Goldilocks Procedure without a Vertical Incision and a Comprehensive Literature Review.

Breast cancer, by far the most common invasive cancer found in women, makes up around 25% of cancer cases and 14% of cancer deaths in women, where it affects one in seven women worldwide.1 Treatment approaches are usually multifactorial, based on the cancer stage and patient age, comorbidities, and preference. Treatment can include chemotherapy, radiation therapy, hormonal therapy, monoclonal antibodies, and surgery. Surgical approaches can include lumpectomy and mastectomy, which can be partial or total.2 The “Goldilocks mastectomy” was first described in 2012 and was designed for postmastectomy breast reconstruction by preserving and de-epithelializing the residual mastectomy flap to create an autologous tissue breast mound. As opposed to being too flat (traditional mastectomy) or too complex (microsurgical or implant-based), this option is meant to be just right for selected patients.3 This technique has been described in case series and case reports in patients who were poor candidates for implant-based reconstruction, simply did not want implants, or did not want to undergo major surgery, although there has been one published article using the procedure in conjunction with a lateral intercostal perforator flap on 14 women with good results.4–12 Ideal candidates for Goldilocks procedures include patients with medical comorbidities (diabetes or obesity) presenting with macromastia or severe breast ptosis, as these patients typically have excess skin and adipose tissue remaining after the mastectomy that can be used to recreate a breast mound, improve contour and/or shape, and enhance the overall aesthetic appearance.13 The degree of total mastectomy is again based on cancer stage and patient age, comorbidities, and preference. This can include simple mastectomy (total mastectomy), modified radical mastectomy (Patey’s mastectomy), radical mastectomy (Halsted’s mastectomy), skin-sparing mastectomy, nipple-sparing/subcutaneous mastectomy, extended radical mastectomy, and prophylactic mastectomy.14 An incisional approach can vary and includes the hidden incision category (inframammary fold incision and scarless circumareola incision), vertical incision category (vertical incision, circumvertical incision, circumvertical incision with skin excision, and wise pattern), and transverse incision category (lateral incision, circumlateral incision, and transverse incision).15 The Goldilocks technique has evolved in use in that it can be used for salvage after implant-based reconstruction or can also be used in conjunction with nipple reconstruction.16,17 This technique will provide a breast mound with variable degrees of projection depending upon the amount of tissue present in the native breast and the type of incision used. This approach is not a complete substitute for formal breast reconstruction but is an alternative to near-total mastectomy in patients who may be poor candidates for traditional reconstruction or those patients who prefer a one-stage reconstruction without the time commitment and potential morbidities of traditional multistage reconstruction.13 All the articles from 2012 to 2020 on this procedure use either the anchor, inverted T, or even a lateral circumareolar incision; however, no studies have been published performing the procedure without a vertical incision in conjunction with the inframammary incision. The aim of this article is to emphasize the potential benefits of the Goldilocks procedure without a vertical incision utilizing a case series of three patients, and to review the literature on surgical techniques and outcomes compared to our patients.