What Are the Advantages/disadvantages to a Dual Plane Technique Vs. Completely Under the Muscle for Breast Augmentation?

Total submuscular augmentation is essentially obsolete at this point.  The vast majority of plastic surgeons use the dual plane technique for a much nicer result.

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.

Dual plane breast augmentation simply means that the implant is placed partially under the muscle. Just the top portion of the implant is put under the chest muscle, while the rest of the implant is only under the glandular tissue. True sub muscular placement involves the implant being placed entirely under the muscle, and this is usually only done for breast reconstruction patients because of its related risks.Dual plane is very common because it provides greater coverage. It is also better supported, slowing the rate of sagging.

Today, the terms "Dual Plane" and "submuscular" are essentially interchangeable in breast augmentation surgery. The bottom of the pectoralis muscle sits above the bottom of the breast. Unless this is released, a breast implant will sit too high and the nipple will typically point downwards. Don't allow these terms to confuse you.

Almost all women need the dual plane approach because the pec sits up a bit too high in most women. It needs to be released to allow the implant to drop down just a bit. If not, the implants sit just a bit high and the nipple too low. You can see many examples of this on this site. The only time I consistently leave full muscle coverage of the implant is when I am doing a lift as well. Then I can bring the breast tissue up to the implant!

For cosmetic breast augmentation the implant is never placed completely under the muscle. In the past, total muscle coverage was performed routinely during tissue expander & implant reconstruction for breast cancer; the tissue expander was placed behind the pectoralis major and serratus muscles. This method has been replaced by placing the tissue expander behind the pectoralis muscle and using an acellular dermal matrix sling to support the bottom of the expander. It provides a more comfortable and aesthetic result, and expansion is easier and faster.

A breast implant could be placed almost totally submuscular if the inferior origins of the pectoralis muscle were not released. A portion of the implant would still remain uncovered by the muscle and the implant would be positioned too high on the chest wall.

In a “dual-plane” pocket the implant is placed beneath the pectoralis major muscle, but it lies partially behind the muscle and partially behind the breast gland – thus in two different planes. The upper and medial portion of the implant is covered by the pectoralis major muscle, while the lateral and lower portion of the implant is covered only by breast tissue. A dual-plane pocket is the most common position used when a breast implant that is placed beneath the muscle.

The pectoralis major muscle origins arise from the ribs (inferior origins), the sternum (medial origins), and the clavicle (superior insertions); the muscle inserts on the humerus in the upper arm. The anterior surface of the pectoralis major muscle is attached to the posterior surface of the breast tissue.

To create a dual-plane pocket, the inferior origins of the pectoralis major muscle are released from the ribs along the inframammary crease. This muscle release extends from the lateral border of the muscle (near the lateral inframammary crease), continues along the inframammary crease, and then stops at the medial aspect of the inframammary crease leaving the medial muscle origins from the sternum uncut.

The “dual-plane” sub-pectoral dissection is further classified, into three types, based upon the amount of additional muscle release (from the undersurface of the breast gland) that is performed. The ‘dual-plane I’ technique involves no additional pectoralis muscle release, the ‘dual-plane II’ involves some release, and ‘dual-plane III’ involves the most pectoralis muscle release from the undersurface of the breast gland.

In a ‘dual-plane I’ augmentation the lower origins of the pectoralis muscle are released from the ribs along the inframammary crease. No additional dissection is performed between the breast tissue and the pectoralis muscle.

In a ‘dual-plane II’ augmentation the lower origins of the pectoralis muscle are released from the ribs along the inframammary crease. Dissection is then performed behind the breast gland (up to the level of the inferior border of the areola), to separate the attachments to the pectoralis muscle.

In a ‘dual-plane III’ augmentation the lower origins of the pectoralis muscle are released from the ribs along the inframammary crease. Dissection is then performed behind the breast gland (up to the level of the superior border of the areola), to release the attachments to the pectoralis muscle. In a ‘dual-plane III’ augmentation more of the pectoralis muscle is separated from the posterior surface of the breast gland.

The ‘dual-plane I’ pocket allows the least amount of contact and interaction between the breast implant and the posterior surface of the breast gland. The ‘dual-plane I’ technique is used for the more routine breast augmentations and is the most common form of dual-plane dissection. The ‘dual-plane I’ pocket allows for greater muscle coverage of the implant.

The ‘dual-plane II’ and ‘dual-plane III’ techniques alter the dynamics between the breast implant and the overlying tissues by repositioning a portion of the pectoralis major muscle relative to the breast implant --This in turn alters how the implant interacts with the overlying breast.  In other words, the ‘dual-plane II’ and ‘dual-plane III’ techniques allow the inferior border of the pectoralis major muscle to move upward and exposes more of the breast implant to the posterior surface of the breast gland. This allows the breast implant more direct force and interaction with the breast tissue. The ‘dual-plane II’ technique is used for patients that have more mobility of the breast tissue over the top of the pectoralis major muscle. The ‘dual-plane III’ technique is used for patients that have more drooping breasts, constricted lower poles, or tuberous breast deformity.

I hope you find this helpful. I have tried to explain this as best I could without the benefit of anatomic drawings.

Best wishes, Ken Dembny

Great question!When a patient presents with a small amount of breast ptosis (sag) a dual plane breast augmentation is a very effective technique to help avoid the need for a breast lift and still allow the implant to be placed under the muscle. When an implant is placed under the muscle and the overlying breast has some degree of sag the muscle will hold the implant back and not allow it to fill the loose tissue at the bottom of the breast The word dual means two and the word plane refers to the natural separation between two layers of tissue. In the breast there is a natural separation between the breast tissue and the underlying muscle. During a dual plane augmentation the breast tissue in the lower part of the breast is separated from the underlying muscle. The muscle is then released along its entire attachment at the bottom of the breast. The muscle then moves upward like a window shade toward the nipple. With the restriction of the muscle in the lower part of the breast removed the implant is then allowed to fill the loose sagging part of the lower breast. This is a very effective technique to help prevent the need for a breast lift in a patient with a small amount of sag and still have a benefits of an implant placed under the muscle. This technique is also very helpful in the treatment of other conditions with constriction in the lower part of the breast.

An implant placed above the muscle is referred to as ‘sub-mammary’ (or ‘sub-glandular’), while an implant placed under the muscle is referred to as ‘sub-pectoral’ (or ‘sub-muscular’).The muscle in question is the pectoralis major.The term ‘sub-pectoral’ or ‘sub-muscular’ is somewhat misleading, as implants placed under the pec major are only partially covered by the muscle.The pec major covers the upper/medial half of the breast area, so a ‘sub-pectoral’ implant is truly subpectoral only in the upper and medial aspect of the augmented breast, while the lower and lateral aspect of the implant is actually in a sub-mammary position.Because sub-pectoral implants are, in reality, both sub-pectoral (upper/medial breast) and sub-mammary (lower/lateral breast), this placement has more recently been referred to as a ‘dual plane’ approach to breast augmentation.There is also ‘total submuscular’ implant placement, in which the implant is positioned behind the pec major and the serratus anterior muscle, so that the entire implant surface is covered by muscle tissue.This is not commonly done for cosmetic breast augmentations, but has been used for breast reconstruction using breast implants.

Your skin quality is the main determinant of location and so the best person to answer this question is your plastic surgeon. In my practice a majority of women get submuscular or dual plane implants and especially in those women who have lost weight. The skin has lost volume and elasticity and as such cannot bear the weight of the implant. In dual plane t implantis partly under te muscle a partly subglandular in the lower pole.

Dual plan positioning of a breast implant allows for a natural appearance for an augmentation by allowing the implant to sit in the appropriate position on the chest wall. The pectoralis muscle is used for improved camouflage of an implant in a small breasted woman, to decrease capsular contracture rate, and to improve vascularity of the breast and nipple in cases of augmentation mastopexy. Unfortunately, the pectoralis major muscle does not always line up anatomically with the overlying breast and the resultant inframammary fold. By dividing the inferior attachments of the muscle and placing the implant where the breast is (rather than where the pectoralis is) the augmentation has a much more natural look.