Modified goldilocks nipple-sparing mastectomy with immediate prepectoral implant-based reconstruction: a case report

Background: Nearly 80% of women who undergo post-mastectomy reconstruction opt for implant-based reconstruction. Preservation of the nipple-areolar complex (NAC) in nipple-sparing mastectomy (NSM) significantly improves patient satisfaction; however in women with macromastia or breast ptosis, NAC preservation carries an increased risk of nipple ischemia. Traditional options have included free nipple grafts or a staged reconstruction, however in patients with aggressive or multifocal breast cancer, this is not feasible due to the need for timely oncologic resection. The Goldilocks mastectomy, which utilizes redundant adipodermal tissue to recreate a breast mound, was originally designed for women with large or ptotic breasts who did not desire post-mastectomy reconstruction. However, this technique has been modified in several ways. In this case report, we present our approach to a patient with breast ptosis and multifocal breast cancer who desired NAC preservation, volume preservation and mastopexy using the modified Goldilocks technique with pre-pectoral implant-based reconstruction. Case Description: A 38-year-old woman, with a bra size of 36C, presented with grade II, multifocal, estrogen receptor positive, progesterone receptor negative, human epidermal growth factor receptor-2 positive right breast infiltrating ductal carcinoma. The patient's aesthetic goals included: preservation of the NACs, elevation of NAC position, reduction in areola diameter, and maintenance of breast volume using implant-based reconstruction. As a result of her multifocal breast cancer, she was not a candidate for staged mastopexy followed by mastectomy and reconstruction. Therefore, the patient underwent bilateral Goldilocks NSM, right sentinel lymph node biopsy, and immediate implant-based reconstruction using the modified Goldilocks technique with acellular dermal matrix (ADM). At 3-month follow-up, the patient was satisfied with the overall aesthetic outcome of her breasts. Conclusions: We present a patient with breast ptosis and multifocal breast cancer who desired NAC preservation and implant-based reconstruction, but was not a candidate for staged reoperation. This case report is the first to describe a modified Goldilocks NSM with pre-pectoral implant-based reconstruction.