In a dual plane augmentation, what holds the implant up (bottoming out?), and how does it increase the size of the lower pole?

I have an almost non-existent lower pole to my breasts and was recommended a dual plane augmentation instead of an augmentation paired with a lift. I am pleased with this response from my PS, but I am concerned about the dual plane approach in relation to the look I want to achieve (a much fuller lower pole), as well as the risk of complications with bottoming out ( a terrible fear of mine).

Doctor Answers 8

Properly done, the dual plane technique should not cause implants to "bottom out"

This is a very excellent question, and I'm glad you asked it.  It will take a bit of mental imagery on your part to understand what's going on, because it all has to do with the anatomy of the breast and chest.  In short, what a "dual plane" augmentation means is that we have lifted the breast tissue on the bottom of the breast, between the level of the nipple to the level of the inframammary fold below the breast, off of its connections to the underlying muscle.  Are you with me so far?  The breast is normally connected to the underlying muscle, and if we simply go in and lift breast and muscle as a unit, without first disconnecting the lower breast tissue attachments to the muscle, we are doing essentially a classic submuscular pocket.  Lifting the lower breast tissue first away from the muscle and then lifting the bottom of the muscle from the rib cage makes this a dual plane.  The important thing to recognize is that the lower breast tissue is now free to drape and wrap around the implant, while the upper breast remains attached to the muscle and the implant goes under all of that on top.  This creates a better fill of that lower breast tissue and a more natural look in most cases.  It prevents that lower breast tissue from remaining attached to the muscle and behaving independently of the implant, causing things like "Snoopy breast" with the loose breast tissue hanging off of the bottom of the implant.  Thus, the thing that prevents bottoming out is the surgeon keeping that entire pocket dissection above the level of the inframammary fold and the tough attachments of that fold to the underlying chest wall.  This is the lower border of the breast, and it is when this is violated that implants can slide down behind it along the chest wall and cause "bottoming out."  As long as this fold is respected and left intact, the implants won't bottom out.  The dual plane, done properly, in my opinion is the technique MOST likely to produce a fuller lower pole, as it creates the most tension, and thus expansion, of the lower pole tissues between the (remember, intact) inframammary fold and the nipple.  That is what creates that nice, full lower breast contour.  That happens with a properly done dual plane.  I do at least some degree of dual plane on just about 100% of my breast augmentations, regardless of age or other factors, simply because I think it creates the most natural results, and I have about a 0% incidence of bottoming out.  I also don't have a problem with implants falling out to the side under the arms either, and  I would venture to say that the dual plane is probably more likely to prevent any implant displacement problems at all, bottoming out included.  This is because the exposure of anatomical landmarks like the lower and lateral edge of the pectoralis muscle is so much better that the surgeon has better control and accuracy of these critical endpoints of pocket dissection, so he is less likely to over-dissect the pocket in those locations and have displacement or malposition issues later.  In some instances we might have to adjust that inframammary fold placement if it's too high, or if the lower pole tissues are constricted, such as in cases of tuberous breast or constricted breast deformities.  I wonder if you don't have something like that going on, based upon your description of an "almost non-existent" lower pole and possibly needing a lift.  Some girls with tuberous breast require a lift to control areolar herniation.  Even still, I would do a dual plane dissection in cases like that, relaxing incisions in the breast tissue internally if need be, and a reattachment of deep tissues to the chest wall lower down to re-create a fold and prevent bottoming out, if need be.  But I would still do the dual plane dissection, regardless, as that will still help expand the lower breast tissues better.

Thanks for your excellent question, and it sounds like your surgeon has things "under control."  As long as he relates to you his understanding of the importance of the inframammary fold, I would say he knows exactly what he's doing with regard to the fuller lower pole, and you should trust his instincts with the dual plane approach.  Best of luck.

In a dual plane augmentation, what holds the implant up (bottoming out?), and how does it increase the size of the lower pole?

The connective tissue along the inframammary fold holds the implant up no matter what technique is used. I don't completely understand from your description why you were told that you may need a lift. If you have a non-existent lower pole, I'm assuming that you don't have any sagging. If your nipple to fold distance is short and you have a well defined inframammary fold, I prefer to leave the fold at its current location and elevate the nipple. I find that trying to lower tight folds causes a double bubble most of the time. I understand that many doctors score and stretch the fold, but I frequently see patients for revision surgery that have a lower pole crease caused by trying to lower the fold.

In a dual plane augmentation, what holds the implant up (bottoming out?),

How does a dual plane augmentation of the breast keep the implant from bottoming out? First, practically speaking and with few exceptions, every submuscular breast augmentation is a dual plane procedure because the pectoral muscle only covers the upper 2/3 and medial part of the breast. Below that there is no pectoralis muscle coverage, and any muscle coverage below the pectoralis muscle would have to be the serratus muscle if it were totally submuscular.

It sounds like you have a very high inframammory crease and maybe a bit of what is called a Snoopy deformity if the nipple area sags over the IM crease. If that is the case, you may need an uplift (mastopexy). I would rely on your PS to make that determination since eh/she has examined you personally, which is necessary in such cases. If the crease is high, it will have to be lowered, which every PS has done numerous times.

There should be no problem with achieving fullness in the lower pole. Controlling any bottoming out would be done by limiting the dissection of the IM crease. Sometimes suturing the crease is necessary to prevent this from occurring. It sounds like your PS is dialed in to the proper method to achieve your desired result.

Thank you for your thoughtful question and best of luck.

In a dual plane augmentation, what holds the implant up (bottoming out?), and how does it increase the size of the lower pole

Great question.
The dual plane technique was developed for women who refuse a lift . This technique cuts the muscle to allow the implant to fall directly behind the existing breast mound (low on the chest). Once the muscle is cut, there is nothing to help keep the implant in place. Bottoming out or lateral displacement of the implant is usually the result after a couple of years depending on the size (weight) of the implant. I never cut the muscle as this violates the only supporting structure that helps keep implants in place long term. I hope this helps.
Best wishes and kind regards,
Gary Horndeski M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.7 out of 5 stars 209 reviews

Dual plane explained

A dual plane breast lift means that the upper part of the implant is covered by muscle, but the lower part is released, which allows the implant to expand the overlying breast tissue.  If the muscle is not released (as in a submuscular augmentation), then the breast tissue may not be as fully expanded because the muscle is in between.  Even if the muscle can stretch, the overlying breast tissue is not fully expanded due to the attachments between the breast tissue and muscle.

Bottoming out is more likely to occur with any adjustments to the level of the inframammary fold, as well as the weight of the implant.  Some stretching is likely, but the best support is the natural support made by your body.  If muscle is not release to the correct degree (even for a submuscular pocket), one can have a high riding implant with a droopy breast on top. 

In your question you don't state if you have droopy empty breast tissue and skin in your lower pole, or you just don't have much in your lower pole, and your skin is not stretched out.  If you don't have much skin, you will likely need less of a dual plane created because your tissue will stretch with the muscle.  However if you have excess skin (saggy breast), then a dual plane is definitely needed to adequately expand that lower pole when you get your implants.

Seek an experienced board certified plastic surgeon.

Roxanne Sylora, MD
Orlando Plastic Surgeon
5.0 out of 5 stars 17 reviews

Dual plane

When the lower pole is short, stretching the lower pole is easier said than done regardless of which augmentation technique you use. Often patients develop a double bubble deformity which then may necessitate a lift or mastopexy. Most submuscular  breast augmentations are dual plane as the lower pole does not is not covered by muscle anyway. Just be prepared that a lift may be required one day anyway.

Timothy Fee, MD
Jacksonville Plastic Surgeon
4.4 out of 5 stars 53 reviews

In a dual plane augmentation, what holds the implant up (bottoming out?), and how does it increase the size of the lower pole?

Thank you for your excellent questions and for doing your research.  Dual plane augmentation is the standard procedure for most plastic surgeons in the US, with muscle covering the upper portion of the implant and the lower portion of the implant covered by your breast gland.  There is a network of supporting tissue along the breast crease termed the inframammary fold that helps reduce the risk of bottoming out and is protected during the surgical dissection.  The lower portion of the breast enlarges due to the redistribution of the implant volume once the implant "drops."  This places pressure on the lower pole causing the skin to stretch.  Hope this helps.

Nelson Castillo, MD
Atlanta Plastic Surgeon
5.0 out of 5 stars 43 reviews

Degree

Dual plane breast augmentation is a powerful way to improve your aesthetic results.  It is used to describe the procedure and should not be confused with some fancy procedure.  Most of the breast implants placed under the muscle is placed in the dual plant.  It is just the degree of release that the surgeon controls to maximize control of the breast pocket.  Dual plane does not cause or prevent bottoming out.  I am sure your surgeon is quite aware of this and you will have a great result.
In my practice, bottoming out is not a common complication.
Best Wishes,
Nana Mizuguchi, MD

Nana N. Mizuguchi, MD, FACS
Louisville Plastic Surgeon
4.7 out of 5 stars 45 reviews

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