Reduction mammoplasty for severe breast hypertrophy (macromastia) or gigantomastia (where 1–2 kg of tissue may be removed per breast) is a technically challenging procedure. The long pedicle required to preserve the nipple areolar complex (NAC) may increase the risk of nipple necrosis so the standard approach is simple breast amputation through a Wise pattern incision with free NAC grafting onto a de-epithelised dermal bed [6]. However as with the Goldilocks procedure, this technique results in a flat wide breast with minimal projection. A number of modifications have been described to preserve sufficient dermoglandular tissue on a standard pedicle around which the skin flaps can be draped to allow a more projected breast mound [7, 8].

Kollias and colleagues [9] in Australia have described the breast amputation/inferior pedicle mound technique for reducing the contralateral breast in women with breast hypertrophy when the index breast has been removed for cancer.

Following mastectomy and implant reconstruction through a Wise pattern incision, the lower pole de-epithelised dermal flap can provide implant support and coverage similar to that described for acellular dermal matrices (ADMs) and meshes [10, 11]. As the dermal flap is a living autologous tissue, it has advantages over manufactured meshes or acellular animal derived dermal matrices (ADM). The vascularised flap lies behind the vulnerable «T» junction (angle of sorrow) so protecting the implant if there is any T junction dieback [12]. For subpectoral implant reconstruction, the dermal flap can be sutured to the lower border of the elevated pectoralis major, or alternatively it may be sutured to the anterior surface of pectoralis major for prepectoral implant placement [13]. The dermal flap can also be used in combination with an ADM or meshes if required.

The Goldilocks approach can be considered for women who are not suitable for standard breast reconstruction techniques and would otherwise have a simple mastectomy with no reconstruction. The mastectomy can be oncologically indicated or a woman’s preference to manage her cancer, or it may be for risk reduction in high penetrance gene carriers or those with a high-risk family history.

Reconstruction may not be possible or recommended because of a range of patient factors that might restrict reconstruction choices (e.g. a large body habitus with large breasts may not be suitable for implants, and the corresponding obesity may contraindicate a DIEP) or because the risks of prolonged time on the operating table, anaesthesia and post-operative recovery is unacceptable for whatever reason.

Usually women deemed not suitable for breast reconstruction are older with multiple comorbidities such as diabetes, hypertension and smoking, often compounded by obesity (BMI > 30). Richardson and Ma commented that such women automatically exclude themselves from reconstruction as clinicians are usually focused on simplifying the treatment process to minimise risk and the need for multiple interventions and complex follow-up.

As life expectancy continues to increase in the EU [14] where the average life expectancy of a woman in Spain is now 86 years, the Goldilocks procedure may offer the opportunity of reconstruction to older women who may not wish to undergo more major autologous procedures and for whom implants are not age appropriate. Older women also tend to exclude themselves from reconstruction often because of its perceived risks and complexities [15].

Patient selection is crucial to the success of this approach. The Goldilocks technique is essentially an extreme reduction mammoplasty: so to create enough volume to give any semblance of a breast shape, patients require ample skin and subcutaneous adiposity between the inframammary fold and nipple.

A successful Goldilocks procedure requires the combination of obesity and a large breast (macromastia) with grade 3 or 4 ptosis (Regnault’s classification [16]. The definition of macromastia is variable and not standardised, but in short there has to be sufficient lower pole skin and adiposity to give a volume that will create an aesthetically acceptable breast mound. A large breast with limited ptosis and a limited inframammary fold (IMF) to NAC distance or a very ptotic but involuted thin breast will have insufficient lower pole dermal/subcutaneous fat to create a convincing breast mound.

Previous breast RT may compromise the vascularity of the lower pole tissue and increase the risk of post-operative wound healing problems and fat necrosis of the dermal flap. In the Richardson and Ma paper, two women had undergone previous RT.

The poorly informed patient with high aesthetic ideals.

The Goldilocks procedure is contraindicated in the following circumstances: