Is double incision my only option? May I get keyhole then later get revsions to remove excess skin?

Based on your pictures a keyhole can be designed.  I would use your own tissue for the reconstruction if that were possible based on your exam.  I also would use a tool in the operating room called the SPY Elite to evaluate your skin after mastectomy and before I did the reconstruction and then again after it was complete to make sure the skin was still getting adequate blood flow.Three basic forms of breast reconstruction exist. You can
use your own tissue, implants or a combination of the previous two techniques.
Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP flap
or fat grafting. Implants can be done in one stage or two stage. Two stage
reconstructions are started by placing expanders at the time of mastectomy.
Once they expanders are placed they are able to be inflated as determined by
wound healing. The final time consists of combining any of the above
techniques.

It isn't clear what you are asking.  Are you getting a mastectomy (removing the entire breast, typically related to cancer) or are you wanting a reduction (removal of some breast tissue to reduce size), or are you wanting a lift (removal of excess skin to create more perky breasts)?  Also, explain more what you mean by "double incision" versus "keyhole".  Your question cannot be answered clearly if we are not sure exactly what you are asking.

Unfortunately you are not a candidate for a keyhole incision  as you have a lot of excess skin.  Your only option is the double incision or you will not be happy with the results.Good luck,Dr. Luong