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Goldilocks Mastectomy: Am I the Right Fit?

Mastectomy, What’s Next?

Considering a mastectomy is a deeply personal and difficult decision for many women. Once the decision is made, the next step is often considering options for reconstruction. While a growing number of women are choosing not to undergo reconstruction and may proceed with an aesthetic flat closure, most women seriously consider some form of immediate post-mastectomy reconstruction. Approximately 80% of American women who choose to undergo breast reconstruction, choose an implant-based reconstruction which can be performed in one-stage (“direct to implant”) or in two stages where a tissue expander is first placed and a definitive implant is placed in a separate, second surgery.

Breast Reconstruction Options Post Mastectomy

Women choosing post-mastectomy reconstruction have several options:

  1. Implant-based Breast Reconstruction

Breast Implants can provide beautiful, symmetrical breast mounds for women after mastectomy. But for some women, implant-based breast reconstruction just is not an option. The concerns about Breast Implant Illness (BII), future leakage, rupture, or interference with cancer detection, the need for future surgeries for implant replacement, fear of higher complication rates in certain patients, or other reasons lead them to explore alternative options as they refuse breast reconstruction with implants.

  1. Flap-based Breast Reconstruction

There are many possibilities for flap-based breast reconstruction, using women’s autologous (own) tissue. Dr. Schwartz specializes in utilizing primarily the soft tissues from the back based on the latissimus dorsi muscle for his flap-based breast reconstruction, which is the less invasive reconstruction using a woman’s tissue.

Most reconstructive surgeons utilize tissues from the abdomen referred to as DIEP flap (deep inferior epigastric perforator, which refers to the blood vessels used in the procedure). A DIEP flap reconstruction is a complex microsurgical procedure, which requires specialized training and the use of small instruments to operate on delicate tissue. This surgery requires many hours in the OR and usually several days in the hospital, with a significantly longer recovery, usually at least 4 weeks.  During the DIEP flap reconstruction, a surgeon removes skin, fat, and blood vessels from the lower abdomen and uses them to reconstruct the breast. The abdominal muscles are left intact.

Some women also opt out of autologous flap breast reconstruction due to the higher rate of complications, longer surgery and recovery time, multiple surgical sites and scars, or donor tissue site problems, despite their good aesthetic results and patient satisfaction.

Goldilocks Mastectomy

Some women may not prefer either implant-based reconstruction or the complexity of DIEP flap reconstruction. These women may be interested in a “Goldilocks Mastectomy,” a technique that utilizes the same skin incisions that a plastic surgeon would use for a breast lift or breast reduction – a “Wise-pattern” or “anchor” incision. This approach uses the excess breast skin and fat that is left over after a mastectomy to create a breast mound without the use of implants or incisions to harvest tissue from other parts of the body. We have covered the details and before and after pictures in our previous article, Finding The Perfect Fit: The Goldilocks Mastectomy,  so in a nutshell, here are a few reasons why women choose a Goldilocks mastectomy:

  • Breast size

The Goldilocks mastectomy is a good option for women with large or sagging breasts. It’s also an alternative to traditional reconstruction techniques that may not be suitable for larger breasts.

  • Breast reconstruction

The Goldilocks mastectomy is a middle ground between a flat-chest appearance and full reconstruction. It can be used as a starting point for future reconstruction, or it can be the only step in the process.

  • Pain and recovery

The Goldilocks mastectomy can cause less pain and have a shorter recovery time than traditional breast reconstruction.

  • No implants

The Goldilocks mastectomy doesn’t require implants or other artificial devices.

  • Prophylactic mastectomy

The Goldilocks mastectomy can be used as a prophylactic mastectomy (preventive or risk-reducing mastectomy.

  • Single surgery

The Goldilocks mastectomy is a single-stage procedure that can be performed on one or both breasts.

  • Cost

The Goldilocks mastectomy is theoretically cost-effective.

Women often conduct extensive research online, join support groups, talk to friends and family, and compare before and after pictures when considering their breast reconstruction options, to make informed decisions about what they want.

Being a suitable candidate for a Goldilocks Mastectomy depends on various factors, including individual anatomy, breast size, overall health, personal preferences, and treatment goals. It’s important to gather as much information as possible and perhaps consult with others who have gone through similar experiences. Another must is to have open and honest discussions with their healthcare providers to explore all available options and make informed decisions that align with their unique needs and circumstances. Each woman’s journey is deeply personal, and it’s important to approach the decision-making process with understanding, compassion, and support.

Am I the Right Fit for Goldilocks Mastectomy?

A lot of women like the idea of Goldilocks mastectomy for the reasons mentioned above, our office gets daily inquiries from women asking specifically for this procedure. However, not every woman is a suitable candidate for this procedure. The decision of whether a woman is a good candidate for a “Goldilocks Mastectomy” depends on various factors.

You can review a few key points below to help you determine if you are the right fit for Goldilocks Mastectomy.

  • Women who were at one point considering breast reduction surgery are usually excellent candidates for this procedure.
  • Women who have grade 3 ptosis (nipples point straight to the ground) are also usually good candidates.
  • Women whose nipples lie at the mid-level of their upper arm (Figure A) are poor candidates for Goldilocks Mastectomy
  • Women whose nipple-to-breast crease distance (the length of the curve, Figure B) is less than 10cm are typically poor candidates for this surgery.
  • Women whose clavicle (collarbone) to nipple distance (Figure C) is greater than 25cm are good candidates.
  • Finally, women who are a bit heavier, perhaps with BMIs  >25-30, are better candidates because they have additional subcutaneous tissue on their skin flaps that can aid in reconstructing a breast mound.

Barely There: Can I Still Qualify for Goldilocks Mastectomy?

For some patients, who don’t have enough extra skin and fat in their breasts to undergo a Goldilocks Mastectomy, we can try to add additional steps to help the final outcome:

This procedure uses fat from other parts of the body to improve the appearance and slightly increase the volume of the newly reconstructed breast mounds. Fat is harvested from areas like the abdomen, hips, thighs, or arms using liposuction, then injected into the breasts helping them to look and feel more natural

  •  LICAP flap, or lateral intercostal artery perforator flap

It is a surgical procedure that uses skin and fat from the side of the chest, near the armpit to reconstruct the breast. It doesn’t affect movement or strength in the arm or shoulder, but it does leave a scar on the side of the chest wall, which is usually hidden by a bra.

Although more extensive than LICAP, this flap is a less invasive option than DIEP and can offer patients great results. We can add this back flap at the time of their surgery to give them a better result.  These patients usually do not require an overnight stay in the hospital.

Finally, some women may choose a second-stage reverse tummy tuck ( reverse abdominoplasty) if they have significant fat in their upper abdomen. This can be easily added to their first-stage Goldilocks procedure, giving them a better result.  These patients are also discharged home the same day after surgery.

Our group described many of these surgeries for the first time a few years ago. So, while some patients are excellent candidates for the Goldilocks procedure and others are more marginal, we can often add fat transfer or a local flap to give these less ideal patients a good result.  Unfortunately, some patients are very thin with minimal extra breast skin (ptosis) and cannot be offered a Goldilocks Mastectomy. In these cases, we listen closely to what they are trying to accomplish and together we develop a plan they are comfortable with, giving them the best outcome given their anatomy.

Post originally appeared on https://notputtingonashirt.org/2024/10/05/goldilocksschwartz/