Keyhole Top Surgery

Keyhole top surgery is a form of single-incision mastectomy in which breast tissue is removed through a small incision placed along the lower border of the areola. Unlike other chest surgery techniques, this approach does not involve removal of excess skin or repositioning of the nipple–areola complex. As a result, it is only suitable for a highly selected group of patients with a very small volume of breast tissue and excellent skin elasticity. When performed in appropriate candidates, keyhole surgery can achieve effective tissue removal with minimal external scarring and preservation of nipple sensation.

Careful pre-operative assessment is therefore essential. Keyhole top surgery is considered one of the most limited but least invasive options within the spectrum of single-incision chest surgery techniques.

Advantages of Keyhole Top Surgery

The primary advantage of keyhole top surgery is the minimal extent of scarring, with the incision confined to the areolar border and often less noticeable once healed. Because the nipple–areola complex remains attached, there is a high likelihood of preserving nipple sensation. Recovery is generally faster than with more extensive techniques, as there is less disruption to skin, nerves, and surrounding tissues. In carefully selected patients, this approach can result in a smooth chest contour without the need for additional incisions or skin excision.

Limitations and Considerations

Keyhole top surgery is only appropriate for a small proportion of patients. If performed in individuals with insufficient skin elasticity or a larger volume of breast tissue, the outcome may include residual tissue or excess skin, which can affect chest contour. This technique does not allow for resizing or repositioning of the nipples, meaning nipple position remains unchanged from its pre-operative location. For these reasons, strict patient selection and specialist surgical assessment are critical to achieving acceptable outcomes.

Please note: For all images on this page, blue is used for body outline, light pink is used to show contouring, and dark pink is used for scar lines.

Periareolar Top Surgery (Donut Technique)

Periareolar top surgery, also known as the donut technique, is a form of single-incision chest surgery that allows for removal of breast tissue with limited skin excision. The procedure involves two circular incisions around the areola, enabling removal of a ring of excess skin and breast tissue. This technique is suited to patients with a small volume of breast tissue and good skin elasticity, where some skin tightening is required but a full double-incision mastectomy is not indicated.

Periareolar surgery occupies a middle ground between keyhole surgery, which removes no skin, and double-incision techniques, which involve more extensive skin removal and nipple grafting. Careful patient selection is essential, as outcomes depend on chest size, skin quality, and the ability of the remaining skin to heal smoothly around the areola following closure.

Advantages of Periareolar Top Surgery

A key advantage of periareolar top surgery is the ability to achieve skin tightening while keeping scars confined to the border of the areola. In many patients, the scar blends with the natural pigment transition, making it less conspicuous than longer chest incisions. This technique also allows for areola resizing, which is not possible with keyhole surgery. There is a higher likelihood of regaining nipple sensation. For appropriately selected patients, periareolar surgery can provide an effective balance between contour improvement and limited scarring.

Limitations and Considerations

Periareolar top surgery is not suitable for patients with significant breast volume or poor skin elasticity. One potential limitation is pleating or puckering along the incision line, which occurs because a larger circle of skin is closed around a smaller areola. While this often improves over time, it may persist in some cases and is a key factor when assessing suitability for this technique. Although the areola can be resized, the nipple itself cannot be reduced or repositioned. Additionally, areolar stretching or scar widening may occur post-operatively due to tension on the closure, and revision options can be limited if significant stretching develops.