Rethinking Breast "Non-Reconstructive" Reconstruction: Expanding the Spectrum with Aesthetic Flat Closure and Goldilocks Reconstruction.

Abstract

Aesthetic flat closure (AFC) and Goldilocks reconstruction (GL) are increasingly utilized for patients seeking prosthesis-free breast reconstruction after mastectomy. Both techniques leverage the inferior adipodermal flap (IAF) to achieve contour restoration, yet remain underrepresented in reconstructive algorithms. This study evaluates outcomes of AFC and GL performed using a standardized IAF-based approach. A retrospective review of patients undergoing mastectomy with AFC or GL reconstruction using the IAF from April 2021 to August 2024 at a single institution was performed. Patient demographics, operative characteristics, and postoperative outcomes were compared between groups. Fifty-five patients underwent reconstruction, including 11 GL (20.0%) and 44 AFC (80.0%). The median age was 59.0 [IQR=18.0] years. Patients undergoing GL had a higher body mass index (33.1 [IQR=14.1] vs. 26.3 [7.3] kg/m2, P=0.003). The median operative time was 184.0 (83.0) minutes. Sixty-day complications occurred in 9.1% of patients, with a revision rate of 7.3%. No mastectomy flap or nipple-areola complex necrosis was observed, and no patients converted to implant-based or autologous reconstruction. When performed using a standardized inferior adipodermal flap technique, AFC and GL are reliable, prosthesis-free reconstructive options with low complication rates. These approaches represent endpoints along a reconstructive spectrum and can be tailored to patient anatomy and goals, supporting their integration into contemporary breast reconstruction practice.