Keyhole Top Surgery

Female To Male (FTM) & Female To Nonbinary (FTN) Reconstruction Chest Surgery

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A Keyhole incision is ideal for patients with a small volume of breast tissue present, good skin elasticity and no nipple ptosis, with an areola that is close to the desired size. Unlike the Periareolar approach, the incision lies only along the inferior 180 degrees of periareolar dermis(between the colored areolar skin and the surrounding normal skin), making this approach unique in that it involves the least scarring of any other top surgery approach.

This procedure results in a very flat chest and no extra skin is excised, which is why it is only appropriate for patients with no extra skin and there is no movement of the nipple areola complex on the chest wall. Unlike the Periareolar approach, the nipple areola does not change in size or shape to any significant extent. Essentially, the nipple areola retracts back against the chest wall in its exact location after the underlying breast tissue is removed. In our experience, we have noticed that there is some small amount of natural “areola shrinkage” that does occur after Keyhole top surgery, which is noticeable but not significant enough to shrink an areola that is overly sized.

Nipple Projection

The only aspect of the nipple areola that is customizable with this approach is the extent of nipple projection. If you feel you have an overly projected nipple, it is possible with the Keyhole technique to reduce the projection of the nipple, without reducing the diameter of the areola. This involves an incision around the midsection of the nipple itself.

How the Procedure is Performed

An inferior semicircular incision is made along the inferior 180 degrees of the areola border (at the junction of colored areola skin and normal surrounding skin), and all the breast tissue is removed through this singular incision. Like the Periareolar approach, a uniform chest wall flap is developed and left behind. Once the tissue is removed, the skin incision is closed without any skin excision whatsoever.

Indications for the Keyhole Approach

Small amount of breast tissue
No skin excess
No nipple ptosis
Minimal scarring desired but ok with nipple position that is slightly more central
No need to reduce areola diameter

In the Keyhole approach, maximal chest wall flatness can be achieved through a minimal scar, but there is little to no control over nipple areola complex location and no ability to resize or reshape the areola, though it is possible to shrink the projection of the nipple itself. If you are concerned about the size or shape of your areola, you may be better off with a Periareolar approach.

Downsides to the Keyhole Approach

Nipple Numbness

Similar to the Periareolar approach, even though the nipple areola is kept attached, there is a very high likelihood of having nipple areola numbness after Keyhole top surgery, because so many of the nerve endings present in the tissue underlying the nipple and inferior to the nipple are no longer providing sensation. As with the Double Incision approach, this numbness is likely to resolve with time because nerves will usually regenerate into the nipple over time. However, permanent numbness is a possibility.

No Ability to Control for Areola Size or Nipple Position

The inability to control for areola size may influence you into choosing the Periareolar approach if you feel that your areola diameter is too large or if the areola shape is too circular or otherwise undesirable in shape.

The lack of ability to control for nipple position may influence you into choosing the Double Incision approach if you feel that the aesthetic of the Double Incision is more in line with your surgical goals. We recommend you look in the mirror at where your nipple currently lies and imagine all the breast tissue below disappearing, after which your nipple will retract against your chest wall. If you can visualize where this location will be, think about whether you would be happy with the vertical and horizontal location of your nipple.

Nipple Blood Supply

As with the Periareolar approach, there is some risk of ischemic complications (loss of blood supply), though this is less of a risk without any type of skin excision around the nipple because there will be less tension on the nipple at the time of closure. However, it is still important to avoid nicotine products before and after Keyhole top surgery because nicotine limits the amount of oxygen delivery in the blood that reaches your healing nipple areola.

Summary

Keyhole top surgery is best for patients with no skin excess, a small volume of breast tissue, and an areola diameter that is desirable. If the areola diameter is larger-than-desirable, a Periareolar approach is a good alternative option for patients that otherwise qualify for the Keyhole approach. Patients who are not ideal candidates for the Keyhole or the Periareolar approach due to the size of their chest or the amount of skin excess would be better served with a larger-scar approach such as the Double Incision.

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