From Reconstruction to Going Flat – Helping Women Look & Feel Better After Breast Cancer with Oncoplastic Surgery

Barry Rosen, MD, Guest Contributor

Barry-Rosen-OR-photo-1.jpgRecovery from breast cancer can be a difficult journey, both physically and emotionally. An important part of recovery from the trauma of cancer diagnosis is to be able to put the entire experience in the rear view mirror, so to speak. But it’s hard to do that if you have a daily reminder in the form of a disfiguring scar.

It was once common for surgeons to focus solely on removing a breast cancer tumor with little regard for the appearance of the breast. But we now know we can deliver excellent cosmetic outcomes without compromising oncologic safety. There have been tremendous advances in the past 20 years in the diagnosis and treatment of breast cancer that enable us to help our patients look and feel better after breast cancer.

One of these important advances is oncoplastic surgery (OPS). Though popular in Europe for several decades, it’s only begun to gain traction in the United States within the last 10 years. OPS combines breast surgery with plastic and reconstructive techniques to achieve the best possible cosmetic outcomes without compromising cancer care. It can be as simple as closing the cavity and hiding the scar, or performing a more complex procedure like a breast lift or reduction in conjunction with removing the tumor.

OPS is more of a philosophy than a specific technique. Oncoplastic principles can be applied to any type of breast cancer operation — whether it’s breast conserving surgery (lumpectomy) or total removal of the breast (mastectomy). OPS isn’t about vanity; it’s about recovery. It’s performing the operation in a way that gets a woman back to feeling as good, if not better, about herself than she did before surgery.

For some women, this means rearranging the tissue at the time of lumpectomy to fill the space in the treated breast left by the tumor. Or it could mean reconstruction following a mastectomy.

But some patients may choose to forego reconstruction altogether — a growing trend known as “going flat.” According to a study published in the Journal of Clinical Oncology, approximately 25 percent of double mastectomy and 50 percent of single mastectomy patients opt out of reconstruction.

The reasons are varied. Some choose to go flat for comfort, some are athletes, some are looking to avoid the potential complications and longer recovery associated with reconstruction. Regardless of the reason, more patients are looking for their chest walls to be as flat as possible following breast cancer surgery.

Unfortunately, these women’s wishes are sometimes ignored. According to a September 2018 article in Cosmopolitan, many women are finding that physicians are either not discussing going flat as an option, or are deliberately ignoring patients’ desires to opt out of reconstruction.

Women report waking up after surgery to find their surgeons left extra skin in case they change their minds and want to pursue reconstruction later. This forces women to choose between living with sagging skin where their breasts once were, or undergoing an additional operation to remove the skin. This is avoidable. A woman’s decision to go flat should be as respected as another woman’s decision to undergo reconstruction.

However, while “going flat” may sound like it would be a simpler procedure than, say, reconstructing a breast from the remaining tissue, it’s not as straightforward as one might anticipate. Every general surgeon has the skill set to learn the procedure — but it’s not regularly taught in surgical training or fellowships, which may be why some women are seeing such poor outcomes after mastectomies without reconstruction.

My colleagues and I are hoping to change that. As co-director of the upcoming CME course, A Team Approach to Oncoplastic Surgery, my goal is for every attendee to learn practical skills that they can apply immediately and improve the care they’re providing their patients. Many oncoplastic techniques are basic and can be mastered in a short time; others require advanced procedures that are ideally performed in partnership with a fellowship-trained plastic surgeon. We want to help breast and plastic surgeons offer their patients the full-spectrum of oncoplastic procedures – from breast reconstruction to “going flat.”

Oncoplastic surgery is the ultimate precision medicine. It’s truly “one-size-fits-one.” What works for one woman may not work for another. It’s about designing the operation to fit the patient, and then finding the most qualified person or people to do that particular procedure. It’s also about caring enough to ask the patient the right questions, presenting her with the full range of options, and then honoring her wishes.

Every woman deserves to feel good in her own body, and it’s our responsibility as surgeons to help our breast cancer patients fulfill that goal.

Dr. Rosen is a breast surgeon and founding member of Advanced Surgical Care of Northern Illinois. A nationally recognized expert in oncoplastic surgery, he teaches for the American Society of Breast Surgeons (ASBrS), the School of Oncoplastic Surgery, and the National Consortium of Breast Centers. Dr. Rosen’s practice philosophy is centered on delivering individualized, precision care to every patient.

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