The outcomes of nipple sparing Goldilocks mastectomy in a primarily overweight and obese population

Introduction

The Goldilocks mastectomy was first described in 2012 by Richardson and Ma as a post-mastectomy procedure that utilized residual skin and subcutaneous fat after complete resection of breast tissue to create a breast mound. This procedure is achieved by preserving and de-epithelializing the residual mastectomy flap, allowing for natural contouring without the need for implants or complex reconstruction. The name “Goldilocks” is derived from the eponymous classic fairytale, in which the protagonist chooses an option that is “just right” rather than extremes of “too hot” or “too cold” (1). Similarly, the Goldilocks mastectomy represents a middle-ground approach—offering an alternative to both traditional implant-based reconstruction and intricate microsurgical techniques. Initially developed for patients who did not want a breast amputation or to commit to a traditional implant-based or autologous reconstruction, this technique has since evolved as a viable solution for select patients desiring a more natural, autologous flap-based reconstruction.

In a standard nipple-sparing mastectomy, the surgeon removes all breast tissue while preserving the nipple and areola. Although effective, nipple sparing mastectomies, especially when performed with immediate reconstruction in obese patients, carry a high risk for complications, including nipple areolar complex (NAC) ischemia and necrosis, delayed wound healing, increased risk of infection, and superficial skin loss (1-3). In a Goldilocks mastectomy, the existing skin of a large or ptotic breast is utilized to create a smaller, lifted breast mound without the need for implants, an ideal alternative for women with large breasts who would want a size reduction following surgery. This technique was originally intended to reduce complications and improve aesthetic outcomes, especially in women with very large breasts; however, the nipple was typically not spared (4-6).

The Goldilocks mastectomy is a valuable reconstructive option for patients who are not ideal candidates for traditional reconstruction. However, limited data exist on its outcomes when combined with nipple-sparing techniques. Although risk factors such as high body mass index (BMI), smoking, and diabetes are well-known contributors to complications in breast surgery, their specific impact on nipple-sparing Goldilocks mastectomy remains poorly understood. This study aims to address this gap by evaluating the feasibility and outcomes of the nipple-sparing Goldilocks mastectomy in a high-risk population. We present this article in accordance with the STROBE reporting checklist (available at https://abs.amegroups.com/article/view/10.21037/abs-25-23/rc).

Methods

This was a retrospective single-center cohort study performed in West Palm Beach, Florida. All patients in this study were consecutively recruited between December 2019 and March 2025, and underwent nipple sparing Goldilocks mastectomy. The inclusion criteria for this study were female adults ≥18 years old, undergoing nipple sparing Goldilocks mastectomy. The indications for surgery included breast cancer and high-risk status for breast cancer with and without fibrocystic disease or severe mastalgia. There were no criteria for cup size or BMI, therefore, all breast sizes and a wide range of BMIs were included in this study. There were no exclusion parameters for this study.

Patient demographics included BMI, age, genetic risk factors for breast cancer, and type of breast cancer. The comorbidities assessed included diabetes, hypertension, smoking, and a composite score for multiple comorbidities. The composite score for multiple comorbidities was defined as having 2 out of 3 of the following: obesity, diabetes, or smoking.

The primary outcomes assessed in this study were post-operative complications, recurrence of breast cancer, partial NAC ischemia, total NAC loss, and pain after surgery. The complications reported include delayed wound healing, infections categorized by abscess or cellulitis, hematoma, Mondor’s disease, keloids, pain, or ischemia. Pain after surgery was measured subjectively by patient-reported values on a 1–10 Likert scale. This study also examined the association between patient comorbidities and overall complications through a logistic regression model.

Surgical technique

A nipple sparing mastectomy is performed in a breast reduction pattern using a standard Wise pattern (Figures 1,2A) or through a transverse incision just above the level of the NAC (Figures 2B,3-5), depending on the level of ptosis. A careful, sharp dissection is used to de-epithelialize the lower dermocutaneous flap inside the boundaries of the Wise pattern incision or inferior to the transverse incision towards the inferior mammary fold, save the NAC. All grossly visible breast parenchyma is removed, including the anterior breast fascia. The utmost care is placed to maintain adequate perfusion to the skin flaps with extremely gentle handling of the flaps with minimal instrumentation and cauterization to the flaps. When necessary, sentinel lymph node biopsy and/or axillary dissection is carried out through the same incisions. The upper and lower poles are then sharply divided from one another, sometimes with the exception of the upper medial region to maximize blood supple to the NAC. The lower pole tissue rests on the chest wall in a semblance of a mound, mostly as an inferior or inferomedial NAC pedicle. The remaining skin envelope is closed using the standard Wise-pattern with the most inferior portion of the upper pole sutured to the limit of de-epithelialized dermis of the lower pole. The median point to which the inverted T-junction is affixed tends to be 10–12 cm from the patient’s mid-sternal line.

Figure 1 A nipple sparing mastectomy using a standard Wise pattern: a 56-year-old female with an initial BMI of 29.7 kg/m² with R. DCIS who underwent bilateral nipple sparing Goldilocks mastectomy. The following presents before (left), 4 months post operation (middle), and 1.5 years post operation (right) images. This image is published with the patient’s consent. BMI, body mass index; R. DCIS, right pure ductal carcinoma in-situ.

Figure 2 Incision patterns utilized for nipple sparing Goldilocks mastectomy. (A) An example of the standard Wise pattern used for nipple sparing Goldilocks mastectomy procedures; (B) a transverse-inframammary fold incision pattern made for the extremely ptotic patients for the nipple sparing Goldilocks mastectomy. This image is published with the patient’s consent.

Figure 3 A nipple sparing mastectomy using a transverse incision at the level of the nipple areolar complex: a 34-year-old female, BMI =41.5 kg/m² with T2N1 invasive ductal carcinoma status-post bilateral nipple sparing Goldilocks mastectomy. The patient underwent post-mastectomy radiation therapy. Images were taken before (left), 3 days post operation (center), and 6 months post-mastectomy radiation therapy (right). This image is published with the patient’s consent. BMI, body mass index; N, node; T, tumor.

Figure 4 A nipple sparing mastectomy using a transverse incision at the level of the nipple areolar complex. Here, a 39-year-old female, BMI =42 kg/m² with a family history of breast cancer underwent prophylactic nipple sparing Goldilocks mastectomy. Images were taken prior to operation (left) and 2 months post operation (right). This image is published with the patient’s consent. BMI, body mass index.

Figure 5 A nipple sparing mastectomy using a transverse incision at the level of the nipple areolar complex. Long-term follow-up of a 59-year-old female, BMI =40 kg/m² with a diagnosis of ductal carcinoma in-situ and family history of breast cancer who underwent nipple sparing Goldilocks mastectomy. Images were taken prior to operation (left) and at 3 years follow up (right). This image is published with the patient’s consent. BMI, body mass index.

In the extreme grade 3 ptosis (Figures 3-5), a transverse incision is used to separate the superior and inferior poles of the breast to perform the mastectomy. After nipple sparing mastectomy is performed, again, taking care to minimize trauma to the superior skin flap and inferior dermocutaneous NAC flap, the inferior NAC pedicle is then molded to produce central fullness simulating a breast mound. A 2-0 Vicryl suture is used to fix the inferior NAC flap against the mastectomy cavity. The superior skin envelope is then draped over the inferior NAC pedicle and approximated to the inframammary line. The NAC is delivered through a new 38–45 mm diameter hole that is created in the superior dermocutaneous flap. To minimize skin necrosis of the superior flap against the inferior mammary fold incision, indocyanine green (ICG) dye is injected intravenously to identify and preserve larger vessels in the flap before making the aperture for the NAC. After at least 20 minutes of ICG dye injection, the flaps are re-evaluated with ICG angiography. Topical nitroglycerin is applied to ischemic regions, and where necessary, sharp debridement is performed.

Regional anesthetic block at the pectoralis muscle is used with intraoperative ultrasound with liposomal bupivacaine. A Jackson-Pratt drain is placed in each chest wall and left in for an average of 3–6 days postop. All patients are placed on postoperative antibiotics for at least 1 week.

Statistical analysis

All continuous variables were reported as mean ± standard deviation and all categorical variables were reported as n (%). Continuous variable associations were determined using 2-sided t-tests. Univariate analysis was used to assess baseline demographic differences between patients with and without complications. Measures of association were determined with odds ratio (OR), followed by 95% confidence interval (CI). All ORs were determined using logistic regression. A multivariate model was used to assess potential multicollinearity among variables that were determined significant in univariate analysis. A two-sided P value ≤0.05 was determined as significant for this study. All variables of interest were complete, and no missing data were observed in the dataset. All statistical analyses were performed in STATA BE18.5.

Ethical consideration

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Nova Southeastern University (No. 2024-480) and informed consent was obtained from all individual participants.

Results

This retrospective single-center study examined a total of 203 consecutive subjects treated with nipple sparing Goldilocks mastectomy from December 2019 to April 2025 and were followed for an average of 12.1±12.5 months. A total of 202 patients underwent bilateral Goldilocks mastectomy and one patient had unilateral Goldilocks mastectomy. As a result, there was a total of 405 breasts examined in this study, of which 259 were non-cancerous breasts and 146 with cancer. A detailed flowchart of excluded subjects is provided in Figure 6. The average age of patients in this study was 56.7±13.2 years old and the average BMI for patients was 30.4±6.7 kg/m². The prevalence of breast cancer in this cohort was 141, of which 5 (3.5%) were diagnosed with bilateral breast cancer. Patient comorbidities included hypertension, diabetes, obesity, and smoking. Hypertension prevalence was 63 (31.0%), diabetes prevalence was 19 (9.4%), obesity prevalence was 101 (49.8%), and smoking prevalence was 56 (27.6%). Analysis of Table 1 demographics showed patients with complications to have a greater BMI (P=0.03), were more likely to be smokers (P=0.01), and more likely to be diabetic (P=0.03) compared to patients who did not experience complications in this study.

Figure 6 Patient inclusion flow chart.

There was a total of 38/203 (18.7%) patients with complications in this study, of which 6 patients had ≥2 post-operative complications and one patient had ≥3 post-operative complications. When accounting for individual mastectomy cases, 46/405 (11.4%) breasts experienced post-operative complications in this study. The most common complication was delayed wound healing 18/405 (4.4%). Reasons for delayed wound healing were attributable to 13 with obesity (BMI ≥30 kg/m²), and 3 with morbid obesity (BMI ≥40 kg/m²). Partial unilateral NAC loss occurred in 6 patients, and two patients had bilateral partial NAC loss, resulting in a total of 10/405 (2.5%) breasts having partial NAC loss, resulting in hypopigmentation of part of the NAC and/or flattening of the nipple. Complete NAC loss occurred in 4 patients, for a total of 4/405 (1.0%) breasts. Among the 4 patients with total NAC loss, three patients had multiple comorbidities (obesity, diabetes, and active smoking), and one patient had three previous breast surgeries, including implant mastopexy and capsulectomies. All patients with total NAC loss underwent subsequent nipple reconstruction.

There was a total of 6 (1.5%) infections within this cohort. Infections included both cellulitis (n=3) and abscesses (n=3). Five of these six patients were obese, and three of these five were morbidly obese. Cellulitis in one patient was attributed to uncontrolled diabetes with a measured hemoglobin A1c (HbA1c) (12%) and a history of radiation to the breast. Seromas occurred in 4 (1.0%) breasts, of which 1 was obese and 1 was morbidly obese. Mondor’s disease was reported in 1 (0.3%) breast. There were no significant differences observed between total or each individual type of complication between patients with breast cancer and patients without breast cancer (Table 2).

The reoperation rate in the entire cohort was 45/203 (22.2%) patients. Among the cohort, 22/147 (142 unilateral cancers + 5 bilateral cancers) breasts with cancer (15.0%) underwent reoperations for positive margins. Among these 22 cases, 7 were pure ductal carcinoma in-situ (DCIS), 2 were lobular pathology, and the remaining 13 were at least T2 disease with extensive DCIS. After re-excision, 4 (18.0%) had residual disease, of which 3 had T3 disease and the other had 4.5cm with DCIS (Table 3). There was a total of 15/203 (7.4%) revision surgeries, where 8 were within the cancer cohort and 7 within the non-cancer cohort, for which the primary reason was due to cosmesis (P=0.14). The overall recurrence rate in this cohort was 3/147 (2.0%), with a mean time until recurrence of 32.67±18.58 months. All patients with recurrence underwent reoperations and appropriate adjuvant therapies were offered. Of the three patients with hematomas, two had reoperations. One patient who returned to the operating room was initially placed on Heparin followed by Eliquis for a suspected pulmonary embolism, which was subsequently ruled out. The remaining reoperations were for NAC debridement and nipple reconstruction (n=2).

Among all subjects, five were planning to receive implants in the future, two have already undergone implant placement, and two have opted for lipofilling.

Overall patient pain on a 10-point Likert scale showed an average of 8±1.7 units. Among the patients who did complain of pain, only one continued to report consistent breast discomfort for about 3 months following their initial surgery. This patient was originally admitted for risk-reducing mastectomy due to a family history of breast cancer and a variation of unknown significance in the BRIP1 gene. She was managed with Motrin, gabapentin, and lidocaine cream to sleep and was also followed with physical therapy and pain management, before being lost to follow up. Incidentally, she had already had submuscular implants, which were left untouched through the procedure.

In a univariate logistic regression model, diabetes was significantly associated with an increased odds of complications (OR =2.9, 95% CI: 1.0–7.9, P=0.04), and the association between smoking and complications was an OR =2.6, 95% CI: 1.3–5.4, P=0.01. In a multivariate model accounting for obesity (OR =1.8, 95% CI: 0.9–3.8, P=0.11), diabetes (OR =2.11, 95% CI: 0.7–6.0, P=0.16) and smoking (OR =2.4, 95% CI: 1.1–5.0, P=0.03).

Discussion

In this retrospective study, we report an overall complication rate of 11.4% and an overall rate of total NAC loss of 1.0% among breasts treated with nipple sparing Goldilocks mastectomy. This study also demonstrates a statistically significant relationship between BMI, smoking, and diabetes with post-operative complications. To our knowledge, this is the largest consecutive series of patients undergoing nipple sparing Goldilocks mastectomy examined for real world outcomes. With low rates of complication and a predominantly pain-free cohort following surgery, nipple sparing Goldilocks mastectomy can be an effective and viable option for women with high BMI undergoing therapeutic or risk reducing mastectomy.

The established relationship between smoking and post-operative complications has been well documented in studies examining patients undergoing mastectomy procedures. A prior analysis has shown there is a 1.5-fold increase in complications among smokers compared to nonsmokers following the treatment for primary breast cancer (7). Furthermore, a large meta-analysis that encompassed 33 studies on breast reconstructive surgery reported smoking history as a significant factor leading to major or re-operative complications (OR =1.05, 95% CI: 1.02–1.18) (8). In our study, we reported a greater association between smoking and post-operative complications (17/56 smokers, OR =2.6, 95% CI: 1.3–5.4, P=0.01), of which were attributed to 35.3% (6/17) with delayed wound healing, 29.4% (5/17) with infections, 17.6% (3/17) with total NAC loss, 11.8% (2/17) with hematomas, and 5.9% (1/17) with partial NAC loss. Throughout the follow-up period among smokers, 4 were brought back to the operating room for further debridement and the three patients who had complete NAC loss underwent nipple reconstruction. Following nipple reconstruction, no patients experienced further complications. It is worth noting that despite similar complication rates to previous studies, our patients did not have to undergo mastectomy with staged reconstructions with expanders followed by implant placements.

A similar tale can be said for diabetes and complications following mastectomy. The presence of diabetes has negative effects on immune regulation, resulting in a greater risk for infection and poor wound healing (9,10). In our study, while the overall rate of infections was low (6/405 breasts), the proportion of infections among diabetics was significantly greater compared to non-diabetics [3/19 (15.8%) vs. 3/184 (1.6%), P=0.001]. The overall complication rate in our cohort between diabetics and non-diabetics was 18.4% vs. 7.3%, showing some consistency with a previous meta-analysis on breast reconstruction, which reported an overall complication rate of 11.6% in diabetics to 5.6% in non-diabetics (11).

In the largest dataset examining post-mastectomy margin rates, encompassing over 34 studies and 22,548 patients, the overall reported positive or close margin rate was 12.0%, with notable geographic variability—11.0% in North America, 22.0% in the United Kingdom, 12.1% in other European cohorts, and 16.4% in cohorts from Australia and Asia (12). Our margin rate of 15.0% aligns with these prior reports, with 4 patients (18.0%) subsequently being found to have residual disease. Importantly, higher margin rates often reflect the complexity of the treated cohort. In our study population, many patients had multifocal or multicentric disease and larger breast volumes, both of which increase the difficulty of achieving clear margins while preserving adequate tissue for reconstruction. It should be noted that in most of these cases, intraoperative needle localization was performed to target the lesion, with placement of clips as close to the area of interest. This allowed for precise re-entry and re-excision of additional tissue to optimize oncologic outcomes.

Additionally, patient factors such as BMI play a significant role in margin clearance. A recent study reported that women with BMI ≥30 kg/m², invasive lobular carcinoma (ILC), and undergoing either breast-conserving surgery or mastectomy had a positive margin rate of 28.5% (13). Tumor stage further impacts this rate; among T3 ILCs, the positive margin rate was 18.7% compared with 11.8% for T2 and 1.6% for T1 disease (14). Considering these factors—and that our cohort included a mix of high-risk breast cancers as well as overweight and obese individuals—our findings remain consistent with the current literature.

In our cohort, we observed the recurrence rate for disease to be 2.0%. All patients with recurrences returned to the operating room for additional management. Our observed recurrence rate remains consistent with previous literature in nipple sparing mastectomy, where recurrence has been reported as low as <3% (15).

In 2012, Richardson and Ma first proposed the Goldilocks mastectomy technique and included 32 women (50 breasts in total) who underwent the procedure (12). The selection criteria for the study included both women with breast cancer as well as one woman who chose Goldilocks as a prophylactic measure. The average BMI in this cohort was 30.3 kg/m² (range of 18–51.9 kg/m², median of 30 kg/m²) and post mastectomy radiation (PMRT) was done in 5/32 subjects. Henderson and Ma’s total complication rate was 8% and included one patient with seroma and 3/50 breasts developed cellulitis. The nipple sparing rates were not reported in this study.

A following study by Chaudhry conducted in 2019 examined a larger cohort of only breast cancer patients (n=55), with a total of 96 breasts (5). In this study, the average BMI was 33.7 kg/m² (19.2–54.6) and 43/53 underwent bilateral Goldilocks mastectomy and 10/53 underwent unilateral Goldilocks mastectomy. The overall complication rate in this cohort was 9.38%, comparable with Richardson and Ma, with a breakdown of complications including seroma (n=2), cellulitis (n=2), hematoma (n=1), wound dehiscence (n=3), and return to operating room (n=1) (5,16).

Both Richardson and Ma and Chaudhry report comparable complication rates compared to our cohort 8% vs. 9.38% vs. 11.2% of breasts, respectively (5,16). However, neither study used a nipple sparing Goldilocks technique. In 2015, Krishnan et al. first described the use of a nipple sparing Goldilocks mastectomy in a 35-year-old (bra size 36D) with biopsy-proven stage 2a invasive ductal carcinoma of the left breast (17). This case report was the first to address the possibility of saving the NAC and showed the feasibility and positive aesthetic outcome of such a procedure. In 2023, Setit and colleagues published the first cohort study of nipple sparing Goldilocks mastectomy in 15 patients (18 breasts total) (18). They followed patients for a total of 15 months and reported a total of 5 NAC ischemic changes, including two (11%) partial and three (17%) total. Comparing these findings to our study, we show a much lower NAC ischemic change rate of 2.5% in partial NAC and 1.0% in total NAC loss among 405 breasts.

In women with larger breasts, staged mastopexy prior to nipple sparing mastectomy has been suggested to improved outcomes and reduce rates of skin flap necrosis (19). In a previous meta-analysis on two-staged procedures, the authors report flap necrosis rates ranging from 0–17% and nipple loss from 0–6% (20). However, the BMI ranges within these studies were primarily in the normal to overweight categories. In another meta-analysis, BMI ≥30 kg/m² was an independent risk factor for both minor and major complications and implant removal (21). Likely, the reasons for patients with obesity to experience higher complication rates are multifactorial, including delayed wound healing secondary to impaired immunity, increased tissue mass resulting in longer procedures and poor perfusion following surgery, higher risk for infections, especially with the use of tissue expanders (22,23). Likewise, the addition of implant-based reconstruction also carries a heightened risk for major complications in patients with obesity (23). In a previous study done at the Mayo clinic, Goldilocks mastectomy with immediate implant-based reconstruction in overweight and women with obesity carried a 2.3× higher major complication rate and 2.8× higher minor complication rate compared with Goldilocks mastectomy alone (24). While this paper did not examine the nipple sparing technique, the authors had noticed a similar trend of complications, especially with nipple loss, if an immediate implant-based reconstruction was performed. Therefore, we defer any implant-based procedure to at least 4–6 weeks after a patient’s index nipple sparing Goldilocks mastectomy. The current study reflects this change in the author’s practice. We observed <5% of patients with Goldilocks mastectomy undergoing subsequent implant placement surgery or lipofilling, suggesting overall patient satisfaction.

Those undergoing PMRT also have an increased risk for implant loss/reconstruction complications, with previous studies showing reconstruction failure in up to 37% of patients (25-28). In our study, 16 (7.9%) patients underwent PMRT, and aside from minimal asymmetry, no one had reconstruction failure or additional surgeries to correct the asymmetry (Figure 3), despite being offered additional reconstruction for symmetry.

The limitations of this study are inherent in the design. Due to the study’s retrospective nature, there may be an impact on the results due to selection or recall bias. Additionally, this study’s population was predominantly from a select county in South Florida and may not represent the general population. Surgical technique should also be considered a limiting factor when it comes to nipple sparing Goldilocks mastectomy. The operating surgeon received additional oncoplastic training and routinely works simultaneously with reconstructive plastic surgeons. Given that this study was conducted by a single surgeon with oncoplastic training and supported by a specialized team in a high-volume elective setting, the reproducibility of these outcomes may be limited in lower-volume centers or practices without similar expertise and infrastructure. Limitations were also apparent in the interpretation of our numeric results. In the univariate model assessing diabetes with complications, the lower limit was 1.0, indicating borderline significance and further warrants cautious interpretation of this finding. Lastly, this was a feasibility study with an average follow-up period of 12.1±12.5 months and therefore did not examine long-term outcomes of oncologic integrity of therapeutic mastectomy.

The nipple-sparing Goldilocks mastectomy offers an alternative to two-staged procedures by eliminating the need for multiple operations. This approach reduces the risk of complications, provides comparable aesthetic outcomes, and enhances patient psychological well-being. Our study demonstrates the feasibility of this technique, presenting it as a viable option.

Conclusions

The nipple sparing Goldilocks mastectomy offers a viable option for select patients seeking autologous breast reconstruction without implants or microsurgery. Our findings highlight the feasibility of the nipple sparing Goldilocks mastectomy technique as well as the advantages in providing high patient satisfaction and low complication rate. However, further research is needed to refine patient selection criteria and optimize long-term outcomes. By expanding reconstructive options, this technique contributes to a more personalized approach to breast surgery, especially in women with obesity.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://abs.amegroups.com/article/view/10.21037/abs-25-23/rc

Data Sharing Statement: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-23/dss

Peer Review File: Available at https://abs.amegroups.com/article/view/10.21037/abs-25-23/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://abs.amegroups.com/article/view/10.21037/abs-25-23/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Nova Southeastern University (No. 2024-480) and informed consent was obtained from all individual participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Becker H, Vazquez OA, Komberg J. Goldilocks Procedure without a Vertical Incision and a Comprehensive Literature Review. Plast Reconstr Surg Glob Open 2021;9:e3786. [Crossref] [PubMed]
2. Franceschini G, Masetti R. Evidence-based nipple-sparing mastectomy in patients with higher body mass index: Recommendations for a successful standardized surgery. Am J Surg 2020;220:393-4. [Crossref] [PubMed]
3. Webb C, Gupta N, Kosiorek H, et al. The effects of body mass index on operative time and outcomes in nipple-sparing mastectomy. Am J Surg 2020;220:395-400. [Crossref] [PubMed]
4. Alhussini MA, Mohamed SM, Elfayoumi T, et al. Goldilocks mastectomy; a modified technique enhancing the aesthetic outcome presented as a single center single-arm prospective cohort study. Eur J Surg Oncol 2024;50:108586. [Crossref] [PubMed]
5. Chaudhry A, Oliver JD, Vyas KS, et al. Outcomes analysis of Goldilocks mastectomy and breast reconstruction: A single institution experience of 96 cases. J Surg Oncol 2019;119:1047-52. [Crossref] [PubMed]
6. Ogawa T. Goldilocks mastectomy for obese Japanese females with breast ptosis. Asian J Surg 2015;38:232-5. [Crossref] [PubMed]
7. Murthy BL, Thomson CS, Dodwell D, et al. Postoperative wound complications and systemic recurrence in breast cancer. Br J Cancer 2007;97:1211-7. [Crossref] [PubMed]
8. Mrad MA, Al Qurashi AA, Shah Mardan QNM, et al. Predictors of Complications after Breast Reconstruction Surgery: A Systematic Review and Meta-analysis. Plast Reconstr Surg Glob Open 2022;10:e4693. [Crossref] [PubMed]
9. Kjærgaard K, Wheler J, Dihge L, et al. Impact of type 2 diabetes on complications after primary breast cancer surgery: Danish population-based cohort study. Br J Surg 2024;111:znae072. [Crossref] [PubMed]
10. Rifkin WJ, Kantar RS, Cammarata MJ, et al. Impact of Diabetes on 30-Day Complications in Mastectomy and Implant-Based Breast Reconstruction. J Surg Res 2019;235:148-59. [Crossref] [PubMed]
11. Liu Q, Aggarwal A, Wu M, et al. Impact of diabetes on outcomes in breast reconstruction: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2022;75:1793-804. [Crossref] [PubMed]
12. Bundred J, Michael S, Bowers S, et al. Do surgical margins matter after mastectomy? A systematic review. Eur J Surg Oncol 2020;46:2185-94. [Crossref] [PubMed]
13. Falade I, Switalla K, Quirarte A, et al. Balancing risks of surgical complications and positive margins for patients with invasive lobular carcinoma of the breast and elevated BMI: An institutional cohort study. Am J Surg 2025;241:116073. [Crossref] [PubMed]
14. Hewitt KC, Miller P, Piper M, et al. Positive margins after mastectomy in patients with invasive lobular carcinoma of the breast: Incidence and management strategies. Am J Surg 2022;223:699-704. [Crossref] [PubMed]
15. Boyd CJ, Salibian AA, Bekisz JM, et al. Long-Term Cancer Recurrence Rates following Nipple-Sparing Mastectomy: A 10-Year Follow-Up Study. Plast Reconstr Surg 2022;150:13S-9S. [Crossref] [PubMed]
16. Richardson H, Ma G. The Goldilocks mastectomy. Int J Surg 2012;10:522-6. [Crossref] [PubMed]
17. Krishnan NM, Bamba R, Willey SC, et al. Explantation following nipple-sparing mastectomy: the Goldilocks approach to traditional breast reconstruction. Plast Reconstr Surg 2015;135:795e-6e. [Crossref] [PubMed]
18. Setit A, Bela K, Khater A, et al. Nipple Sparing Goldilocks Mastectomy, A New Modification of the Original Technique. Eur J Breast Health 2023;19:172-6. [Crossref] [PubMed]
19. Awaida CJ, Bernier C, Bou-Merhi JS, et al. Staged Mastopexy before Nipple-Sparing Mastectomy: Improving Safety and Appearance in Breast Reconstruction. Plast Reconstr Surg 2024;153:864e-72e. [Crossref] [PubMed]
20. Winder AA, Quinnen N. Skin reducing nipple sparing mastectomy and implant reconstruction: Surgical options and risk factors for complications in the larger ptotic breast. Clin Surg Oncol 2023;2:100017.
21. Odgaard EB, Frid NL, Lauritzen E, et al. The impact of body mass index on direct to implant and two-stage immediate breast reconstruction procedure: a systematic review. Ann Breast Surg 2024;8:34.
22. Goltsman D, Warrier S, Mak C, et al. Association between body mass index and adverse surgical outcomes of implant-based breast reconstruction: a prospective cohort study of 5,545 breast reconstructions. Ann Breast Surg 2022;6:32.
23. Yuen JC, Coleman CA, Erickson SW. Obesity-related Risk Factors in Implant-based Breast Reconstruction Using AlloDerm. Plast Reconstr Surg Glob Open 2017;5:e1231. [Crossref] [PubMed]
24. Bustos SS, Nguyen MD, Harless CA, et al. The Goldilocks Procedure with and without Implant-Based Immediate Breast Reconstruction in Obese Patients: The Mayo Clinic Experience. Plast Reconstr Surg 2021;148:703-16. [Crossref] [PubMed]
25. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue expander and autologous tissue breast reconstruction. Ann Surg Oncol 2010;17:202-10. [Crossref] [PubMed]
26. Krueger EA, Wilkins EG, Strawderman M, et al. Complications and patient satisfaction following expander/implant breast reconstruction with and without radiotherapy. Int J Radiat Oncol Biol Phys 2001;49:713-21. [Crossref] [PubMed]
27. Tallet AV, Salem N, Moutardier V, et al. Radiotherapy and immediate two-stage breast reconstruction with a tissue expander and implant: complications and esthetic results. Int J Radiat Oncol Biol Phys 2003;57:136-42. [Crossref] [PubMed]
28. Reinders FCJ, Young-Afat DA, Batenburg MCT, et al. Higher reconstruction failure and less patient-reported satisfaction after post mastectomy radiotherapy with immediate implant-based breast reconstruction compared to immediate autologous breast reconstruction. Breast Cancer 2020;27:435-44. [Crossref] [PubMed]