Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique

doi:10.4236/mps.2012.24022

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Modern Plastic Surgery, 2012, 2, 91-96

http://dx.doi.org/10.4236/mps.2012.24022 Published Online October 2012 (http://www.SciRP.org/journal/mps) 91

Breast Surgery with Application of Doughnut Mastopexy

Lumpectomy Technique

Kyoichi Matsuzaki1,2

1Department of Plastic and Reconstructive Surgery, Kawasaki Municipal Tama Hospital, Kawasaki, Japan; 2Department of Plastic

and Reconstructive Surgery, St. Marianna University School of Medicine, Kawasaki, Japan.

Email: [email protected]

Received June 5th, 2012; revised July 6th, 2012; accepted August 3rd, 2012

ABSTRACT

Purpose: Doughnut mastopexy lumpectomy (DML) is a breast resection technique in which a tissue segment is re-

moved and the breast reshaped through a doughnut-shaped de-epithelialized periareolar area. In this study, we at-

tempted to determine whether the DML technique could be useful for other types of breast su rgery, in addition to br east

cancer lumpectomy. Methods: This study examined a total of 4 patients who underwent the DML technique and were

followed up for at least 1 year postoperatively. One patient underwent phyllodes tumor resection, 1 patient underwent

removal of a siliconoma, and 2 patients underwent breast reduction mammaplasty. Results: This method enabled

en-bloc removal of a large tissue mass or large for eign body that could not be r emoved through a short periar eolar inci-

sion. The surgical method of this study enabled the extent of de-epithelialization to be changed according to the size and

location of the mass to be excised; good cosmetic results were also obtained. In addition, the surgical method enabled

the facile excision of tumors and foreign materials. Conclusions: The DML technique is a useful surgical method that is

applicable to other breast surgeries, in addition to breast cancer surgery.

Keywords: Breast; Doughnut Mastopexy; Lumpectomy

1. Introduction

Scar revision after breast surgery is in greater demand

from patients than ever before. Many female patients find

it difficult to accept surgery which results in prominent

scarring, and this scarring can lead to patient dissatisfac-

tion with the surgical results [1]. Asians in particular are

more susceptible to hypertrophic scarring and keloid

formation, compared with Caucasians [2,3], and the se-

lection of surgical approach is especially important in

this population.

The periareolar incision was first reported by Dufour-

mentel in 1928. This incision results in less prominent

scarring and is used not only for breast augmentation and

gynecomastia procedures, but also for benign tumor ex-

cision [4]. As a periareolar incision is small, it is difficult

to remove a large tissue mass en bloc. Even if such a

mass can be removed, there will likely be redund ant skin

after resection, resulting in an aesthetically poor appear-

ance. Treatment using a periareolar incision is also diffi-

cult in cases with the affected sites distant from the are-

ola.

Doughnut masto pexy lumpectomy (D ML) is a surgical

method which begins with a periareolar incision, but then

proceeds to de-epithelialize the periareolar skin in a

doughnut shape. An incision is made along a portion of

the outer border of the doughnut, and lumpectomy is

performed. Remnant tissue is reshaped after lu mpectomy

to adjust the shape of the breast. Any redundant skin re-

maining after lumpectomy is adjusted by plication of the

outer and inner circumferences of the doughnut-shaped

de-epithelialized area [5]. DML is considered a useful

alternative to standard lumpectomy for 2 reasons. First, a

periareolar scar is more discreet than a scar resulting

from direct incision over the affected area, and has an

overall more pleasing aesthetic result. Second, glandular

volume is rearranged with DML to create a pleasing

breast contour, and breast skin is reshaped as well [5].

This study examined whether the DML technique could

be useful in breast surgeries other than lumpectomies

performed for breast cancer.

2. Patients

The subjects were 4 surgical patients who were followed

up for at least 1 year postoperatively. One patient was a

50-year-old female who underwent phyllodes tumor re-

section. Another was a 75-year-old female who under-

went removal of silicone, injected 30 years ago for breast

augmentation. The other 2 patients were 25- and 39-year-

Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique

old females who underwent breast reduction mamma-

plasty. All surgeries took place between October 2000

and August 2009.

3. Surgical Techniques

To address the issue of excessive skin after resection, the

size of the doughnut-shaped epidermal incision was de-

signed preoperatively with the patient in a standing posi-

tion.

3.1. Cases with Resection near the Areola

If the unaffected breast was normal, the cranial aspect of

the doughnut’s outer circumference was established so

that the distance between the sternal notch and the new

nipple on the affected breast would be the same as the

distance between the notch and the unaffected nipple. If

the affected site was near the areola, the doughnut was

made in concentric circles and the skin of the breast was

stretched from the areola. The skin incision was shallow

at the outer and inner circumferences of the doughnut.

Subsequently, the epidermis was shaved, using a round-

ededge scalpel, and removed. The subdermal vascular

plexus was preserved to the greatest extent possible. The

length of the dermal incision at the outer edge of the

doughnut was kept as short as possible, while still allow-

ing for excision of the mass.

Case Presentation

A 50-year-old female presented with a phyllodes tumor

in the right breast (Figure 1(a)). The distance from the

sternal notch to the nipple was 1.5 cm longer in the af-

fected breast, compared with the unaffected breast. Thus,

a circle was drawn 1.5 cm from the areolar margin on the

affected breast (Figure 1(b)), and the skin between this

circle and the areolar margin was de-epithelialized in a

doughnut shape (Figure 1(c)). A semicircular incision

was made in the caudal aspect of the outer circumference

of the doughnut. The tumor was excised en bloc with

normal breast tissue (Figure 1(d)). The remnant breast

tissue was reshaped to prevent a concave deformity, and

the wound was closed with purse-string suturing of the

areolar margin (Figure 1(e)).

3.2. Cases with Resection Distant from the

Areola

Case Presentation

A 75-year-old female requested the removal of silicone

that had been injected into the right breast for augmenta-

tion 30 years prior. The patient did not request silicone

removal on the left side due to the presence of a pace-

maker. The siliconoma was located mainly cranial to the

areola (Figure 2(a)). Thus, periareolar de-epitheliali-

zation was performed in a more extensive area at the

cranial aspect of the doughnut, and a semicircular inci-

sion was made in the cranial aspect of the doughnut’s

outer circumference. Since the siliconoma invaded the

pectoralis major muscle, the surrounding tissue was also

excised en bloc to include the muscle and prevent spill-

age of the gel-like silicone. The size of the excised

specimen was 12 × 12 × 9 cm (Figure 2(b)).

(a) (b)

(e) (f)

Figure 1. (a) A 50-year-old female with a phyllodes tumor in

the right breast; (b) Preoperative marking. The black circle

was drawn 1.5 cm from the areolar margin. The red circle

was the area in contact with the tumor; (c) The skin was

de-epithelialized in a doughnut shape; (d) The tumor was

excised en bloc with normal breast tissue; (e) The immedi-

ate postoperative result; (f) One year postoperatively.

Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique 93

(a)

(b)

Figure 2. (a) A 75-year-old female with silicone injected for

breast augmentation 30 years prior; (b) The siliconoma wi th

surrounding tissue in the right breast was excised en bloc,

including the pectoralis major muscle; (c) Two weeks post-

operatively. A gathering was observed at the areolar mar-

gin. The patient did not request silicone removal on the left

side due to the presence of a pacemaker; (d) Two and a half

years postoperatively. The periareolar scar was not con-

spicuous. In this patient, tension on the skin was not strong

at the time of suturing. Thus, there was no enlargement of

the areola.

3.3. Breast Reduction Mammaplasty

In 1 case of bilateral breast reduction mammaplasty, the

distance from the sternal no tch to the new location of the

areola was determined to be 20 cm. In a second case,

breast reduction was performed after post-mastectomy

reconstruction of the contralateral breast, which had been

affected by breast cancer. In both cases, the desired,

symmetric position of the areola was established. The

shape of the doughnut was determined based on the

amount of breast resection to be performed in its cranial

and caudal aspects. During surgery, a dermal incision

was made around the entire outer circumference of the

doughnut. The breast tissue was resected in the cranial

and caudal aspects, according to the Góes method [1].

After the target tissue was excised, the remnant breast

tissue was dissected to the minimal extent necessary for

reshaping, and suturing was performed. A purse-string

closure was used for the outer and inner circumferences

of the doug hnut. In the 2 cases of breast reduction mam-

maplasty, areola enlargement was anticipated. A dermal

incision was made around the entire outer circumference

of the doughnut, increasing potential skin tension on the

incision compared with the 2 cases without this circum-

ferential incision. Therefore, a diametrical transareolar U

suture using a straight needle was performed at 2 sites

where there could be minimum tension on the skin before

performing the purse-string closure [6].

Case Presentation

A 39-year-old female had undergone mastectomy for left

breast cancer. The patient requested reconstruction of the

left breast and reduction surgery of the right breast (Fig-

ure 3(a)). Left breast reconstruction was performed us-

ing a superdrainaged transverse rectus abdominis myocu-

taneous flap. Six months later, the plan was to create a

nipple and areola in the reconstru cted breast, 31 cm from

the sternal notch. The extent of de-epithelialization for

the right breast was marked at a position 3 cm cranial to

the areolar margin. The plan was to resect more breast

tissue at the cranial aspect to enhance the effecttiveness

of the mastopexy, and so markings were made 2 cm me-

dial, lateral, and caudal to the areolar margin and an

ovoid was drawn connecting the four points (Figure

3(b)). The skin was de-epithelialized in the doughnut

area (Figure 3(c)). An incision was made along the

doughnut’s outer circumference, and the breast resection

was performed (Figure 3(d)). Enlargement of the areolar

margin was expected, due to strong skin tension at the

suture site. To mitigate this problem, a diametrical trans-

areolar U suture was performed with a straight needle to

bring together the dermis of the doughnut’s outer cir-

cumference at opposite points of the circle, incorporating

the subareolar dermis. A second diametrical transareolar

Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique

(a) (b) (c) (d)

(e) (f) (g)

Figure 3. (a) A 39-year-old female after mastectomy for left breast cancer. The patient requested reconstruction of the left

breast and reduction of the right breast; (b) Six months after left breast reconstruction. Preoperative marking for breast

reduction mammaplasty; (c) The skin was de-epithelizalized in the doughnut area. The cranial and caudal aspects of the

planned extent of breast resection were marked; (d) An incision was made along the doughnut’s outer circumference, and

breast tissue resection was performed; (e) A diametrical transareolar U suture was performed with a straight needle; (f) The

immediate postoperative result. A hypertrophic scar of the left reconstructed breast was resected, and suturing was per-

formed; (g) Two and a half years postoperatively. During this period, a skate flap was used to create a nipple in the left re-

constructed breast, and me dic al tattooing was performed for the nipp le and areola .

U suture was placed along a line perpendicular to the

first (Figure 3(e)).

4. Results

The surgical technique in this study enabled en-bloc re-

moval of a large tissue mass or foreign material through

the doughnut’s outer circumference incision. Such large

specimens cannot be removed en bloc using a small

periareolar incision.

Soon after surgery in all patients, there was significant

gathering in the sutured area due to the difference be-

tween the doughnut’s inner and outer circumferences.

Six months to 1 year postoperatively, the gathering was

no longer conspicuous (Figures 2(c) and (d)).

In long-term follow-up, the areola enlarged in all pa-

tients except the patient who had undergone siliconoma

removal (Figure 2(d)). No patients had any scarring

other than along the areolar margin; these scars were not

conspicuous. The patients were satisfied with the shape

of their breasts, and there were no sensory disturbances

in the nipple or areola (Figures 1(f), 2(d) and 3(g)).

5. Discussion

A recent report compared the excision of fibroadenomas

of 3 cm or smaller using a periareolar incision or an inci-

sion over the tumor. This report described 76 patients

who underwent excision through a periareolar incision

and 82 patients who had an incision directly over the

tumor [4]. At an early stage, the disadvantages in the

periareolar incision group were a longer operating time

by 2 minutes, more blood loss by 10 mL, and more se-

vere skin flap bruising. The periareolar incision group

had more patients with a disturbance of nipple sensation;

this disturbance was seen more frequently when a lateral

incision was used. Nipples and their surrounding areolas

are innervated by the lateral and anterior cutaneous

branches of the third, fourth, and fifth intercostal nerves.

Therefore, special precautions are required when making

a lateral incision [4,7]. Mammary duct damage can be

avoided by careful dissection of the area between the

Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique 95

subcutaneous fat and breast tissu e, in the approach to the

tumor. Even with all the aforementioned disadvantages,

periareolar incisions have the advantage of a better cos-

metic result after removal of fibroadenomas of 3 cm or

smaller [4].

Since the length of a periareolar incision is limited, it

is not suitable for a large mass requiring excision. DML

has been reported to yield good cosmetic results after

tumor excision and excision of normal breast tissue, just

as it does in breast cancer surgery. In this study, tumors

and foreign materials were excised using the DML tech-

nique. If the mass was near the areo la, the doughnut inci-

sions were made in concentric circles. If the mass to be

excised was far from the areola, concentric circles would

stretch and deform the skin on the affected side; in such

cases, the doughnut area on the affected side was

enlarged, and the resected amount of skin was adjusted.

With the DML technique, the outer circumferential inci-

sion can be made much longer, facilitating tumor resec-

tion. The advantage of this method is that the incision

line can be changed according to the size and location of

the matter to be excised.

Unlike su rgery fo r benign tumor s, in su rgery for br east

cancer a large amount of normal breast tissue attached to

the tumor is excised in order to prevent recurrence. This

leaves excess skin behind. Even with benign tumors, the

skin can become stretched due to tumor enlargement;

similarly, the skin can become stretch ed if a foreign body

is present for a long duration. Because of this excess skin

retained after resection, a satisfactory cosmetic result

cannot be obtained by excision of a subcutaneous tumor

or foreign material alone. The DML technique solves that

problem with the adjustable nature of the doughnut skin

resection.

Breast reduction mammaplasty and mastopexy using

periareolar techniques are surgical methods based on the

same concept as the DML technique used in this study.

Typical surgical methods are the periareolar Benelli

mastopexy [8] and the Góes periareolar technique [1]. In

the periareolar Benelli mastopexy, a dermal incision is

made along the doughnut’s outer circumference, where

the epidermis has been resected, from the 2 o’clock to the

10 o’clock position. The skin is dissected from this area

down to the inframammary fold. The central and caudal

breast tissues are usually the areas resected, then the sag-

ging breast is elevated cranially and fixed to the chest

wall. In the Góes periareolar technique, a dermal incision

is made around the entire outer circumference of the

doughnut, and subsequently the skin of the breast is dis-

sected and elevated from the breast tissue. The cranial

and caudal breast tissues are resected and the remnant

tissue is reshaped. The remnant doughnut-shaped dermis

in the periareolar region is dissected from the breast tis-

sue to create a dermal flap; this flap is then stretched over

the surrounding tissue to cover the breast mound as ex-

tensively as possible. The caudal aspect of the dermal

flap is fixed to the pectoralis major muscle and the cra-

nial aspect is fixed to the connective ligaments to en-

hance the effectiveness of the mastopexy. The aforemen-

tioned steps are the original method described by Góes

[1], however, the use of a dermal flap alone results in

laxity due to insufficient fixation of the breast mound.

Thus, Góes subsequently reported a modified method in

which mesh was used to cover the entire breast mound,

over the derma l flap, for fix ation [9]. The method used in

our present report differs from the original method of

Góes in the following ways. In our series, the 2 cases of

breast reduction mammaplasty did not have sufficiently

severe breast enlargement or sagging to require a mesh or

dermal flap. In addition, it was unnecessary to dissect a

doughnut-shaped dermal flap from the breast tissue and

thus interrupt the blood flow to the nipple and areola.

In our study, doughnut mastopexy was performed in 4

breast surgeries that did not involve lumpectomy. Good

results were obtained in all 4 cases. Further studies will

be conducted in cases with different disease entities and

in greater numbers of cases to continue to examine the

usefulness of this method.

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