, 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.
Copyright © 2012 SciRes. MPS
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
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Breast Surgery with Application of Doughnut Mastopexy Lumpectomy Technique
Copyright © 2012 SciRes. MPS
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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