Breast Augmentation Revision. Can dual plane cause animation deformity and double bubble? (Photo)

Question

How dual plane can cause animation deformity and double bubble? Rippling? - internal bra? - b-day lite implants? -how much scarring - side boob and not enough cleavage Can any specialist help?

Alejandro Nogueira, MD · Answer

I have been an enthusiastic practitioner of partial submuscular location of implants (incorrectly though popularly called "dual plane") during the first 10 years of my senior career, and no one of my patients experienced the dynamic double bubble or animation flex deformity. Howeever it is already 10 years now I moved to the subfascial plane of placement and I and my patients could not be happier (minimal pain, complications rate close to real zero, quick return to normal life, long term stability, etc, and of course the conceptual impossibility to sufery animation flex deformity, however such dynamic muscular deformity only happens in not correctly done submuscular procedures).The dual plane is producing such horrendous issue because the surgeon fails to know the essentials of surgical anatomy of breast augmentation, as simple and terrible as it sounds; the animation flex deformity is NOT caused by a list of excuses and justifications like, among others, the following ones: (recorded from my own revision patients' stories told to me in office)-"your muscle is too strong to cope with the implant"-"you doo too much workouts, slow down or quit from gym"-"your body rejects the implants"-"seems an unxeplanaible and unforeseeable adhesion has been formed there"-"oh you have capsular contracture, naughty implants"-"how you dare to offend my reputation and skills! this result is the best possible"-"your breasts are this ugly, you are bad lucky with your anatomy, I'm not at fault"-"eeehm... eeer... the result is awesome, contratulations, you are discharged"-"____________" (fill at your own, many others...)And... beware! the technique is not to blame, a partial submuscular placement NEVER produces this deformity unless its executioner fails to do it correctly, ever.I'll try to put it shortly and plain so that anyone can get it, even any colleague in need of professional updating:-the pectoralis major muscles has tendinous insertions (attachments) at the humerus bone (arm, near the shoulder) and at the chest; I guess we all know what the pectoralis muscle is used for so I don't extend over this-the insertions of the pectoralis muscle take place at the clavicle (collar bone), rib cartilages from 1st to 7th and horizontally at the osseous rib arcs of 6th and/or 7th (there are variations); well, pay attention now: these horizontal attachments are the cornerstone... the core... the key... the pitfall of the animation flex deformity (dear reader... stay tuned, the answer comes next)-the lower border of the pectoralis muscle is, as mentioned above, attached to the bone arc of the 7th rib; when we do a submuscular placement of breast implants there are two options, one banned, proscribed and abandoned which is the "totally submuscular placement", and the second acceptable and efficient (though unnecessary and and unjustified nowadays, the golden standard is the subfascial plane) which is the "partially submuscular placement"-when placing a breast implant TOTALLY under the muscle you create a grotesque deformity called "elevator breast" or breast implant animation deformity; as sounds obvious when the implant is totally embraced by the muscle every pectoralis contraction pulls up from the prosthesis up to the clavicle... therefore the implant is "dynamic" but not the breast, neither the muscle itself, the muscle is not released from the rib insertions and works as normal, the breast tissue does not experience traction, however the implant is submitted to powerful forces deforming it and raising it; that is why this technical option should NEVER be used, apart that the constant rubbing of the silicone against the ribs produces and augmented wear leading to very very early implant rupture; finally the totally under the muscle placement makes anatomically impossible centering the implants beneath the nipples, they alwas ride too high even without pectoral contraction, with pectoral contraction they go up close to the neck or armpit, literally-when the implant is partially placed under the muscle in a CORRECT MANNER the surgeon releases the attachments of the pectoralis to the ribs at its lower and part of the inner borders, BUT... and this is an important but... ALSO has to release from the fascial ligament joining the lower border of the pectoralis muscle to the breast tissue and skin; this natural ligament (all women are born with it) is not a problem ever unless the muscle is freed from the ribs, since when the lower end of the muscle is firmly attached to the ribs its contraction does not raise the muscle and dose neither raise such ligament; and... why is the lower border of the pectoralis  freed from the ribs? because otherwise we would produce an horrendous and problematic totally submuscular technique (read previous item)-so, we have the dual or partial submuscular plane in which the lower border of the pectoralis muscle is disinserted from the ribs and also such muscular lower border is freed from the breast tissue, allowing free gliding of the lower border of the muscle during muscular contraction and thus preventing any distortion or deformity: the muscle does not push the implant upwardly and does neither pull the lower breast pole up by traction on the fascial ligament which links muscle and breast skin; however... -...IF THE SURGEON FAILS TO RELEASE THE BREAST-MUSCLE LIGAMENT the lower end of the pectoralis muscle will glide free upwardly escorted or followed by the lower breast skin due to anatomical solidarity, and this is the ONLY cause of the animation flex deformity-as brief summary: the totally under the muscle location produces dynamic IMPLANT deformity, in which the prosthesis is displaced up with the muscular contraction causing a grotesque deformity but the muscle and the breast do not ascent or experience any kind of direct deformity (muscle, ribs and breast tissue stay solidary en bloc); the incomplete and erroneously done partially under the muscle location (aka dual plane) produces dynamic BREAST deformity, in which the lower end of the muscle is freed from the ribs but not from the breast tissue, therefore during contraction the lower end of the pectoralis ascends pulling its cutaneous insertions and splitting the lower pole into two halves, pulling up from the breast but not from the prothesis (muscle free from ribs but breast tissue and muscle stay solidary en bloc); in the properly done partially under the muscle location (aka dual plane) there is no deformity, given the lower end of the muscle is free from both, ribs and breast, and glides smoothly between breast and implant free of adhesions when it is contracted during its daily use; needless to say all these disquisitions are pointless in the modern, highly recommended and awesome subfascial technique of placementIMHO if a surgeon is not able to understand such a basic concept he needs to refresh his skills before going one with breast augmentations by attending few colleagues ORs to update his concepts; we are talking about concepts developed about 20 years or longer ago.But that's not all; the erroneously done dual plane producing animation deformity always leads to a progressive onset of other subsidiary deformities; not only talking about the split lower pole and the dynamic double bubble; over the following months of years after surgery the breasts develop:-lateralization of implants, due to the muscular contraction conflict-due to same reason, lowering or bottoming out of implants-due to the former ones, empty cleavage and side boob deformity-as as direct consequence or part of the former, lateral and lower expansion of the initially carved breast pocket, including skin over expansion-due to the side boob commonly patients suffer chronic pain or sensation loss in the breasts due to the intercostal nerves compression neuropathy-eventually severe psychological distress and desperation to seek "creative" or revolutionary solutions to the dynamismThe solution to animation flex deformity is the simplest one can imagine, actually is the same than the prevention of its occurrence... guess which one? correct: if you (surgeon) perform a dual plane don'r forget to release the congenital ligament between the lower muscular border of the pectoralis and the breast tissues, just it!So breast revision in your case has 100% success rate with a very very simple surgical gesture: surgical splitting of the muscular ligament to the breast, no more than 15 min surgical time each breast... 100% success as long as the revision surgeon has experience and understanding of the problem; this can be accomplished keeping the same plane (partial submuscular, acceptably but criticizable) or by means of conversion to subfascial plane (my choice).Unfortunately that is not all, now comes the correction of the aforementioned subsidiary deformities, and a complex multipoint capsulorrhaphy has to redefine the breast pocked and allow closing the lateral excess tailored by the animation deformity and also get rid of the lower over expansion or muscle-induced bottoming out by raising the submammary crease to a proper position.I strongly recommend using anatomical shaped implants, filled with cohesive (4G) or ultracohesive (5G) silicone gel and macrotextured or polyurethane coated at the shell to provide the highest grade of tissue adhesion and capsular contracture prevention.See the link below to find few cases of my own practice very similar to yours which I had the opportunity to operate successfully on, sharing a lot of common features with the technical problem you have posted.You'll see they are shockingly similar to your case... this technical fault is unfortunately very common and its deformity always very similar; on the good side its correction is always the same successful if the hands are proficient and talented.Seek the help of a good expert in revisions, capsulorrhaphies and modern breast implants. Difficulty 8-9 out of 10 in breast revisions. Surgical time 4-5 hours.Other treatments to this issue you might read online or might be offered to you are not working or can even worsen your situation, even precluding future repair.
If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, also from underneath.
Feel free to request any additional information from me.

Richard Baxter, MD · Answer

Frequently the type of animation deformity you have and double bubble are caused by the same thing: detachment of the lower portion of the pectoral muscle. The cut edge of the muscle then adheres to the capsule as it forms, pulling the crease up. Correction of this requires that the cut portion of the muscle be re-attached behind the implants, which can be done by converting to either the split muscle plane or subfascial. There are examples, videos, and articles on my website.

Gary M. Horndeski, MD · Answer

In your before photograph, your breasts where too low on the chest wall.  In order to place implants, the surgeon had to release your inframammary fold and that is what created the double bubble and the inferior descent of the implant.  At this time, I recommend explantation using The Bellesoma Method.  The implants are removed, your breast tissue is reshaped creating upper pole fullness, elevated higher on the chest wall and more medial to increase your cleavage.  Vertical scars are avoided, nipple sensation and the ability to breast feed are maintained, if not injured during your previous surgery.  At the same time or later, fat transfers can be performed if additional volume is desired.Best Wishes,Gary Horndeski, M.D.

Richard J. Restifo, MD · Answer

I am sorry for the difficulties that you are having.  The good news is that the situation can be greatly improved.  Animation to some degree will always be present with implants that are under the muscle.  The double bubble can be corrected by reconstruction of the fold internally.  This can be done without addition scarring on the skin. It is important that you consult with a plastic surgeon that has experience in these kinds of revisions and that is confident that he or she can fix the situation.  Best wishes.

Paul E. Chasan, MD, FACS · Answer

Thank you for your question. I'm sorry to see that you have a double- bubble. In your case, it is clear that your surgeon dissected under the inframammary crease ligament when performing the initial breast augmentation. A large portion of my practice is dedicated to revisionary breast surgery. A capsulorrhaphy (suturing the bottom part of the pocket) is very effective double-bubble cases like yours. You should be able to have beautiful breasts. Best wishes to you.

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