The increased rates of obesity coupled with the increased rate of breast cancer development in the obese has resulted in a patient population for whom there are few reconstructive options after mastectomy.1,2 Multiple studies have shown unacceptable complication rates for both prosthetic and autologous reconstruction in these patients.3–5 These complications include implant and flap loss and reconstructive failure, skin necrosis, wound complications, fat necrosis, and donor-site complications.
The previously described “Goldilocks mastectomy” was developed for patients who were poor candidates for traditional postmastectomy reconstruction.6 This technique involves a skin-sparing mastectomy through Wise incisions and utilizes the residual cutaneous mastectomy flaps to create a breast mound. We developed an updated version of this technique that includes a free nipple graft and aggressive sculpting of the inferior mastectomy flap with division of the lateral inframammary fold for medial tissue transfer to create a more central breast mound.7,8 In the minority of women with significant macromastia and ptosis, this might allow for a single-stage autologous reconstruction. Most women require additional volume supplementation, some of whom can be accommodated with lipotransfer surgery.9 However, most obese women require significant additional volume that must be supplied by an implant or flap. Here, we present successful implant-based reconstruction in 10 consecutive women who were either morbidly obese or super obese [body mass index (BMI), 37–50; average, 45]. In these women, Goldilocks mastectomy with free nipple grafts was followed by definitive submuscular implant placement 3 months later without an instance of reconstructive failure or significant complication that delayed care.
The technique for Goldilocks mastectomy with free nipple grafts is described in Figures 1, 2 as previously described.8 Representative obese preoperative patients are shown in Figure 3. In Figure 4, we demonstrate postoperative Goldilocks mastectomy patients 3 months after surgery. In Figure 5, we have 1-year follow-up after second-stage subpectoral definitive implant placement.
Obesity is a risk factor for complications after autologous and implant-based postmastectomy reconstruction. As these increased rates of complications are thought to be linearly related to increasing BMI,10 one would expect that the morbidly obese (BMI > 40) and super obese (BMI > 50) would have the highest rates of complication. Indeed, many reconstructive surgeons would certainly regard these patients as not appropriate candidates for breast reconstruction of any kind.
Here, we present 10 postmastectomy reconstructions in patient with BMIs ranging from 37 to 50 with a mean BMI of 45. All 10 patients had diagnosis of unilateral cancers but chose to undergo bilateral mastectomy. Two of 10 patients had wound healing complications after Goldilocks mastectomy and reconstruction but were completely healed within 8 weeks of their index surgery. All 10 patients underwent subpectoral breast reconstruction at a minimum of 3 months after their initial surgery. There were no implant-related complications, instances of delayed wound healing, or reconstructive failures after prosthetic placement. With at least 9 months of follow-up on all patients, we have no instances of capsular contracture, significant malposition, or other complications requiring reoperation.
There have been many theories on why increasing BMI results in increased rates of surgical complications including longer operative times, increased dead space with resultant seroma formation, poorer perfusion, and compromised wound healing. Our strategy presented here for successful implant-based reconstruction delays placement of prosthetic material into the postmastectomy milieu until there is complete healing of the mastectomy flaps. This minimizes risk of implant extrusion, infection, or malposition, which are at highest risk in the immediate setting when the flaps are ischemic and the tissue less reliably maintains the implant in place. This strategy effectively makes second-stage prosthetic placement nearly equivalent in safety and reliability to that of an elective subpectoral breast augmentation. In addition, we immediately salvage the nipple as a graft during the initial surgery, placing it into ideal position. In addition to insuring that the prosthetic is placed into a sterile and well-perfused environment, we manage the excess skin envelope in the initial surgery, deepithelializing and involuting the excess skin. This skin and underlying fat are used for soft-tissue coverage over the implant, centering this excess tissue over the meridian by recruiting it from the inferolateral mastectomy flap as previously described.8 This skin and soft-tissue rearrangement in the initial surgery allows for reasonable aesthetic outcomes in the obese using implant-based techniques. This is because we now have an ideal skin envelope and have shifted excess lateral skin and fat medially, which allows us to match a premade breast implant with a limited volume range to a more manageable space—the bony thorax plus the additional soft-tissue coverage supplied by the Goldilocks mastectomy. In this way, standard sized implants can be used to effectively and safely reconstruct the morbidly and super obese with very acceptable aesthetic outcomes in 2 simple surgeries.
The obese patient poses a significant postmastectomy reconstructive challenge for which no reproducible approach has been described. Here, we present a 2-stage strategy—the previously described Goldilocks mastectomy with free nipple grafts followed by second-stage subpectoral definitive implant placement. This strategy allows us to delay the mastectomy flaps before implant placement, salvage nipple-areola complex as a free nipple graft and establish a manageable soft-tissue envelope, where standard sized implants can be used to safely reconstruct patients with the very highest BMIs with good aesthetic outcomes.
We thank Dr. Piotr Skowronski for his assistance and thoughtful insight.
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