Subglandular or Dual Plane? (photo)

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.  

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.

Your surgeon has taken a very conservative approach.  I would make sure you try the implant sizes on before surgery.  I am concerned that a 286 cc implant and no lift will not give you much upper pole fullness.

Thank you for your photographs.  Based on the photos I would place your implant in a dual plane to help hide the top edge of your implant and decrease the risk of capsular contracture.  Secondly, you at least have Grade II ptosis and will need a lift.

Dr. ES

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!

From your photos, you appear to have poor upper pole fullness even though your measurements suggests otherwise.  Either a dual plane gel implant or a shaped textured sub glandular implant are good options.  

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.

Different surgeons have different techniques they prefer to use.   I think you will do well with either subglandular or a dual plane technique.  I prefer the dual plane technique as it allows be to create a very natural tear drop shape result.   If you are looking for more upper pole fullness, then a wider implant may be needed.

I consider two factors when selecting implants for my patients:

1.Dimensional planning

2.Gel Implant Sizing system

Dimensional planning – The measurements of your chest wall are taken. Also, the breast dimensions including the height, width, and current dimensions of each breast form the basis of dimensional planning. Based on these measurements, the implant size is recommended. This will give you a unique breast implant that is suited for your body frame. However, there are some limitations of what size we can recommend. For instance, some implants may just be too big for a narrow chest wall. Your surgeon can review this with you during the consultation.

Gel Implant Sizing system – During the preliminary breast implant consultation, you will be provided with an option to “try on” a variety of implant shapes and sizes. You can also visualize the possible outcomes of your surgery which helps you to get that perfect size to give you the shape that you longed for. This way your preferences are known and you can then pick a range of implants that will “fit” just right to give a soft natural fuller look.  If you have decided on saline implants, then based on the gel sizer you select, we can guide you to the saline implant that achieves a similar look.

Hope this helps.

Dr. Basu
Houston, TX

Thank you for your question and for the photos.  It does not appear to me that you have 4cm of upper pole thickness.  You also have ptosis.  An important measurement is the nipple to fold distance, which we do not know.   If you do not need a lift, which from the photos it looks like you may, then with ptosis the subglandular position is best.  However, your tissues are thin in the upper pole and submuscular is better for this situation.  So, in my office we would recommend submuscular with dual plane; the dual plane will maximize the amount of implant in the subglandular position, which will give a little more lift.  However, if your tissues in the lower pole are thin, you may feel the implant with dual plane.  If you are a candidate for a lift, then I would recommend lift with submuscular implant.  You can also consider a shaped implant, which has more projection in the lower implant and I have found this very helpful in cases where submuscular position is ideal and the patient technically needs a lift but refuses one.  The shaped implant can maximize the amount of lift that an implant will give.  Hope this helps.

Tracy Pfeifer, MD

 

 

Thank you for the question and pictures.

There are pros and cons to the placement of breast implants in the “sub muscular” position versus the "sub glandular position”.    I will try to outline some of the differences here;  you may find the attached link helpful as well.



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.  Also, the immediate recovery period may be  more comfortable  after sub glandular breast augmentation as compared to sub muscular breast augmentation surgery.


Best wishes.