic surgeon they have worked with and had a great outcome – this is ideal. Most happy patients are willing to let you see their results and give you first-hand candid feedback of their entire experience.
2. Internet: you can search for a board-certified plastic surgeon and read their reviews – I recommend using multiple sites for patient reviews. Beware of patient reviews for physicians on their hospital websites. These have usually been ‘filtered’, meaning that the negative reviews have been removed and only positive reviews are published.
3. Once you have selected the plastic surgeons you wish to consider, arrange a consultation. During the consultation, you want to gauge the experience of the plastic surgeon in aesthetic flat closures, ask for before and after photos (if they have not offered) and be mindful of the discussion. Beware of the plastic surgeon who has no photos to show you or does not discuss the procedure, risks and benefits of surgery.

Alternatives to an Aesthetic Flat Closure

The alternatives to Aesthetic flat closure after mastectomy include:

1. No breast reconstruction and a high chance of looking deformed and deflated with asymmetric scars – particularly for heavier patients and/or large bra cup size
2. Traditional forms of breast reconstruction such as implants based or autologous reconstruction

Why Choose Dr. Wai-Yee Li for an Aesthetic Flat Closure Surgery?

Dr. Li is a female board-certified plastic surgeon with extensive experience in immediate, delayed-immediate and delayed (revision) aesthetic flat closure. For the past 10 years she has worked in concert with oncologic surgeons and performed many aesthetic flat closures, producing excellent cosmetic and functional results. She has also performed research in this area and understands the nuances to getting the best results after aesthetic flat closure. During your consultation, she will listen to your concerns, give you an honest assessment of what to expect and the result she will likely achieve for you.

References

• Reference 1: Aesthetic Flat Closure After Mastectomy: Is Immediate Reconstruction Superior to Delayed?
  Cheung, R and Li, WY. Society of Asian Academic Meeting, New Orleans, Louisiana, September
  2024
• Reference 2: Aesthetic Flat Closure After Mastectomy: Is Immediate Reconstruction Superior to Delayed?
  Cheung, R and Li, WY. California Society of Plastic Surgeons 73rd Annual Meeting, San Francisco,
  California May 2023
• Reference 3: LDMCF= Latissimus dorsi myocutaneous flap published in: Doan L, Sam AP, Li, WY. Optimizing the pedicled latissimus dorsi myocutaneous flap in breastreconstruction: Lessons learned from 110 consecutive flaps. Plastic & Reconstructive Surgery-Global Open12(5):p e5791. DOI: 10.1097/GOX.0000000000005791. May 2024