Incision preferences for mastectomy with aesthetic flat closure?
Hi - I had a lumpectomy recently, but because of some surprises with pathology, I may end up having a mastectomy. If so, I would likely prefer a double mastectomy with no reconstruction -- aesthetic flat closure.
But - I actually care deeply about the aesthetic result. I've looked up photos online, and see a lot of different incision placements. Single horizontal line straight across the chest at (former) nipple level, two flat lines at the bottom of the breast, diagonal lines, curved lines, etc. But the photos are not 100% informative. For one thing, it's impossible to deduce how they would look in different lighting conditions, different body positions, etc.
I'm feeling very lost for information about this...
Scar placement etc is discussed all the time for reconstruction and regular augmentation. But not for flat closures.
Is one type of incision is preferable over the others?
I'd love to hear anybody's experience with flat closure. What type of incision do you have? How has it worked out for you? How do you feel about it? TIA for any info, experiences, and thoughts!
Sarah
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Diagnosis: Mixed IDC and ILC (with DCIS and LCIS). Right breast (5 cm before chemo). Right axillary lymph node.Biopsy Pathology: ER negative (0%), PR negative (0%), HER2 positive. IHC 3+ (100% of cells). FISH positive (ratio 16.1). Grade 3.
Treatment so far: TCHP (Taxotere, Carboplatin, Phesgo) 6 cycles, Dana Farber Cancer Institute. Lumpectomy (2.5 cm plus margins) and targeted SLNB (4 nodes removed included previously biopsied clipped node, isosulfan blue dye, sulfur technetium colloid radiotracer), Massachusetts General Hospital
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I had a single mastectomy with an aesthetic flat closure. I don't recall having any options as far as the incision. I'm pretty sure it has more to do with the location of the cancer, whether you'll have lymph nodes removed, your weight, etc. You'll have a meeting with your surgeon before the surgery and you'll have the opportunity to ask plenty of questions and make it clear what you want. I am pleased with my surgical scar though it is longer than I expected, I suppose because I had an ALND under my arm and a lymphovenous bypass procedure where they used the same incision. A breast surgeon removed my breast and lymph nodes, and a plastic surgeon did the bypass and the surgical closure. Good luck!
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Thanks lw422. One of the most stressful things about all this is not being able to compare surgeons (my local health systems prevent patients from meeting with more than one breast surgeon). I've see two, and they had very different plans for the incision, and neither had photos or even drawings to show me. It's great that yours was willing to work with a plastic surgeon!
There are obviously so many options, but I don't have any way to learn about them.
It's ironic to me that, for augmentation surgery, patients can shop around, meet with different surgeons, and even see photos, to find a good fit.
But for patients like me who want flat closure, we have no access to that kind of info, and are not allowed much choice. All I can do is cross our fingers or pray.
It sounds like your incision was diagonal. Do you know whether a diagonal incision is also typical for bilateral mastectomies?I just wish there were a way to share information for flat surgery, like the "realself" site does for reconstruction surgery.
It feel unfair that we aren't allowed to have aesthetic concerns and choices, the way people who choose reconstruction do. I hate going into this blind!
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Sarah--my incision is horizontal, crossing my chest at about the middle of my breast. The scar extends from mid-chest to just under my right axilla and is almost invisible after 10 months. I made sure that I stressed that I wanted the smooth "aesthetic flat closure", that I never planned reconstruction, and that I did NOT want "dog ears". Those were my specifications, haha. I wanted a double mastectomy but since I was an IBC patient it was not the standard of care. They wanted the cancerous breast off and healed ASAP to whisk me to radiation.
After dealing with nerve pain, tightness, and the discomfort of the surgery and fear of lymphedema, I decided I won't go back to have the prophylactic mastectomy on the other side. I was so tired of treatments and hospitals, etc. I just wanted a break from it so now I'm a uniboob. It has been an adjustment but I'm still here to whine about it, so there's that.
Write down ALL of your concerns and if you find pictures that look like what you hope your outcome will be, take them with you to the meeting with your surgeon. Make sure you get all your questions answered and stress exactly what you are wanting. Unless the cancer is in a location that will be problematic, they should do their best to give you a good outcome. Ask if your surgeon has any photos of their work.
I'll mention one more thing was was a surprise to me. I expected my chest to be really smooth where the breast was removed, but it actually feels slightly uneven. The area where the tissue was removed feels hard because it seems like my rib bones are right under my skin...so that's kind of weird.
Seems to me that there are a few Facebook groups for people who went flat, and if you belong to one of those groups you can see pictures that people share. I'm not on Facebook so I don't know exactly what the groups are. Also, check out this website... https://notputtingonashirt.org/gallery/
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I had a flat closure last summer. It's sort of curved like where the bottom of my breast was. I don't remember having a choice but I did ask her to keep it neat so I wouldn't have dog ears. Unfortunately she kept it so neat and tight that it's pretty tight. You can very clearly see my ribs. It's not uncomfortable anymore but it was uncomfortably right for a long time.
That said I don't really care how it looks. The only person seeing it is my husband (and doctors), so it is what it is.
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I'm in the process of meeting with surgeons for a prophylactic bilateral mastectomy, and I used two main resources to learn about and discuss scar patterns: the new book Flat & Happy (found on Amazon, be sure to check out the appendix) and the "AFC Scar Patterns & More" page on the Not Putting on a Shirt website. (Sorry, I'm not allowed to post links!)
Combined with different galleries of flat results, those resources helped me narrow down which scar patterns I like and which hopefully will work best for my body. And I was able to show a surgeon diagrams of those, and she pointed out the ones she would be closest to.
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Sarah, I had a friend who had a BMX seven years before me and her surgeon clearly did not believe her that she did not want reconstruction and left her with dog ears and a real mess. So, hoping to improve on her experience, I asked for a plastic surgeon to close me, brought photos of what I was hoping for (for heaven's sake, surgeons make women into men routinely). I thought I made myself so clear, but in the end my plastic surgeon left plenty of skin because she thought I'd change my mind. It's the one part of my treatment that can get my blood boiling. Otherwise, I'm grateful to be alive and am grateful for every day. I've thought of having a "rebuild your body" kind of PS do a revision, but my whole reason for choosing BMX without reconstruction was to avoid long/more surgeries and move on with life. When I complained to my MO about the outcome, he said he could hook me up with another PS at MD Anderson and I laughed and told him I gave them one shot--If I were going to do that, I'd go outside of MDA. At 35, I had a cystosarcoma phyllodes and lost half of the right breast--I'd worn a prosthetic for 22 years (otherwise my bra would ride up). When I was diagnosed with IDC in 2018, I knew I wanted both off—I wanted to be even. I have no regrets about that decision. The same breast surgeon who did my first surgery at MD Anderson did my BMX. He did an amazing job 22 years before—he did the whole surgery through the nipple, so while the two breasts didn't look like they should be on the same body, I had two, fully functioning breasts; at the time, he thought I was crazy not to have reconstruction but I never considered it. When preparing for the BMX, I asked him to have a PS close. I think it hurt his feelings because he was a true artist in his own right, but I thought I was helping myself to end up with the best outcome. Boy, was I wrong--and I later told him so! By this point, we were like old friends (I was seen by him for ten years after the first surgery to be sure it didn't come back) and I knew he really cared for me. He chose my surgery date based on being able to get who he believed was the best PS on staff at MD Anderson. Ha! What I learned is that plastic surgeons want you to have reconstruction—it's what they do.
Sarah, you asked about our feelings about choosing no reconstruction. Besides getting my blood pressure up over thinking about how the FEMALE plastic surgeon disregarded what I asked for, I would make this choice all over again. Do I wish breast cancer had never happened? Of course I do, as we all do! But if I had to make the choice again, I would do the same. At home, I look like a ten year old girl in my nightgown and am very comfortable doing so, but when I get dressed, I do wear prosthetics in my bra (and I live in hot Texas). When dressed, I look exactly as I did before cancer--it's uncanny, actually. My adult daughters will even remark about it now and then.
gb2115, I find it interesting that you were so tight it was almost uncomfortable (probably good for me to hear). I have tightness because of radiation, but certainly not from having a neat and tidy incision!
eladnarra, I looked up the book you recommended—and wow! Boy, I wish I had known about that book! I am buying it so that I have it in the event that someone I know is in this boat in the future. I realize most women choose reconstruction and understand and respect that choice, but I have two friends who had only the one breast removed who regret it now because they are now having neck issues from the differences in weight only having the one breast.
Lastly, Sarah, if it would help for me to send you photos of my chest via private message, I am happy to do so. Even if you use it only to say, "this lady asked for an aesthetic flat closure" and this is not what I want to look like, I'm happy to send them.
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Thank you! These replies are so helpful. I hope it's ok to ask some more questions!
beesy_the_other_one : Yes I would love a photo of your result, to show surgeons an example of a person asking for flat, but not receiving it. If it helps make an equal exchange, I can PM you a pic of my own unexpected result (my lumpectomy a few weeks ago removed more tissue than I expected, and I seem to be missing the bottom third of my breast now). This is so generous of you to offer!
eladnarra : Which scar patterns/placements did you like best? (I keep changing my mind!)
Also, thank you for the resources! I will print out the scar pattern page to show surgeons (and will also try to get that book tho I'm basically out of time). Here is the link, for anyone else who wants to take a look: https://notputtingonashirt.org/aesthetics/.
gb2115 : Are your incisions similar to the "U-shaped" incisions on the Not Putting on a Shirt Link (https://notputtingonashirt.org/aesthetics/)?
lw422 : Are you happy with the mid-breast horizontal incision, and did it leave any remaining residual tissue (like a bit of puffy tissue where the lower part of the breast was) below the scar?
Also, did you have to specially ask for the plastic surgeon to help with the surgery, or does your breast surgeon arrange that routinely?
One surgeon suggested a mid-breast horizontal incision (all the way across the chest) for me, and I worry about it leaving the "inframammary fold".
Has anyone heard about "fat transfer" after flat mastectomy, not to make a breast, but just as a way to pad the ribs and avoid concavity?
Sarah
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I’ll join in here as a newbie flattie. I just had my single mastectomy with aesthetic flat closure on June 16. My surgeon did a beautiful job. It’s a simple incision that goes from just next to my sternum and curves slightly upward along the side of my body. My surgeon did this to spare me the armpit incision for lymph node removal. She just went in through the mastectomy incision. I’ve been using Bio-Oil and a scar gel that a kind nurse gave to me to keep it moisturized.
Not sure if this matters, but I’ll throw it out there. I began stretching almost immediately after surgery and 4 weeks later pretty much have total mobility now. There is still tightness but it’s minimal. I had no pain after surgery. Only had to take Tylenol and Advil a couple of times. I have heard of others having nerve pain, so I count myself fortunate. I had sensitivity near my armpit that felt like a sunburn for about 2 1/2 weeks but it’s gone now. I do have almost total numbness across my chest but there is still feeling near my collar bone and below my incision.
Ditto to what lw422 said about it feeling like it’s hard on the chest. In the days immediately after surgery I had a lot of swelling that felt like it was going to take a long time to go down but it went down almost totally after about 3 weeks. I still have some areas that feel tough on the side of my body but it’s improving all the time.I’m happy to send you a pic if you like, just PM me.
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Ladies, I surely wish I'd had this level of detail of information four+ years ago, but I didn't find it, even looking. KUDOS to you ladies! I will pipe in again tomorrow answering specifics, but wow. I feel like I would be able to help someone navigate this in the future better because of this conversation alone, and so I thank you.
jh40, I started stretching the night of my BMX, because the friend I mentioned didn't do it at all and became like the dinosaur in Toy Story who couldn't raise his arms. I literally started stretching hours after my BMX and when I was evaluated by PT two weeks later they told me they couldn't improve on my situation. I was so well healed and doing so well after two weeks, they started radiation. I was shocked.
More tomorrow, but I hope someone in the future reads this when they are making such choices. Everyone in my world thought I was doing crazy amounts of research, but you all have eclipsed me and I am thrilled you have done so!
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beesy good for you! I wasn’t given any information before or post surgery about stretching, as in what to do or not do, intervals, how much is too much, etc. And my breast surgeon is a genius. Thankfully I knew that I’d end up with T-Rex arm if I didn’t, and I only knew that much from watching a Youtuber who’s documenting her breastcancer situation.
I think you’re right that researching like crazy makes us look like we’ve lost our marbles but people don’t realize how little quality information is given. I think the medical community sees this stuff so often they forget how it is for people just coming into it.
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Sarah, I know that plastic surgeons will do fat transfers after flat mastectomy to improve the outcome, so you should ask! You also asked about if we had to ask for a PS specifically. At MD Anderson, yes, this was my experience. One thing I'm grateful for is that my breast surgeon did not cut under my armpit for the SNB--I wear sleeveless shirts from April to October in hot Texas.
This topic has made me wonder again whether it would be worth considering revision surgery, or at least going to talk to a PS to find out what would be involved. I have the name of one, given to me by my radiation buddy (who sadly passed away last fall). I have pictures of her chest and it was exactly what I was looking for. I need to order the book eladnarra recommended before even thinking about it, but looking again at the photos on notputtingonashirt.org, my outcome is not the worst, but it's definitely not the best, either.
I have PM'd Sarah the photos of my chest. If anyone in the future is reading this and would like photos of "what you don't want" to show your doctor, feel free to PM me.
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Sarah--I did not have to ask for a plastic surgeon and I am a patient at MD Anderson in Houston. Of course I was having the lymphovenous bypass microsurgery at the same time as my mastectomy which was done by the PS along with the surgical close. They mentioned fat grafting to me to "soften" my chest but I just don't want anymore procedures, surgeries, etc. I will have a small revision to a little marble-sized bump at the end of my incision that still tends to swell, but the PS said it would be done in his office with local anesthetic. (If it were a more complicated procedure I'd just live with the bump.)
As far as stretching, please follow your surgeon's recommendations. I was told strictly to NOT lift my arm above shoulder height for a couple of weeks and to wait till after the drains were removed. Each surgery is different and each will have specific instructions for aftercare. I did start gentle exercises as instructed and have had no range-of-motion issues. I had an ALND which was the hardest part of the surgery. It took months for the "softball under my armpit" feeling to resolve and the area is still tender.
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lw422 is right about following doctor's instructions on stretching--and the ALND alone would warrant more restrictions. Mine had no restrictions on me, but every surgeon has different "rules." My PS was insistent I take daily showers, whereas I've known many women who've had the same surgery and their surgeon won't allow showers.
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Beesy--I got to shower right away, too. It was so wonderful to stand under that warm water; I looked forward to that every day. (Though managing the drains was a hassle!!)
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Sarah--I forgot to answer this:
"Are you happy with the mid-breast horizontal incision, and did it leave any remaining residual tissue (like a bit of puffy tissue where the lower part of the breast was) below the scar?
One surgeon suggested a mid-breast horizontal incision (all the way across the chest) for me, and I worry about it leaving the "inframammary fold".Yes, I'm satisfied with my surgical result (not sure "happy" is the word...haha.) I don't have any residual tissue or any evidence of the inframammary fold. Everything is just flat and relatively smooth. I would imagine that a person's anatomy will effect how the outcome is... extra weight, older skin, etc. Just a lot of variables so no two people will have exactly the same result.
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Interesting about the showers. I only had to wait 2 days before I was allowed to take a shower, no other instructions. But that first shower really tired me out! I don't think I could have taken daily showers the first week!
My surgeon had pads of diagrams that she could draw on to show the incision line for my BMX and lymph node removal. She'd just tear off the page for me to take home. My incision runs from under my arm (not the arm pit but the side of my chest) to the center of my sternum. Then after an inch gap, it runs across to the other side, under my arm. There are tiny corners next to the gap, but they should flatten out.
The incision seems to be at the midpoint of my nipple. The only disadvantage is if like me, the underside of your breast is very porous. I rarely saw this side. The top of my breast was nice and smooth. But now with the breast area flattened out, the skin textures don't match. Oh well, its not really an issue, in the grand scheme of things.
My BMX was almost a month ago, and my chest "landscape" is settling down. There are odd lumps of flesh, some hard, some soft near the sides. The thing I wish I had known was how things should look week by week, month by month. I thought it looked like a hot mess, but knew it would get better. The visiting nurse reassured me that everything looked great and was healing nicely.
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My experience was much like JH40 - started gentle stretching right away and regained full range of motion within a few months. My surgeon did a great job with a nice, smooth closure. Here are some pics of my scar - with some decorations.
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This is all so helpful! It's crazy how different surgeons are, even for the same patient/body type. The very first surgeon I saw (whirlwind multi-appointment at Dana Farber) said two short straight lines, right at the crease at the very bottom of my breast. The next surgeon (who did my lumpectomy at Massachusetts General) said a single line straight across my chest, at nipple level. The third (who I just saw at Dana Farber said lazy-S incisions, much like miriandra's photos, with the inner ends slightly further down.
miriandra - Thank you so very much for posting those photos. I think your scar looks great, and the decorations are cute and fun (at first I thought it was a tattoo...then noticed they were different in the two pics)!
Also, thank you blinx and lw422 for your descriptions and experience. And thank you beesy_the_other_one!
If I end up opting for mastectomy, I plan to do bilateral, both for symmetry and because I have a higher chance of developing a new cancer in the contralateral breast.
(Now I am worried because the latest surgeon says post-mastectomy radiation is so much tougher than post-lumpectomy radiation.)
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I have a set of "tattoo pens", skin-safe ink that washes off after a few showers.
Post-mastectomy rads? I was told that because I went with a mastectomy instead of a lumpectomy (the position and shape of my tumor made a lumpectomy possible, but tricky) I wouldn't need radiation. Of course, our situations could be very different, but it's worth double-checking on.
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Sarah--best of luck to you no matter how you choose to proceed. I don't understand the surgeon saying that post-mastectomy rads are more difficult...?? Did he say in what way? To my way of thinking, radiating a flat surface should be much easier, plus the patient doesn't have skin-on-skin rubbing of the radiated tissue (like under the breast). Anyway, my best to you!
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Sarah, I agree with LW! I had two radiation buddies who were usually on either side of me during the six weeks of radiation and I became friends with both (sadly, one died last fall but I still keep up with her daughter). The other buddy had a lumpectomy and her nipples were so sore and chapped she just wanted to cry all day every day. She has large breasts, and like LW said, she was just raw underneath of them. I have what my mother calls "cheap Irish skin" . . . and I sailed right through radiation--which started two weeks after the BMX. I would definitely reach out to a radiologist on this one; something smells rotten in Denmark to me about that comment.
Miriandra, your incision looks amazing. I sent photos of mine to Sarah, and she can vouch that I did not end up with such an aesthetic flat closure. I ordered the book Flat & Happy--I'm so glad that resource is out there for women now!
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miriandra Excellent, I am totally getting tattoo pens!
Unfortunately I probably can't avoid radiation. Pre-chemo, I had at least two positive nodes. Chemo eradicated the cancer in breast and nodes. BUT official guidelines and Drs say I still need radiation -- including hardcore nodal radiation -- even with mastectomy. Because "there is no evidence for omitting radiation" in patients who had positive nodes before chemo.
The guidelines are based on outdated info, and recent data suggests that radiation has little to no benefit for patients like me. There's even a randomized trial currently studying this. But I don't want my Drs to fire me. I may try to argue my way out of radiating the internal mammary nodes tho...
lw422 I totally agree - I do not understand the surgeon's argument. I wonder if she based that on post-mastectomy radiation including the chest wall, whereas post-lumpectomy radiation usually does not? I suspect anyone who requires post-mastectomy radiation would get some kind of "extra" chest-wall radiation if they had a lumpectomy instead.
I clicked your history and it looks like you had post mastectomy radiation? If so, I hope it's not too off-topic to ask, did it cause trouble with range of motion, stretching, skin-hardness, etc?
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beesy_the_other_one Oops I must have been composing my earlier post right as you posted yours! I'm sorry your buddy had a hard time with post-lumpectomy chemo, but it is good information to know.
Best I could tell -- tho I could be wrong! -- the surgeon was talking about more long-term issues like tightness/hardness/discomfort/non-stretchability to the skin and underlying tissue? But you are right, I need to ask the radiation oncologist about that. I swear though, all these doctors give a different story!
I truly appreciate you being willing to share your bad experience of requesting a flat closure, and being a perfect candidate for it, but having the surgeon make the decision to go against your wishes. Simply because they thought they knew better than you. As you mentioned you were slightly ahead of the game, as aesthetic flat closure wasn't an "official" medical term quite yet, so I don't know what you could have done differently. But it is an important cautionary story, especially now that AFC is official!
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Hello,
I am new to all of this, but considering going flat. I would be interested in see your surgery results. I wouldnt know where to start. concerned about what my husband thinks, but I dont want to add additional surgeries and complications. it just seems crazy to think this way. Especially because it is DCIS. I am mostly worried about my husbands reaction. We havent met the breast surgeon yet
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Hi L&G! Welcome! I hope you have an easy time on your journey. It's never fun, but we are happy to offer support.
I posted pictures of my incision on the previous page in this thread. You can find them there. I have been very happy with my decision and satisfied with my results. There is also an Aesthetic Flat Closure (AFC) organization, Not Putting On a Shirt, that has a gallery of closure images and a directory of surgeons who do AFC.
I hope your husband's reaction is like my DH's was, "It's your body, hon. Do what you need to do." It's normal to be worried and scared; but in the end, did he marry you or did he marry your breasts? I think he married you.
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Hi - I'm just checking back in to say how helpful everyone's posts were! I ended up asking my surgeon for separate diagonal incisions, which she said would be gently sloped upward towards the armpit. I'm happy with my result so far, tho it's only been a few weeks. Will post a pic when scars are healed up. Thank you to everybody for being willing to share and discuss this!
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Hi - just wanted to post pics as promised, in case anybody researching flat aesthetic closure lands here. My surgeon did what I requested. Flat closure. Symmetric diagonal incisions. She initially wanted to do just a single incision across the chest, which would avoid any risk of medial dog ears, but I felt it would look too severe on my body. So I asked her about separate lazy-s shapes (which another surgeon had suggested), and she said those can have unpredictable symmetry, and she didn't want to do them. So we agreed on separate gently-sloped diagonals. But the result looks like sort of a hybrid which I actually like better. I feel like a lazy-S shape is really the ideal solution, for a bunch of reasons, but most surgeons don't have much or any experience with them.
I am happy with the result and I think my surgeon did a great job. I'm flat without extra skin, and no general lumpy/bumpy-ness. My shape still looks and feels like me. No pain. Full strength and range of motion. Full sensation down the middle of the chest, with numbness under the scars and in a small area laterally on each side. Also numb in my right (cancer side) armpit and around to the back, but that was from my previous SLNB.
Now for my list of annoying things: (Annoyance 1) There is a swollen area under my left-side scar at the drain site (the photo is a mirror image). Which I assume is permanent? That was my non-cancer side. That drain was a problem from the get-go, it was my only site of post surgical discomfort, and I ended up with a shallow seroma there. (Annoyance 2) Incisions are very close to each other in the center. I think that was to minimize the risk of medial dog ears. (Mini-annoyance 3) Teeny millimenter-size version of dog ears at the armpit-end of my incisions. But I think those are geometrically inevitable unless you extend the scar to the back. My surgeon forewarned me and said they can easily be snipped later.
Anyway I feel like I made the right decision, given the crappy circumstances! I hope this is useful.
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Looks good, SarahNH! The scars look nice and flat too, not keloid.
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Thanks Miriandra! Your post and photos were helpful (and reassuring) to me, back when I was researching my decision. So I hope adding mine will be helpful to future "researchers".
I feel like our scars have a similar shape. Which reminds me, I need to get some tattoo pens! :-)
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Thanks, sarahnh, for continuing this thread. I know if I need future surgery, I would choose AFC, so the discussion is very helpful. This post (mine) bumps it to make it easier to find if someone else is looking at the same issues.
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