The GOLI procedure: goldilocks mastectomy with extended lateral intercostal perforator artery flap—a surgical technique for total breast reconstruction

Introduction

Influence of obesity and multiple co-morbidities on total breast reconstruction

Mastectomy remains a crucial treatment option for approximately one-third of breast cancer patients. Nevertheless, certain patients within this subset face challenges that may prevent them from undergoing conventional reconstructive procedures. These challenges can arise due to concurrent comorbidities and characteristics, such as obesity (1) and nicotine (2) use, which pose increased risks of complications (e.g., fat necrosis, superficial skin loss, and delayed wound healing) (3,4). Additionally, advanced age and significant medical comorbidities can hinder patients’ pursuit of complex reconstructive interventions, presenting an ethical dilemma regarding the provision of traditional reconstruction procedures. Advanced age (5) has been associated with patients’ reluctance to undergo complex reconstructive procedures. The decision-making process may be influenced by factors such as perceived surgical risks, recovery time, and potential impacts on overall quality of life. Patients with significant medical comorbidities may present contraindications to prolonged operative times (6). In these cases, clinicians must prioritize patient safety, considering the potential risks associated with lengthy procedures and anaesthesia exposure. As a result, patients with substantial medical complexities may not be suitable candidates for traditional reconstructive procedures, leading to the consideration of alternative approaches.

Influence of simple mastectomy on patient well-being

Furthermore, in obese patients opting for simple mastectomy without reconstruction, changes in body mass distribution may influence postural control (7). The removal of breast tissue can alter the body’s centre of mass, which, particularly in individuals with higher body mass index (BMI), may contribute to balance and stability challenges. These effects may be further influenced by the use of external prostheses, which have been reported to be poorly tolerated in obese patients (8,9), potentially exacerbating discomfort and functional limitations. This, in turn, may impact patient satisfaction and overall quality of life.

These factors further underline the challenges faced by patients recommended for mastectomy without reconstruction. This raises an ethical dilemma: on one hand, prioritising patient safety and avoiding potential complications associated with complex reconstructive procedures may be appropriate. On the other hand, withholding reconstruction options may compromise psychological well-being and body image, potentially leading to diminished quality of life and dissatisfaction with treatment outcomes.

Alternative techniques to create a breast mound following mastectomy

Goldilocks mastectomy

The Goldilocks mastectomy, first described by Richardson and Ma in 2012 (7), utilises redundant inferior mastectomy flap tissue to create a breast mound, primarily in patients with macromastia or significant ptosis where conventional reconstruction poses increased risk (8,9). Several modifications have further expanded its utility. Richardson and Aronowitz (10) reported a bilateral in situ nipple-preserving approach using a dermal pedicle, demonstrating the adaptability of Goldilocks principles in achieving autologous reconstruction without implants or microsurgery. A scoping review (11) demonstrates its safety in women with obesity, providing a reproducible method to create adequate breast volume in high-risk patients. Zavala et al. (12) described its role as a salvage strategy following prosthetic reconstruction failure, illustrating its potential to achieve satisfactory volume and projection when conventional approaches are not feasible. While effective, the volume achievable with the Goldilocks technique alone is often insufficient in patients with higher BMI or lateral thoracic tissue redundancy (8).

Chest wall perforator flap (CWPF)

CWPF has been used for total breast reconstruction in several studies (13-16), with the lateral intercostal artery perforator (LICAP) flap (17,18) being the most popular option (14,19). The LICAP can produce a large skin paddle without dissection of muscle or fascia and, importantly, it can be performed in an outpatient setting with low rates of revision. It is associated with minimal donor site morbidity (20,21) even after radiation (18), and heals reliably well regardless of BMI, and the flap viability is likely independent on the degree of macromastia or obesity (22). Harvesting CWPF does not prolong operating time due to more constant anatomy, the less tedious harvesting technique, and a shorter learning curve when compared to other reconstructive techniques (19), obviating the need for microsurgery and input from plastic surgeons. Interestingly, some patients in the above studies had a lower BMI (13,17,19) and required additional fat grafting to improve the volume (13-15,17), suggesting that the CWPF as a standalone technique does not reliably provide sufficient volume in patients with higher BMI and macromastia. Similarly, thoracodorsal artery perforator (TDAP) flaps represent another well-established locoregional option, offering reliable vascularity and the ability to reconstruct moderate breast volumes without microsurgery (13). However, both LICAP and TDAP flaps, when used in isolation, may provide insufficient volume in patients with macromastia or obesity and may require adjunctive procedures such as lipofilling to optimise aesthetic outcomes.

Rationale for a hybrid approach

Given the limitations of these techniques when used in isolation, particularly the insufficient volume generated in patients with high BMI and macromastia, and the rising incidence of obesity and associated comorbidities, which parallel increasing breast cancer prevalence (23), alongside improving breast cancer survival rates (24), there is a growing demand for alternative reconstructive strategies. These approaches must provide both satisfactory aesthetic outcomes and maintain oncological safety. Hybrid techniques that maximise autologous tissue utilisation while maintaining a low-risk profile are therefore of increasing interest. The combination of a Goldilocks mastectomy and a LICAP flap represents one such strategy, aiming to enhance reconstructive volume and contour in a single-stage procedure. This approach builds upon established techniques while addressing their individual shortcomings, particularly in patients with obesity and multiple comorbidities. We present this article in accordance with the SUPER reporting checklist (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-436/rc).

Preoperative preparations and requirements

We present two cases where patients underwent the GOLI procedure, which combines the Goldilocks mastectomy with an extended LICAP flap as an alternative approach to reconstruction after mastectomy. All procedures were carried out at Whipps Cross Hospital, which is a large university hospital in London, United Kingdom. The lead author was the primary operating surgeon with over 10 years of oncoplastic breast surgery experience. The corresponding author recently completed oncoplastic breast surgery training. All authors were present in both cases. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Case 1

A 79-year-old female with left breast 80 mm grade 2 [invasive lobular carcinoma estrogen receptor (ER) 8 human epidermal growth factor receptor 2 (HER2) 0 with nipple involvement] (Figure 1) was recommended for a mastectomy. Her BMI was 35.5 kg/m² with DD bra cup size, grade 3 ptosis, and she suffered from hypertension and hypercholesterolaemia. She had no known drug allergies. Preoperative axillary ultrasound demonstrated no lymphadenopathy, and therefore, a sentinel lymph node biopsy (SLNB) was planned at the time of mastectomy.

Figure 1 Preoperative photographs of a 79-year-old obese (BMI 35.5 kg/m²) patient with grade 3 ptosis and left nipple retraction related to 80 mm grade 2 invasive lobular carcinoma. She was unsuitable for autologous free-flap and implant-based reconstruction, and she was counselled for the GOLI procedure. BMI, body mass index; GOLI, Goldilocks mastectomy with extended lateral intercostal artery perforator flap.

The patient was counselled for a left mastectomy; however, she was keen to have reconstruction. Her options for reconstruction were limited. Following consultation, a decision was made to offer her the GOLI procedure under general anaesthesia. Pre-operatively, a Doppler assessment was performed of the LICAP vessels, and the skin paddle required was estimated and marked (Figure 2). The patient was also marked using the standard Wise pattern in preparation for the Goldilocks mastectomy as previously described (7).

Figure 2 Pre-operative planning of GOLI procedure and Doppler assessment of intercostal artery perforator signal demonstrated by the red arrow. The extended LICAP flap skin paddle volume is estimated and marked in blue. GOLI, Goldilocks mastectomy with extended LICAP flap; LICAP, lateral intercostal artery perforator.

The patient was positioned in the lateral position with the elbow and shoulder flexed to 90 degrees. Firstly, the LICAP was de-epithelialized and raised off the chest wall with the fascia intact, as demonstrated in Figure 3. The extent of mobilisation was determined by the location and proximity to the LICAP vessels. The LICAP flap was then wrapped with Povidone-iodine-soaked gauze and covered with a sterile transparent dressing and gently placed medially. The wound was closed with 2.0 undyed barbed suture and 3.0 undyed monocryl subcuticular.

Figure 3 Deepithelialised LICAP flap in the lateral position being lifted off the latissimus dorsi and chest wall with preservation on the fascia. The prepared flap will then be rotated on its pivot point and inserted into the mastectomy wound. LICAP, lateral intercostal artery perforator.

The patient was then transferred to the supine position to complete the Wise pattern skin-sparing mastectomy. The inferior dermal flap was deepithelialised, and the mastectomy dissection was completed along oncological planes down to the pre-pectoral fascia. The LICAP flap was mobilised anteriorly through 180 degrees rotation (Figure 4) and the free end of the LICAP flap was tucked under to provide bulk laterally.

Figure 4 Following completion of the Wise pattern Goldilocks mastectomy the inferior deepithelialised dermal flap (blue arrow) superior skin flap (yellow arrow) and rotated LICAP flap (green arrow) are set to create the new breast mound.

The inferior dermal flap of the Golidlocks mastectomy was incised laterally along the inferior mammary fold and its free end folded onto itself to provide bulk medially. The edges of the two flaps were secured in the midline with 2.0 Vicryl. The Wise pattern limbs were approximated, and the wound closed in a standard fashion, resulting in an inverted ‘T’ scar (Figure 5).

Figure 5 Re-creating the breast mound by folding free end of the LICAP (yellow arrow) onto itself to give volume laterally and securing the inferior border of the LICAP to the infra-mammary fold. The inferior deepithelialised dermal flap (blue arrow) is detached laterally up to the breast meridian and the free end folded onto itself to give volume medially. The superior skin flap (green arrow) limbs are draped over the new breast mound and secured. LICAP, lateral intercostal artery perforator.

Case 2

A 72-year-old female with bilateral breast cancer, grade 1 (9 and 4 mm invasive ductal carcinoma ER8, HER2 negative on the right), and grade 2 (50 mm invasive ductal carcinoma ER8 HER2 negative and high-grade ductal carcinoma in situ) on the left. Her BMI was 24.3 kg/m² with a D bra cup size, grade 3 ptosis (Figure 6), and she suffered from hypertension and non-insulin-dependent diabetes. She had no drug allergies. Preoperative axillary ultrasound showed no lymphadenopathy, and SLNB was performed bilaterally at the time of mastectomy.

Figure 6 Preoperative photographs of a 72-year-old (BMI 24.3 kg/m²) patient with grade 3 ptosis and bilateral breast cancer. She refused an autologous free-flap and implant-based reconstruction, and she was counselled for the GOLI procedure. BMI, body mass index; GOLI, Goldilocks mastectomy with extended LICAP flap; LICAP, lateral intercostal artery perforator.

The patient was keen for a reconstruction; however, they declined implant-based and free-flap reconstruction. Following further discussion and incorporating the principles of shared decision making, we proceeded with the bilateral GOLI procedure. The patient was marked pre-operatively and a Doppler assessment was performed like the first case.

The procedure was first performed in the prone position, where bilateral LICAP flaps were mobilised in the standard fashion as described above, simultaneously by two oncoplastic surgeons. The LICAP flaps’ wounds were closed as depicted in Figure 7 and the patient was then placed in the supine position to complete the Wise pattern Goldilocks mastectomy. Suction 10 Fr drains were placed in both reconstructed breasts. The same procedural steps were completed as in the first case to create the breast mounds.

Figure 7 Raising bilateral LICAP flaps for the GOLI procedure in the prone position. The donor site wounds are closed, and both LICAP flap covered with sterile dressing prior to turning the patient in the supine position to complete the procedure. GOLI, Goldilocks mastectomy with extended LICAP flap; LICAP, lateral intercostal artery perforator.

Postoperative considerations and tasks

Case 1

Post-operative recovery was uneventful, and the patient was discharged the next day. She attended the wound clinic a week later with a donor site seroma, which was drained. Both mastectomy and donor site wounds healed well, and the patient was referred for radiotherapy. Her cosmetic outcome following radiotherapy was satisfactory (Figure 8), and despite asymmetry in a bra, at the time of writing, the patient declined symmetrisation (Figure 9).

Figure 8 Cosmetic outcome at 6 months following radiotherapy, demonstrating reasonable breast volume and healed scar from donor site.

Figure 9 Cosmetic outcome and relative asymmetry whilst wearing a bra.

Case 2

Post-operatively, the patient had to have input from the diabetic nurse due to variable capillary blood glucose measurements prior to discharge. She recovered well and both the mastectomy and donor site wounds healed well. She has an excellent cosmetic outcome (Figure 10), and the donor site wounds were concealed within the bra strap (Figure 11). She was recommended to commence endocrine therapy with open-access follow-up.

Figure 10 Cosmetic outcome at 6 months demonstrating excellent breast volume and healed scars from donor site.

Figure 11 Cosmetic outcome with symmetry whilst wearing a bra.

Tips and pearls

To the best of our knowledge this procedure has not been reported in the UK, a similar technique has been reported in the US (22). However, here the author performed deepithelialisation of the LICAP and inferior mastectomy flap in continuity. We preferred to perform this in two stages to ensure the donor site was sutured closed prior to performing the mastectomy, reducing the cold exposure of the donor site wound. We also used the inferior dermal flap to provide volume to the breast mound medially and LICAP laterally, as opposed to Schwartz JC, who described covering the inferior flap over the LICAP. Our approach provided better projection. An important technical consideration in LICAP flap harvest is the orientation of the skin paddle, typically designed either horizontally along the inframammary fold or obliquely along the lateral chest wall. Horizontal designs allow for improved scar concealment within the inframammary crease and may provide a more aesthetically favourable donor-site outcome, particularly in patients with redundant lateral thoracic tissue. However, this orientation may be limited in arc of rotation and flap reach, especially when greater medial volume replacement is required. In contrast, oblique designs, as more commonly described in the original LICAP and lateral thoracic perforator flap literature, can maximise perforator capture and increase flap mobility, facilitating improved reach and volume recruitment for breast reconstruction (20). This may be particularly advantageous in patients with larger body habitus, although it may result in more visible scarring and potential contour irregularities along the lateral chest wall. The choice of flap design should therefore be individualised, balancing reconstructive requirements with aesthetic considerations and patient preference.

To ensure surgical quality and consistency in performing the GOLI procedure, a structured and standardised approach is essential. Pre-operative planning with Doppler mapping of LICAPs helps accurately identify flap vessels, while Wise pattern skin markings guide mastectomy and flap design. Multidisciplinary team (MDT) discussions play a critical role in patient selection, allowing integration of oncological, anaesthetic, and reconstructive perspectives to tailor care for patients with obesity and comorbidities.

Operatively, the procedure benefits from a stepwise approach: harvesting the LICAP flap in the lateral or prone position before performing the Goldilocks mastectomy in the supine position ensures efficient workflow and flap integrity. Flap viability is preserved by wrapping the harvested tissue in moist gauze to prevent desiccation, while donor site closure before repositioning the patient reduces infection risk and exposure. Rotating the LICAP flap 180 degrees requires careful tunnelling to avoid pedicle kinking or vascular compromise. Closed-suction drains at both the donor and mastectomy sites help reduce seroma formation. Intraoperative safety can be enhanced through meticulous haemostasis, especially when dissecting near intercostal vessels. For high-risk patients, particular attention should be paid to positioning during prone or lateral phases to minimise cardiopulmonary strain, with appropriate padding and anaesthetic monitoring. In case of intraoperative complications, such as flap compromise, the procedure can be safely converted to a standard Goldilocks mastectomy to maintain oncological safety. Postoperatively, monitoring for flap viability, donor site healing, and early complications such as seroma or dehiscence is key, particularly in patients with diabetes or compromised wound healing.

While the technique has been successful in morbidly obese patients, caution is advised, especially when manoeuvring patients prone, due to potential cardiopulmonary risks. The approach should be selectively considered for patients who decline implants or abdominal flaps and insist on a single-stage reconstruction. This strategy is particularly applicable to the obese patient demographic, where conventional methods carry a higher risk of complications, including reconstructive failure.

Discussion

The GOLI procedure offers patients a relatively low-risk, single-stage autologous reconstructive option, with adequate final breast volume compared to the goldilocks mastectomy or LICAP alone. This technique works best for large-breasted individuals with ptosis and higher BMI who have good donor areas in the back and are not suitable for more complex free flaps or implants. The volume achieved with this combination approach is more proportionate to the patient’s body habitus and could obviate the need for symmetrisation. The advantage of the LICAP flap lies in its minimal donor site morbidity, contrasting with the issues related to procedures involving skin undermining and muscle mobilization, like the latissimus flap. Microsurgical skills aren’t necessary as the flap’s perforators are reliably located near the anterior border of the latissimus muscle at the inframammary fold. Furthermore, there was no deleterious effect on oncological safety, and no delay to adjuvant therapy in the two cases described.

This technique shares conceptual similarities with other locoregional, perforator-based autologous reconstructive options such as TDAP flaps (13) and the skin-sparing Wise-pattern internal mammary perforator (SWIM) flap described by Cassileth et al. (23). These approaches are particularly valuable in patients who are not suitable candidates for microsurgical reconstruction, enabling volume replacement using well-vascularised local tissue without the need for free tissue transfer. However, the GOLI approach differs in its integration of Goldilocks mastectomy principles with an extended LICAP flap design, allowing for enhanced volume recruitment from the lateral chest wall in a single-stage procedure. Unlike TDAP or SWIM flaps, which rely on a single vascular territory, this hybrid approach leverages multiple tissue sources to optimise breast shape and projection, particularly in patients with higher BMI.

A key consideration in this extended flap design is perfusion reliability. Although the flap extends beyond a single classical perforasome, its viability is supported by the established vascular anatomy of intercostal artery perforators and their interconnecting linking vessels within the lateral thoracic region, consistent with angiosome (24) and perforator flap theory (25). Clinically, flap perfusion in our series was assessed intraoperatively using standard parameters including dermal bleeding, capillary refill, and flap temperature, with an emphasis on preserving multiple perforators where feasible. No adjunctive perfusion imaging was utilised. Importantly, no cases of partial or total flap necrosis were observed, suggesting that the extended LICAP design can be safely employed in selected patients. Nevertheless, we acknowledge that objective perfusion assessment and larger clinical series are required to further validate the safety and reproducibility of this modification.

Given the limited number of cases presented, this work should be interpreted as a preliminary technical report aimed at describing a reproducible modification and sharing early clinical experience. Further studies with larger cohorts and comparative analyses against established techniques such as TDAP and SWIM flaps are warranted to better define indications, outcomes, and long-term efficacy.

Conclusions

The GOLI procedure represents a novel, single-stage autologous reconstructive option for patients with limited suitability for conventional techniques due to obesity and comorbidities. By combining Goldilocks mastectomy with an extended LICAP flap, this approach enhances reconstructive volume and aesthetic outcomes while maintaining a favourable safety profile.

Given the limited number of cases presented, this technique should be considered a preliminary innovation requiring further validation. Future directions should include prospective evaluation and comparative studies against established techniques such as Goldilocks mastectomy, LICAP, and TDAP flaps. These studies should assess reproducibility, complication rates, aesthetic outcomes, and patient-reported outcomes across diverse patient populations to determine the broader applicability and long-term efficacy of this hybrid approach.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Visnu Lohsiriwat and Chayanee Sae-Lim) for the series “Transformative Approaches in Breast Surgery: Cutting-Edge Innovation, and Practice” published in Gland Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-436/rc

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-2025-436/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-2025-436/coif). The series “Transformative Approaches in Breast Surgery: Cutting-Edge Innovation, and Practice” was commissioned by the editorial office without any funding or sponsorship. The authors have no other 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. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

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/.

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