Goldilocks Mastectomy – Will it have a fairy tale ending?

Goldilocks mastectomy is a relatively new procedure developed by Dr. Grace Ma and Dr. Heather Richardson. This is a single stage procedure, which gives women facing mastectomy an option that takes the best features of having and not having reconstruction and combining them into a single procedure. This procedure has been a recent topic of debate at many scientific gatherings.

The first question which pops to the mind is that why was this surgery named as Goldilocks mastectomy? The following is the reply given by the surgeons who developed this surgery:

“Most of us are familiar with the story of the young girl faced with uncertainty in the woods and with a big, bad wolf nearby. She had many choices to make, and each time she face a choice, she evaluated the pros and cons; risks and benefits of each one.  Most involved extremes -too hot or too cold; too hard or too soft. But there was a third choice that had attributes of both and fell somewhere in the middle. This was considered “just right”.

We chose this name because this technique embodies the simplicity of not having reconstruction and only having a single surgery with as little as possible discomfort and down time. Yet it preserves as much of the patient as possible and avoids an amputated appearance.

For those who still aren’t quite as large as they would like to be and choose to wear a prosthesis, wearing a bra is much more comfortable and the cleavage much more natural appearing.  Redundant tissue under the arm is avoided and the final result very soft and supple.

When discussing the different choices and options pre-operatively, it is easy to remember what a “Goldilocks” is and how it differs from mastectomy with and without formal reconstruction.”

Not all patients are eligible for Goldilocks mastectomy. It is mainly suitable for patients with large breasts, who have enough tissue left behind after mastectomy, which can be used to reconstruct the breast. It is NOT suitable for patients with small breasts!!

The following are the advantages of this procedure, as highlighted by the surgeons on the website (www.goldilocksmastectomy.com)

  • Can be performed on one or both breasts
  • Can be performed for prophylaxis or treatment of disease
  • No additional surgeries are required
  • No implants or artificial devices are used
  • Decreased pain and shorter recovery time when compared to formal breast reconstruction
  • Surgical removal of breast gland under the skin means:
    • No screening mammograms required
    • Most patients do not require radiation (dependent on the stage of disease)
  • Excellent option for patients who don’t want reconstruction or are otherwise poor surgical candidates for formal reconstruction
  • Patients with extremely large breasts or sagging breasts have the best outcome from this procedure

In this procedure, all the breast tissue is removed and the remaining redundant skin and tissue is mobilized and used to reconstruct the breast, which is usually much smaller than the original size and also in some cases deformed.

As it is a relatively new procedure, long term data is yet to reveal the efficacy and safety of this procedure compared to the conventional mastectomy. Another point which I could gather after reviewing the limited data available on this surgery is that cosmetic results are far INFERIOR than a regular reconstruction (whether implant based or autologous). Another reason for its limited use is that it can only be used in patients with LARGE breasts and a point which has not been highlighted by the authors is the gross disparity in size of the two breasts after the surgery (which is a source of worry to the patient).

It is still early days for this procedure and only time will tell whether it will have a fairy tale ending or not!!

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Why aren’t Indian Breast Cancer patients opting for Breast Reconstruction?

Breast reconstruction following breast cancer is an acceptable modality and it can either be carried out at the same time as the mastectomy or as a delayed procedure. Immediate breast reconstruction is the standard of care these days, as it avoids a future surgery and also avoids the psychological trauma, which a patient faces after removal of the breast. Many studies have proven beyond doubt that it does not interfere with the oncological clearance of the cancer and that patients with breast reconstruction enjoy a better quality of life. Then why is it that Indian patients are not opting for breast reconstruction? The patients are not the only one to be blamed for this. Physician related factors are equally important in this regard.

The first and the foremost reason is lack of awareness. Many patients are unaware of these reconstructive modalities and don’t inquire about these options from the treating surgeon. Another important factor in India is the lack of awareness/ expertise about these reconstructive modalities among surgeons. There are only a handful of centres in India which offer breast reconstruction.

Breast Cancer is now the most common cancer among urban India women and the incidence is going up each year. Majority of our patients still present in an advanced stage and require mastectomies as a part of their treatment. With the improvement in the treatment modalities, many of these patients are cured of their disease and live a relatively normal life afterwards. As majority of these patients present in the advanced stage, they receive chemotherapy before surgery (neo-adjuvant chemotherapy). During this period, tackling with the side effects of chemotherapy shadows all other thoughts in their minds and they only think about surviving the onslaught of chemotherapy. By the time they get over with their chemo, they are mentally and physically so exhausted that they stop thinking about their quality of life after their treatment. This is another reason why they don’t opt for reconstruction at this stage.

Another important point is the lack of guidance/ counselling. We are fortunate to have a dedicated Breast Counsellor in our unit, who happens to be a breast cancer survivor as well. We have seen a more positive attitude towards the diagnosis and management in patients who have been counselled properly.

If more awareness is created among the patients and surgeons, more patients can benefit from these reconstructions and have a better quality of life.

Various Reconstructive Options after Mastectomy are:

  1. Microvascular free flap reconstruction: These flaps are the standard of care these days. It can either be a DIEP (deep inferior epgastric artery perforator) flap, in which fat is taken from the abdomen to reconstruct the breast or an ALT (antero-lateral thigh) flap, in which muscle and skin is taken from the thigh.
  2. Pedicle flaps: Latissmus dorsii flap – tissue take from the back or TRAM (transverse rectus abdominus myo-cutaenous flap) – tissue taken from the abdomen
  3. Implant based reconstructions using silicone implants.

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