Goldilocks reconstruction

Dr Alexandra Grubnik tells us about a new and versatile tool in the reconstructive arsenal – Goldilocks reconstruction.

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History of Goldilocks reconstruction

Goldilocks reconstruction is a type of post-mastectomy reconstruction using your own tissue. It was described, in 2012, by Dr Richardson and Dr Ma from Atlanta, USA. They proposed an alternative option for reconstruction after mastectomy that does not involve using implants or large complex flaps to recreate a breast mound. 

This procedure is a skin-sparing mastectomy which entails removing  the breast tissue but preserving the skin envelope of the breast that is subsequently used to form a new breast mound. It was originally offered to women with large pendulous breasts, as they would have sufficient skin to create a small breast mount. 

The doctors named it after the tale of Goldilocks and the three bears as, in their view, it offered a “just right” option for many patients – in-between radical mastectomy, leaving a flat chest and linear scar, and complex reconstructive procedures, involving long operations or use of prostheses.

Widened patient eligibility

Goldilocks procedure has been offered to patients of the Netcare Breast Care Centre of Excellence since 2014. It has rapidly gained popularity as it offers a reconstructive method that uses patients’ own tissue and yet does not sacrifice a muscle or result in extensive scarring. Due to growing popularity, several modifications were introduced to widen the patient base eligible:

• The most common request was performing Goldilocks on women with small to moderate size breasts. To add extra volume, we recruit tissue from the upper abdomen. 

• This tissue is folded over into the new breast mound and tummy skin is pulled up and secured under the breast. Similar to a reverse tummy tuck. It creates a natural shape by adding volume in the lower pole of the new breast mound.

• Another common desire is preservation of the nipples. Nipple-sparing mastectomy has gained wide acceptance and popularity due to the ‘Angelina effect’. Scientific studies showed that preserving the nipples is safe in selected patients. We routinely perform a nipple biopsy which is checked by our pathologist in theatre to confirm absence of cancerous or suspicious cells.

• Loss of volume in the upper pole of the breast mound is relatively common following Goldilocks reconstruction. Especially, if the original breast size was small to medium. This is successfully addressed with fat grafting six months after the first procedure. Fat transfer is a versatile procedure that not only allows to increase the volume of the breast mound and correct any contour irregularities, but also get rid of unwanted fat deposits anywhere on the body.

What you need to know

Who is a candidate for Goldilocks reconstruction?

Any patient who wishes to have breast reconstruction with her own tissue and needs to have a mastectomy on one or both sides for a medical indication or as a risk-reducing procedure.

How long is the operation and hospital stay?

The operation takes three hours and you’ll be in hospital for two to three days.

How long is the recovery?

Wound healing and recovery varies between patients. After surgery, you will have drains in for a week. You will be asked to avoid cooking, cleaning or lifting anything heavy for several weeks after surgery. It’s recommended to refrain from driving for two weeks. Four to six weeks’ sick leave is recommended, depending on the type of work you do. Sports and exercise may be resumed after six weeks.

What will my scars look like?

The incisions are like breast reduction incisions, so scars will be located around the areola, extending vertically down and into the infra-mammary crease, in an inverted-T pattern. There are no additional scars on the abdomen even when tissue is recruited from that area. It’s of paramount importance to follow a scar management protocol given by your plastic surgeon to ensure the scars are as inconspicuous as possible. 

When can a touch-up procedure be performed?

The second stage breast reconstruction, which includes fat grafting, scar revision and nipple reconstruction (if required) is performed at least six months after the first procedure, or after completion of radiation therapy (if indicated).

What are the possible complications and side effects?

Bleeding or collection of fluid, infection, prolonged wound healing and unsightly scarring can occur with any operation. Preventative measures are taken routinely and will be discussed with you in detail by your plastic surgeon. Loss of sensation of the nipples and breast mounds is expected following a skin-sparing mastectomy, regardless of the reconstructive method used. Blood supply to the nipple and areola may also be compromised due to all the breast tissue being removed. Total nipple loss occurs very rarely. Nipple congestion and delayed healing may occur. 

Will I need yearly mammograms after Goldilocks?

No, Goldilocks is a type of mastectomy so mammograms should not be necessary. You will need to have a yearly ultrasound of the breasts for screening.

Can I have Goldilocks reconstruction if I need radiation or chemotherapy?

Yes, Goldilocks is resistant to the adverse effects of radiation. So, you are unlikely to lose volume in the breast. It is important to wait for the wounds to be completely healed before you have adjuvant radiation or chemotherapy.