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When it comes to Top Surgery, most patients come in for a consultation hoping I will tell them a Keyhole Mastectomy is what I can offer them. The incisions are small (especially in comparison to a Double Mastectomy), the procedure avoids needing a free
nipple graft, and there is a high probability of maintaining nipple sensation post-surgery. Realistically though, only about 5% of the patients I see are good candidates for a Keyhole. Furthermore, I’ve become more stringent with whom I deem a good candidate for this procedure. Why the shift? To be quite honest, I’ve learned from my own experiences that those who aren’t absolutely great candidates for a Keyhole will likely need revisions. And, even with revisions, I’ve found myself less than satisfied with the outcomes.
UNDERSTANDING THE OPTIONS
In order to understand just who is an optimal candidate for a Keyhole Mastectomy, it’s worth reviewing the two most commonly performed procedures for Top Surgery. A Double Mastectomy is the primary procedure we utilize to achieve masculinization of the chest. During this procedure, excess skin and breast tissue are removed from the chest, and the nipple areolar complexes are removed and replaced as full-thickness skin grafts. This procedure leaves large scars on either side of the chest that hug the lower and lateral borders of the Pectoralis Major muscle. In contrast, a Keyhole Mastectomy is performed through a tiny incision along the areolar/skin margin through which the excess breast tissue is removed. No skin is generally removed during a Keyhole, and the nipple areolar complex remains attached to the underlying tissue.
UNDERSTANDING THE LIMITATIONS:
So why be so selective with a Keyhole Mastectomy? Well, because the procedure itself has many limitations. For starters, a Keyhole Mastectomy does not remove excess skin and most patients who come to see me either have loose breast skin to begin with or will have loose skin once we remove the underlying breast tissue. Loose skin is, in itself, problematic since it never retracts and tightens with any certainty or reliability. The second, more overlooked limitation to a Keyhole Mastectomy is its inability to move or resize the areola. To a minimal extent, when the breast tissue is removed behind the areola it will shrink and slightly elevate its position. However, this change is only minimal and will not give us the masculine qualities to the nipple areolar complex we are usually seeking. What are those masculine qualities you ask? Well, we want the areolas around 2cm in diameter and placed in a more lateral position on the chest wall.
WHY REVISIONS ARE PROBLEMATIC:
The two main revisions I see with a Keyhole Mastectomy pertain to the two biggest limitations described above-- excess skin and a large, malpositioned areola. When excess skin is present, we try to tighten the skin around the areola. Essentially, this means we remove a donut of skin from around the areola and then close the two edges of skin in a circle. This is problematic for a couple of reasons. This can lead to bunching of the skin, areolar widening over time, and distortion of the areola. Similarly, to move the areola more lateral or to decrease the areolar diameter, we also remove a donut of skin from around the preexisting areola and thus have the same potential problems as described above.
My perfect Keyhole candidate has good skin elasticity (better chance of tightening), minimal skin excess, only a small amount of glandular breast tissue, and has an areolar diameter no greater than 3cm. In my practice, it's important that both good and bad candidates for Keyhole Mastectomies understand the limitations. This helps to set realistic patient expectations for those who will undergo the procedure, and helps manage the disappointment patients may feel should they not be a good candidate for the procedure. At the end of the day, it’s about producing a good outcome. Performing the correct procedure on the correct patient is the best way to ensure this, even if it means more scars than the patient envisioned.
For more information on Keyhole Top Surgery, visit www.drmeganmd.com. Are there topics you would like covered? Leave your suggestion in the comments. To schedule your consultation, call 206.860.5582.
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