Donut mastectomy
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donut mastectomy periareolar technique indications outcomes
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"periareolar mastectomy" OR "donut mastectomy" nipple sparing
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https://pmc.ncbi.nlm.nih.gov/articles/PMC8376345
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"nipple sparing mastectomy" periareolar incision
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PMID: 38857011
Donut Mastectomy (Periareolar / Circumareolar Mastectomy)
The term "donut mastectomy" refers to a breast tissue removal technique using a circular (periareolar/circumareolar) incision placed at the border of the areola, producing a donut-shaped pattern of skin excision or deepithelialization. It is used in several distinct clinical contexts.
Anatomy of the Technique
A concentric pair of circles is marked around the areola:
- The inner circle runs along the areola border
- The outer circle defines the skin to be removed
- The ring of skin between them is excised or deepithelialized, creating the "donut" shape
- A purse-string suture closes the outer circle down to the areola diameter, hiding the scar at the areola-skin junction
Clinical Applications
1. Gynecomastia (Males)
This is the most classically described use. According to Sabiston Textbook of Surgery:
"A nipple-sparing mastectomy can be performed to remove the enlarged breast. A donut of deepithelialized skin around the nipple is then enfolded to remove the excess skin, as one would do for a Benelli reduction mammoplasty."
- A subcutaneous mastectomy removes the hypertrophied breast tissue
- The donut technique simultaneously addresses any skin excess without visible scars beyond the areola margin
2. Chest Masculinization (Transgender / Non-binary Surgery)
Also called periareolar top surgery, this is one of the most common applications today. It is indicated using the Fischer Grading Scale for patients with:
- Smaller chest (A-B cup, Fischer Grade I-II)
- Minimal or no skin laxity
- Nipple position above the inframammary fold
- Good skin elasticity
The nipple-areola complex remains on its native pedicle (preserving sensation and blood supply), unlike the double-incision technique where the nipple is transplanted as a free graft.
3. Skin-Sparing / Nipple-Sparing Mastectomy for Breast Cancer or Prophylaxis
Periareolar incisions are used in skin-sparing mastectomy (SSM) when tumor location allows access via the areola. A 2024 paper by Zarei & Carlson reviewed 54 periareolar SSMs with immediate implant-based reconstruction, finding:
- Suitable for small-to-moderate breasts with mild ptosis
- Overall wound complication rate: 24.1% (mainly mastectomy skin flap necrosis at 18.5%)
- Direct-to-implant reconstruction had higher necrosis rates (33.3%) vs. tissue expanders (11.1%)
- Two-stage tissue expander reconstruction is preferred to reduce mastectomy skin flap necrosis (MSFN)
4. Oncoplastic Breast-Conserving Surgery (Round Block / Benelli Technique)
The Round Block Technique (RBT) applies the donut incision for lumpectomy/wide local excision, allowing:
- Wide tumor access through concentric periareolar incisions
- Glandular reshaping after excision
- Excellent cosmetic outcome with a hidden scar
- Best suited for centrally located or periareolar tumors in small-to-moderate breasts
Advantages
| Feature | Detail |
|---|---|
| Scar concealment | Scar hidden at the natural areola-skin color transition |
| Nipple sensation | Preserved (nipple remains on its pedicle) |
| Short operative time | Relatively simple access |
| Simultaneous skin tailoring | Excess skin removed without additional incisions |
Disadvantages and Complications
| Issue | Comment |
|---|---|
| Areolar spreading | Stretching of the areola postoperatively is common; plan for a smaller areola |
| Hypertrophic scar | Periareolar scar may widen or thicken |
| Ptosis recurrence | Especially in larger/heavier breasts |
| Skin flap necrosis | ~18% in SSM with implants (Zarei & Carlson, 2024) |
| Limited access | Not suitable for large-volume resections or significant ptosis |
| Dog-ear / puckering | May occur at the purse-string closure site |
Patient Selection
The periareolar/donut approach works best when:
- Breast volume is small to moderate
- Skin laxity is minimal (nipple above the inframammary fold)
- Tumor (if oncologic) is centrally located or periareolar
- Simultaneous modest skin reduction is needed (as in gynecomastia)
It is not suitable for large, ptotic breasts where more extensive skin excision is required (these need a vertical or inverted-T pattern mastopexy/mastectomy).
Sources:
- Sabiston Textbook of Surgery, p. 1386 (gynecomastia section)
- Zarei M & Carlson GW, Ann Plast Surg 2024 - periareolar SSM with implant reconstruction (PMID 38857011)
- Periareolar approach review: PMC8376345 - 5028 procedures over multiple indications
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