It is important for patients considering any kind of breast reconstruction to be informed and educated about all your options. My guest on the DiepCJourney podcast are two microsurgeons from Midwest Breast and Aesthetic Surgery in Columbus, Ohio. Dr. Pankaj Tiwari and Dr. Ergun Kocak worked and trained together at Ohio State. “All things in Columbus come back to THE Ohio State University” as Dr. Tiwari states. They are two ideal surgeons to discuss the topic on episode 9, optimal flat closure.
The Change in Breast Surgery Terms
I stated in the podcast during my surgical consultation in 2002, correction, I meant to say 2014, I was not given the options for optimal flat closure. There is a reason I was not. The procedure, closure after mastectomy, has been around for an exceptionally long time. The change that has taken place recently is in the terminology used with emphasis on the word “aesthetic.” Dr. Kocak points out this is the term which is now recognized in larger circles and organizations for both breast cancer and breast reconstruction surgical options.
Dr. Tiwari points out there has been a disconnect between patients and surgeons as to how to manage the excess skin component if no reconstruction is done. This has led to the thought process behind aesthetic flat closure.
Why Patients Consider Optimal Flat Closure
Plastic surgery is focused on form and function. When a patient does not care to reconstruct after a mastectomy using their own tissue, as in DIEP flap, or with implants, aesthetic flat closure gives the benefit of a proportional, even, clean closure that allows for prosthetic use without a lot of excess additional tissue. Reasons patients might consider aesthetic flat closure:
- Removal of implants due to discomfort or issues with their implants.
- Choosing aesthetic flat closure after mastectomy and have decided not to choose a reconstruction with tissue or implants.
The Psychological Decision to Choose Flat Closure
Using new terminology and knowing the surgical procedures that have changed over time serves to minimize decisional regret for patients. It was often thought in the past that choosing flat closure was not considered breast reconstruction. We have come to accept that aesthetic flat closure is very much a reconstructive option. It does not mean “no reconstruction.” When we say aloud and use words like aesthetic flat closure, we are educating patients on what is now a breast reconstruction surgical option after mastectomy.
Breast surgeons heard from patients they did not want reconstruction and often the redundant or extra skin was left thinking the breast cancer patients may want some type of reconstruction at a later time. When patients know the term, aesthetic flap closure and use it with their surgeon, they are telling them they want as clean and symmetrical outcomes as possible.
Clearing up the Misunderstanding of Patient Decision Making
Dr. Tiwari makes a compelling statement reflecting the shared decision-making process. He says,
If our job is anything, it is to match the patient’s desires with the right procedure for them.
Dr. Pankaj Tiwari
Dr. Kocak follows with another powerful and important statement for patients to keep in mind.
I think it is important to really emphasize that those desires may change over time.
Dr. Ergun Kocak
When a patient is newly diagnosed, they may not desire surgery for reconstruction at all. Having aesthetic flat closure does not preclude you from having another type of breast reconstruction surgery at a later time. In fact, any reconstructive option, for the most part can be reversed or done at another time. Dr. Kocak reminds patients they do not have to make “the perfect” decision at the time of the mastectomy. Knowing this can give a sense of relief to the patient, minimizing decisional regret.
It is important for patients to ask about the affects of radiation on any type of reconstructive tissue. We discuss the dilatory affects this can have on skin. Dr. Kocak and Tiwari discuss the advantages fat grafting can have for an optimal flat closure. The reality is, like other types of breast reconstruction, optimal flat closure can often mean more than one procedure. Be sure to discuss insurance coverage with whomever your surgeon is who will be performing your reconstructive surgery.
Honoring the Decision for Optimal Flat Closure
There is really no right answer for any one patient, DIEP flap, implants, flat closure. Dr. Tiwari points out a lot of this decision is understanding the patient and considering their personal preferences. Having the shared decision-making conversation is paramount to the entire reconstructive decision process. Let’s put aesthetic flat closure on the menu as a reconstructive option for patients and encourage patients and surgeons to use the terminology. We want to get the word out it is a phrase that should be used in the breast surgery and plastic surgery nomenclature when patients present with breast cancer and mastectomy.
You can listen to the entirety of the podcast here.