What Are the Advantages/disadvantages to a Dual Plane Technique Vs. Completely Under the Muscle for Breast Augmentation?

Doctor Answers (14)

What Are the Advantages/disadvantages to a Dual Plane Technique Vs. Completely Under the Muscle for Breast Augmentation?

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Almost all women need the dual plane approach because the pec sits up a bit too high in most women. It needs to be released to allow the implant to drop down just a bit. If not, the implants sit just a bit high and the nipple too low. You can see many examples of this on this site. The only time I consistently leave full muscle coverage of the implant is when I am doing a lift as well. Then I can bring the breast tissue up to the implant!


Phoenix Plastic Surgeon
4.5 out of 5 stars 15 reviews

Dual Plane breast implants

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An implant placed above the muscle is referred to as ‘sub-mammary’ (or ‘sub-glandular’), while an implant placed under the muscle is referred to as ‘sub-pectoral’ (or ‘sub-muscular’).The muscle in question is the pectoralis major.The term ‘sub-pectoral’ or ‘sub-muscular’ is somewhat misleading, as implants placed under the pec major are only partially covered by the muscle.The pec major covers the upper/medial half of the breast area, so a ‘sub-pectoral’ implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position.Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a ‘dual plane’ approach to breast augmentation.

There is also ‘total submuscular’ implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue.This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.

Michael Law, MD
Raleigh-Durham Plastic Surgeon
4.5 out of 5 stars 37 reviews

Dual plane and submuscular

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Your skin quality is the main determinant of location and so the best person to answer this question is your plastic surgeon. In my practice a majority of women get submuscular or dual plane implants and especially in those women who have lost weight. The skin has lost volume and elasticity and as such cannot bear the weight of the implant. In dual plane t implantis partly under te muscle a partly subglandular in the lower pole.

Raj S. Ambay, MD
Tampa Plastic Surgeon
4.0 out of 5 stars 13 reviews

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Dual plane is the procedure of choice.

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Dual plan positioning of a breast implant allows for a natural appearance for an augmentation by allowing the implant to sit in the appropriate position on the chest wall. The pectoralis muscle is used for improved camouflage of an implant in a small breasted woman, to decrease capsular contracture rate, and to improve vascularity of the breast and nipple in cases of augmentation mastopexy. Unfortunately, the pectoralis major muscle does not always line up anatomically with the overlying breast and the resultant inframammary fold. By dividing the inferior attachments of the muscle and placing the implant where the breast is (rather than where the pectoralis is) the augmentation has a much more natural look.

David Bogue, MD
Boca Raton Plastic Surgeon
5.0 out of 5 stars 8 reviews

Dual Plane the procedure of choice...

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as mentioned by my colleagues.  This technique allows for significant inferior releases of muscle and breast tissue so subglandular approaches are becoming less and less desired.  The advantages of having partial muscle coverage are well known and with the amount of release, my patients have very little muscle movement when the chest muscle is contracted.  I doubt anyone really does a total submuscular position anymore. 

Curtis Wong, MD
Redding Plastic Surgeon
4.5 out of 5 stars 16 reviews

Dual Plane Breast Augmentation

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Total submuscular augmentation is essentially obsolete at this point.  The vast majority of plastic surgeons use the dual plane technique for a much nicer result.

Michael Orseck, MD
Greenville Plastic Surgeon
5.0 out of 5 stars 33 reviews

True Total Submuscluar Placement Rare

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Today, the terms "Dual Plane" and "submuscular" are essentially interchangeable in breast augmentation surgery. The bottom of the pectoralis muscle sits above the bottom of the breast. Unless this is released, a breast implant will sit too high and the nipple will typically point downwards. Don't allow these terms to confuse you.

Lawrence Iteld, MD
Chicago Plastic Surgeon
5.0 out of 5 stars 19 reviews

Total Submuscular Cover v. Dual Plane for Breast Implants

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Submuscular augmentation was introduced in the 80's as a method to decrease capsular contracture.  Originally it was thought that complete muscle cover was best.  The muscles used included the pectoralis and the serratus anterior.  Over time it was recognized that this technique pushed the implant too far laterally.  It is not used today.  The dual plane technique is now synonymous with a submuscular breast augmentation.  In this method the implant is under the pectoral muscle until the lower portion of the beast.  The second "plane" of the implant is beneath the breast gland.  The pectoral muscle is released from its attachment to the ribs.

Mary Lee Peters, MD
Seattle Plastic Surgeon
5.0 out of 5 stars 82 reviews

Dual Plane vs Total Muscular Coverage for Breast Implants

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There is lots of confusion about Dual Plane vs Total Muscular coverage, there are benefits to placement of an implant below just the breast and there are benefits of placing the implant below the muscle. I believe that the Dual Plane technique combines the best of both worlds, half under the muscle and half under just the gland. No surgeon places a cosmetic implant completely below the muscle, the implant is not under the muscle laterally and somewhat inferiorly, only Breast Reconstruction implants are sometimes placed completely submuscular. A true Dual Plane technique devides the chest muscle from it's connections to the abdominal muscles allowing the breast to round at the inferior aspect, which most people find very cosmetically appealing, it also can allow for the niple/areola to raise upi just a bit often improving a breast that has a slight amount of sagginess. I utilize a dual plane on the majority of my patients, but there are certainly patients that are not good candidates for this technique. I would advise you to consult with an experienced Board Certified Surgeon to dicuss these techniques and ask your doctor which is the best for you.

Jonathan Weiler, MD
Baton Rouge Plastic Surgeon
4.5 out of 5 stars 15 reviews

What is a “Dual-Plane” Pocket?

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For cosmetic breast augmentation the implant is never placed completely under the muscle. In the past, total muscle coverage was performed routinely during tissue expander & implant reconstruction for breast cancer; the tissue expander was placed behind the pectoralis major and serratus muscles. This method has been replaced by placing the tissue expander behind the pectoralis muscle and using an acellular dermal matrix sling to support the bottom of the expander. It provides a more comfortable and aesthetic result, and expansion is easier and faster.

A breast implant could be placed almost totally submuscular if the inferior origins of the pectoralis muscle were not released. A portion of the implant would still remain uncovered by the muscle and the implant would be positioned too high on the chest wall.

In a “dual-plane” pocket the implant is placed beneath the pectoralis major muscle, but it lies partially behind the muscle and partially behind the breast gland – thus in two different planes. The upper and medial portion of the implant is covered by the pectoralis major muscle, while the lateral and lower portion of the implant is covered only by breast tissue. A dual-plane pocket is the most common position used when a breast implant that is placed beneath the muscle.

The pectoralis major muscle origins arise from the ribs (inferior origins), the sternum (medial origins), and the clavicle (superior insertions); the muscle inserts on the humerus in the upper arm. The anterior surface of the pectoralis major muscle is attached to the posterior surface of the breast tissue.

To create a dual-plane pocket, the inferior origins of the pectoralis major muscle are released from the ribs along the inframammary crease. This muscle release extends from the lateral border of the muscle (near the lateral inframammary crease), continues along the inframammary crease, and then stops at the medial aspect of the inframammary crease leaving the medial muscle origins from the sternum uncut.

The “dual-plane” sub-pectoral dissection is further classified, into three types, based upon the amount of additional muscle release (from the undersurface of the breast gland) that is performed. The ‘dual-plane I’ technique involves no additional pectoralis muscle release, the ‘dual-plane II’ involves some release, and ‘dual-plane III’ involves the most pectoralis muscle release from the undersurface of the breast gland.

In a ‘dual-plane I’ augmentation the lower origins of the pectoralis muscle are released from the ribs along the inframammary crease. No additional dissection is performed between the breast tissue and the pectoralis muscle.

In a ‘dual-plane II’ augmentation the lower origins of the pectoralis muscle are released from the ribs along the inframammary crease. Dissection is then performed behind the breast gland (up to the level of the inferior border of the areola), to separate the attachments to the pectoralis muscle.

In a ‘dual-plane III’ augmentation the lower origins of the pectoralis muscle are released from the ribs along the inframammary crease. Dissection is then performed behind the breast gland (up to the level of the superior border of the areola), to release the attachments to the pectoralis muscle. In a ‘dual-plane III’ augmentation more of the pectoralis muscle is separated from the posterior surface of the breast gland.

The ‘dual-plane I’ pocket allows the least amount of contact and interaction between the breast implant and the posterior surface of the breast gland. The ‘dual-plane I’ technique is used for the more routine breast augmentations and is the most common form of dual-plane dissection. The ‘dual-plane I’ pocket allows for greater muscle coverage of the implant.

The ‘dual-plane II’ and ‘dual-plane III’ techniques alter the dynamics between the breast implant and the overlying tissues by repositioning a portion of the pectoralis major muscle relative to the breast implant --This in turn alters how the implant interacts with the overlying breast.  In other words, the ‘dual-plane II’ and ‘dual-plane III’ techniques allow the inferior border of the pectoralis major muscle to move upward and exposes more of the breast implant to the posterior surface of the breast gland. This allows the breast implant more direct force and interaction with the breast tissue. The ‘dual-plane II’ technique is used for patients that have more mobility of the breast tissue over the top of the pectoralis major muscle. The ‘dual-plane III’ technique is used for patients that have more drooping breasts, constricted lower poles, or tuberous breast deformity.

I hope you find this helpful. I have tried to explain this as best I could without the benefit of anatomic drawings.

Best wishes, Ken Dembny

Kenneth Dembny, II, MD
Milwaukee Plastic Surgeon
5.0 out of 5 stars 17 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.