Is the Biplane Technique a Better Option over Dual Plane for Athletic Women Seeking Augmentation? (photo)

I live in Toronto, Canada and read an article on Pubmed about Dr Umar Khan's biplane implant placement technique. He's a UK doc that developed this technique in 2007. I was wondering if there are any doctors in North America, or even Toronto, that practice this technique. It sounds like it would be a better option over dual plane, resulting in no movement/displacement when the pectoral muscle is flexed. This is important to me as a figure competitor. I don't have enough tissue for subglandular.

Doctor Answers 8

"Biplane" versus dual plane for athletic breast augmentation

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While the two techniques as described are essentially the same concept, that being placement of the top part of the implants under the pectoralis muscle and the lower part of the implant in the subglandular plane by first elevating the breast tissue from the muscle on the lower part of the breast, there is an important difference between the two, and they should not be considered identical.  The so-called "biplane technique" as described by Mr. Khan is a muscle splitting procedure whereby the pectorals muscle is split in line with its fibers at about the junction of the middle and lower thirds of the muscle, leaving the lower portion of the muscle attached to the ribs and sternum while the upper part is raised allowing the implant to be placed beneath it.  In contrast the dual plane technique as most of us use it here in the US typically involves elevation of the entire muscle from the ribs at the bottom and releasing it partially along the lower inner corner to accommodate the implant.  I use the dual plane technique on all of my breast augmentation patients, including several out here in Southern California who are figures and fitness competitors and models as well as athletes of all types:  golfers, swimmers, lacrosse players, softball players, basketball players, and runners, and I also use it on military, police, fire, and rescue personnel on whom I do the operation.  I have some real concerns about the biplane technique as described, and that is why I really don't use it.  First, Mr. Khan advances this technique primarily as a solution to "dynamic distortion" of the breasts, or movement of the breasts with muscle contraction.  This is something that is really a side-effect of any submuscular breast augmentation procedure, as the breast is really not a submuscular organ; we just put implants behind the muscle for several reasons including camouflage, capsule contracture prevention, and enhanced mammography.  Thus, while it may be diminished somewhat with the biplane technique, as described, I can't imagine that it is totally alleviated.  I think there is always the chance of some breast movement with muscle contraction, even with the biplane technique, and this is probably amplified in girls without much natural tissue to cover the muscle or the implant.  Furthermore, if done properly, the dual plane can actually allow for the same kind of weakening of the lower portion of the muscle (and the upper part for that matter) to produce the same type of reduction in muscle activity on the breasts.  The biggest concern I have with this idea though is that this decreases the amount of muscle available to cover the implant, and that does two things.  First, it risks inadequate camouflaging of the  implant or the creation of a visible muscle edge above the implant.  Second, it allows the potential transfer of muscular forces to a greater downward and outward vector against the implant, and this will create downward and outward displacement of the implants over time.  You can almost see both of these things happening just by looking at the illustration of the techniques that you have posted here.  This displacement of the implants by the muscle over time is a well-described phenomenon, and I can see it happening especially in patients who are led to believe that this technique will somehow allow them to return to the same degree of rigorous pectoralis exercise that they did before the surgery.  The truth is, if you have ANY muscle coverage of the implant at all or any contact of the muscle with the implant capsule, you may have some movement of the breasts with muscle contraction, whether you had a "biplane," dual plane, or other form of submuscular placement.  If the muscle edge is positioned so high that it doesn't move the implant, you will then essentially have no muscle coverage and a subglandular placement.   Additionally, there are other factors than simply the degree of muscle coverage that influence dynamic distortion, some we understand, and some we probably don't even realize.  I believe that the thickness and tightness of the capsule is one of those, and we don't have any way to control that.  Also, the larger the implant, the more that a foreshortened muscle must stretch to cover it, and typically what happens is a process called "window shading" in which the muscle shortens over time and migrates above the implant like a window shade.  This can happen with any muscle releasing procedure, but it is more likely to occur if the muscle coverage is shorter.  I can tell that in the diagram Mr. Khan expects to prevent this by leaving the lower - innermost fibers of the muscle intact, but in reality, this either won't be possible like the drawing, or it will, and it will maintain the same degree of muscle contraction and "scissoring" on the implant, squeezing it in a downward/outward direction, that I have been discussing.  I don't think any patients with submuscular implants of any form - complete submuscular, biplane, or dual plane - should expect to engage in strenuous pectoralis exercises after their surgery.  This is why for serious competitive athletes and bodybuilders who simply do not want to compromise their pectoralis function in any way, the best approach is subglandular placement, and while this has its risks and downsides, it is the trade-off to leave the pectoralis undisturbed.  I have some degree of dynamic distortion with the dual plane technique, but when I strategically weaken the muscle, I find that this is very mild and very acceptable, and again, I prepare all ladies with any kind of submuscular implants to expect this.  

While I don't think  the "biplane technique" is bad, I just don't think that what it purports to deliver is something that isn't available with the dual plane, yet it does present some distinct disadvantages compared to the classic dual plane technique as I have described.  My advice is to find a board certified plastic surgeon who has significant experience with the dual plane technique who can also understand and perform the nuanced modifications of the muscle as I have described to minimize dynamic distortion.  I'm sure that there are many good results with the biplane technique, but my question isn't about the good results - it's about what can go wrong with the procedure, and how much of a problem that it when it happens.  The dual plane technique has proved itself to be reliable and reproducible over many, many years and many thousands of operations.  

Another thing you should also consider in addition to the dual plane technique is the use of form stable, anatomically shaped implants.  These will also create a more natural shape for your breasts, especially since you are competing in figures and don't have a lot of your own breast tissue to camouflage the implants.  Again, I have used these implants in a number of similar patients, and they surf, do sports, and have no difficulties with their muscles.  They are all happy with the appearance and feel of the breasts as well.  Thus, you should also consult with a surgeon who is experienced in the use of those implants too just so that the option can be offered to you if indicated.  Good luck

San Diego Plastic Surgeon

Which technique is best?

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If you're truly into competitive sports, the form stable textured anatomic implants were designed for people just like you.  Even with minimal coverage, they do not wrinkle as much (some people say they don't at all but I find that difficult to believe).  Their temperature changes slowly so be forewarned if you're out in the cold.  Also, these implants do not move so when you lay down, they stand straight up. 

Curtis Wong, MD
Redding Plastic Surgeon
4.8 out of 5 stars 33 reviews

Small implants require less revisions

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The technique I prefer is Breast Augmentation with Mini Ultimate Breast Lift.  Using only a circumareola incision it is possible to place the implant, reshape your breast tissue creating upper pole fullness, elevate them higher on the chest wall and more medial to increase your cleavage.  Aligning the areola, breast tissue and implant over the bony prominence of the chest wall gives maximum anterior projection with a minimal size implant.  Smaller implants can be placed totally retro-pectoral, will not extrude inferiorly or laterally and will not give you complications of the biplane technique.  I  recommend the smallest implant possible to minimize complications requiring revisions. 


Best Wishes,

Gary Horndeski, M.D.

Gary M. Horndeski, MD
Texas Plastic Surgeon
4.6 out of 5 stars 230 reviews

Biplane Technique a Better Option over Dual Plane for Athletic Women Seeking Augmentation?

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Based on the terminology and diagrams, I think that you are considering the same procedure being described by 2 different terms. In other words, the breast implants are being placed in the sub muscular position (partially) and in the sub glandular position  (partially).

I think it is in the best interests of most patients seeking breast augmentation surgery to have implants placed in the “dual plane” or sub muscular position. This includes athletic patients.
The submuscular positioning allows for more complete coverage of the breast implants leading to generally more natural feel/look  of the implants in the long-term. This position will also decrease the potential for rippling and/or palpability  of the implants (which may increase with time, weight loss, and/or post-pregnancy changes).

The submuscular positioning  also tends to interfere with mammography less so than breast implants in the sub glandular position. The incidence of breast implant encapsulation (capsular  contraction)  is also decreased with implants placed in the sub muscular position.

On the other hand,  sub glandular breast implant positioning does not have the potential downside of “animation deformity” ( movement/ distortion of the breast implants  seen with flexion of the  pectoralis major muscle)  they can be seen with breast implants placed in these sub muscular position. 

Overall,  after considering pros/cons carefully, I find that there are many  advantages to placement of breast implants in the sub muscular ( dual plane) position.  I have found that this positioning works well for patients involved with athletics, competition, and bodybuilding.

 I hope this, and the attached link, helps.

Biplane and dual plane augmentation are effectively the same thing.

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Your basically describing to operations that are the same. The real issue is whether or not the implant should be below the pectoralis muscle or above it.

Biplane vs. Dual Plane Breast Augmentation

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I agree with Dr. G's comments below.  I perform the so-called biplane technique, and implant movement does continue to occur with muscle contraction. Subfascial augmentation is perhaps your best option, although the fascia is not always thick enough and it is not always possible to establish a subfascial plane for placement of the implant.

Michael Kreidstein, MD
Toronto Plastic Surgeon
4.6 out of 5 stars 33 reviews

Dual plane or bi-plane augmentation

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The procedures you mention are one and the same. As a bodybuilder you know the anatomy as the pectoralis is present only under the upper half of the breast. Under the muscle can only be under just so much to keep the implant centered in the breast. Any muscle coverage will deflect or deform an implant and tradeoffs have to be considered in your sport. Perhaps a smaller cohesive subglandular anatomic gel?

Peter E. Johnson, MD
Chicago Plastic Surgeon
4.0 out of 5 stars 44 reviews

Is the Biplane Technique a Better Option over Dual Plane for Athletic Women Seeking Augmentation?

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As with most "Personalized Techniques" in plastic surgery, many are not new and most have been done elsewhere by others. Biplane and dual plane techniques are not new and many plastic surgeons use these techniques for selected patients. There should be a Toronto plastic surgeon who can offer this to you.

Karol A. Gutowski, MD, FACS
Chicago Plastic Surgeon
4.9 out of 5 stars 76 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.