Thermal injury in TAPIA breast reconstruction—thermal injury to thoracodorsal artery perforator flap
A recently published paper describes the TAPIA method for delayed breast reconstruction (1). When this technique is used the patients mobilize quickly following the reconstruction and postoperative complications seem scarce. However, in two cases thermal injury to the reconstructed breast has been an unforeseen consequence of indirect sun exposure.
Thermal injuries after flap-based breast reconstruction are described in the literature (). This is mainly due to the patients lacking the ability to detect nociceptive stimuli from the denervated flap and thereby act appropriately. We report the first two cases of thermal injury in a TAP-flap occurring in the early period after delayed breast reconstruction.
In a year-old woman received a right-sided mastectomy and axillary lymph node for invasive ductal carcinoma. No adjuvant therapy was offered her. The patient was a non-smoker without comorbidity.
In she was referred for delayed breast reconstruction. She was found eligible for reconstruction by the TAPIA method using a cc silicone implant. The procedure was performed in late May and the postoperative course was uneventful. The patient was discharged after eight days and scheduled for a clinical control 15 days postoperative.
In the outpatient clinic the patient presented with a full-thickness skin burn on the medial part of flap, measuring 8 cm × 4 cm (Figure 1A,B). This burn had occurred whilst the patient had been sitting outside in warm weather wearing a black T-shirt. The flap had not been exposed to direct sunlight. The full-thickness skin burn was debrided revealing viable tissue underneath, enabling the defect to be covered with a split-thickness skin graft (Figure 1C). The healing was uneventful. The patient has since refrained from nipple areola complex reconstruction and is satisfied with the result (Figure 1D).
Figure 1 The first patient a year-old woman with a severe “sunburn” to a TAPIA breast reconstruction. (A,B) Presenting with a full-thickness burn 15 days post-operative; (C) the breast reconstruction after debridement and skin grafting; (D) final result. The patient has refrained from NAC-reconstruction.
A year-old woman diagnosed with invasive ductal carcinoma in was treated by a right-sided mastectomy without adjuvant therapy. The patient was a non-smoker and apart from well-treated hypertension she had no comorbidity. She was reconstructed by the TAPIA method in April using a cc Becker implant. She was discharged day 11 after an uneventful postoperative course.
The patient presented with a satisfying result at the first postoperative control in the outpatient clinic three weeks after surgery. However, one week later she presented with a full-thickness skin burn, measuring 8 cm × 6 cm (Figure 2A). She too had been exposed to the sun in hot weather wearing a dark shirt not exposing the flap to direct sunlight. The defect was debrided, revealing a viable flap underneath (Figure 2B). We applied negative pressure wound therapy for 14 days and then covered the defect with a full-thickness skin graft (Figure 2C). The nipple areola complex have since been reconstructed using a skate-flap and a tattoo (Figure 2D).
Figure 2 The second patient a year-old woman with a severe “sunburn” to a TAPIA breast reconstruction. (A) Presenting with a full-thickness sunburn three weeks post-operative; (B) the reconstruction after debridement and NPWT; (C) the breast reconstruction after skin grafting; (D) the final result.
Thermal injury following breast reconstructions is a rare incident. The first case was reported more than two decades ago and since only few cases have been reported and compiled in two literary reviews (9,11). Most of the published material covers complete autologous reconstructions using either DIEP or TRAM flaps.
The most frequent cause of thermal injury to the flaps seems to be heat exposure due to sunlight most often when the patient has been wearing dark clothes or bathing suits (3,9). The extent of the injury varies but most published cases have been treated conservatively. Approximately 16% required surgical revision and application of a skin graft (11).
The etiology behind the increased risk of thermal injury is multi factorial. It is well documented that the sensibility of a reconstructed breast is scarce, especially in the initial period following reconstruction (9). The reconstruction seems to be most susceptible to thermal injury in the early postoperative period. However, the flaps tend to regain some autoregulation and sensitivity over time, however the duration may depend on the type of flap (3).
The impaired or absent sensation may be the most important factor leading to increased risk of thermal injury. However, other thermoregulative capacities of the flaps such as sweating and vasodilation is probably also inhibited due to an affected or absent autonomic regulation. This adds to the increased susceptibility to thermal injury (3). Furthermore the thickness of the flap is invers correlated to the risk of thermal injury, thus a thinner flap is at greater risk of thermal injury (10). The type of flap and its properties may perhaps also affect the overall susceptible to thermal damage.
Thermal injuries to the Latissimus Dorsi flap (LD-flap) seem less frequent than those of the abdominal flaps and caused by more severe or direct heat exposure, such as application of an electric heat pad or hot water bottle (7). This may be due to the flaps general properties with some degree of preserved innervation, a solid blood supply and the mere thickness of the LD-flap.
When the TAP-flap is used for total breast reconstruction it is harvested as a pedicled propeller perforator-based flap, which in most cases leaves the flap totally denervated. The thermoregulative capabilities are not only compromised by the denervation and limited blood flow through the perforator(s), but also due to the rather thin flap design. In comparison to the LD-flap the TAP-flap may be more prone to thermal injury due to all of these factors.
As a consequence we find that patients should be informed of the risk of thermal injury following total breast reconstruction using a TAP flap. We recommend that they avoid heat exposure in the initial three months following reconstruction.
When using the TAPIA technique for breast reconstruction it is important to inform patients of the risks of thermal injury. The patients should be instructed to avoid heat exposure in the initial period after the reconstruction.
Conflicts of Interest: These authors have no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
- Børsen-Koch M, Gunnarsson GL, Udesen A, et al. Direct delayed breast reconstruction with TAP flap, implant and acellular dermal matrix (TAPIA). J Plast Reconstr Aesthet Surg ; [Crossref] [PubMed]
- Maxwell GP, Tornambe R. Second- and third-degree burns as a complication in breast reconstruction. Ann Plast Surg ; [Crossref] [PubMed]
- Alexandrides IJ, Shestak KC, Noone RB. Thermal injuries following TRAM flap breast reconstruction. Ann Plast Surg ; [Crossref] [PubMed]
- Beckenstein MS, Beegle PH, Hartrampf CR Jr. Thermal injury to TRAM flaps: a report of five cases. Plast Reconstr Surg ; [Crossref] [PubMed]
- Aslam A, Khoo CT. No sense; no sensibility--a tale of two adult hairdrier burns. Burns ; [Crossref] [PubMed]
- Nahabedian MY, McGibbon BM. Thermal injuries in autogenous tissue breast reconstruction. Br J Plast Surg ; [Crossref] [PubMed]
- Agarwal SK, Williams MR. Burn injuries after latissimus dorsi breast reconstruction in a cold climate. Breast ; [Crossref] [PubMed]
- Delfino S, Brunetti B, Toto V, et al. Burn after breast reconstruction. Burns ; [Crossref] [PubMed]
- Enajat M, Rozen WM, Audolfsson T, et al. Thermal injuries in the insensate deep inferior epigastric artery perforator flap: case series and literature review on mechanisms of injury. Microsurgery ; [Crossref] [PubMed]
- Delfino S, Brunetti B, Toto V, et al. Does tissue expansion increase skin susceptibility to thermal injury? A physical model. Burns ; [Crossref] [PubMed]
- Mohanna PN, Raveendran SS, Ross DA, et al. Thermal injuries to autologous breast reconstructions and their donor sites--literature review and report of six cases. J Plast Reconstr Aesthet Surg ;e [Crossref] [PubMed]
Cite this article as: Børsen-Koch M, Gunnarsson GL, Sørensen JA, Thomsen JB. Thermal injury in TAPIA breast reconstruction—thermal injury to thoracodorsal artery perforator flap. Gland Surg ;6(1) doi: /gs
What Is a Latissimus Dorsi Flap?
The latissimus dorsi flap breast reconstruction is a procedure that uses skin, fat, and muscle from the upper back (the flap) to rebuild the breast after a mastectomy, often in conjunction with a breast implant. The procedure gets its name from the latissimus dorsi, a large, triangle-shaped back muscle that is used to rebuild the shape of the breast.
After a latissimus dorsi flap reconstruction, your newly reconstructed breast will not look and feel exactly the same as your natural breast, but it will look and feel more like natural breast tissue than it would after having breast implants alone. You'll need additional surgery to create a nipple and areola.
Latissimus dorsi flap breast reconstruction is also known as autologous tissue reconstruction because it uses donor tissue from your own body.
Purpose of Procedure
Your breast surgeon and plastic surgeon can work to determine the best surgical treatments and reconstruction surgery for your unique situation. It is necessary to meet with your plastic surgeon before having your reconstruction. This gives you the chance to discuss expectations, risks, and benefits of the procedure, and to have an examination of your breasts so your reconstructed breast can be recreated as accurately as possible.
During a latissimus dorsi flap breast reconstruction, an oval section of fat, muscle, and a small amount of skin is tunneled from your upper back to your chest. The blood vessels in this tissue are left attached to their original blood supply in your back so the tissue can survive in its new location.
The latissimus dorsi muscle is considered "expendable" because the shoulder girdle muscle remains in place and is able to carry out the movements that the latissimus dorsi muscle would have carried out.
If there's not enough tissue to create a new breast, a small breast implant may be used under the flap to adjust size, shape, and projection. The flap provides added coverage over an implant and makes a more natural-looking breast than just an implant alone.
It's notable that women who had flap procedures reported significantly greater satisfaction with their breasts, sexual well-being, and psychosocial well-being than women who underwent implant reconstruction, according to a study published in JAMA Surgery.
In one study, this "workhorse" flap has been shown to be safe for overweight and obese patients as well. Researchers reported that the incidence of complications after latissimus dorsi flap reconstruction was not significantly different in overweight and obese patients compared to those of a healthy weight.
- While the transplanted skin has a slightly different color and texture than the surrounding tissue, it will be a close color match for your breast skin.
- The flap will feel warm and flexible like your normal tissue because it is your tissue.
- The flap may feel less "foreign" to you than an implant.
The function of the latissimus dorsi muscle is replaced by other muscles, so the majority of people who have this procedure adapt comfortably and are able to do the important physical activities that they were able to do before surgery.
The latissimus dorsi flap reconstruction is considered a major surgical procedure, and the procedure takes longer than a breast implant surgery. Healing will also take longer with a tissue flap procedure since you'll have two surgical sites and two scars.
After this surgery, you may have weakness in your arm and back muscles. This requires physical therapy. For active people who play tennis, golf, or other sports, this may not be the best reconstruction option.
A study published in JAMA Surgery found higher complication rates within two years following surgery among women who underwent flap procedures compared with women who underwent implant procedures. Rates of complications ranged from 36 to 74% among the flap procedure group compared with a range of 27 to 31% among the implant group.
However, the study authors point out that with additional years of follow-up, implant-based procedures are more likely than flap procedures to have increased complication rates. Also, more surgery is often needed years later to remove, modify, or replace implants.
Are You a Candidate?
The latissimus dorsi flap may be a good option for women who have small- to medium-sized breasts because there's often not enough fat tissue to reconstruct large breasts.
Blood vessels will be moved and/or reconnected during a tissue flap procedure, so if you smoke or have any conditions that affect your circulation—including uncontrolled diabetes, vascular disease, or connective tissue diseases like rheumatoid arthritis and scleroderma—you may not be a good candidate for this procedure. Smokers, including recreational drug users, may be asked to quit for four to six weeks prior to surgery.
Candidates for latissimus dorsi flap can also include those who:
- Are very thin and don't have enough tissue to use from the lower abdomen
- Have prior scars that may have damaged important blood vessels
- Have previously had radiation
- Have had previous flaps that have failed and are seeking an alternative
Breast reconstruction can be done at the same time as the mastectomy or after treatment. If you're having a mastectomy and reconstruction at the same time (immediate reconstruction), your surgeon will first remove your breast before your reconstruction, sparing as much skin as possible.
If you need radiation therapy to the underarm area or chest, you may need to wait before having this surgery. Having a latissimus dorsi flap done before your radiation treatment is complete may limit a radiation therapist's ability to treat you properly.
Risks and Contraindications
Though not a health risk, you should know that the procedure will leave a back scar, but your surgeon will attempt to take the skin graft from an area that will be covered by your bra strap. While health risks from this surgery are rare, it's still important to be aware of them.
Surgical risks include:
- Blot clots
- Surgical site infection
- Wound healing difficulties
- Fluid build-up, pain, or swelling in the breast or donor site
Rare, delayed problems include:
- Necrosis, or tissue death, in part or all of the reconstructed breast. Necrosis can be treated with removal of the dead tissue, but the affected tissue cannot be returned to good health. The risk of failure for the latissimus dorsi flap is less than 1%, though that is higher if you've had prior radiation therapy.
- Loss of or changes to nipple and breast sensation
- Problems at the donor site, including loss of muscle strength
- Changes or problems to the arm on the same side as the reconstructed breast
- Problems with the implant, including leakage, rupture, or scar tissue formation
- Uneven breasts
- The need for more surgery to fix problems that may arise
Tips for Choosing a Great Surgeon
Making Your Decision
When meeting with your surgeon, be sure to discuss all of your breast reconstruction options in detail, including the pros and cons of each, anesthesia, recovery, and follow-up. Ask your surgeon to show you pictures of other women who have had the procedure (this is commonly done; ask for both the best and worst results the surgeon has). You can also ask to speak to women who've had the surgery.
You should follow all instructions your surgeon gives you as you prepare for your procedure. This may include instructions regarding your diet, medications, and quitting smoking.
Location and Timing
Latissimus dorsi flap reconstruction is performed in a hospital. The procedure will take three to four hours. Post-surgery, you'll be admitted to the hospital, where you will stay for three to four days as you begin healing.
What to Wear
You'll likey be sore and have a limited range of motion (plus drains and bandages) after your procedure, so bring comfortable clothing that's easy to put on, such as loose or stretchy shirts that wrap or button up the front, as well as pull-on pants.
Know, too, that you will need to heal before you can wear a bra or prosthesis; your healthcare provider will provide specific information about how long you'll need to wait. Purchase a camisole for support and to secure any surgical drains that will be used as part of reconstruction surgery. The camisole is usually worn home from the hospital after surgery.
Food and Drink
You will be told when to stop eating and drinking prior to surgery, but typically you'll be instructed not to have anything for eight to 12 hours beforehand. Ask your healthcare provider if you should take your medications with water the morning before surgery. Sometimes, even a sip of water could force your healthcare provider to cancel or postpone your procedure.
Cost and Health Insurance
Federal law requires insurance companies that cover mastectomy for breast cancer to also cover breast reconstruction. Check with your insurance company to find out what your costs will be.
This surgery can be expensive. Without health insurance, breast reconstruction with flap techniques can run as high as $50, per breast; some people may face high deductibles or co-payments. Some insurance companies require a second opinion before they will agree to pay for surgery.
Insurance providers each have their own unique policies and procedures regarding precertification, predetermination, and authorization for medical procedures. When a patient has been diagnosed with cancer, this process is generally completed promptly by the insurance provider, however, in other non-immediate or delayed cancer cases, it could take up to six weeks for finalization.
Medicare coverage includes reconstructive surgery and prostheses, breast forms that fit into your bra and that you may need before or during the reconstruction. Medicaid coverage varies in each state, so you'll have to get information for your state.
How to Get a Second Opinion on Surgery
You'll have intravenous sedation or general anesthesia, so you won't be awake during your mastectomy or reconstruction. Talk to your surgeon and the anesthesiologist beforehand about which type of anesthesia works best for you, and be sure they are informed of all medications and supplements you are taking.
Prior to surgery, your plastic surgeon will use a marker to carefully plan for the incision that will create your skin flap. A pointed ellipse (oval-like shape) will be drawn over your latissimus dorsi muscle. This ellipse will become the skin flap that closes the incision for your reconstructed breast.
When the incision for the flap is closed, it will leave a four-inch to six-inch scar on your back, however, most surgeons try to place the incision so the scar is covered by your bra strap.
Moving Muscle and Skin
Your plastic surgeon will make an incision on the skin markings, raising the skin and muscle flap. A tunnel will be created under your skin so that the flap can be relocated. This latissimus dorsi tissue flap will go through the tunnel to the front of your chest, keeping its blood supply intact so the skin and muscle will continue to survive in their new location.
If the flap is completely removed and moved to the chest, the blood vessels must then be reattached with the use of a microscope. The skin will be positioned so that it fills in the area of skin that was lost during your mastectomy. If you need an implant, the muscle will be draped over it to create the new breast mound.
Your back incision will be closed, and a surgical drain may be placed in it to help remove excess fluid.
On your chest, the skin flap will be carefully joined to the mastectomy incision. If needed, scar tissue from your mastectomy may be removed in order to create a smoother skin texture at the new incision.
It's critical that you get enough blood flow to the flap, and your blood flow will be closely monitored while you're in the hospital. If you have surgical drains, you'll learn how to empty them and how to keep records of the fluid volume.
Tell your healthcare provider or nurse if you have any pain so that you can get pain treatment. Your surgeon may recommend that you wear a compression garment for up to eight weeks after surgery to keep swelling in check.
Don't plan to go right back to work—you'll need to take it easy while you recover. Be sure to have someone around to help drive you and do any lifting. Also, be sure to go for your follow-up appointments so your surgeon can keep an eye on your incisions and dressings and remove your drains.
People heal at different rates, so recovery times vary. Because you've had surgery at two sites on your body, you might feel worse than a person would feel after a mastectomy without reconstruction, and it will probably take you longer to recover.
You can anticipate gaining normal function for activities, such as driving, in four weeks. It may take as long as a year or even more to see the final result.
Nipple and areola reconstruction, should you choose to have it, is performed at about three to six months after the primary reconstruction, though that timing can vary considerably based on preference and the specific techniques used in both procedures. The reconstructed nipple doesn't have the same sensitivity as the original nipple, but it does provide for a more natural appearance.
A Word From Verywell
There are a wide variety of options in breast reconstruction, and a latissimus dorsi flap approach, although highly effective for many people, is not necessarily the best choice for everyone. Though reconstruction procedures using tissue taken from your abdomen (i.e., TRAM flap reconstruction, or DIEP flap) have become more popular over the years, latissimus dorsi flap breast reconstruction continues to be a viable option for both immediate and delayed reconstruction. Talk with your plastic surgeon and work together to find an approach that will give you the best possible results.
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Sood R, Easow JM, Konopka G, Panthaki ZJ. Latissimus Dorsi Flap in Breast Reconstruction: Recent Innovations in the Workhorse Flap. Cancer Control. ;25(1) doi/
Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term Patient-Reported Outcomes in Postmastectomy Breast Reconstruction. JAMA Surg. ;(10) doi/jamasurg
Yezhelyev M, Duggal CS, Carlson GW, Losken A. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann Plast Surg. ;70(5) doi/SAP.0bea2c02
Bennett KG, Qi J, Kim HM, Hamill JB, Pusic AL, Wilkins EG. Comparison of 2-year complication rates among common techniques for postmastectomy breast reconstruction. JAMA Surg. ;(10) doi/jamasurg
Breastcancer.org. Latissimus dorsi flap. Mar 7,
Yun JH, Diaz R, Orman AG. Breast reconstruction and radiation therapy. Cancer Control. ;25(1) doi/
Wilkins EG, Hamill JB, Kim HM, et al. Complications in postmastectomy breast reconstruction: one-year outcomes of the mastectomy reconstruction outcomes consortium (MROC) study. Ann Surg. ;(1) doi/SLA
Breastcancer.org. Latissimus dorsi flap reconstruction: what to expect. Mar 7,
American Cancer Society. Breast reconstruction using your own tissues (flap procedures). September 18,
American Society of Plastic Surgeons. Breast reconstruction.
Leonardis J, Diefenbach BJ, Lyons DA, et al. The influence of reconstruction choice and inclusion of radiation therapy on functional shoulder biomechanics in women undergoing mastectomy for breast cancer. Breast Cancer Res Treat. ;– doi/s
Santosa KB, Qi J, Kim HM, Hamill JB, Wilkins EG, Pusic AL. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. ;(10)– doi/jamasurg
Sood R, Easow J, Konopka G, Panthaki Z. Latissimus dorsi flap in breast reconstruction: recent innovations in the workhorse flap. Cancer Control. ;25(1) doi/
Yezhelyev M, Duggal CS, Carlson GW, Losken A. Complications of latissimus dorsi flap breast reconstruction in overweight and obese patients. Ann Plast Surg. ;70(5) doi/SAP.0bea2c02
If the cast release for ABC's The Bachelorette doesn't mark your favorite day of the year, then who even are you? Seriously, I don't even know.
This year's crop of 25 hopefuls in the running for either/both Bachelorettes (both Kaitlyn Bristowe and Britt Nilsson will face a vote in the two-part season premiere) have now been confirmed; their cast photos are here and I'm giddy because oh boy, is it a sadsack post-collegiate bro fashion extravaganza. Let us count the sad, bad, tragic ways their V-neck tees, V-neck sweaters, and smart-casual mall store shirts are so wrong, even though I bet the nice sales clerk working the clearance section at Men's Wearhouse told them otherwise
1. As worn by Bachelorette contender Jared:
ABC / Craig Sjodin
I would wear this American Apparel V-neck to the gym, if (1) I went to the gym and (2) American Apparel tees didn't chafe my nipples. But that's all. Per his bio, Jared and his jawline volunteer at a summer camp for kids with cancer though, so my snark stops here.
2. As worn by Bachelorette contender Joshua:
ABC / Craig Sjodin
FYI, I can see your undershirt Joshua. (That's a no-no.)
3. As worn by Bachelorette contender Tanner:
ABC / Craig Sjodin
You too, Tanner. I'm here to make a serious stand against these basic V-necks, even if they're mostly hidden. The Bachelorette deserves better.
4. As worn by Bachelorette contender Tony:
ABC / Craig Sjodin
Tony is the only contestant polite enough to wear the belt his mom — who he describes as the person he admires most in the whole world, aww — bought him for Christmas last year. Actually, Tony is the only contestant to bother with a belt, period. What the fuck is this, guys, a nacho-heavy afternoon at the sports bar?!
(To clarify, this outfit still sucks.)
5. As worn by Bachelorette contender Justin:
ABC / Craig Sjodin
Nipple flap button pockets, never a good idea.
6. As worn by Bachelorette contender Clint:
ABC / Craig Sjodin
OK, nope, not hating on these pecs or anything related to them other than the T-shirt, obviously. That's what we're here for. Clint apparently walks "a fine line between cocky and confident," Bachelorette host Chris Harrison told Yahoo! TV; make of that what you will.
7. As worn by Bachelorette contender Shawn B:
ABC / Craig Sjodin
This bro looks like Calvin Harris. That's all! Also, he picked One Direction as one of his favorite bands. PICK HIM, Bachelorettes, seriously.
8. As worn by Bachelorette contender JJ:
ABC / Craig Sjodin
Déjà vu much? We're only at no. 8 on this list and it already feels like we've been here forever. Also, I mean, of course JJ is wearing a "Livestrong" bracelet (or a plastic piece of similar-looking man jewelry) but why is it halfway up his forearm?!
9. As worn by Bachelorette contender Shawn E:
ABC / Craig Sjodin
Also filed under bad man jewelry: this. It might take you a second to spot it — i.e. for your eyes to adjust to this blinding shade of pleated scarlet — but there's a pendant there worthy of the beta bad guy in a '90s made-for-TV movie.
Oh and wait, did I mention that Shawn's occupation is listed as "amateur sex coach" on his Bachelorette bio? I'm not even kidding, though funnily enough, this job title would only show up on the business card of someone who's yet to crack third base.
As worn by Bachelorette contender Bradley:
ABC / Craig Sjodin
A question for Bradley/the universe: What is even the point of wearing a reasonably smart suit jacket if you're going to pair it with a salmon pink shirt and pale khaki pants?! I am Ana Steele, all like, "Enlighten me, please," when Christian is pussyfooting around his S&M fetish, except I just want to know about menswear, not foreplay.
As worn by Bachelorette contender Josh:
ABC / Craig Sjodin
In a similar vein, why pair a skinny tie with such unabashedly casual separates. Those black pants are positively baggy. The only acceptable answer here is that it's a costume that exotic dancer Josh (no, really) plans to rip off in particularly expressive routine.
As worn by Bachelorette contender Corey:
ABC / Craig Sjodin
In his Bachelorette bio, Corey describes the Dalai Lama as an "enlightened cat."
As worn by Bachelorette contender Cory:
ABC / Craig Sjodin
Me right now:
And as worn by Bachelorette contender Ian:
ABC / Craig Sjodin
Meanwhile, "one time I made a clock with a picture in the background," says Ian. These guys are something, that's for sure. UNLIKE THEIR CLOTHES.
As worn by Bachelorette contender Brady:
ABC / Craig Sjodin
Points for trying something different OK, wait, no, no points for this.
And as worn by Bachelorette contender Ryan M:
ABC / Craig Sjodin
OK, look, the real reason this is so terrible is because I bet Ryan M, who, by the way, is a "junkyard specialist" and also used to date Bachelor winner Nikki Ferrell, has the perfect ~dad bod~ under his sad striped sweater. (Disclaimer: I do knot know if Ryan M has any children, but I stand by this descriptor and my desire to see him shirtless.)
Bonus Ryan M fact, because I think he is my favorite: When asked to describe his worst date, he simply says, "The person being terrible." I love it! I love him! Look what this damn listicle has reduced me to.
As worn by Bachelorette contender Joe:
ABC / Craig Sjodin
*Sigh.* I hope there's a group date for all the guys this season, and it's just Kaitlyn/Britt taking them shopping. There can be a "most improved styling" challenge for a rose or something. Bachelorette producers, hit me up; I'm full of great ideas like this!
As worn by Bachelorette contender Kupah:
ABC / Craig Sjodin
SUSPENDERS?! Suspenders that, as an outraged Cosmopolitan.com's Eliza Thompson notes, ARE NOT EVEN BEING WORN PROPERLY (they're just drooping around Kupah's pants here, asking to get caught on a door handle). For real, that's too much.
Not pictured: Bachelorette contenders Ben H, Ben Z, Chris, Daniel, David, Jonathan, and Ryan B, because none of their outfits made me want to rub my eyes in a sassy way I sometimes do when I'm forced to look at something I don't want to. (Also not pictured, one much-rumored late arrival to the competition, with Bachelorette experience in his pocket already.) Honorable mention to Chris in particular for making his grand entrance at the Bachelorette mansion in a cupcake car, because that never won't be amazing.
P.S. Just to make the style snark ~balanced~ across both genders, would-be Bachelorette Britt's promo photo gown is "Fifty Shades of Cray" in its own frothy tulle right:
ABC / Craig Sjodin
P.P.S. For the sake of a positive conclusion to this piece, all the guys do look dapper in their suits.
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Alex ReesDeputy Editor of NewsI’m the news director here at Cosmopolitan.com, and I could really use a cup of tea right now.
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Super Bowl XXXVIII halftime show controversy
controversy over indecent exposure on television
The halftime show at Super Bowl XXXVIII, which was broadcast live on February 1, , from Houston, Texas, on the CBS television network, is notable for a moment in which Janet Jackson's breast—adorned with a nipple shield—was exposed by Justin Timberlake to the viewing public for approximately half a second. The incident, sometimes referred to as Nipplegate or Janetgate, led to an immediate crackdown and widespread debate on perceived indecency in broadcasting.
The halftime show was produced by MTV and was focused on the network's Choose or Lose campaign (the year was a presidential election year in the United States). The exposure was broadcast to a total audience of million viewers. Following the incident, the National Football League (NFL) excluded MTV, which had also produced the halftime show for Super Bowl XXXV, from future halftime shows. In addition, CBS parent company Viacom and its co-owned subsidiaries, MTV and Infinity Broadcasting, enforced a blacklist of Jackson's singles and music videos on many radio formats and music channels worldwide. The Federal Communications Commission (FCC) fined CBS for an indecency violation of US$27, and increased it to US$, They eventually fined CBS a record US$, for the incident, but that fine was ultimately voided by the Third Circuit Court of Appeals in , and a case to reinstate the fine was refused in
The incident was ridiculed both within the United States and abroad, with a number of commentators opining that it was a planned publicity stunt. Some American commentators viewed it as a sign of decreasing morality in American culture, while others considered the incident harmless and argued that it received undue attention and backlash. Some, including Jackson herself, argued it was being used as a means to distract the public from the ongoing Iraq War. The increased regulation of broadcasting raised concerns regarding censorship and free speech in the United States.
YouTube co-founder Jawed Karim credits the incident with leading to the creation of the video sharing website. The incident also made Janet Jackson the most-searched person and term of and The incident broke the record for "most-searched event over one day". It became the most-watched, recorded and replayed television moment in TiVo history and "enticed an estimated 35, new [TiVo] subscribers to sign up". The term "wardrobe malfunction" was coined as a result of the incident, and was eventually added to the Merriam-Webster's Collegiate Dictionary.
In April , celebrity stylist Wayne Scot Lukas claimed that it was planned by Timberlake, who sought to upstage his ex-girlfriend Britney Spears' MTV Video Music Awards appearance at which she kissed Madonna. In , Lukas had stated that he was not aware of what happened with Timberlake. In , USAToday reported Lukas was seen purchasing a sunburst nipple shield from Byriah Dailey the weekend prior to the Superbowl, telling Dailey ‘OK, watch the halftime show. There’s going to be a surprise at the end.’
Background and development
Janet Jackson was the original choice to perform at the halftime show for Super Bowl XXXVI, but the NFL ultimately selected U2 after a group of NFL owners and officials attended the band's concert in New York City shortly after the September 11 attacks. In September , the NFL chose Jackson as the headline performer of the Super Bowl XXXVIII halftime show. Because the event was occurring during an election year, MTV decided that the show's theme would heavily focus on the network's "Choose or Lose" campaign, which encouraged younger viewers to be politically active and register to vote.
Timberlake had attended Jackson's Rhythm Nation Tour as a kid, and Jackson's energetic dance routines and daring performing style had made a deep impression on him. While Timberlake was a member of pop group 'N Sync, Jackson selected the boy band as the opening act for many dates of her blockbuster Velvet Rope World Tour, which helped promote and introduce the then-relatively unknown group and Timberlake to the public worldwide. While on the tour, Jackson further promoted the group by performing with 'N Sync on several dates, including joining the group for a live a cappella duet of Stevie Wonder's "Overjoyed". Following the tour, Timberlake and Jackson became "good friends", with Jackson also praising Timberlake. Timberlake recreated Jackson's "That's the Way Love Goes" video with 'N Sync and was inspired by Jackson's performing style. When asked who he thought was "the sexiest woman on the planet", Timberlake had said "I've thought Janet Jackson has nothing but sex appeal, so I'd probably say her." Timberlake later asked Jackson to sing backing vocals on "(And She Said) Take Me Now", a song from his debut solo album Justified.
At Live Aid Mick Jagger ripped off Tina Turner's skirt on stage, an event that created wide media publicity. 
During the halftime show at Super Bowl XXXVIII, Jackson performed a medley of hits, beginning with "All for You", "Rhythm Nation" and a brief excerpt of "The Knowledge". Surprise guest Timberlake then appeared onstage to perform a duet of his song "Rock Your Body" with Jackson. The performance contained several suggestive dance moves by both singers. As Timberlake reached his final line of "Rock Your Body" ("Gonna have you naked by the end of this song"), he pulled off a part of Jackson's costume; the move revealed Jackson's right breast—adorned by a nipple shield—for less than a second, after which the CBS broadcast immediately cut to a wide shot of the stage for a pyrotechnic effect, then to an aerial view of Reliant Stadium.
"It's truly embarrassing for me to know that 90 million [ million] people saw my breast, and then to see it blown up on the Internet the size of a computer screen  But there are much worse things in the world, and for this to be such a focus, I don't understand."
– Jackson on Super Bowl incident.
The baring of Jackson's breast during the Super Bowl performance became referred to as a "wardrobe malfunction".
Following the Super Bowl, both MTV and CBS apologized for the incident and asserted that they had no prior knowledge that Jackson and Timberlake's duet would involve partial nudity. MTV's CEO Tom Freston claimed in an interview with the Reuters news agency that the exposure was a stunt orchestrated by Jackson. However, an MTV representative confirmed that the costume tear was conceptualized by the MTV staff, but added that nudity was not the intended result. The incident was publicly criticized by NFL Commissioner Paul Tagliabue,FCCChairmanMichael Powell, and NFL Executive Vice PresidentJoe Browne. An hour-long MTV documentary titled "Making the Super Bowl Halftime Show" was scheduled to premiere the following week, but was canceled.
Jackson's representative explained the incident, saying: "Justin was supposed to pull away the rubber bustier to reveal a red lace bra. The garment collapsed and her breast was accidentally revealed." According to Rolling Stone, CBS required Jackson to make a public apology for the incident. Jackson released a video apology in which she said: "The decision to have a costume reveal at the end of my halftime show performance was made after final rehearsals. MTV was completely unaware of it. It was not my intention that it go as far as it did. MTV, CBS, [and] the NFL had no knowledge of this whatsoever and unfortunately, the whole thing went wrong in the end. I apologize to anyone offended, including the audience, MTV, CBS and the NFL." Speaking to USA Today, Jackson said she felt humiliated that tens of millions of people saw her exposed breast, but did not feel the outrage was justified. Regarding continued backlash, she responded, "Who knowsMaybe they'll get mad at something that I do in my show, but at least it won't be new to me, since I've already gone through all of this. But I feel very positive that things are going to work out just fine. Everything happens for a reason."
Jackson later briefly discussed the incident on Good Morning America and the Late Show with David Letterman. Jackson's outfit was designed by famed designer Alexander McQueen, with Jackson later commenting "I don't blame him; he didn't rip it. Alexander is so great at what he does—he's a genius." In an interview with Australia's Herald Sun, Producer Jimmy Jam revealed Jackson considered writing a song about the incident for her Damita Jo album.
"[The furor] is hypocritical, with everything you see on TV. There are more important thing to focus on than a woman's body part, which is a beautiful thing. There's war, famine, homelessness, AIDS.  They needed something to focus on instead of the war, and I was the perfect vehicle for that.  People are going to think what they want. It was an accident. It was not a stunt."
– Jackson questioning media's focus on the event.
Michael Musto of The Village Voice commented on the media's reaction to the incident, saying, "Janet became a symbolic Joan of Arc to burn at the stake. I actually do think her breast was used as a diversionary tactic—I'm not sure to distract from Iraq specifically—but it did distract from important issues, from things we actually should be appalled by. The story got an undue amount of attention when the fact is, nobody has proved how her breast harmed anyone." Speaking to Robert Tannenbaum of Blender Magazine, Jackson had strong, if guarded, views on the reactions, reiterating her embarrassment at being exposed but argued that there was no sense in complaining about part of a woman's body while world events as grim as war and disease occurred. Jackson declared the reaction to the accidental exposure as "contradictory", noting it to occur in an era where commercials for beer and Viagra are both "very sexual" and "practically omnipresent". Jackson also said the mishap was "not intentional" and a "costume accident", also commenting on some media outlets editing her taped apology, saying, "Sometimes they cut out that I said it was an accidentThat's what the media does, that's the way they are because they want it to be told a different way." In Glamour Magazine, Jackson exclaimed, "It's hard to believe that there's a war and famine going on in the world and yet people made such a big deal about a breast. People said that it was done intentionally to sell records. Do you know what? I have never pulled a stunt. Why would you do that and have your album come out two months later? It doesn't make sense." In the ensuing months, Jackson felt overwhelmed by the hostility towards her. "People think I'm immune to being hurt by what's said. They ask me questions that shock me. Not everybody is as strong as the next person and words can kill. People push you and you start to think, 'Can I handle this?' But I know I can."
Immediately following the incident, Timberlake sounded unapologetic for his actions, telling Access Hollywood, "Hey man, we love giving you all something to talk about." Timberlake later released a statement saying "I am sorry that anyone was offended by the wardrobe malfunction during the halftime performance of the Super Bowl. It was not intentional and is regrettable." Timberlake also addressed the incident at the Grammy Awards the following week, saying: "I know it's been a rough week on everybody. What occurred was unintentional, completely regrettable and I apologize if you guys are offended." Timberlake gave an additional interview at the Grammy event and stated, "All I could say was, 'Oh, my God. Oh, my God,'" Timberlake said. "I looked at her. They brought a towel up on stage. They covered her up. I was completely embarrassed and just walked off the stage as quickly as I could. I'm frustrated at the whole situation. I'm frustrated that my character is being questioned."
Media diversion theories
Jackson suspected ulterior motives in the media's reaction, expressing, "It was just perfect timing to take people's focus off of other things. That's what happens, and it happened to me." Comments from Michael Rich, director of Harvard's Center on Media and Child Health; Jay Rosenthal, attorney for the Recording Artists' Coalition; and Simon Renshaw of management group The Firm expressed similar sentiments. The Boston Legal episode "Let Sales Ring" likened the incident to being used as a distraction, portraying a news corporation which used the mishap to attract attention over other important events in the media. Daniel Kreps of Rolling Stone opined, "For the FCC, Nipplegate provided an opportunity to restore order and flex whatever power they had left. Faced with lax broadcast standards for cable TV and satellite radio, as well as the absolute lawlessness of the Internet, the FCC becomes hell-bent on preserving common decency in the family-friendly realm of network television While the aftermath of Nipplegate starts to fade, the FCC will continue to carry its torch for the next half-decade." Cynthia Fuchs of Popmatters stated, "It behooves TV producers and consumers to focus their attentions on significant "news", rather than the daily distractions offered up by politicians, performers, professional spinners, and journalists. Janet is not that person you watch on TV. And neither is anyone else."
A decade after the incident, former FCC chairman Michael Powell gave his first interview regarding Jackson's performance, saying Jackson was treated unfairly and the controversy, including his own reaction, was completely overblown. Powell stated, "I think we've been removed from this long enough for me to tell you that I had to put my best version of outrage on that I could put on. Part of it was surreal, right? Look, I think it was dumb to happen, and they knew the rules and were flirting with them, and my job is to enforce the rules, but, you know, 'Really? This is what we're gonna do?' " Powell also said the treatment of Jackson, who was lambasted for causing "an outrageous stunt", was unfair, and commented on Timberlake not receiving the same backlash. "I personally thought that was really unfair", he said. "It all turned into being about her. In reality, if you slow the thing down, it's Justin ripping off her breastplate."
In the United States, the exposure of Jackson's breast by Timberlake led to much media attention and headlines. The incident was sometimes referred to as "Nipplegate". The socially conservative media watchdog group Parents Television Council (PTC) issued a statement condemning the halftime show, and called on PTC members to file indecency complaints with the FCC. In addition, the FCC received nearly , complaints from Americans, with the PTC claiming responsibility for around 65, of them. (In its appeal to the Third Circuit Court of Appeals, CBS disputed how many of the complaints were filed by individual, non-organized viewers.) Columnists L. Brent Bozell III (who also founded the Parents Television Council) and Phyllis Schlafly also expressed criticism of the halftime show in their weekly columns. Democratic senator Zell Miller of Georgia, both on the floor of the United States Senate and in an editorial on Salon.com, denounced the halftime show as an example of declining morality in America. The day immediately following the Super Bowl, then-FCC chairman Michael Powell ordered an investigation into the halftime show. However, an Associated Press poll taken nearly three weeks after the Super Bowl found that although 54% of American adults considered the exposure distasteful, only 18% supported the FCC's investigation. Film director Spike Lee, speaking at Kent State University at Stark on February 3, called the incident a "new low" in entertainment. Democratic presidential candidate Howard Dean called the FCC's investigation "silly", commenting: "I think the FCC probably has a lot of other things they should be pursuing."
The Super Bowl controversy was also a subject of humor on late-night talk shows. For example, CBS's own Late Show with David Letterman mocked the incident all week following the Super Bowl. The day after the Super Bowl, host David Letterman joked that he "was happy to see this thing happen because that meant for one night I wasn't the biggest boob on CBS". The next day, he also joked that President George W. Bush formed a "Department of Wardrobe Security" to prevent further wardrobe malfunctions. On February 4, Letterman opened his monologue by joking about having a wardrobe malfunction and referenced the incident in this night's Top Ten List. Jackson's appearance on the Late Show the following month increased the show's ratings 20% from the program's usual weeknight opener.Larry King also stated Jackson jokingly gave him a pair of suspenders with open holes around the nipples, commenting "I wore them once, they were cute."
The halftime show continued to be a subject of discussion in The parody newspaper The Onion ran a lead article on January 26, entitled "U.S. Children Still Traumatized One Year After Seeing Partially Exposed Breast On TV". The article's satirical target was the nation's reaction to the incident rather than the incident itself. On February 1, , exactly one year after the halftime show, the PTC released a report titled MTV Smut Peddlers: Targeting Kids with Sex, Drugs, and Alcohol, covering MTV programming during the network's "Spring Break" week from March 20 to 27, , accusing MTV of irresponsibly promoting sex, drugs and alcohol to impressionable youth. In response to the report, MTV network executive Jeannie Kedas argued that the report "underestimates young people's intellect and their level of sophistication." On February 6, New York Times columnist Frank Rich argued that censorship on television was becoming more prevalent following the halftime show. Examples he cited included PBS editing obscene language out of certain programs such as the British terrorist drama Dirty War and more than 60 ABC-affiliated stations (including those owned by the Sinclair Broadcast Group, E. W. Scripps Company, Hearst-Argyle Television and Cox Broadcasting) refusing to broadcast Saving Private Ryan due to the profanity prevalent throughout the film. (The latter, which would later be ruled the FCC to not violate regulations, would air on cable afterwards to avoid controversy.) The ESPN series Playmakers was also canceled following the incident. A commercial from Budweiser, which depicted a man opening a beverage on the outfit's breastplate and tearing it before it was worn, was intended to be aired during Super Bowl XXXIX the following year, but was pulled before its broadcast.
In Canada, where the Super Bowl telecast was broadcast by the Global Television Network, the incident passed largely without controversy: only about 50 Canadians complained about the incident to the Canadian Broadcast Standards Council (CBSC). The CBSC received roughly twice as many complaints about other aspects of the Super Bowl broadcast, including music and advertising issues (though some were expected complaints about Canadian content/simsub issues preventing viewing of the popular American advertisements, which is a common issue among Canadian viewers of the Super Bowl to the present day). Professor Robert Thompson, director of the Center for the Study of Popular Television at Syracuse University, stated: "I know many people in other countries are scratching their heads and thinking 'What in the world is the big fuss over there?'"
New Zealand news outlets re-broadcast the "nipplegate" moment (some in slow motion) with commentary explaining that US ultra-conservatives had made the incident into a major controversy. The nation's largest newspaper, the New Zealand Herald, ran an op-ed from a New Zealander living in America detailing his bafflement at his American friends, who had expressed outrage at the glimpse of a nipple while supporting their country's invasion of Iraq and being fans of the television show Sex and the City.
On February 4, Terri Carlin, a banker residing in Knoxville, Tennessee, filed a class action lawsuit against Jackson and Timberlake on behalf of "all American citizens who watched the outrageous conduct". The lawsuit alleged that the halftime show contained "sexually explicit acts solely designed to garner publicity and, ultimately, to increase profits for themselves". The lawsuit sought maximum punitive and compensatory damages from the performers. Carlin later dropped the lawsuit. Three months later, Eric Stephenson, a lawyer from Farmington, Utah, filed a US$5, lawsuit in small-claims court against Viacom for false advertising of the Super Bowl halftime show, as he, the father of three young children, claimed that pre-game advertising led him to believe that the halftime show would consist of marching bands, balloons and a patriotic celebration. The lawsuit was rejected because Stephenson should have filed a federal lawsuit or complaint to the FCC, which was already investigating the halftime show.
America Online, the Internet service provider that sponsored the halftime show, demanded a refund of the approximately US$ million that it paid to sponsor and advertise on the halftime show. However, no other advertisers of the Super Bowl had similar demands.
The incident triggered a rash of fines that the FCC levied soon after the Super Bowl, alleging that the context of the "wardrobe malfunction" was intended "to pander, titillate and shock those watching" because it happened within the lyrics within Timberlake's performance of Rock Your Body: "Hurry up 'cause you're taking too long gonna have you naked by the end of this song." In addition, the FCC cited a news article on MTV's website (MTV.com) claiming that the halftime show would promise "shocking moments" and that "officials of both CBS and MTV were well aware of the overall sexual nature of the Jackson/Timberlake segment, and fully sanctioned it—indeed, touted it as 'shocking' to attract potential viewers". CBS, however, argued that the exposure was unplanned, although in later statements CBS asserted that while the exposure was unplanned by CBS, it was deliberately planned by Timberlake and Jackson "independently and clandestinely". On September 22, , the FCC fined Viacom the maximum penalty of US$27, for each of the 20 CBS-owned television stations (including satellites of WFRV in Green Bay, WCCO in Minneapolis and KUTV in Salt Lake City; current CBS owned-and-operated station KOVR in Sacramento at the time was owned by the Sinclair Broadcast Group) for a fine totaling US$,, the largest ever placed against a television broadcaster at that time. However, the Parents Television Council and even some of the FCC commissioners criticized the Commission for fining only 20 CBS stations, not all of them, for the halftime show. 66% of respondents to a March Time magazine poll believed that the FCC overreacted to the halftime show by fining CBS.
On November 24, , Viacom paid out US$ million to settle outstanding indecency complaints and stated that it would challenge the US$, penalty related to the incident, on the grounds that the broadcast was unintentional and thus exempt from indecency regulation. In March , the FCC affirmed that the Super Bowl halftime show was indecent, so CBS paid the FCC's issued fine in July in order to take their appeal against their fine to federal court. CBS appealed the fine on September 17 at the U.S. Third Circuit Court of Appeals in Philadelphia.
On July 21, , the Third Circuit Court of Appeals ruled in favor of CBS, voiding the FCC's fine on the grounds that the enforcement involved a significant deviation from prior practice that was not issued as a clear policy change. On May 4, , however, the Supreme Courtvacated and remanded the case back to the Third Circuit for reconsideration in light of the previously decided Federal Communications Commission v. Fox Television Stations ().
On November 2, , the Third Circuit Court ruled 2–1 that its earlier decision was correct, citing that the broadcast was legal under the FCC's then-current policy of allowing "fleeting" indecency on the airwaves, and that it was unfair of the FCC to change the policy retroactively. On June 29, , the Supreme Court declined an FCC appeal.
Prior to the broadcast, CBS rejected the MoveOn.org Super Bowl adBush in 30 Seconds because it was deemed too controversial. CBS stated that it had a "decades-old" policy of rejecting advertisements regarding "controversial issues of public importance", although MoveOn charged that the networks had previously accepted similar advertisements from other groups. The Super Bowl broadcast contained numerous commercials for erectile dysfunction medicines and advertisements for Anheuser-Busch's Bud Light brand featuring a flatulating horse and a dog attacking male genitalia; however, no politically charged advertisements appeared during the telecast. CBS, which also held the rights to Super Bowl XLIV, later aired a commercial during that game featuring then-Florida Gators quarterback Tim Tebow and his mother that discreetly refer to their anti-abortion viewpoints. The ad, sponsored by Focus on the Family, received similar controversy. In a league-mandated policy meant to clear the airwaves of such advertisements, the NFL banned those types of commercials from Super Bowl broadcasts (the league ended an advertising relationship with Levitra in March as an official league sponsor).
In January , Fox, the network that carried Super Bowl XXXIX under the NFL's alternating network contract for the championship game, rejected an advertisement for the cold remedy Airborne that briefly showed the naked buttocks of veteran actor Mickey Rooney.
Moments after the Jackson-Timberlake tangle, streakerMark Roberts added to the controversial halftime by running around the field naked except for a well-placed G-string attached to half of a miniature football. Part of Roberts' stunt was broadcast in the United States before players from both teams tackled him, allowing stadium security and police to take Roberts into custody.
Aside from Jackson's exposure, minor controversy was created when rapper Nelly performed his song "Hot in Herre" when a group of female backup dancers all pulled the top-layer of their costumes off, revealing shorter shorts and smaller shirts underneath.Kid Rock appeared in a poncho made from a slit American flag, which he later threw towards the audience. U.S. Senator Zell Miller complained that Kid Rock's outfit was a desecration of the American flag.
Aftermath and effects
Censorship and regulation of broadcasting
Website Soap Opera Central speculated that the fallout from this incident may have had a subtle effect on daytime television. These television shows are known for "love in the afternoon" and regularly depict romantic couplings; shortly before the Super Bowl, the Procter & Gamblesoap operasAs the World Turns and Guiding Light had gone as far as featuring rear male nudity during sexual scenes. After the Super Bowl controversy, FCC commissioner Michael J. Copps stated that it was time for a crackdown on inappropriate sexual content in daytime television, and indicated that he was reviewing whether soap operas were violating the agency's indecency prohibitions. In The NewsHour with Jim Lehrer, NewsHour correspondent Tom Bearden reports the excerpts from hearings today on regulating broadcast decency.
Two other major sporting events that followed the Super Bowl that year also changed their respective halftime shows following the incident. At the Pro Bowl, which would be played on February 8 at Aloha Stadium in Hawaii, singer JC Chasez, a member of boy band 'N Sync as was Timberlake, was to sing the National Anthem before the game and perform his hit song "Blowin' Me Up (with Her Love)" at halftime. However, the NFL did not allow Chasez to perform during halftime due to the sexually suggestive content of his chosen song (even though the game was carried by ESPN, which is not under the content purview of the FCC as it is a cable network, and therefore only self-regulates content as an advertiser-supported service), replacing it with traditional Hawaiian hula dancers. The NBA All-Star Game also changed its act, despite being broadcast on TNT (which is not bound by FCC content regulations as a cable network), having halftime performer Beyoncé perform "Crazy in Love" instead of "Naughty Girl", which they feared would incite controversy given its sexual content. Jackson was in attendance at the game, and dressed conservatively. The networks that were to broadcast the 46th Grammy Awards (CBS) and the 76th Academy Awards (ABC), live events scheduled for February 8 and February 29 respectively, enhanced their broadcast delays to accommodate editing of inappropriate video in addition to audio.
Guiding Light[clarification needed] edited out nudity from an episode that had already been taped. A week later, the show's executive producerJohn Conboy was fired and replaced by Ellen Wheeler. All nine American network soaps began to impose an unwritten rule of avoiding any sort of risqué adult scenes, and in the months following, editors of soap opera periodical Soap Opera Digest wrote about how daytime television was losing its steam.NBC also re-edited a scene from an episode of its medical drama ER where paramedics were wheeling an elderly woman into the hospital, and her breast could be seen in the context of her injury and treatment. Even as late as Veterans Day (November 11) of , 65 ABC-affiliated stations pre-empted the uncut network presentation of the film Saving Private Ryan over concerns about the film's violent content and FCC regulations. Benjamin Svetkey of Entertainment Weekly quoted L. Brent Bozell III and Peggy Noonan associating the mass pre-emption of the film with the halftime show incident. The annual Victoria's Secret Fashion Show was cancelled for that year in reaction to the incident.
A petition was filed by a consortium of broadcasters (which included Viacom) and the RIAA over an FCC indecency ruling, regarding fleeting expletives uttered by Bono of U2 when accepting an award at the 60th Golden Globe Awards in It argued that the FCC had implemented a standard "that would allow it to censor all kinds of things—anything considered blasphemous, coarse or vulgar", and observed that many radio stations, especially rock-formatted stations, had been engaging in self-censorship by censoring or removing songs from their libraries, so that they would not run afoul of the stricter regulation.Clear Channel Communications removed talk-radio host Howard Stern from several of its large-market radio stations within a month of the incident, citing the raunchy content of Stern's show. The FCC fined Clear Channel over allegedly indecent content on the Bubba the Love Sponge radio show. As a result of the incident, some networks established regulations requiring time delays of as much as five minutes for live broadcasts such as awards shows and sporting events. In late , the United States House of Representatives passed a bill to raise the maximum FCC fine penalty from said US$27, to US$, per violation; the United States Senate voted to decrease it to US$, per incident, with a cap of US$3 million per day. By June , the two houses reconciled the differences in fine levels, settling for a fine of US$, per violation in the Broadcast Decency Enforcement Act of 
The incident also prompted tighter control over content by station owners and managers. Viacom, at the center of the controversy, also employed the controversial Howard Stern in its radio division (at the time called Infinity Broadcasting). The expanding control on content is said to be a contributing factor that drove Stern away from terrestrial radio and onto Sirius Satellite Radio, and is sometimes credited as the media figure most responsible for introducing a new era in radio. It has also been reported that some teen-oriented awards shows in the summer of had also been purged of most sexual and profane content that had been perceived as staples in such awards telecasts in the past, including Fox's Teen Choice Awards and MTV's self-created Video Music Awards. Author Frederick S. Lane stated in an interview with John Eggerton of Broadcasting & Cable magazine that the controversy surrounding the halftime show was the primary inspiration for his book The Decency Wars: The Campaign to Cleanse American Culture, which explains moral controversies in the American media over the years.
Beginning with Super Bowl XXXIX in , the halftime show began to be produced by Don Mischer Productions and White Cherry Entertainment; those shows contained classic rock artists who mainly performed songs from the s and s (with a notable exception being Bruce Springsteen and the E Street Band performing their single "Working on a Dream" during the Super Bowl XLIII halftime show in ). This practice ended after Super Bowl XLIV in ; beginning with Super Bowl XLV in , the halftime performance returned to having pop artists.
In , during the halftime show for Super Bowl XLVI, rapper M.I.A.pointed up her middle finger during her performance. That incident drew comparisons with the exposure of Janet Jackson's breast in the Super Bowl halftime show eight years prior. The Associated Press asserted that people learned what M.I.A. did only when reports surfaced in the media and quoted TV critic James Poniewozik: "I had no idea she even did it until NBC issued an apology for it." NBC blurred the entire screen albeit a second too late to obscure M.I.A. giving the finger. The NFL ultimately sued M.I.A. for US$ million on breach of contract grounds. The lawsuit was settled in August and the terms of the settlement remained private. As an indication of the reduced level of complaints, only complaints were filed over the incident.
Sports would be greatly affected by the controversy. Three weeks later, NASCAR stiffened penalties on use of improper language or gestures including larger fines, loss of points (if it occurred in a post-race interview or after the driver fell out of a race), ejection of a team from the race, or lap penalties (if in-race) under the circuit's "detrimental to NASCAR" rule.Johnny Sauter was fined US$10, and 25 points a week after the new rule took effect for obscene language in an interview. Later in , Dale Earnhardt Jr. received a point penalty and a US$50, fine when he used an obscenity after winning the EA Sports at Talladega Superspeedway. He lost the championship lead after that incident and lost the championship by points. In , Tony Stewart received a similar penalty after using an obscenity in a post-race interview following his Brickyard win. Kyle Busch, in November , was fined US$25, for an obscene gesture caught on ESPN, along with an in-race two-lap penalty, as the gesture was aimed at a NASCAR official.
The NFL also came under some smaller controversies over its telecasts. The FCC received a complaint about Fox's telecast of a January playoff game between the Green Bay Packers and Minnesota Vikings; the complainant alleged that Minnesota player Randy Moss, who scored a touchdown, apparently made movements appearing to moon the spectators. However, the FCC denied the complaint because Moss was fully clothed at all times, and his gestures were shown for only a few seconds, thus warranting that the display was not indecent; game commentator Joe Buck also immediately condemned the act (and additionally, Moss was fined by the NFL). On January 13, , during Fox's coverage of an NFL playoff game between the New Orleans Saints and Philadelphia Eagles, the camera cut to the stands, showing for four seconds a shirt with the words "Fuck DA EAGLES" that was worn by a female spectator. That drew a backlash from the Parents Television Council, which filed complaints with the FCC.
During NBC's live broadcast of Super Bowl XLIII on February 1, , the five-year anniversary of the original incident, affiliate KVOA-TV's analog broadcast feed (the high definition feed of the station was unaffected) over Comcast's Tucson, Arizona system was interrupted by an unknown party, when an excerpt of a film aired by adult cable channel Shorteez was broadcast for 30 seconds to local Comcast subscribers just after Larry Fitzgerald scored his fourth-quarter touchdown to take the Cardinals to a 23–20 lead. Afterwards, 10 seconds of an end credit segment from ClubJenna (which, like Shorteez, is owned by Playboy Enterprises) was shown. Comcast offered a US$10 credit for customers who claimed to have seen the incident, and the Federal Communications Commission investigated the cause of the incident. E! Online columnist Josh Grossberg stated: "This almost makes us nostalgic for the days of Nipplegate."
Further information: United States presidential election
Frederick S. Lane argued in his book The Decency Wars that the Super Bowl halftime show controversy influenced the primary focus on "moral values" and "media decency" in the Democratic Party primaries. Jackson claimed the incident was used in the media as a diversion for President George W. Bush's poor approval ratings and the Iraq War, with Bush and First LadyLaura Bush giving public commentary on the incident rather than focusing on other issues.
Impact on Jackson
"[We are] absolutely bailing on the record  The pressure is so great, they can't align with anything related to Janet. The high-ups are still pissed at her, and this is a punitive measure."
" radio wouldn't play it and MTV wouldn't play her videos for "I Want You" and "All Nite", two songs that would've been out-of-the-park hits at any other point in Jackson's career."
– Viacom revealing Jackson's blacklist; commentary from The Charlotte Observer
Viacom CEO Les Moonves ordered that Janet Jackson's singles and music videos be blacklisted from all of its properties, including CBS, MTV, and its radio station group Infinity Broadcasting. Jackson was intended to appear at the 46th Grammy Awards, which was being held the following week and televised by CBS, but her invitation was withdrawn due to the incident. Jackson was originally scheduled to appear as a presenter for a tribute to Luther Vandross, performed by Celine Dion, Richard Marx and Alicia Keys, and was chosen due to previously collaborating with Vandross on the number-one hit "The Best Things in Life Are Free". According to People Magazine, Jackson "had been slated to speak before the accolade but was being pressured to bow out gracefully—or face being uninvited", before later being completely barred from attending. However, Timberlake was still allowed to attend and perform at the event. Both Jackson and Timberlake were initially disinvited and later re-invited under the condition that they agree to apologize on air. The majority of the artists at the ceremony were also asked to comment on Jackson's incident. Jackson's long-time producer Jimmy Jam during a pre-Grammy party "Last time I talked to her about it, she was up in the air about it", Jam told CNN. "She was literally sitting on the fence about whether she was going to come or not, or whether she was going to sit back and watch it on TV.".
Jackson had also been cast to play Lena Horne in a movie about the singer and activist's life, which was to be produced by ABC, but was forced to resign following the performance incident. A statue of Mickey Mouse wearing Jackson's iconic "Rhythm Nation" outfit was mantled at Walt Disney World theme park the previous year to honor Jackson's legacy, but was removed following Jackson's controversial performance. A spokesman for Disney said, "Considering all the controversy [the performance] drew, we talked it over for a couple of days and decided it would be best to replace hers with a new one."
The blacklisting affected promotion of Janet Jackson's first album released since the incident Damita Jo—her eighth studio album. A majority of the reviews for the album, including those by AllMusic, the BBC, Entertainment Weekly, The Guardian and The New York Times focused on the negative backlash suffered by Jackson as a result of the incident but gave favorable reviews to the album itself. Despite the blacklisting, Damita Jo was a success and certified Platinum, selling over three million copies worldwide and also receiving a Grammy nomination. Singles from the album like "Just a Little While" and "All Nite (Don't Stop)" reached #1 on the Hot Dance Club Songs chart. Although receiving positive reception, the incident also affected the performance of following albums 20 Y.O. and Discipline due to the blacklist. However, 20 Y.O. managed to sell over million copies worldwide, was certified Platinum in the US and received a Grammy nomination. Additionally, "Feedback" reached the top 20 pop hit on the Billboard Hot , selling one million copies worldwide. Subsequent releases "Make Me" peaked atop the Hot Dance Club Songs and top 20 internationally; "Nothing" reached #1 on the digital pop and music video charts, also considered for an Oscar nomination.
In her first interview since the incident, Jackson appeared on CBS's Late Show with David Letterman on March 29, , which increased the show's ratings over 20%. In April , Jackson poked fun at herself in an appearance on Saturday Night Live, first while playing Condoleezza Rice in a skit, nervously answering a question by exposing her right breast (which was pixelated by NBC), and again by viewing a mock home video from her childhood in which her bathing suit top came off in a wading pool, calling it a "swimsuit malfunction". An NBC spokesman said Jackson was wearing a bra beneath her blouse during the skit. During a performance on ABC's Good Morning America, the network promoted Jackson's appearance as her "first live performance since the Super Bowl", hinting at the chance of shock value. In , during an interview on The Oprah Winfrey Show, Jackson upheld her claim that the Super Bowl scandal was an accident.
Impact on Timberlake
People Magazine stated Timberlake was referred to as "the Teflon man" at the 46th Annual Grammy Awards because the incident did not affect him as it did Jackson. Media coverage overwhelmingly minimized Timberlake's role, largely mentioning him only in passing, if at all. In a interview with MTV, Timberlake said that compared to the huge backlash Jackson suffered, he himself received only about 10% of the blame; and he accused American society of being both "harsher on women" and "unfairly harsh on ethnic people". Prior to plans for the Super Bowl performance, Jackson and Timberlake had discussed potentially recording a duet for Jackson's Damita Jo album, as well as a rumored collaboration for a Quincy Jones album, though neither came to fruition. In November , Timberlake performed a cover of Jackson's "Let's Wait Awhile" on The 20/20 Experience World Tour before transitioning into one of his song which was regarded as a sign of affection or apology to Jackson.
Media commentators stated Jackson was treated too harshly by the media and public, while Timberlake's career was not affected much by the incident. Shannon L. Holland in Women's Studies in Communication argued that the media reaction after the incident focused disproportionately on Jackson, "represent[ing] her as a contemporary Jezebel in that her racial and gendered Otherness was often juxtaposed with the 'normalcy' of Timberlake's white masculinity. That is, she emerged in a public discourse as the primary (if not sole) instigator of the lewd act, a scheming seductress who manipulated Timberlake for her own economic gain." Rob Sheffield of Rolling Stone stated "Justin isn't exactly Mr. Loyalty—he totally left Janet Jackson to take the heat after the Super Bowl.'" E! Online also commented "Timberlake wasted no time placing the bulk of the blame for the incident on Jackson. And, of course, the woman takes the blame even though the man stripped her. Pathetically typical." A reporter for VH1 said "JT still gets a side eye for leaving her out to dry."
One observer claimed "Despite her 'wardrobe malfunction'—for which we think Justin Timberlake wasn't punished nearly as severely for—Janet put on a pretty amazing show."The New York Times noted "[a]fter her right breast upstaged the Super Bowl, she was criticized by the first lady, vilified by media executives and abandoned by her co-conspirator, Justin Timberlake; less excitable commentators suggested she was merely a shrewd publicity-stunt woman with a new album to promote." Jackson's parents, Joe and Katherine Jackson, also expressed concern that Timberlake did not stand by Janet following the incident, commenting, "What I didn't like is there wasn't one person on that stage, there were two people. After a while, there was only Janet Jackson. That's all there was. Janet Jackson", adding "Janet don't [sic] pull that thing open herself. He did it. We were surprised that they didn't say anything to Justin about it."
Timberlake would eventually be given a "second chance", being invited back to the Super Bowl halftime show when he was named headlining act for the Super Bowl LII halftime show in February  During his performance, Timberlake again sang a portion of "Rock Your Body", but stopped right before reaching the "Gonna have you naked by the end of this song" lyric, saying "hold up! Stop!" and smiling, as a reference to the incident.
On February 12, , after the documentary Framing Britney Spears aired, Timberlake publicly apologized to both Britney Spears and Janet Jackson in an Instagram post, pledging to "take accountability" and that "I can do better and I will do better."
Pop singer Katy Perry parodied Jackson's Super Bowl incident in the music video for her single "Last Friday Night (T.G.I.F.)" during a scene where Perry's breast is accidentally exposed at a school event. Jackson's incident is also recreated in Eminem's "Ass Like That" music video. The controversy and sexual nature surrounding Miley Cyrus' performance of "We Can't Stop" and "Blurred Lines"/"Give It 2 U" with guest artist Robin Thicke at the MTV Video Music Awards was likened to Jackson's performance with Timberlake at the Super Bowl event.
The term "wardrobe malfunction" began to be used by various entertainers when describing accidental public exposures or nudity, or revealing outfits. The term's frequent usage also led to numerous entertainment outlets compiling various celebrity "wardrobe malfunctions", with Jackson included in the lists as the most infamous example and originator of the term.
On the April 10, episode of Saturday Night Live, Janet Jackson as Condoleezza Rice is told by Darrell Hammond as Vice PresidentDick Cheney that she should show her breast at hearings. It appears that she did, with her breast pixellated, but NBC said Jackson was wearing a bra.
Justin Timberlake referenced the incident when ripping off part of Kristen Wiig's outfit during an appearance on Saturday Night Live in  The Family Guy episode "PTV" was written as a parody of the FCC's strict measures and regulations following Jackson's Super Bowl halftime show performance controversy. A scene from the episode involving the fictional portrayal of an extreme reaction to actor David Hyde Pierce having a wardrobe malfunction at the Emmy Awards was also a recreation and reference to the incident. Jackson's performance is again referenced in a brief scene where Peter Griffin is dressed in Jackson's Super Bowl outfit and has his breast exposed by Justin Timberlake during the musical number "The Freaking FCC". The song itself was introduced when Lois called the FCC in response to a PTV show called "The Side Boob Hour." The episode received Primetime Emmy Award and Annie Award nominations for its subject matter. Jackson's performance also inspired the South Park episode "Good Times with Weapons". In the episode, the show'screators draw attention to the media and public's unnecessary reaction to Jackson's brief exposure while disregarding or accepting extreme acts of violence during a scene where the public is outraged when Eric Cartman is seen naked and having a "wardrobe malfunction" on stage, while character Butters Stotch is ignored although he is bleeding and severely injured. Several game shows have also mentioned Jackson's performance.
Several presenters at award shows have referenced the incident, including Anna Nicole Smith at the first annual MTV Australia Video Music Awards, Dave Chappelle at the MTV Video Music Awards, and singer Alanis Morissette at the Juno Awards, commenting, "It's disturbing and curious to me to see what came of that. We're all sexual beings, and if we don't let it out organically, we repress ourselves. If we repress anger, it turns to depression. If we repress our sexuality, it turns to pornography and rape. To think that the country was in an uproar because of a nipple." Comedian Russell Brand referenced the incident when hosting the MTV Video Music Awards, saying "I can almost guarantee a Janet Jackson-style Super Bowl nip slip." American rapper MC Zappa made reference to the controversy in his song "It's All A Game" from the album of the same name, saying "problems keep poppin' up like a titty at the Super Bowl/They say God never give you more than you could hold".
The performance incident made "Janet Jackson" the most searched term, event and image in Internet history. Jackson was later listed in the edition of Guinness World Records as "Most Searched in Internet History" and the "Most Searched for News Item". It also broke the record for "most searched event over one day". 'Janet Jackson' also became the most searched term and person for and also of the following year. It also set a record for being the most watched, recorded and replayed moment on TiVo. A company representative stated "The audience measurement guys have never seen anything like it. The audience reaction charts looked like an electrocardiogram." Monte Burke of Forbes magazine reported, "[t]he fleeting moment enticed an estimated 35, new [TiVo] subscribers to sign up." Janet's Super Bowl halftime incident also coined the phrase "wardrobe malfunction", which was later officially added to the Webster's English Dictionary in  In the immediate aftermath of the incident, Entertainment Weekly stated "Radio stations rushed to add Jackson's new single, "Just a Little While" to playlists on Monday following the incident  And USA Today reports that jewelry stores and piercing studios are seeing increased customer interest in silver sunburst-shaped nipple shields."
YouTube co-founder Jawed Karim revealed that his frustration at not being able to easily find a video clip of the incident provided the inspiration for the creation of YouTube, and later of Vevo. The launch of Facebook commenced three days following the incident, in a potential attempt to capitalize on its publicity through social networking.
Rolling Stone stated Jackson's Super Bowl performance "is far and away the most famous moment in the history of the Super Bowl halftime show".PopCrush called the performance "one of the most shocking moments in pop culture" as well as a "totally unexpected and unforgettable moment".Gawker ranked the performance among the most recent of the "10 Shows that Advanced Sex on Television", commenting the set "had all the elements of a huge story" and "within seconds the world searched furtively for pictures", concluding "it remains so ubiquitous, it's impossible to look at a starburst nipple shield without thinking "Janet Jackson"".E! Online ranked it among the top ten most shocking celebrity moments of the prior two decades. A study of television's most impactful moments of the last 50 years conducted by Sony Electronics and the Nielsen Television Research Company ranked Jackson's Super Bowl performance at # The incident was the only Super Bowl event on the list and the highest music and entertainment event aside from the death of Whitney Houston.TV Guide Network ranked it at #2 in a special listing the "25 Biggest TV Blunders".Complex stated "It's the Citizen Kane of televised nip-slips—so unexpected, and on such a large stage, that nothing else will ever come close. If Beyoncé were to whip out both breasts and put on a puppet show with them when she performs this year in New Orleans, it would rate as just the second most shocking Super Boob display. Janet's strangely ornamented right nipple is a living legend, and so is Justin Timberlake's terrified reaction." Music channel Fuse listed it as the most controversial Super Bowl halftime show, saying the "revealing performance remains (and will forever remain) the craziest thing to ever happen at a halftime show. Almost immediately after the incident, the FCC received a flood of complaints from parents who just wanted their children to enjoy a nice, wholesome three hours of grown men inflicting damaging and long-lasting pain on each other for sport. Halftime shows would never be the same." Patrick Gipson of Bleacher Report ranked it as #1 in its list of the most "Jaw Dropping Moments of the Last Decade", stating Janet "changed the landscape of live television forever". Gipson explained "It prompted a million mothers to cover their childrens' eyes, fathers and sons to jump out of their seats in shock and numerous sanctions by the Federal Communications Commission, including a US$, fine against CBS. Talk about a halftime show that will be hard to top." The incident was also declared "the most memorable Super Bowl halftime show in history", as well as "the most controversial", adding "you can't talk about this halftime show, or any subsequent halftime show from here to eternity, without mentioning the wardrobe malfunction".
New York City-based production studio Left/Right is currently developing a documentary on the incident with The New York Times, with FX and sister service Hulu stated to be carrying it on linear television and streaming respectively, coming off the entities' collaboration on Framing Britney Spears.
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Goldilocks: the Middle Way
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Oncoplastic techniques to remove all redundant (excess) tissue and create a smooth contour go a long way to producing results patients can live with. But even with a dedicated and highly skilled oncoplastic surgeon, and/or plastic surgeon using traditional techniques, patients can be left with significant concavity (looking scooped out).
In a Goldilocks procedure, instead of removing the redundant tissue, the surgeon instead rearranges it over the mastectomy site to rebuild either a flat chest wall contour with minimal or no concavity or a small recognizable breast mound.
In the story of Goldilocks and the three bears, the first porridge she tries is too hot, the second too cold, and the third just right.
A Goldilocks mastectomy is the middle ground between traditional breast reconstruction that requires implants and/or autologous flaps and traditional non-reconstructive mastectomy. Its just right for some patients!
Minimizing Concavity After Mastectomy or Explant
Many (not all) patients are unpleasantly surprised when they wake up from their mastectomy surgery without conventional reconstruction to find that their chest wall is actually concave, or scooped out, rather than smooth and flat. Concavity is mostly due to the patients anatomy, i.e., the rib cage and the overlying musculature, and can be more pronounced after explant.
There is no way (short of medical imaging, which involves risk and expense and would not be covered by insurance) for the surgeon to anticipate the degree of concavity for a specific patient. To set expectations, many surgeons will mention that concavity is a possibility. But it can be hard for patients to visualize what this means for their own bodies, and waking up concave can be jarring.
There are two ways to surgically address concavity for a patient who does not want to reconstruct breast mounds. Local tissue rearrangement is done at the time of the initial surgery, and fat grafting is done later. Since most patients going flat want to be done in one surgery, it is usually preferable to use local tissue arrangement. There are many types of relatively simple tissue rearrangement techniques.
Goldilocks takes local tissue rearrangement one step further. With this technique, the breast tissue is removed carefully to preserve blood flow to the maximum amount of surrounding, healthy excess fat and skin. The healthy tissues are then rearranged over the mastectomy site. When only a small amount of tissue is available, the result may be simply a flat chest with minimal or no concavity (below, right). With a large amount of tissue, the surgeon may be able to create a small breast mound if the patient so desires (below, left).
Why Choose Goldilocks?
All reconstruction options are equally valid choices. This section explains why some women may choose to go flat or have Goldilocks instead of conventional breast reconstruction or conventional non-reconstructive mastectomy. Choice is a beautiful thing!
Conventional breast reconstruction involves additional risk beyond simple mastectomy, and can impair function. Patients who reject traditional breast reconstruction are often motivated by wanting to preserve form and function for the rest of their bodies.
Rejection of autologous flap reconstruction, for example, avoids a second surgical wound that may compromise recovery time and/or function especially in the case of muscle tissue transfer, i.e., LD and TRAM flaps. Rejection of submuscular implant reconstruction avoids damage to the pectoral muscle that can impair function (this muscle is partially detached from the ribs to accommodate the device).
Other motivations for rejecting traditional breast reconstruction include reduced time spent under anesthesia, faster recovery time, reduced risk of surgery-related complications, and simply not prioritizing the creation of an artificial breast mound.
But patients who reject conventional breast reconstruction still care about how they look, and a smooth flat contour is both more aesthetically pleasing AND more comfortable than a concave or discontinuous/lumpy contour. Goldilocks can be an excellent option to maximize cosmesis for those patients who prioritize cosmesis and find a somewhat longer anesthesia burden to be acceptable.
Who is a Candidate for Goldilocks?
Any patient who is a candidate for a skin-sparing mastectomy from an oncologic perspective is technically a candidate for Goldilocks, whether they are interested in producing a recognizable breast mound or just having a smooth chest wall contour. Patients who are explanting their implant reconstruction may be candidates for similar tissue rearrangement to counteract potential concavity.
Patients with very large or pendulous breasts have significant redundant fatty tissue and skin for the surgeon to work with are more likely to be able to achieve a recognizable breast mound.
Risks & Benefits
Risks. While there is no long-term data on the oncologic safety of Goldilocks, surgeons offering this procedure say that the oncologic and surgical risks are similar to that of a skin-sparing mastectomy. The reason is that Goldilocks is a skin-sparing mastectomy performed in such a manner that the remaining redundant tissues can be rearranged in order to produce either a recognizable breast mound or a smooth chest wall contour to minimize concavity caused by the removal of the glandular tissue. Preserving the tissues and doing so in a way that preserves the blood supply, as well as rearranging the tissues, all take extra time in the operating room. Extra time under anesthesia carries with it proportional increased risk.
Benefits. Goldilocks typically results in improved chest wall aesthetics (minimal or no concavity) and avoids implants and distant donor sites.
We do not have data on patient-reported outcomes or quality of life after Goldilocks mastectomy versus other types of breast or chest wall reconstruction. However, Goldilocks does typically improve concavity, which is one of the main cosmesis complaints that patients going flat have particularly when they were not anticipating seeing a concave contour.
Anecdotally, most of the patients in the flat community online report that they are very happy with their choice to have a Goldilocks procedure. Theres a relatively new Facebook group for Goldilocks information sharing and support here.
Who Performs Goldilocks Surgery?
A Goldilocks mastectomy is an oncologic surgery, and the surgeon performing your mastectomy must be a cancer surgeon that is, a surgical oncologist, general surgeon, or breast surgeon. The cancer surgeon may also do the tissue arrangement themselves, or they may enlist the services of a plastic surgeon. Sometimes the plastic surgeon helps plan the incisions, and then the cancer surgeon performs all the surgery themselves.
Note: most surgeons do not offer this procedure. It can be technically complex and requires specific training as well as additional operating room time. However, its important to note that many surgeons, particularly breast specialists and those with oncoplastic training, may offer similar or related procedures (see next section).
V-Y Plasty & De-Epithelialization
There are many variations on local tissue rearrangement that can be used to produce an aesthetic flat closure. In addition to Goldilocks, the popular v-y plasty is used to minimize dog ears under the arms and results in a y-shaped incision. To address concavity for patients who have minimal redundant fatty tissue, a procedure called de-epithelializationcan be performed on the excess skin and it can then be folded under to create padding before closing the primary mastectomy flap. This is often done after explant, because the mastectomy flap is typically quite thin and was spared during the initial mastectomy, so its available to be used for rearrangement.
Autologous fat grafting is a procedure where subcutaneous fat is liposuctioned from a donor site on your body, treated, and then injected under your skin in an area the surgeon wants to bulk up. Radiation fibrosis adhered to the chest wall, divots, and areas of concavity are some examples where fat grafting may be used to optimize the cosmesis of a flat closure. Fat grafting is not performed at the initial mastectomy, but at a later date, and sometimes can require multiple procedures. If you decide to pursue fat grafting, its critical to choose a surgeon who has a lot of experience with the procedure in order to maximize your chances of success. (Read More)
Questions to Ask Your Surgeon
Since the end result of a Goldilocks procedure is largely dependent on the amount and quality of tissue the surgeon has to work with, your surgeon may not be able to tell you in advance exactly what your result will look like. The exact location and integrity of the blood supply, the presence of additional disease, and other factors can affect your ultimate aesthetic outcome. Be clear with your surgeon about your goals:
- Contour Preference. Do you want a flat chest, or do you want a breast mound? This is an important conversation to have because if you prefer to have a flat chest, it must be clear that that is your goal in the event that additional tissue is available to produce a breast mound. Ask your surgeon to explain to you what you should expect in terms of your final contour.
- Nipples. Are you interested in preserving any part of the nipple area or complex? Depending on your medical situation, you may be eligible for a nipple-sparing procedure or an areola sparing procedure.
- Are you interested in surgical nipple reconstruction? If so, will the surgeon perform that reconstruction at the time of the mastectomy or will you need a separate surgery? What about restorative tattooing?
- Incision Pattern. Will they be using a wise pattern incision (resulting in an anchor pattern scar, with or without nipple grafts)? If not, why not? Do you have a preference for your scar pattern?
Read More:Preparing for Your Surgery
Read More: Going Flat After Mastectomy
Read More: Going Flat at Explant
Frequently Asked Questions (FAQ)
The few online resources that showcase Goldilocks frame it exclusively as a type of breast mound reconstruction. You wont find many (if any) pictures or Goldilocks or resulting in aesthetic flat closure at present, besides our Gallery. Thats because until very recently, very little attention was paid to the aesthetics of patients going flat. But thats changing now, and we hope to see surgeons showcasing their own flat closure pictures soon!
Any patient who is a candidate for a skin-sparing mastectomy from an oncologic perspective is technically a candidate for Goldilocks. Ask your surgeon about your specific medical situation.
Because it is in between traditional breast reconstruction and going flat. In the story of Goldilocks and the three bears, the first porridge she tries is too hot, the second too cold, and the third just right. In planetary science, a Goldilocks planet is just the right distance from the star (sun) it orbits to allow for life to evolve not too close, not too far. A Goldilocks mastectomy is the middle ground between traditional breast reconstruction that requires implants and/or autologous flaps and traditional non-reconstructive mastectomy. Its just right for some patients!
It can be, but it doesnt have to be. The Goldilocks procedure can be used to produce a recognizable breast mound, but it can be also used to produce an aesthetic flat closure. The outcome depends on the patients goals, and on how much extra tissue is available for the surgeon to work with. With very little tissue, the result may be less or even no concavity. With a lot of tissue, the result may be a recognizable breast mound.
Note: Goldilocks is currently advertised exclusively as a type of breast reconstruction because it was first performed on patients with very large and pendulous breasts with the goal of producing a recognizable breast mound. Historically, the idea of employing plastic surgery techniques for a patient going flat was not widely considered or accepted. Thankfully, that is changing now.
The surgeons who offer this procedure typically say that the risks are similar to skin or nipple-sparing mastectomy. But theres no long-term data on the oncologic safety of Goldilocks specifically.
It can be, if the patient is otherwise a candidate for nipple-sparing but it doesnt have to be. The procedure can be performed with or without saving the nipple and/or areola. Note: Most patients who are not candidates for nipple-sparing, are eligible for nipple reconstruction. That can involve surgical reconstruction of the nipple and/or restorative tattooing and is typically covered by insurance.
It varies, but its on the order of hours. Compare that with an autologous flap reconstruction which can take six hours or more.
Both procedures are types of local tissue rearrangement, but they serve different functions and result in different scar patterns. A v-y plasty is done to minimize dog ears under the arms but does not address concavity where the breast tissue was removed and results in a y-shaped scar with the fork under the arm(s). In a Goldilocks procedure, tissue is rearranged over the mastectomy site in order to bulk it up (to minimize concavity, or to produce a breast mound). Goldilocks typically uses a wise pattern incision which results in an anchor-shaped scar with or without a repositioned nipple/areola.
In a lumpectomy, the disease (tumor) is removed but the rest of the breast glandular tissue is preserved. In an oncoplastic lumpectomy, this excision is done in such a way to reshape the breast contour and optimize cosmesis, and is often combined with a contralateral breast reduction to achieve symmetry. In a Goldilocks mastectomy, similar tissue arrangement techniques are used, but all of the breast glandular tissue is removed to the greatest extent possible.
In local tissue arrangement, the blood vessels supplying the tissue being moved are largely preserved during the surgery. This requires that the surgeon take meticulous care planning the excision and handling the tissues and is one reason the procedure takes longer than a non-reconstructive mastectomy without tissue rearrangement.
You can visit our Gallery page .
You can search our Flat Friendly Surgeons Directory and check the Goldilocks checkbox to filter for those surgeons offering the procedure. We currently have only a handful of such surgeons on our Directory, and we are hoping that grows over time.
A Goldilocks mastectomy is an oncologic surgery, and the surgeon performing your mastectomy must be a cancer surgeon that is a surgical oncologist, general surgeon, or breast surgeon. The cancer surgeon may also do the tissue arrangement themselves, or they may enlist the services of a plastic surgeon. Sometimes the plastic surgeon helps plan the incisions, and then the cancer surgeon performs all the surgery themselves. Other times the plastic surgeon may be present in the operating room to perform the closure (this is a co-surgery).
Absolutely! You can apply to be listed on the Directory by filling out the short form here. You can find more resources on aesthetic flat closure here.
SWIM is an acronym for Skin-sparing Wise-pattern Inframammary Perforator, which is a synonym for Goldilocks used by some surgeons and describes the main blood vessel preserved in a Goldilocks mastectomy.
SWIM Flap Breast Reconstruction Cassileth Plastic Surgery
Goldilocks Mastectomy The Bedford Breast Center
Goldilocks Mastectomy with Bilateral In Situ Nipple Preservation Via Dermal Pedicle, Richardson, H.,
The Goldilocks Mastectomy, Richardson, H.,
Outcomes Analysis of Goldilocks Mastectomy and Breast Reconstruction: The Mayo Clinic Experience, Oliver, J.,
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This site contains copyrighted material. Not Putting on a Shirt’s educational materials and resources on this site are freely available for “fair use” (Title 17 U.S.C. Section ) in accordance with our mission to advocate for optimal outcomes for those who choose to go flat after mastectomy. The copyrighted material on this site is distributed for educational purposes without profit – all donations to Not Putting on a Shirt directly fund our advocacy work. If you wish to use copyrighted material from this site for purposes that go beyond “fair use”, you must first obtain explicit permission from the copyright owner. Please direct requests or questions to [email protected]
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As the temperature starts to rise, and the "sun's out, guns out" practitioners emerge, we urge you to take a closer look at the T-shirt's more sturdy, well-dressed cousin: the polo. When done right, it's the most casual way of looking put together. When done wrong, however, it can make you look ridiculous. Here's what to look for when you're out there in the wild shopping and, eventually, wearing.
Watch Your Ass
Traditionally, the common piqué (a weave of cotton that adds texture) polo shirt is longer in the back and shorter in the front to help it stay tucked in when you bend over. But when worn untucked, as we recommend, they're menswear mullets (though we doubt a mulleted man wears polos). You'll want to take this into consideration when looking for one. If it covers more than half of your back pockets, it's too long.
Don't Go Deep
Once you find a length that you like, be sure that you take a quick look at the buttons. Many polos have pretty deep Vs, which when left open and floppy is TMI for everyone. But every brand is different. Lacoste polos, for example, have two buttons with a placket (the piece of fabric the buttons sit on) that stretches down to the nipple line; it demands to be buttoned. On the other hand (chest?), J.Crew's offering doesn't go quite so low (about midway down the chest) and can be worn completely unbuttoned.
Mind the Sleeves
Another thing you'll want to look for is the ribbing on the sleeves. This varies across all brands and comes down to personal preference. Some have no tension at the end of the sleeve, some hug you like a rubber band. If you've been up in the gym all winter polishing your guns, you might want sleeves that hug (not constrict) your arms to show that off. Just be sure you don't get anything that's too tight. Nobody looks good when their muscles are fighting their clothes. They should complement each other.
Polos Are Team Players
If you're not going with piqué and are instead opting for a more old-school knit polo (something with a ’50s vibe that feels like a super-light sweater), you may have to contend with a banded bottom. This can get a little tricky with the rest of your clothing. A waistband will cinch everything in, which can make you look slimmer. The only thing is, you have to make sure your pants aren't at odds with it. That means nothing low-rise—waistbands usually hit just around where your belt would sit, and you don't want any glimpses of midriff. Go for a pair of pants that complements the vintage vibe of the polo. Rule of thumb: If they're JFK-appropriate, they're knit-polo-appropriate. And avoid leather belts—you sweat more around them, and that can easily seep through the leather and stain your precious polo.
Wear It Right
Now, when you've actually found your dream polo, there are some tricks to rocking it properly that'll make you look completely at ease. First, do not wear them with an undershirt. They're meant to be casual. They're meant to project the notion that you may or may not be on a boat in the next few hours. An undershirt will bulk you up (in a bad way), and the sleeves might peek out from underneath—not a good look. Go commando above the waist! And if you're concerned about sweat stains under your pits, you should be. So apply that deodorant and make sure it's aluminum-free—otherwise your beautiful white tennis shirt will get yellow in as little as one wear. Protect the polo!
Oh—and never, ever pop the collar.