Risk factors affecting tissue expander use and nipple areolar complex sparing in Goldilocks mastectomy

The Goldilocks mastectomy offers breast mound reconstruction using residual mastectomy skin flaps and has become a valuable option for patients with macromastia or elevated surgical risk. Increasingly, the technique is being combined with nipple-areolar complex preservation and immediate implant-based reconstruction; however, the risk factors that influence nipple viability and tissue expander success remain poorly defined. This single-institution retrospective cohort study evaluated 26 patients (41 breasts) who underwent Goldilocks mastectomy performed by a single surgeon between August 2021 and June 2024. Procedures included Goldilocks alone (29.3%), nipple-areolar complex-sparing Goldilocks (26.8%), Goldilocks with immediate tissue expander placement (21.9%), and nipple-areolar complex-sparing Goldilocks with immediate tissue expander placement (21.9%). The mean patient age was 55.6 years and mean body mass index was 35.8 kg/m². Overall complication rates included major events in 19.5% of the breasts and minor events in 9.8%. There were no cases of hematoma or tissue expander exposure. Most tissue expander losses (80%) were from infection or necrosis. Diabetes was significantly associated with mastectomy skin flap necrosis (p = 0.0092), whereas no other comorbidities or breast measurements were significantly associated with infection, necrosis, readmission, reoperation, or tissue expander loss. Trends toward higher complications were observed in patients with advanced age, hypertension, and elevated body mass index, though these did not reach statistical significance. These findings indicate that diabetes meaningfully increases necrosis risk in Goldilocks reconstruction and should strongly influence patient selection when planning nipple-areolar complex-sparing procedures or immediate tissue expander placement.