What is the Goldilocks Mastectomy?

The Goldilocks Mastectomy is a confusing term because it actually describes a method of breast reconstruction, rather than a mastectomy.

A mastectomy is a procedure to remove the breast tissue after a diagnosis of cancer or to reduce the risk of getting breast cancer (‘prophylactic mastectomy’). 

After a mastectomy has been performed, a Goldilocks procedure recreates a small breast mound by rearranging the remaining breast skin and small layer of tissue directly beneath the skin.

For this reason, it is more accurately known as a ‘Goldilocks procedure’, and was first described in 2012 (Reference 1). 

In order to produce a normal looking breast shape, we use the principles of a breast reduction (see Image 1).

Why is it called a Goldilocks mastectomy or Goldilocks Procedure?

The terminology is based on the character of Goldilocks, the little girl in the well-known fairy tale ‘Goldilocks and the three bears’.

As in the story, this is a middle of the road choice when it comes to breast reconstruction.

You may recall that Goldilocks found the porridge in the first bowl to be ‘too hot’ and the second bowl to be ‘too cold’.

Finally the third bowl was ‘just right’.

In breast reconstruction, ‘too little’ would be no reconstruction and ‘too much’ would be the traditional forms of breast reconstruction, implant based reconstruction or autologous flap reconstruction, such as DIEP (deep inferior epigastric perforator) flaps.

Am I good candidate for Goldilocks Procedure?

First and foremost, to be a good candidate for the Goldilocks procedure, you need to be a candidate for skin-sparing mastectomy. This is a type of mastectomy where the nipple areolar complex is removed, but the skin of the breast is preserved. 

It is critical that you discuss this with your cancer surgeon, who may be a surgical oncologist, who removes cancer from anywhere on the body, or a breast surgeon, who specializes in surgery of the breast.

(Reference 3. See Youtube video 2: Goldilocks Procedure).

The other consideration is how large your breasts are at the time of diagnosis and how small you are willing to be after your mastectomy.

For instance, if you are a small A cup breast size, there will be very little tissue remaining after a mastectomy and not enough tissue to rearrange for a Goldilocks procedure.

The patients with a large pendulous (D cup size or above) typically have enough tissue to make a good-sized breast after a Goldilocks procedure (Reference 3. See Youtube video 2: Goldilocks Procedure).

What are the Benefits of a Goldilocks Procedure/Mastectomy?

There are several benefits to getting a Goldilocks Procedure.

• Firstly, you can avoid ‘going flat’ or even being concave (or ‘caved in’), meaning your chest will not look ‘sunken in’. Thin patients are particularly at risk of this, because once the breast is removed, there is not much tissue left and you may be able to see the bowed appearance of the ribs.
• Heavier patients, especially those with large breasts, are at risk of having redundant tissue (known as ‘dog ears’) left behind after mastectomy, if they choose not get reconstruction (see video 2). This can be very upsetting to patients and make it hard to wear clothes properly.
• Patients with large pendulous breasts may have sufficient tissue to make a ‘decent’ sized breast (see Image 2). Naturally, because we use the ‘left over’ tissue after mastectomy, the newly reconstructed breast will be much smaller but will have a more ‘lifted’ appearance.
• In patients with early-staged breast cancer (without axillary lymph node disease) and large breasts, this can be an ideal method of reconstruction because you may be able to avoid post-surgery radiation. (You must consult with your treating physicians to establish if this applies to your clinical situation).
• Can avoid potential complications of traditional methods of breast reconstruction, such as silicone implant-based reconstruction and autologous flap procedures, such as DIEP flaps (deep inferior epigastric perforator) or latissimus dorsi flaps (LD flap).
• Faster surgery – experienced plastic surgeons can perform a Goldilocks in less time than either implants or autologous flaps
• Easier and faster recovery – 2- 4 weeks compared with 6-8 weeks for conventional methods of reconstruction such as flaps.

What are the risks of Goldilocks Procedure

The risks of surgery are the same as any other surgery and include bleeding, infection scarring, risk of general anesthesia, poor cosmetic outcome, breast asymmetry, and pain.

Dr Li minimizes pain in her patients by performing intercostal nerve blocks using a long-acting, slow-release (up to 4-5 days after surgery) local anesthetic at the time of surgery.

The complications associated specifically with the Goldilocks procedure include delayed wound healing, meaning your wounds can partially open up ( known as wound dehiscence) after initially healing.

In these cases, in the absence of a breast implant, we can usually manage the wound with dressing changes, that we can guide you  to do yourself and the wound will eventually heal.

Very rarely would we need to repair these small areas of dehiscence by re-stitching this.

Scarring can be quite long and noticeable, especially if you have darker skin.

Usually with time, the scars will fade.

Dr Li usually places three layers of dissolvable sutures, to avoid the permanent type of stitches that leave permanent marks on the skin and need stitch removal.

Patients will have drains placed at the time of surgery and they typically stay in for 2 weeks.

Occasionally, in some patients, after the drains have been removed, their body continues to produce tissue fluid, resulting in a fluid collection inside the newly reconstructed breast. This is known as a seroma and is treated by removing (aspirating) the fluid using a syringe. This is not typically painful and may be performed by your surgeon or their staff or an interventional radiologist. 

Patients that are heavier and/or doing too much activity after the surgery, are more at risk of seroma formation and wound healing problems like delayed healing.

When is the Goldilocks Procedure Performed?

In most cases, the Goldilocks Procedure is performed on the same day, immediately after the mastectomy, what is known as ‘immediate reconstruction’.

In this scenario, you will have the mastectomy or mastectomies and wake up with your new breast(s). 

In some cases, it is better to wait a couple of weeks before performing the reconstruction.

This may be ensure the pathology is ‘all clear’, meaning all the cancer has been removed.

Dr Li has also performed delayed-immediate Goldilocks procedure, for patients travelling from out of town.

This way, the patient can get their mastectomy close to home and travel to Los Angeles to get their reconstruction by Dr Li.

This delayed-immediate timing of reconstruction is something Dr Li has been performing for many years with excellent outcomes.

She has been teaching this to other surgeon and her work on immediate-delayed breast reconstruction was presented at the SAAS meeting in September 2024 (Reference 7; see Image 3). 

How long does the Goldilocks Procedure take?

Depending on the size of the breast and the experience level of your plastic surgeon, the Goldilocks procedure can take 90 minutes to 2 hours to perform one side.

Typically, it is performed during the same surgery as the mastectomy, so the total duration of the case also depends on the timing of the mastectomy, and whether or not axillary nodes need to removed.

Your mastectomy and plastic surgeon should be able to give you an estimate of the time it will take.

Is the nipple saved or removed in a Goldilocks procedure?

A Goldilocks procedure is typically performed after a skin-sparing mastectomy, where the nipple is typically removed.

If a patient has very large and ptotic (droopy) breasts, it is usually not possible to save the nipples due to the blood supply.

Also if the tumor is close to the nipple, it is not advisable to keep the nipple.

After a Goldilocks procedure has been performed, patients are usually candidates for nipple reconstruction or 3D nipple areolar complex tattoo at a later date, when the reconstructed breast(s) have healed and settled in their final position.

What to expect immediately after surgery

You will wake up in the recovery (PACU= Post-anesthesia care unit) area with dressings in place and typically Dr Li will have patients placed into a surgical bra.

You will have drains in place that have been secured to the skin using a simple stitch and you will go home with these drains. Please refer to Dr Li’s ‘Guide to getting drains after surgery‘ blog.

The nursing staff will provide training on how to take care of the drains, including how to empty them and measure and record the output.

You will be discharged with new dressings, so you may replace your old ones.

You will also be sent home with oral pain tablets and antibiotics for 1-2 weeks.

You may have some discomfort in the area of the surgery but the skin itself is typically numb.

You will be able to drink and eat the same day of surgery and walk normally.

You may remove your dressings the next day and take a shower.

Do I need to stay in hospital after Goldilocks Procedure?

Most patients getting mastectomy and immediate Goldilocks procedure stay overnight, especially if you are getting double mastectomy and live far away.

Some patients prefer to go home the same day after the surgery and this is acceptable too, as long as your pain is controlled with oral medication and you have an adult to take care of you. 

Post Surgery Care (Day 1 – Day 7 after surgery)

If you stayed overnight after surgery, Dr Li, or her team, will check on you the next day and discharge you if you are doing well.

Longer Term Recovery (Day 8 – 6 weeks)

The first post-surgery visit will be scheduled a week after surgery and the second visit will be at 2 weeks.

After your drains are removed, we will send you to the occupational therapist for exercises.

We recommend no driving for 4 weeks and no lifting > 5 pounds during this time.

Patients are usually seen at 6 weeks after surgery and then cleared for return to work at that point. Patients may slowly resume exercising at this stage.

At 3 months after surgery, most patients are back to their pre-surgery condition.

At this point, we can also discuss any revision surgery and/or options for nipple replacement (see section on nipple reconstruction vs 3D nipple areolar tattoo).

After a Goldilocks Procedure, can I get enhancement if the size is not big enough?

Yes. Although the Golidlocks procedure was described to be a 100% autologous (i.e. using only the patient’s own tissue) procedure, you can get enhancement to improve the volume if it is not big enough.

This includes the use of silicone implants and autologous structural fat grafting (Reference 2; Video 1). Autologous Structural fat grafting removes fat using liposuction from areas such as the abdomen and transfers this to the breast.  

Whilst it is possible to do this at the time of the Goldilocks procedure, we would usually advise this to be performed at a later ‘revision’ surgery. 

What are the alternatives to a Goldilocks Procedure?

If you decide not to get a Goldilocks Procedure, you need to decide if you want a breast mound after mastectomy.

If you do not want a breast mound:

1. You can have your breast (surgical oncology) surgeon close the wound to the best of their ability. Some surgeons may feel comfortable offering a flat closure
2. If you have a plastic surgeon available, you can request that the plastic surgeon performs a flat closure after the mastectomy (Reference 3; Video 2).

If you wish to get breast reconstruction, provided you are a candidate, you can have conventional methods of breast reconstruction:

1. Implant-based reconstruction. Silicone implants are used more widely than saline implants for mastectomy patients, due to looking and feeling more normal after the breast tissue is removed. This is by far the post popular method of breast reconstruction in the USA.

• Autologous breast reconstruction. This involves using the patient’s own tissue. This includes Deep inferior epigastric perforator (DIEP) flap, Transverse rectus abdominis myocutaneous (TRAM) flap and latissimus dorsi (LD) flap. Because tissue is taken from another part of the body, this is a higher risk procedure with more scarring and longer surgery times and longer and more difficult post-surgery recovery.

Does getting Goldilocks Procedure make it harder for long-term disease surveillance?

Dr Li usually follows up her patients after Goldilocks procedure once a year and performs a clinical exam.

Patients are usually also followed up by the oncology team, including some being seen in survivorship clinics.

Dr Li’s research showed that long term, there was no increased risk of disease recurrence in patients who had Goldilocks procedure after mastectomy compared with patient who had skin-sparing mastectomy without Goldilocks procedure.

Dr Li’s work was presented at the American College of Surgeons Clinical Congress in 2021 (Reference 4).

How to Find the Best Plastic Surgeon for a Goldilocks Procedure 

The surgeon performing your mastectomy may have recommendations for a plastic surgeon. Make sure they are recommending that surgeon because they have good outcomes and patient care, not out of convenience because they operate in the same hospital. (Reference 5; See Youtube video)

You should ensure that your plastic surgeon is familiar with this procedure, and can show you before and after photos of their work.

You can also ask friends and family if they have a plastic surgeon they worked with who specializes in breast reconstruction.

There are still many plastic surgeons who do not perform Goldilocks procedure and you do not want to be their first one!

You can also check out this excellent website as a resource to find a surgeon familiar with Goldilocks Procedure (Reference 6).

Why Choose Dr. Wai-Yee Li for a Goldilocks Procedure?

Dr Li has been performing Goldilocks Procedure for more than 10 years and has extensive experience, producing excellent outcomes.

Patients have been very happy with the entire experience, starting with the consultation, the surgery and the immediate and long term after care.

She has performed immediate Goldilocks procedure (i.e. same day as the mastectomy), one side (unilateral) and double (bilateral) breast reconstruction using this technique.

She has performed many 100% autologous (using only a patient’s tissue) and placed implants at the same time, as well as implants at a later stage, where desired.

She has also performed autologous fat grafting after Goldilocks procedure when patients wanted a small increase in volume without using implants. 

Dr Li has trained many surgeons on the Goldilocks procedure, both in the operating room and also during national plastic surgery conferences.

What is the Cost for a Goldilocks Breast Procedure Surgery?

The costs can vary based on your current size, one side vs both sides, so it’s best to discuss this during the initial consultation.

References

• Reference 1: The Goldilocks Mastectomy. Richardson H and Ma G. International Journal of Surgery 10 (2012) 522-526.
• Reference 2: Video 1: Dr Li’s channel: http://www.youtube.com/@DrWaiYeeLiPlasticSurgeon
  Youtube video: Goldilocks Mastectomy/Procedure: Top 5 things You Must Know from Board Certified Plastic Surgeon. https://youtu.be/YotL8owoi9E?si=d_GJNUhOQqCO4b4T
• Reference 3: Deng, I, Player H and Li, WY. Society of Asian Academic Meeting, New Orleans, Louisiana, September 2024
• Reference 4: Podium Presentation: Cancer Recurrence Surveillance After Goldilocks Mastectomy. Campos A, Maniskas S, Li WY.  American College of Surgeons Clinical Congress October 2021.
• Reference 5: Video 3: Dr Li’s channel: http://www.youtube.com/@DrWaiYeeLiPlasticSurgeon
  Youtube video: Board Certified Plastic Surgeon’s TOP 3 SECRETS to choosing a plastic surgeon. https://youtu.be/kLADwgyzvYM?si=CACAThCiFrSzL5e4
• Reference 6: Website: section on Goldilocks mastectomy:  https://notputtingonashirt.org/goldilocks/
• Reference 7: Presentation and abstract: Delayed Immediate Staged Breast Reconstruction: A solution for Rural Breast Cancer Patients?