Dual Plane Differences? (photos)

Thank you for your excellent question and for doing preoperative research.  Dual plan references placing the upper portion of the breast implant underneath your chest muscle, while the lower half of the implant is covered by your natural breast tissue.  For the majority of patients this is the technique used to obtain natural appearing results, while minimizing any risks of surgery.  The types of dual plane techniques references the amount of chest muscle that is released from its attachments along the ribs and breastbone, as well as to the overlying gland.  The technique used will depend on your specific breast appearance and degree of sagging.  Best to see a board certified plastic surgeon for an in-person examination and evaluation to have the best treatment recommendations.

The technical concerns you are discussing are differences that the surgeon would be considering to treat your particular anatomy.  It is really not something that you would be involved in deciding.  The technique is the same for 1, 2, and 3.  This is just an article that is finely differentiating what is happening when you are operating on a specific breast type.  The surgeon does not start a case and say, "I'm going to perform DP2".  The most sophisticated approach to
breast augmentation is through the armpit with a surgical camera (transaxillary
endoscopic). Using this modern approach the space can be crafted under direct
vision, with virtually no bleeding and no postoperative bruising. Most
importantly, the shape of the breast is meticulously created. The other, older
methods of insertion are technologically less advanced. Both silicone and
saline implants can be placed through the armpit by a surgeon with skill and
experience using this approach. The incision in the crease is the oldest method
of placing the implants and puts a scar directly on the breast.



A round implant would be a better
choice because they move more like breasts. The anatomic implants have a
textured surface which makes them feel very unnatural. In addition, there is no
benefit to anatomical. There is an X-Ray study that shows the implants from the
side at 6 months. Standing, the round and the antomical implants have the same
profile. When you lie down however, the anatomical implants do not change,
which is unnatural. A round implant will change when you lie down, like a natural
breast would.



HP implants, which are a more modern
shape than moderate profile implants, fit most women better. They have a more
appropriate base diameter and can be made to look very natural or very
augmented, depending on where in the range the implants are filled to achieve a
particular volume. High profile implants are the first choice in my opinion. I
rarely find an indication to use moderate or moderate plus implants. The
subtlety in the final outcome is not achieved by which profile implant is used,
it is determined by the skill in the creation of the pocket, the choice of
volume, and where in the range the implant is filled.



There
are many advantages to sub muscular dual plane placement and very many
disadvantages to sub glandular placement. I would see no indication to do
anything but sub muscular dual plane. Subglandular silicone implant
placement is the historical approach to this surgery, and was widely used in
the 1960's. The implant edges are more visible, the risk of rippling is
higher, the implant is in contact with the non-sterile breast tissue so the
risk of infection and capsular contracture is higher. The interface
between the breast tissue and the muscle is blurred so the implant interferes
with mammography more than sub muscular placement. The blood supply
surrounding the implant is worse so the risk of capsular contracture is higher.
The support for the implant is less so there is more long term shape
abnormalities and sagging. The look of a sub glandular implant is much
less appealing than a sub muscular implant. The placement of sub
glandular implants makes any subsequent revision surgeries more complicated and
less successful. There are no advantages to sub glandular implant
placement.



The choice between saline and silicone
is one that requires a complex discussion of all of the advantages and
disadvantages of both implants. The issues to be considered are safety,
density, mobility, rippling, rupture rate, consequences of rupture, detection
of rupture, need for follow-up care, cost of follow-up, appearance, feel,
sensation of heaviness, radio-density, mammograms, and costs, among other
things. There are advantages and disadvantages of both products. The decision
will ultimately be up to you based on what is appropriate for your particular
situation. Beautiful results can be obtained with either implant.



The best way to determine the size that
fits your personal perception of the perfect breast is to try on sizers. This
way you can see how they fit on you, how they add to your current volume, and
whether they fit your frame. Although the surgeon can guide you, only you will
be able to tell what is the right size. Try on sizers. Measuring a diameter and
then telling the patient what volume they can have (in high, moderate or
moderate plus implants) in my mind is backwards. The patients should be allowed
to choose the volume. Then the surgeon carefully considers the base diameter,
projection, profile, manufacturer, and fill material that will achieve the
patients goals of size as well as qualitative look (natural, intermediate, or
bold upper pole fullness or projection), all the while taking into consideration
the patient's anatomic features that will affect the outcome. The experience of
the surgeon and the degree to which they explain the options to you is of
utmost importance. The subtlety in the final outcome is not achieved by which
profile implant is used, it is determined by the skill in the creation of the
pocket, the choice of implant. Don't let the doctor tell you what would look
good on you. They cannot tell what you perceive to be the best size. There is
no maximum. That is up to you.

Thank you for your question. 90% of the augmentations that I perform place the implants in a subpectoral dual plane. When i need to keep the implant a little lower on the chest to account for lower sitting nipples, then I release more of muscle, similar to a type 3. I hope this helps. The image you posted is for surgeons to reference when discussing breast augmentation. Best of luck with your surgery.- Dr. Bryson Richards (Las Vegas Plastic Surgeon)

In reality, there is NOT a clear cut difference between one stage and the next, but of course the experienced surgeon will have to decide during the operation to WHAT DEGREE the muscle is released from the underside of the breast, to let it slide upwards.  For breasts like yours where the implants needs to sit lower on the breast to account for nipples being low, then the surgeon will have to release MORE muscle.  Surgeons may argue over whether a particular operation was a I or a II, but the bottom line is the result on table that has to be good before the patient leaves the operating room.

Dual plane refers to positioning an implant in a sub muscular pocket and how much release of the gland from the muscle is performed.  The actual numbers really are theoretical amount of release from the gland.  In my opinion, just by releasing the muscle from its insertion along the inferomedial aspect will case the muscle to only cover the upper 1/3-1/2 implant.(2,3)

Only difference in all these photos is the extent of implant that is sub glandular and the extent that is covered by muscle.  Subglandular makes an excellent option in many cases.

Board Certified Plastic Surgeons experienced in multiple techniques are best to decide what works to create the most symmetric breast situation. Sometimes the decision about the amount of release is made during the surgery. A certain degree of release may be performed and the surgeon will ask the anesthesiologist to elevate the OR table back so that even though you are asleep, you are placed in more of a sitting position and the appearance of the breast can be visualized most realistically. This may be done a half a dozen times while making adjustments, especially when there is a lot of difference between one breast and the other. SO I would not try to pin down your doctor to a particular amount of muscle release. You may even need a breast lift to correct your asymmetry. There are really great short scar techniques available for you today. Lastly, the new shaped breast implants help to actually shape the breast. Using these implants, often less surgery on the breast tissue itself is needed to achieve the goal of a beautiful breast that matches the other side. I congratulate you on doing your homework, but don't box your doctor into only one particular way to improve the situation for you.

Hi,

Thanks for posting your question. I am happy to try and help you. It is
important to remember that a board certified plastic surgeon will be your best
resource when it comes to an accurate assessment of your situation, and
concerns. Pictures would allow for a better evaluation of
your current situation. Please be so kind as to resubmit photos
from the side views of each side and from the front. Ideally, have someone else
take the photos so that you can rest your arms at your sides.

Having said that, please do not take personal the next point that I am trying to make.A lay person does not and will not be appreciate the YEARS of training and experience required to determine which surgical technique is required to achieve the best result for a breast augmentation. Furthermore, even if a person may think they have selected the right technique and tell the surgeon what needs to be done and how. What happens intraoperatively when the person is asleep and something inside of them warrants a modification to be made in the surgery to get them an optimal result? Should the surgery be stopped so they can participate in the decision? No, of course not. The plastic surgeon has YEARS of training and experience to make the correct decision then.  So if they have the experience then, then they certainly have it now. Let the plastic surgeon examine you and help you select the proper size and look you would like. Then let them worry about how to do it. You will have enough trouble being certain of which size you want. This is a difficult decision that only you should make.  So your two decisions are what size and which plastic surgeon. Then trust the plastic surgeon to focus on 'the how' to achieve your realistic goals.

Best wishes,

Dr. Michael J. Brown
Northern Virginia Plastic Surgeon

Thank you for your inquiry.  The difference as you noted has to do with the degree of muscle release.  this is actually determined at the time of the procedure even though your surgeon will have an idea of what is needed before the procedure.  The extent of release is based on the appearance of the breast following the initial release.  Good luck with your procedure and be sure to follow your doctor's recommendations afterwards.John J. Obi, MD

Each great, chest anatomy dictate possible using different placement. But you have not posted self photos so can not advise...