Subglandular or Dual Plane? (photo)

I'm 5'4" 110lbs, size 32B. I have grade-1 ptosis and my PS suggested I do moderate profile silicone 286cc subglandular. I have 4cm of pinch in the upper pole and I am a fitness instructor by profession. My PA is concerned about possible animation deformity with a dual plane. My concern is not getting enough fullness in the upper pole and ending up with a matronly or bottom-heavy breasts from this approach but I don't want to end up with snoopy deformity or double bubble either.

Doctor Answers 20

Concerns about breast shape

Hi joycal33, You have a lot of breast tissue for a 32B and something that we call glandular ptosis where the nipple is likely in the normal position, (or slightly low), but the breast gland is mostly in the lower half of the breast. It doesn't appear that you have 4 cm of upper pole of your breasts but that is hard to say without an exam. Some surgeons prefer to place a sub-glandular implant in this case but this can lead to more implant exposure with thinning out of breast tissue and more visible rippling over time in the upper pole of the breast. A dual plane procedure can often achieve a lift to the breast when the plane under the breast and over the pectoral muscle is elevated to allow the implant to displace the breast better while preventing the artificial upper pole bulge and later implant visability and rippling. I have placed sub-pectoral implants in body builders with good results but there can be some animation deformity by pectoral contraction which is well tolerated if the patient understands this. I would explore the possibility of the form stable implant which can be placed sub-glandular plane to provide nice upper pole fullness. In cases where a periareolar mastopexy is a possibility, I will discuss the option of performing the circumareolar mastopexy during the procedure if it is necessary but not do this at the first surgery if the breast looks like it will lift with the implant alone as long as the patient understands that a circumareolar lift is a possibility later on. Often the proof is in the pudding which depends on the tightness of the breast tissue and the elasticity of the breast skin. Your breasts, while there is some ptosis, look firm with good breast gland firmness and shape so they might be fine with implants alone. The size of the gel implant is difficult to know without a consultation and measurement. Do not make the mistake of using too large an implant to lift the breast as this can lead to accelerated sagging. If you haven't done this, try a Vectra 3D imager to look at the options. I have one and it is a great tool to discuss the potential results and tradeoffs. Remember, there are tradeoffs with any choice of implant type/size and choice of implant placement. My goal is that the shape of the breast and long term results should trump all considerations.  

Bellevue Plastic Surgeon
4.1 out of 5 stars 13 reviews

Subglandular Breast Implant Best For Sagging Breast

Thank you for your question. Because there is some ptosis or sag of your breast, a dual plane breast augmentation can result in the muscle holding the implant too high and create a "snoopy deformity".

If you want your implant under the muscle then you will likely need a breast lift as well.

A sub glandular breast implant over the muscle is an acceptable alternative for you if you do not want the breast lift scars.

Subglandular vs dual plane

I think both options are valid for your situation.  As I usually harp, the key for you is an implant that is wide enough to provide adequate upper pole fullness (your stated goal) yet not so wide it will create lateral fullness.  I believe the 286 is OK, but make sure it is the widest that will fit.  The moderate profile is an excellent choice for subglandular.  Also, a "Classic" design Sientra will offer you one extra centimeter of upper pole fullness and works very well  in the subglandular plane. 

David Marcus, MD
Santa Rosa Plastic Surgeon
4.9 out of 5 stars 33 reviews

Breast Implant Placement

For someone like you needing some lift and very actively using your arms and with 4 cm of pinch of upper breast, there is no question that a sub-glandular implant is the correct choice. I would personally use a textured implant. There should be no worry abut a double bubble, lack of upper fullness or bottoming out when done correctly.

Robert T. Buchanan, MD
Highlands Plastic Surgeon
5.0 out of 5 stars 6 reviews

Sub glandular or sub muscular

I almost always do the submuscular implants. I think they look better and can cover any upper implant ripples if you are going with saline implants.  You do have some slight sagging of the breasts, but I do not think you need a lift.  If you are choosing saline implants, definitely go under the muscle.  Good luck!

Ronald J. Edelson, MD
San Diego Plastic Surgeon
5.0 out of 5 stars 27 reviews

Breast augmentation options with minor breast sagging

Placing the implant above or below the muscle can be one of personal choice.  As long as you are not doing heavy bench pressing then below the muscle is an option.  Your breast appears to have a wide base so it will be important to select the right implant to match your breast base diameter.  Your ideal photograph shows a breast with only modest upper pole fullness, this can be achieved with a low profile implant.  Your nipples appear to be just at the level of your inframammary crease and I believe that a straight forward breast augmentation will give you a nice result.  

Jeffrey Zwiren, MD
Atlanta Plastic Surgeon
4.5 out of 5 stars 19 reviews

Breast implant placement with ptosis

There really are a few issues packed into your question here.  I am assuming that you have either decided against a breast llift or your surgeon has not discussed this with you, but if your concern is getting enough fullness in the upper pole of your breast, you ought to at least have this as part of the discussion.  Without the benefit of examining you and only having your photos to rely on, I would expect that you will have some residual ptosis and not get maximal upper pole fullness with just breast augmentation alone, whether you had your implants placed into a dual plane or the sub glandular plane.  You have a sufficient amount of breast laxity that even with a large implant in the sub glandular position, you would likely still have "bottom-heavy" breasts.  I don't think you would require more than a periareolar lift based upon what I see here, but you should at least consider it if upper pole fullness is your goal.  With respect to placement of the implants, I'll try to be brief.  I typically do a dual plane on just about all of my patients, ptosis or not.  The concept was originally described for patients with ptosis to avoid the "Snoopy breast," but I have found that it creates a much more natural appearance in all of my patients.  Subglandular placement has its main advantages in that it sometimes fills a lax breast envelope a bit better, and it also does not disrupt the muscle and lead to animation distortion.  The big drawbacks of the subglandular placement are that you give up some camouflage on the upper pole and may see a distinct implant contour, and there is a higher rate of capsular contracture associated with that placement.  These are almost cut-and-dry decisions, and you'll just have to make a selection of implant placement based upon those implications and your personal preferences.  If you and your surgeon decide to place your implants in a subglandular position, I would suggest that you consider a textured implant to help mitigate the risk of capsule contracture.  You can select from anatomically shaped implants and round implants.  The anatomically shaped implants will have more of a "natural teardrop" shape with less roundness at the upper pole.  With a subglandular placement you may be more prone to seeing the shape of your implant, and a shaped implant may look less like an obvious implant.  Whether you select a round implant or shaped implant, I would also suggest that you consider the manufacturer as well, because there are some important differences between them.  Of the two companies currently approved to sell shaped textured implants (actually all shaped implants are textured) in the US, Allergan has a shaped implant which in my opinion is a little more firm than the Sientra shaped implant.  This may be of significance when placing implants above the muscle because you will definitely feel the stiffer Allergan implant, and it may be more visible too.  You'll feel the Sientra one too, but I just think they are a little softer.  Those are my thoughts on your case, hope that helps.  Good luck.

Joseph L. Grzeskiewicz, MD
San Diego Plastic Surgeon
4.9 out of 5 stars 87 reviews

Subglandular or Dual Plane?

Hello and thanks for your post. Based on the way you have posted your question, I believe that you have a good understanding of the potential complications and side effects of the breast surgery requested. All of the things you have mentioned could be potential outcomes. You should also consider a breast lift with implants which may augment your upper pole and allow you to avoid concerns about an animation deformity. Best wishes, Dr. Aldo.

Aldo Guerra, MD
Scottsdale Plastic Surgeon
4.9 out of 5 stars 202 reviews

Subglandular or Dual Plane?

All the decisions made are done so after evaluation benefits and risks. Yes, under the muscle or dual plane implants will have animation, and if that bothers you, putting the implants above the muscle is sensible. In that case you should at least discuss use of form stable implants--Allergan style 410, with your surgeon. 

All the best. . 

Jourdan Gottlieb, MD
Seattle Plastic Surgeon
4.6 out of 5 stars 45 reviews

Select the Best Surgeon Not Technique for Best Breast Augmenation

My best suggestion is to pick the best plastic surgeon rather than the procedure. It is their job to guide you through this process. See below link on how to select the best plastic surgeon for the job.
Here is some general information however on the dual plane technique. For cosmetic Breast Augmentation, the dual plane technique refers to the implant being partially beneath the pectoralis muscle. As the lower part of this muscle is above the lower lateral part of the breast most Subpectoral implants are in fact to a degree dual plane although erroneously often called total submuscular.
However, the degree of the implant is beneath the muscle on top and soft breast tissue below can be altered by making the submuscular pocket higher up the muscle leaving some of it below the implant below and some above. The advantage of this is to expand the lower pole of the breast if short or more often for mild drooping breast correction.

Larry S. Nichter, MD, MS, FACS
Orange County Plastic Surgeon
4.9 out of 5 stars 157 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.