Sub Facia or Dual Plane - can I do lower body (heavy) and moderate shoulder and back training with dual plane? (Photos)

Question

Im 32 and wanting to get breast augmentation. Have had 2 consults and 1 suggested dual plane with the other suggesting sub facia due to me training at the gym. Im quite fit and do lift heavy however am not a body builder or anything. I like the idea of sub facia however im worried that I’m on the thinner side so the breast implants might be visable (he has suggested Demi) hence why im hesitant and leaning towards sub facia - however the animation worries me.. i am happy to never do chest again aslong as i can do lower body (heavy) and moderate shoulder and back is that still possible with dual plane?

Yasemin Aydinli, MD · Answer

Let me answer your main worry first, because it is the most reassuring part: yes, with a dual plane implant you can absolutely keep doing heavy lower-body training and moderate shoulder and back work. The animation and implant-displacement concerns that come with a dual plane are caused specifically by the pectoralis major muscle, and that muscle is strongly activated by direct chest exercises &mdash; bench press, chest flys, push-ups, dips. Squats, deadlifts and lower-body work do not involve the pec at all, and moderate shoulder and back training activates it only minimally. So the training pattern you described &mdash; heavy legs, moderate shoulders and back, and giving up direct chest work &mdash; is fully compatible with a dual plane.
The real trade-off for you is actually about your frame, not your training. Because you are on the thinner side, the advantage of a dual plane is that the implant sits partly under the muscle, which gives more soft-tissue coverage over the upper pole. That coverage is exactly what reduces visible implant edges and rippling in slim patients &mdash; so dual plane directly addresses the visibility you are worried about. The cost is animation: when you deliberately flex your chest, the breast can move or distort. For most women this is mild, only appears when the muscle is actively contracted, and is not visible at rest or during everyday activity.
Subfascial has the opposite balance. It places the implant over the muscle (under the fascia), so it avoids animation entirely and fully preserves your chest strength &mdash; which is why the second surgeon suggested it for someone who trains. The honest downside in your specific case is that you are thin, so over the muscle there is less tissue to camouflage the implant, and a higher chance of visible edges, rippling and palpability, especially in the upper pole. A Demi (moderate) profile is a sensible, less projecting choice to limit this, and coverage can sometimes be improved with fat grafting over the implant &mdash; but it still will not match the coverage a dual plane gives.
So the decision really comes down to which you value more: maximum coverage and a natural, non-visible result (dual plane, with the training you described being completely fine), or zero animation and fully preserved chest activation (subfascial, accepting a higher visibility risk on a thin frame). The single most useful thing at your next exam is a pinch test of your upper-pole tissue thickness &mdash; that measurement, more than anything, tells you how much coverage you have and will make this choice clear. Be sure to tell your surgeon explicitly about your training priorities so they are built into the plan.
I will also share a real example from my own practice, because I think it is relevant to you. I once had a patient with almost no breast tissue who trained her shoulders and chest heavily; because her skin was so thin, we still chose a dual plane implant for the coverage. When she first went back to the gym she started too heavily, too soon, and began to show an early bottoming-out appearance. She had travelled from abroad for her surgery, and a plastic surgeon in her own country told her she needed emergency surgery. When she came to me, I advised her instead to pause her training, support the breast for a while with a firm band worn under the breast, and then return to exercise gently and infrequently &mdash; and above all to be patient, while reassuring her that I could of course operate if it did not settle. She followed the plan, her complaint resolved on its own after a while, and now, years later, it has never recurred. One patient is of course not a rule, but examples like this do exist &mdash; and I share it so you know that not every early problem needs rushing back into surgery. Wishing you a result like the very best of these examples.

Daniel Barrett, MD · Answer

Dear SamShadowx,

I almost always place implants submuscular. It lowers the rate of capsular contracture significantly. In addition, it looks much more natural because the muscle provides covering over the implant so its not as round on the top. I've also noticed the implants drop less over time when they are protected under the muscle.

Daniel Barrett, MD
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgery
Member, American Society of Aesthetic Plastic Surgery

Jeffrey M. Darrow, MD · Answer

A sub fascial breast augmentation will give you comparable safety profile to a dual plane augmentation and minimize animation during your weight lifting. Subfascial augmentation also preserves the entirety of your pectoral muscle attachments. If, after your sub fascial augmentation, you feel that the edges of your implant are too visible, alloClae a structural adipose filler can be used to soften this appearance. If you are seeking maximal implant coverage and camouflage of the edges, a dual plane would be your choice. Dual planes, performed correctly can have minimal animation deformity. Best wishes.

Ted Eisenberg, DO, FACOS, FAACS · Answer

Dual plane is possible. I have had triple crown body builders, dual plane, return to workouts light at 6 weeks back to full speed by 8 weeks - all to return for competitions. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

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, dual plane augmentation (once healed) will not preclude weight training. Studies have shown a negligible loss of strength post op as it relates to pectoralis function.

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

Semih Yildiz, MD, FEBOPRAS · Answer

Dual-plane placement does not automatically prevent lower-body lifting or moderate shoulder and back training once healing is complete, but the return has to be gradual and cleared by your surgeon. I could not clearly review the full attached photos, so this answer is based mainly on your description.

The tradeoff is coverage versus muscle animation. Dual plane often gives better upper-pole and implant-edge coverage in thinner patients, but heavy pectoralis activation can cause visible movement or distortion. Subfascial placement avoids pectoralis animation, yet it depends heavily on how much soft-tissue coverage you have; in a thin frame, implant visibility or rippling can be more of a concern. If you are willing to avoid heavy chest work, dual plane can still be compatible with lower-body and selected shoulder/back training, but the final choice should be based on tissue thickness, implant size/profile, and your surgeon’s exam.

Damien Grinsell MBBS, FRACS (Plast) · Answer

Hi
In my opinion if you want long lasting results you need to have textured implants under the muscle (or dual plane). Subglandular and subfascial wrinkle more and descend and bottom out over time.
Regards
Damien

Paul E. Chasan, MD, FACS · Answer

Thank you for your question.  I have been in practice for over 30 years, and breast surgery and revision of breast surgery is a large portion of my practice. Although it sounds nice to not have an animation deformity and perform your implants in the subfascial location, the reality is that, over time, your implants will slide down your chest wall.  I have a whole gallery of patients who underwent a subglandular, which really is a subfascial breast augmentation, only to have significant wrinkling or slide down their chest after a couple of years.  There is no perfect operation but placing the implants under the muscle is the lesser of two evils.  Animation deformities are usually quite mild and most patients tolerate really well. I have operated on 100s of figure and fitness competitors, CrossFit, and body builders placing their implants in a dual plane submuscular position with excellent results.  Best wishes to you.

Ira H. Rex III, MD · Answer

It seems you are plastic surgeons have given you a lot of good information and plenty to think about.  There are positive and negative things about many decisions we make in surgery.  There is no reason why you should not be able to return to and aggressive workouts schedule no manner which plane the implants are placed.  Good luck with your surgery.

Gregory T. Lynam, MD · Answer

A Demi Motiva 225- 275 cc size above the muscle would be ok. A 375cc  would not. The key is you soft tissue quality and quantity. A dual plane can sometimes have a ton of animation deformity.
I hope this helps. Good Luck

Sub Facia or Dual Plane - can I do lower body (heavy) and moderate shoulder and back training with dual plane? (Photos)

Answers (14)

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