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	Double Incision	Subcutaneous Mastectomy
	Double Incision	Keyhole	Peri-Areolar
Other names	Bilateral mastectomy, mastopexy	Sometimes called “peri-areolar” interchangeably	Sometimes called “keyhole” interchangeably
Technique	Skin is opened in two incisions, along top of chest and along bottom of pecs, from center of chest out toward armpits. Almost all breast tissue is removed by scalpel. Nipples are removed, resized / recreated and repositioned in a graft higher up on the chest. Minor liposuction sometimes used to contour fat at borders of surgical area / under arms. Incision is closed together at bottom of pecs line. Some surgeons will maintain original nipple/areola on stalk (“dermal pedicle”) instead of grafting, to preserve nerve sensation.	Skin is opened along bottom half of areola border. Breast tissue and surrounding tissue is removed via liposuction and/or scalpel, depending on the doctor's preferences, through this small hole. Nipples may or may not be resized, but cannot be repositioned. Areola is not reduced; surrounding chest skin is not reduced.	Skin is opened along entire circumference of areola. Skin is separated away from underlying breast tissue. Breast tissue is removed by mostly by scalpel, though some liposuction can be used in conjuction. Nipple nerve and blood supply is maintained on a stalk (“dermal pedicle”). Excess skin is trimmed from around circumference of areola in “doughnut” shape. Minor liposuction sometimes used to contour fat at borders of surgical area. Areola is resized, then skin reattached to areola at its border. Nipples can be reduced in revision if desired. Areola may be repositioned to a limited extent, depending on original chest size (i.e. amount of chest skin available).
Candidates	Larger chests (C, D+, sometimes B). Looser skin, more droop or “ptosis”; ‘deflated’ chest.	Smallest chests (small /very small A has best result in this method). Tightest skin, most elastic skin, least body fat. No sagging of chest (“ptosis”). Works best with smallest amounts of least-dense, least-fibrous breast tissue: glandular tissue must pass through liposuction needle.	A, B, possibly small C in rare cases. Works well with moderate body fat, moderate to very elastic skin. (May show slightly better result when done before starting T.) Some sagging / droop of original chest OK; better result with least stretching / thinning of chest skin. Fibrosity of breast tissue not an issue as tissue is not removed through liposuction needle.
Scars	Larger, more prominent scars; usually in a “W” shape, or two “C”s, across lower pectoral area. Can take several years to fade.	Nearly invisible scarring at incision line along bottom junction of areola and skin. Sometimes also adhesion scars / puckers under chest skin.	Nearly invisible scarring at incision line around the border of the areola and skin.
Sensation	Less sensation in nipples and chest. Better sensation possible if original nip/areolas retained with “pedicled” procedure, instead of reconstructed with graft.	Sometimes sensation in nipples and chest.	Good chance of sensation, normal erectile ability in nipples and chest.
Revisions	Revisions may be necessary. Usually to remove small amounts of breast tissue left near the armpits, or to repair dog-ears or small puckers in scar line.	Revisions may be necessary. Usually to remove chest skin and/or areolar tissue that has not shrunk close enough to the chest. Also to repair adhesion scars, or contour underskin fat around surgical area. Nipples may be resized.	Revisions may be necessary. Usually to additionally contour underskin fat around surgical area; or reduce broadened scars or small pleats in scars. Nipples may be resized.
Risks	Loss of nipple graft, including loss of all or part of areola, nipple. Permanent numbness. Large, dark hypertrophic (“spreading”) scarring. Poor placement / shape of scars by surgeon. Poor placement / sizing of nipple. Irregular appearance of reconstructed nipple; irregular areolar shape. Adhesion scars at scar line if underlying muscle surface is nicked. Puckering at scar. Dog-ears under armpits.	Significant risk to nipple(s), including loss of all or part of areola, nipple, from liposuction trauma to blood and nerve supply. Risk of “fat necrosis” (an under-skin infection) from liposuction trauma. Permanent numbness or nerve pain. “Adhesion” scars under skin (lines where skin surface puckers as scar binds onto chest muscle), from damage to underlying muscle surface by liposuction needle. Insufficient retraction of remaining skin. Insufficient retraction / sagging of areolar skin.	Loss of nipple(s), including loss of all or part of areola, nipple. Permanent numbness or nerve pain. Broadening or “spreading” scars. Off-round areolar shape. Adhesion scars at scar line if underlying muscle surface is nicked. Insufficient retraction of remaining skin. Incomplete flatness of chest. Puckering or pleating at scar.
Overall	Flatter chest initially / during healing process. Nipples are generally smaller, and in a higher position on chest. Very good possible outcome for larger-chested individuals. Healed, well-placed / well contoured scar hides well under developed pectoral muscle. However, scars are more prominent; will be very visible on individuals without developed chest muscles, at least initially. Scar may spread over time and/or take several years to lighten. Grafting brings with it greater possibility of nipple damage, loss or loss of sensation. Grafted / reconstructed nipples frequently recover only “protective” or touch sensation but not erotic sensation.	Less prominent scarring, frequently invisible. Possibility of good nipple sensation. Good possible outcomes for very small-chested individuals. However, more significant risk of loss of sensation / death of nipples, areolas, due to damage to blood supply, tissues and nerves from liposuction needle, if used. Risk of infection, “fat necrosis” from liposuction, if used. More postoperative pain; more risk of ongoing nerve pain. For all but smallest “small A” sized patients, significant risk of insufficient “shrinkage” of chest skin, leaving lumpy, deflated-looking or puckered surface, as no extra skin around areola was removed. Risk of adhesion scars under upper chest skin. Areolas remain original size and at original position on chest.	Less prominent scarring, frequently invisible. Less risk of nipple loss. Possibility of normal sensation in nipples and skin. Less invasive surgery due to lack of significant liposuction damage to tissues; faster healing, less postoperative pain compared to keyhole. Good possible outcomes for A, B sized individuals. However, nipples may remain large and/or in a lower position on chest, compared to double-incision surgery. Procedure done poorly, or on too-large a chest, can leave loose skin or pleating in skin at skin/areola closure. Procedure as done by some doctors (Reardon) may retain more breast tissue than in double incision initially and possibly permanently.