How do permanent sutures around the areola affect the results of a donut lift?

Question

Do permanent sutures around areola cause flattened breasts because of areola reduction during a donut mastopexy or it is just the donut mastopexy that causes the flattening?Is it necessary for a donut mastopexy to use permanent sutures?Or the permanent sutures are used for the areola reduction in order to prevent scar widening ?Does a donut mastopexy without permanent sutures around areola also lead to breast flattening?

Daniel Barrett, MD · Answer

Dear Beautiful800656,
my preferred lift is a lollipop lift when a periareolar won't do (ie greater than 2cm lift required). The lollipop technique was created by a Canadian plastic surgeon named Elizabeth Hall-Findley and treats the breast as a three dimensional structure instead of two dimensions (anchor - lift). Most importantly it does not require the horizontal component scars that the anchor-lift requires and breasts appear much more natural, lifted, and less boxy. Lastly, the lift lasts longer because the lollipop doesn't rely on the skin to hold the breast up, its actually breast tissue thats being brought together to support the breast and hence improves longevity. 
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

Semih Yildiz, MD, FEPOBRAS · Answer

The permanent suture itself is usually not the main reason a donut mastopexy can look flat. The flattening tendency comes from the periareolar/donut design: skin is tightened in a circle around the areola, and that circular tightening can compress or spread the central breast mound, especially if too much lift or too much areola reduction is attempted through that incision alone.

A permanent or long-lasting purse-string suture is commonly used to help control areola diameter and reduce the risk of the areola stretching or the scar widening over time. It is not always mandatory; some surgeons use permanent suture, some use long-lasting absorbable suture, and some use different methods depending on tissue quality, implant size, and how much reduction is needed. The tradeoffs of permanent suture can include palpability, knot irritation, suture exposure, or contour issues, although many patients do well.

A donut mastopexy without a permanent suture can still flatten or widen if the design is asked to do too much. The key issue is choosing the right lift pattern for your anatomy. Your surgeon can explain why they recommend a permanent suture or a different lift pattern after examining your skin quality, areola size, nipple position, and implant/tissue support. Donut lifts are best for mild nipple elevation and modest areola reduction; if more lift, reshaping, or lower-pole control is needed, a vertical or anchor lift often gives a more predictable breast shape, even though it involves more scarring.

Gary M. Horndeski, MD · Answer

Donut lifts are notorious for flatten out the breasts because it is skin only procedure. Also, permanent sutures are used because if not then the scar will widen. An alterative is to use long lasting sutures such as PDS which will last 6 months. Unfortunately, you have not provided photographs or told us your desires. There are other lift techniques that do not require vertical scars. One of which is the mini lift. Using a circumareola incision, your breast tissue is reshaped, elevated higher on the chest wall and more medial to increase your cleavage.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

James Knoetgen, III, MD · Answer

These are excellent and nuanced questions. Let’s break them down to help clarify how donut mastopexy (periareolar lift) and the use of permanent sutures affect breast shape and surgical outcomes, including the risk of breast flattening and scar widening.
What is a Donut Mastopexy?
A donut mastopexy (also called a Benelli or periareolar lift) involves:
•	Removing a circular ring of skin around the areola
•	Tightening the surrounding tissue to lift the breast
•	Often includes areola reduction
It’s typically used for mild to moderate breast ptosis (sagging).
What Are Permanent Sutures Around the Areola Used For?
Permanent (non-absorbable) sutures are often placed in a purse-string (round-block) configuration under the skin around the areola. Their purposes:
•	Prevent areola widening (a common long-term issue)
•	Support the new areola shape over time
•	Provide tension distribution, reducing the risk of wide or thickened scars
They are not always necessary, but many plastic surgeons use them proactively in donut lifts to maintain the surgical result.
Does the Donut Mastopexy Cause Breast Flattening?
Yes — flattening is a known limitation of the donut lift technique, especially when:
•	Significant lift is attempted (beyond what the technique is best for)
•	There is little breast volume or poor skin elasticity
The flattened appearance comes from the skin tightening primarily in the central, periareolar area, which can compress breast projection if not done carefully or without sufficient support.
Do Permanent Sutures Cause Flattening?
No — permanent sutures themselves do not cause flattening.
In fact, they are used to:
•	Maintain areola shape and size
•	Help reduce scar tension
•	Preserve projection better by maintaining structural integrity
The flattening effect is mainly due to the donut lift technique and not the sutures. However:
•	If the lift is over-aggressive, even with permanent sutures, flattening may still occur.
Can a Donut Mastopexy Be Done Without Permanent Sutures?
Yes — but there are trade-offs:
•	Higher risk of areola spreading (widening) over time
•	More tension on the scar, which may cause thickening or irregularity
•	Less support for breast shape, possibly leading to shape distortion
Some surgeons may use long-lasting absorbable sutures instead, but they are not as durable long term.
Does a Donut Mastopexy Without Permanent Sutures Still Lead to Flattening?
Yes — the risk of flattening is inherent to the technique, not the sutures.
•	Without permanent sutures, the risk of flattening and areola stretching increases, especially with poor tissue support.
•	But even with permanent sutures, if too much lift is attempted or there’s not enough volume, flattening can still occur.

Connie Hiers, MD, FACS · Answer

The doughnut lift is a specific lift that some try to use when more lifting is really needed. In those who need the vertical lift but only have the doughnut lift, flattening may occur. With the doughnut lift, if too much stress is applied to the closure trying to minimize the scar, the scars can widen. Permanent sutures are used deeply to minimize that tension of the final closure and help prevent widening of the scars. There are risks, however, to permanent sutures in that area. Don't try to have a doughnut lift when the vertical lift is needed.  Your surgeon can tell you what kind of lift is best.

Mats Hagstrom, MD (license on probation) · Answer

This response was made using Word recognition. My apologies for any potential grammatical errors.
The flattening of the area complex is part of the procedure and has nothing to do with the type of sutures used. Permanent sutures are used in an attempt to keep the areola and scar from widening due to tension on the tissues after surgery.
Relying on permanent suture to hold an excessive amount of tissue tension is a risky proposition.
There is substantial subjective component to how much of a lift should be done without further, extending the scar and skin excision.
Patients went to avoid longer scars, but this sometimes comes at the cost of some significant drawbacks to that doughnut, mastopexy a.k.a. Benelli breast lift.
What could and should be done during surgery is highly dependent on Tuesday the right provider.
This is generally in the end, the most important variable.
Experienced plastic surgeons have a better sense of what can and will work out in regards to long-term outcomes.
The Benelli lift should only be used for minor breast, lifting surgery.
When consulting with plastic surgeons, ask them to open up their portfolio and show you lots of examples of previous patients whose breasts look similar to your own and ask for lots of long-term follow up pictures
Applying the Benelli lift inappropriately set, patients up for potential long-term problems and using this procedure when a more aggressive approaches indicated set up patients for worse potential long-term outcome if revision surgery is needed.
Personally, I’m not a big fan of the Benelli breast lift.
I use it but only for minor procedures.
It may seem like attempting option because of the shorter scar, but this definitely comes at a price in regards to Aesthetic outcome, especially shape and widening of this car long-term. The procedure has been described initially, using substantial Teflon suture aimed at holding tissues against significant tissue tension. relying exclusively on the strength of permanent suture can be a significant problem if the suture gets contaminated or the technique is not applied correctly.
There is no yes or no answer to questions regarding this procedure.
As mentioned earlier, the decisions are highly subjective in regards to when this procedure should be done and how it should be performed.
When in doubt, slow down and schedule more consultations.
As is almost always the case with plastic surgery provider selection is in the end, the greatest, and most important variable
Best,
Mats Hagstrom MD

How do permanent sutures around the areola affect the results of a donut lift?

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