![]() ![]() #GOLDILOCKS PROCEDURE FREE#We developed an updated version of this technique that includes a free nipple graft and aggressive sculpting of the inferior mastectomy flap with division of the lateral inframammary fold for medial tissue transfer to create a more central breast mound. 6 This technique involves a skin-sparing mastectomy through Wise incisions and utilizes the residual cutaneous mastectomy flaps to create a breast mound. The previously described “Goldilocks mastectomy” was developed for patients who were poor candidates for traditional postmastectomy reconstruction. #GOLDILOCKS PROCEDURE SKIN#3–5 These complications include implant and flap loss and reconstructive failure, skin necrosis, wound complications, fat necrosis, and donor-site complications. 1, 2 Multiple studies have shown unacceptable complication rates for both prosthetic and autologous reconstruction in these patients. The increased rates of obesity coupled with the increased rate of breast cancer development in the obese has resulted in a patient population for whom there are few reconstructive options after mastectomy. This is the first proposed description of a reliable strategy for postmastectomy reconstruction in the morbidly and super obese. Here, we present a 2-stage strategy: the previously described Goldilocks mastectomy with free nipple grafts followed by second stage subpectoral definitive implant placement. The obese patient poses a significant reconstructive challenge for which no reproducible approach has been described. With at least 9 months of follow-up on all patients, no patient has had a capsular contracture, significant malposition, or other complication requiring reoperation. There were no instances of delayed wound healing or reconstructive failure after prosthetic placement. Two patients had wound healing complications after Goldilocks mastectomy but were completely healed within 8 weeks. Ten postmastectomy reconstructions in patients with BMIs ranging from 37 to 50 with a mean BMI of 45 underwent bilateral Goldilocks mastectomy with free nipple grafts. ![]() Patients were assessed for implant-related complications including malposition, capsular contracture, dehiscence, and extrusion. Ten consecutive morbidly (BMI > 40) or super obese (BMI>50) women underwent bilateral Goldilocks mastectomy with free nipple grafts followed by second stage subpectoral implant placement at least three months postoperatively. We demonstrate here the utility of the previously described Goldilocks mastectomy with free nipple grafts as a safe bridge to second stage implant-based breast reconstruction. These patients are poor candidates for autologous and prosthetic-based reconstructions as they have a high rate of reconstructive failure, surgical complications, and poor aesthetic outcomes. Reconstructive surgeons are encountering an increasing number of obese women requiring postmastectomy reconstruction. ![]()
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