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Goldilocks Procedure With And Without Immediate Implant-based Breast Reconstruction In Obese Patients: The Mayo Clinic Enterprise System Experience
Samyd S. Bustos, M.D.1, Jason Lin, B.S.1, Doga Kuruoglu, M.D.1, Maria Yan, M.D.1, Minh-Doan T. Nguyen, M.D., Ph.D.1, Jorys Martinez-Jorge, M.D.1, Judy C. Boughey, M.D.1, William Joseph Casey, III, M.D.2, Richard J. Gray, M.D.2, Antonio J. Forte, M.D., Ph.D., M.S.3, Sarah A. McLaughlin, M.D.3, Oscar J. Manrique, M.D., F.A.C.S.1.
1Mayo Clinic, Rochester, MN, USA, 2Mayo Clinic, Scottsdale, AZ, USA, 3Mayo Clinic, Jacksonville, FL, USA.

PURPOSE: Obesity is a risk factor for surgical patients. Thus, implant-based breast reconstruction in obese women may be controversial. We conducted an analysis of obese patients with ptotic breasts who underwent the Goldilocks procedure and compared outcomes between two groups: immediate implant-based reconstruction (IBR) and no IBR.
METHODS:
After Institutional Review Board approval (Study No. 19-008324), we performed a retrospective review of patients treated at the three Mayo Clinic campuses from 2014 - 2019. Patients with BMI ≥ 30kg/m2 and ptotic breasts grade ≥ II who underwent skin-sparing Goldilocks procedure were included. Breasts with prior reduction/augmentation mammoplasty or prior mastectomy were excluded. Demographics, operative characteristics, outcomes and complications were assessed. Two groups were compared: Goldilocks with IBR vs. Goldilocks-only. Patient-reported outcomes using BREAST-Q questionnaire were assessed.
RESULTS: One-hundred-sixteen patients (198 breasts) were included. Mean age and BMI were 54.1 10.4years and 37.9 5.8kg/m2. Median follow-up time was 14.9 months (Q1-9.8, Q3-27.7). A total of 100 (50.5%) breasts underwent Goldilocks-only procedure, 92 (46.5%) underwent Goldilocks with two-stage IBR and 6 (3.0%) with one-stage IBR. In the Goldilocks-IBR group, 87 breasts underwent prepectoral and 10 subpectoral implant placement. Multivariate analyses showed increased risk of 6-months major complications (hematoma requiring drainage, unplanned reoperations, infection requiring drainage or IV antibiotics, skin-flap full-necrosis) in the Goldilocks-IBR group (OR 2.8, 1.3 - 6.2). When only severe obese patients (BMI≥35) were analyzed, Goldilocks-IBR was associated with an even higher risk of 6-months major complications (OR 4.8, 2.0-11.7) compared to Goldilocks-only. Median patient satisfaction was statistically higher in the IBR group than Goldilocks-only group (73% vs. 58%, p 0.02). No difference was found in physical, psychological and sexual well-being between groups.
CONCLUSION:
Breast reconstruction is an important option for women undergoing mastectomy. Goldilocks procedure is feasible, but when performed with IBR it is associated with higher rates of all complications. Despite these Goldilocks-IBR demonstrate higher satisfaction, in obese and particularly in severely obese women, Goldilocks-IBR is associated with higher rates of all complications; delayed reconstruction and consideration of other surgical reconstructive options should be considered due to the higher complication rate.


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