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.
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
92
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)
(c) (d)
(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)
(c) (d)
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
94
(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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