SUBCUTANEOUS MASTECTOMY "KEYHOLE" VS BILATERAL MASTECTOMY "DOUBLE INCISION" A question that is often posed by patients is "Am I a candidate for the 'keyhole' procedure? The procedure has appeal because it results in a minimum amount of skin scarring, that scarring occurring only at the inferior margin of the areola. What determines whether this procedure is the better option for the patient concerns the size of the breasts and the amount of skin overlying the breast, as manifested by the degree of sagging of the breasts. Those patients who exhibit very small breasts, perhaps cup size A or small B, with very little or no ptosis (sagging) are better candidates for the subcutaenous mastectomy (keyhole). They are less likely to require a revision later to achieve an acceptable result. There exists a group of patients with relatively small breasts but appreciable sagging due to excess skin that will not be able to achieve a good result without the likelihood of later revision being necessary. In my experience those patients with cup size average B or greater do not get good initial results with this technique. It is important to consider what can result if the keyhole procedure is performed for the larger or ptotic breast. The results of this operation depend upon the skin's natural ability to contract after the underlying breast is removed. The skin is always in excess once the underlying volume of breast is gone. This ability of the skin to contract depends upon the amount of skin present, the quality of the tissue, the age of the patient, and genetics. When the skin does not contract sufficiently, or evenly, dimples or folds may result, and the location of these folds may appear anywhere on the breast skin. Also, the nipple areola structures may be located too low and/or not symmetrically. The factors which cause these postoperative deformities are not readily controllable at surgery, or with postoperative management. Long term binding may help the tissues contract by enabling them to adhere to the chest wall and minimizing the pull of gravity, but that effect is limited. Revision may require excision of the excess skin that resulted in the folding or dimpling, and this will result in a scar in the area in which that deformity occurred, not always in an optimum location. Rearranging the position of the areola and nipple can be quite problematic with significant scarring. In situations where there is significant residual excess skin and malposition of the areola, the option for revision may be the bilateral mastectomy with nipple areolar repositioning by grafting, which was the "double incision" operation that could have been considered initially. These are important considerations. Certainly in the properly selected patients, the keyhole operation is a very good option, and good results can be anticipated. Proper patient selection by the surgeon will improve outcomes with this operation. Patients want a good result with a minimum of scarring, if at all possible. Scarring is a necessary outcome of surgery, and it should be minimized if possible. Just as important, if not more so, is the goal of achieving the best appearing male chest and contour, with good proportion of structures and good symmetry, done with a minimum number of surgical interventions. Though the bilateral mastectomy has more cutaneous (skin) scarring than the subcutaneous mastectomy, in a significant number of patients, a better result can be achieved with less risk of the need for revision. Most important, ask your surgeon to explain these options and give you a realistic expectation for the procedure he or she will perform should you proceed.