Low tissue patient (55 kg) – 235–250cc Motiva Ergonomix 2: Dual plane or subfascial? (Photos)

Question

Hi doctors, I’m 166 cm tall, 55 kg, with a breast base width of approximately 11–11.5 cm. I have very minimal natural breast tissue and low body fat. I am considering Motiva Ergonomix 2 implants in the 235–250 cc range (mini size), aiming for a small, natural-looking result. My surgeon is currently deciding between dual plane and subfascial placement because I have very little natural breast tissue. However, he mentioned that he may not prefer dual plane in my case because Motiva Ergonomix 2 implants are lightweight and highly cohesive, and he is concerned that under the muscle they might not settle or “drop” in a way that creates a soft, natural slope. He suggested that the implant could potentially stay too high or not create the desired lower pole fullness. At the same time, I am concerned about soft tissue coverage due to my low body fat. Given my anatomy and the relatively small implant size (235–250 cc), would subfascial placement provide enough upper pole coverage and long-term aesthetic stability? Or would dual plane still be considered the more predictable option in a thin patient like me? I would greatly appreciate your professional opinions.

Brian K. Reedy, MD · Answer

Thanks for your question! I would probably stay with the dual plane approach, but I'd have to see you in person and feel your body fat/breast tissue to make an exact determination. Some of it is driven by your goals well. Best of luck!

Ramiro Morales, Jr., MD · Answer

I would reserve a dual plane approach for those patients where you are trying to correct a very modest amount of ptosis or droopiness which you do not have.  In your case I would likely use a moderate high profile Mentor gel implant either in the XTRA or Boost variety to get a nice natural appearance with less risk of the subpectoral implants not settling into place which potentially has a high chance with the Motiva Ergonomix 2

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach.

Subglandular Augmentation (“overs”):

•	Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster 
when compared to subpectoral augmentation.

•	Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection).

•	Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space.

•	Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling.

Subpectoral Augmentation (“unders”):

•	Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients.

•	Subpectoral implants have a lower rate of capsular contracture.

•	Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion.

•	The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle.

Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other.

With regards to your specific question, native breast tissue acts as camouflage for an augmentation. If a patient has inadequate coverage a dual plane approach is always preferred. Subfascial will behave like subglandular in this case, providing inadequate coverage.

As always, your board certified plastic surgeon can help guide you in your decision making process.

Jacob Carlson, MD · Answer

You have obviously done quite a bit of research into this. It's great to see someone who is so invested into their surgery to obtain the best results. All of the information you provided if very helpful.
If you were to have the implants placed in the dual plane position, I wouldn't be too concerned about the implants descending or dropping into the correct position. I would defer to your surgeon's advice, but I have my patients start performing implant massage as one week after surgery to help the implants start to drop down into position.
The Motiva Ergonomix 2 implants are LESS cohesive, so regardless of where the implant is placed, they are going to assume more of a teardrop shape than the Ergonomix or the Round implants.
I agree with your assessment that the amount of native breast tissue present is going to have an impact on the appearance of the augmentation. Placing the implants in the subfascial plane is going to give you a more "augmented" appearance, simply because there isn't a lot of breast tissue to conceal the implant. On the other hand, placing the implant in the dual plane position adds an extra layer of coverage to the front and top of the implant. So comparatively, the dual plane option is going to create a more "natural" look than the subfascial option. In your case, there's not a right or wrong way to do it. It's more of a question of what type of look you're wanting to accomplish.

Laura Roider, MD · Answer

Dual plane will provide the most coverage for your implant in the upper pole. This is often used with thin patients like yourself. Although a subfascial augmentation is also a good option. One thing you could consider is fat grafting (with your fat or will Alloclae - processed cadaver fat) to help build up the thickness of your tissue and help soften the visual edges of your implant.

Low tissue patient (55 kg) – 235–250cc Motiva Ergonomix 2: Dual plane or subfascial? (Photos)

Answers (5)

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