Goldilocks Mastectomy Surgery

Podcast Transcript

Dr. Scott Steele: Butts and Guts, A Cleveland Clinic podcast exploring your digestive and surgical health from end to end. Hi again everyone, and welcome to another episode of Butts and Guts. I'm your host, Dr. Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in the beautiful Cleveland, Ohio. And today I'm very pleased to have Dr. Lauren Kopicky, who is a breast surgeon at Cleveland Clinic Fairview Hospital, and an assistant professor of surgery at Cleveland Clinic Lerner College of Medicine. Today we're going to talk a little bit about the Goldilocks mastectomy surgery. Lauren, thanks so much for joining us on Butts and Guts.

Dr. Lauren Kopicky: Thank you, Scott. Nice to be here. I appreciate the invitation.

Dr. Scott Steele: So, when I got the title of this, I'm super excited to talk a little bit more about it. But before we delve in, tell us a little bit about your background, where you're from, where'd you train, and how did you get to the point that you're here at the Cleveland Clinic.

Dr. Lauren Kopicky: Sure. So I am a fellowship-trained breast surgical oncologist, practice here in Cleveland in the west region. I grew up in Dayton, Ohio, so Ohio is home. I completed my fellowship training at William Beaumont in Michigan, and then I practiced for three years in Fort Wayne, Indiana before joining the Clinic over a year ago. The Goldilocks mastectomy I've been performing for the past five years. It's a favorite procedure to be able to offer patients. It's the, just right procedure, referring to the children's story Goldilocks and the Three Bears.

Dr. Scott Steele: Yeah, so absolutely. So start out first a little bit about the high level. What is a Goldilocks mastectomy surgery?

Dr. Lauren Kopicky: So, a Goldilocks mastectomy can be an option for some patients who do not desire the traditional breast reconstruction options. So what it does is it utilizes any redundant skin that would otherwise be removed to either smooth the contour of a flat closure to prevent any type of concavity to the chest wall after mastectomy, or to utilize this extra skin to reshape it into a more recognizable breast mound. So the Goldilocks mastectomy actually saves the lower breast skin and fat, we all have this fat layer, contains the blood vessels that keeps the skin alive, and then that tissue is what we utilize for closure. And I make sure that patients are aware this is not breast tissue. So we are following our breast planes to remove all of the breast tissue. This is simply the skin that we would otherwise remove comparatively to a simple mastectomy. And the Goldilocks can also be called the SWIM procedure, which stands for skin-sparing wise pattern internal mammary perforator named for kind of the blood supply of the skin that's saved.

Dr. Scott Steele: Well, that's fantastic. And you answered in a nutshell a lot of the questions I had about it. So let's start off in saying who is a candidate for the Goldilocks procedure? Do you have to have a certain size breast or is it something specific about where the cancer is that would allow you to perform this procedure?

Dr. Lauren Kopicky: So, there are a couple different pieces of information I consider when somebody is desiring this type of procedure. So the best candidates for the Goldilocks mastectomy are those who have a little bit more of what we call ptosis, which means essentially kind of droop of the breast. Gravity takes over at some point. So this could be associated with a larger breast size, it might not. And so we measure the distance from the nipple to the fold underneath the breast. So women who have this ptosis or hang of the breast, that nipple position is lower than the fold. So this means that we have a little bit more skin for creation of that kind of pseudo-breast mound. And it is also very important that we know where the cancer is, if this is too close to the skin of any part of this lower part of the breast that would disqualify somebody for this. And then optimal candidates are those who don't smoke, have uncontrolled diabetes or other risk factors that would impact wound healing.

Dr. Scott Steele: Lauren, obviously this is an audio podcast, but can you give us a little bit more information about what does the breast area look like when you're done? Is there a nipple? Is it something that has a mound? Is it something that's flat? What does it actually look like?

Dr. Lauren Kopicky: That can vary a lot depending on what our starting point is. So that's a fantastic question. So some people describe the Goldilocks as a way to really save maybe somebody with thinner skin, not as much skin, that it helps to prevent that concavity of the chest wall. So they may end up with a little bit more of a smooth flat closure, somebody who has a little bit more width to the chest and droop to the breast may have more that gets folded up and essentially becomes a breast mound. The general type of incision that we use is similar to a breast reduction pattern.

So I mentioned earlier the acronym SWIM, the wise pattern, it ends up in an inverted T. So you have an incision underneath where the fold of the breast was and then a vertical limb in the middle. Now there are scenarios where we can strategize to try to save the nipple on the lower pedicle, but not everybody's positioning is with good enough blood supply to be able to do that. So it can be a little variable as far as how much shape or how much of a mound that somebody gets. And we can sometimes utilize our breast imaging to be able to predict that ahead of time. Thinking for instance, on our ultrasound, we're able to see where that subcutaneous fat layer breaks from the breast plane or on our MRI, we can kind of get a sense of how thick that might be.

Dr. Scott Steele: And would the patient postoperatively still have to wear breast support like a bra or would this just not to that point?

Dr. Lauren Kopicky: I think most of the patients that have gone through this procedure really have either option. The breast mound that we create is not as heavy as a normal breast. It doesn't necessarily require any type of underwire support. So it's very variable. Some patients prefer just sort of like a bralette or maybe a camisole with or without padding, padded sports bra. And the Goldilocks can also be a nice segue, say somebody desires just a unilateral mastectomy or removing one breast for cancer reasons, it can mean that they have a little shape there to hold the bra in place and less of a breast prosthesis is necessary.

Dr. Scott Steele: So, you talked a little bit more about as a surgeon, what you look forward to decide if this procedure is right for the patient. But on the other hand, what are some factors that would lead a patient to select the Goldilocks procedure?

Dr. Lauren Kopicky: Absolutely. So I encourage patients to kind of know their options. First and foremost, is it safe from a cancer standpoint? And the second is really what a patient's desires are, what they want to appear or feel and look like after the procedure. So some women desire a flat closure. There's been a lot of discussion with this terminology in recent years, aesthetic flat closure, where we are trying to not leave any excess skin that can be uncomfortable. It can catch on clothing, can inhibit the type of bras somebody might wear after a mastectomy or the type of prosthesis that they want to wear.

So it really depends on whether or not a woman truly desires flat closure or more of a reconstruction option. So there's this type of procedure. There's also formal breast reconstruction, which can be either implant-based or what we call autologous or using your own tissue for reconstruction. And sometimes that procedure, it may actually be more than one procedure to get to the final reconstructed breast shape after the time of mastectomy. So it all starts at the first procedure. But sometimes women don't desire that, they might not be a good candidate for immediate reconstruction if there are a lot of risk factors. And then certainly keeping in mind what's necessary for cancer treatment. So a lot of factors we consider.

Dr. Scott Steele: What can a patient expect as far as recovery time?

Dr. Lauren Kopicky: I feel like recovery time is actually pretty similar to a simple mastectomy with flat closure. When I offer this procedure, the time under anesthesia is not significantly longer. We still leave a surgical drain in place, and I think that recovery is a little bit less than with formal reconstruction because there's not an implant or expander sitting on or beneath the muscle. So I think that there's a little bit less side effect related to that. And the risks are less than with tissue-based reconstruction. So comparative to simple mastectomy, not significantly any longer recovery time from this procedure.

Dr. Scott Steele: So, truth or myth, truth or myth, the Goldilocks mastectomy is a common procedure that most surgeons can perform?

Dr. Lauren Kopicky: So, this is actually a myth. I think that all surgeons have the capability to perform it. We're not necessarily all trained in how to do it, so most surgeons don't perform it. Some breast surgeons do perform this procedure in its entirety as I do, and others may work alongside a plastic surgeon kind of in tandem to complete this we call it local tissue rearrangement. So it really depends on who the surgeon is, if they've done them before and if they're comfortable with it.

Dr. Scott Steele: What questions should patients ask their doctor when exploring this surgery?

Dr. Lauren Kopicky: So, patients should ask their doctor about all of their options. And there's a phrase we use a lot in medicine these days called shared decision-making. And I think that's really important when considering this type of informal reconstruction, patients should really think about what surgery might achieve their goals. As I mentioned before, the oncologic or cancer-removing operation is first and foremost, but in close second is the aesthetics afterwards. So specific points to consider are desired contour of the chest wall, nipple position if they're able to be saved, and then what the intended incision might be. So it's always best to have expectations set prior to surgery so that everybody's on the same page. If I have a patient who is even possibly interested in breast reconstruction, I usually recommend a consultation with one of our plastic surgeons just so that they know all of the options, even if they decline formal reconstruction, it's an informed decision.

Dr. Scott Steele: Are there any advancements on the horizon regarding Goldilocks mastectomies or breast reconstruction surgery after breast cancer?

Dr. Lauren Kopicky: I think that there are so many great options out there that we are really utilizing a lot of tools to optimize our outcomes. I think specifically with using your own tissue of which we call autologous, that the Goldilocks is kind of a type of autologous reconstruction, that we're able to use different tools to look at the blood flow of these tissues before we recreate our breast shape or complete our reconstruction, make sure that everything has good blood flow, that there's not too large of a risk of an area to not survive. And I think that our plastic surgery colleagues do fantastic autologous breast reconstruction using tissue now with muscle-sparing techniques. So often we think about autologous reconstruction as having the added risk of the area where the tissue came from, and we're able to really minimize that by only taking the skin and the fat layer and leaving muscle behind. So I think that there've been a lot of advancements in the last decade or so with regards to reconstructive options.

Dr. Scott Steele: So now it's time for our quick hitters, a chance to get to know our experts a little bit better. So for you first, what was your first car?

Dr. Lauren Kopicky: A Volvo station wagon.

Dr. Scott Steele: And what is a sport that you like to play?

Dr. Lauren Kopicky: I like to play volleyball.

Dr. Scott Steele: What is your favorite meal?

Dr. Lauren Kopicky: Macaroni and cheese.

Dr. Scott Steele: Harken back to when you were a kid and what did you think you were going to be when you grew up?

Dr. Lauren Kopicky: I actually had a, or have, my parents still have this cartoon I drew of me growing up to be a doctor. I think I really liked my pediatrician.

Dr. Scott Steele: That's fantastic. And so give us a final take-home message to our listeners about the Goldilocks procedure.

Dr. Lauren Kopicky: My final take-home message would be to ask your surgeon about all of your options. It's very normal that the initial visit after a cancer diagnosis is so overwhelming. I say that time and time again. I would be surprised if somebody is not overwhelmed. So take the time you need to comprehend all of the information that we give you at that first visit, and then really focus and think about your desires for life after cancer treatment. Then touch base with your surgeon again and have another discussion.

Dr. Scott Steele: That's fantastic. To learn more about Goldilocks mastectomy surgery, or to connect with the breast surgery team here at the Cleveland Clinic, please call 844.589.2649. That's 844.589.2649. You can also visit our website at clevelandclinic.org/digestive. That's clevelandclinic.org/digestive. Dr. Kopicky, thanks so much for joining us on Butts and Guts.

Dr. Lauren Kopicky: Thank you, Scott.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts and Guts.