Breast Augmentation - Dual Plane
Most patients and even surgeons don't really know what is meant by " dual plane ". The simple way to think of it is yes, that implant is under the pectoral muscle up top and below the breast tissue on the bottom. Otherwise known as partially under the muscle. What is actually meant by " dual plane " is that in addition to making the pocket in this location dissection is also performed above the muscle. This plane of dissection is taken up for several centimers and it's purpose is to loosen the muscle from the overlying breast tissue. This technique is supposed to be useful for patients who have slightly droopy breasts where the muscle would restrict the expansion of the overlying droopy breast tissue in an adequate fashion. There are other methods of loosening this breast tissue besides the dual plane technique, but really it is only useful for this specific subset of patients. Most patients don't even need it.
Bottom line is you need to go to someone that does good work. Look at photos ask for a referral from a friend. Asking a surgeon whether or not they do " dual plane " is silly and a waste of time in my opinion. Because really most surgeons haven't read the article so they don't know what it really means. They just assume, as I used to, that it means under the pectoralis muscle.
The question to ask is do you go under the muscle or over the muscle, meaning the pectoralis muscle only. I don't know anyone that does " completely under " the muscle which involves lifting other small muscles.
Let me clarify some terminology that many plastic surgeons themselves misuse.
Submuscular = the implant is COMPLETELY under the muscle with no release of the muscle (rarely done).
Subpectoral = the implant is placed under the pectoralis major muscle, with the inferior edge of the muscle released so that the lower portion of the implant is covered by gland. This is what most people refer to as "submuscular"; however, they are technically incorrect. A classical subpectoral placement is the same as a Dual Plane I.
Dual Plane = a form of subpectoral implantation with varying degrees of muscle release/separation from the gland in order to vary the amount of muscle/gland coverage ratio.
It may be semantics, but semantics are important. In summary, Dual Plane is a form of under the muscle or subpectoral placement.
Understanding "Dual Plane"
Understanding dual plane means you have to understand some basic concepts about the muscle anatomy of the chest wall.
The chest wall muscle important in breast augmentation is called the
pectoralis major muscle….otherwise known as the pec muscle. This muscle extends
from the arm bone, called the humerus, near the shoulder, and attaches to the
chest wall near the midline.
How the implant is placed in relation
to this muscle is important in determining the final long term result.
The implant can be placed in front of
However, most surgeons choose to place
the implants under the muscle which is often referred to as a subpectoral
placement or “unders”.
However, an implant placed under the muscle is never completely covered
by muscle, with the lower part of the implant extending below the lower border
of the muscle.
Dual plane refers to implants that are partially covered by muscle and partially
covered by breast tissue. Therefore, effectively ALL under the muscle implants
are "dual plane".
A standard subpectoral implant pocket is often referred to as a dual
plane type 1 placement.
The placement of the implant in a dual plane type 1 follows several steps:
- The lower end of the pec muscle is identified
and then detached from the chest wall at the lower end to make room for the
implant. However, as the muscle remains attached to the overlying breast tissue
it doesn’t retract, or move too far.
- A space, or pocket, is then created under the
pec muscle large enough to accommodate the chosen implant.
- Once the pocket is created, the implant is then
inserted and positioned.
- In this situation the outer/lower aspect of the
implant is not covered by muscle - "dual plane".
as the muscle remains attached to the breast tissue and close to the lower
curve of the breast, then as this muscle contracts it often pulls the skin in
causing a groove along the lower breast curve. This is referred to as a dynamic
double bubble and is quite common.
Another form of under the muscle implant placement is the dual plane
In this situation, many of the
surgical steps are the same as the dual plane type 1.
- The lower end of the pec muscle is identified.
- However, unlike the dual plane type 1, the
breast tissue is detached from the pec muscle approximately up to the level of
- The space under the muscle is then opened and
the lower end of the pec muscle is detached from the chest wall.
- With the muscle now detached from the both chest
wall and the breast tissue, this segment of the pec muscle retracts upwards.
- With the under muscle pocket created, the
implant is inserted and positioned and the wound is closed.
The dual plane type 2 implant placement results in less of the implant
covered by muscle along the lower half of the implant ….and this can have the
benefit of a fuller more curvaceous underboob.
It also significantly reduces the
potential for a dynamic double bubble as this muscle is no longer close to the
skin along the lower curve of the breast.
One of the negative issues of a dual
plane type 2 approach is that the detached segment of pec muscle is no longer
functional…. so you can expect a slight reduction in pec muscle strength.
However for the majority of people this is not noticeable.
Pros and cons exist for each technique so speak to your plastic surgeon to find out what will give you the best outcome.
Dual Plane Breast Augmentation
Well, we use the term dual plane to refer to a subpectoral breast augmentation. In essence, all subpectoral breast augmentations are dual plane, in that the implant sits both behind the pectoralis major muscle in the upper inner part of the breast, and behind the breast itself in the lower outer part of the breast. There is no pectoralis major muscle coverage in the lower outer part of the breast so all subpectoral augmentations are in essence dual plane. We use the terms dual plane one, two, and three to refer to the level at which the muscle is separated from the breast. All subpectoral augmentations are at least a dual plane one, meaning that the pectoralis major muscle has been released across the entire length of the inframammary fold. We use dual plane two to refer to a situation where the muscle is released up to about the lower border of the areola. Dual plane three is a release to just above the top of the areola. Which level of release you choose depends on: 1) what the patient is starting with, 2) the implant you are using, and 3) the outcome you are trying to achieve.
The dual plane technique incorporates some of the advantages of both the sub glandular and sub muscular techniques while minimizing some of their limitations in the proper setting. When the breast is firm and the nipple areola is in the proper position well above the infra mammary crease then a sub muscular placement is indicated . In the past when there was laxity to the breast tissue envelope and a sub muscular placement was utilized, sometimes the breast would literally fall off the protheses creating pseudo ptosis or a "snoopy nose " appearance which was not ideal.. When the implant is placed sub glandular in these cases this can be avoided.,but over time the implant may become palpable, particularly saline implants. It takes on a round unnatural appearance. The dual plane technique where the top half of the implant is beneath the pectoral muscle and the lower half below the breast better fills the volume with less chance of feeling the implant. It also gives slight elevation to the NAC which sometimes avoids the need for a lift. It is particularly well suited when the lower pole is under developed or tight and the distance from the NAC is short, such as in tubular breast cases. This diminishing a the chance of developing a " double bubble". Many plastic surgeons including myself use some variation in most cases since the result appears more natural.
The "Dual Plane" plane, sub pectoral breast augmentation for tubular/constricted breasts
As Dr. Kim has quite rightly pointed out, that the Dual plane technique involves creating a generous pocket under the pectoralis major muscle while, curiously, separating the upper surface of the pectoralis major muscle from the overlying breast tissue for a few inches. What one ends up with is a loose pectoralis major muscle that covers the superior aspect of the implant similar to an "apron". In this way, the pectoralis major muscle, during the postoperative period of healing, is allowed to find and heal in its own natural resting position relative to the overlying breast tissue.
This technique provides a number of advantages over traditional "under the muscle"/sub pectoral techniques alone.
The first is that this technique allows minimization of flexion/contraction deformity when patients flex their pec muscles while their implants are in the "under the muscle" position.
A second advantage of the "dual plane" technique is realized when a patient has a constricted breast deformity whereby the distance from the lower edge of the areola to the lower breast crease is under 4 cm and their nipple is pointing downwards as a result. This could be part of a tubular breast deformity as well. By performing a dual plane technique in these cases, one can benefit from both the sub pectoral/ "under the muscle" position while having the lower pole of the breast expand maximally to accommodate the breast implant itself. In this way, the implant can sit in its proper position relative to the overlying breast, imparting the most natural result possible in these otherwise difficult cases.
The third advantage was pointed out by one of the other doctors in answering this question. The dual plane technique is appropriate for those breasts that are elongated and "droopy" after children and breast feeding. By fully releasing the muscle and allowing it to act as an apron, the implant can sit in its proper position behind the bulk of the breast (in the standing position) thereby avoiding a high-riding breast implant in which the breast tissue seems to just hang like a "double chin" off the implant itself. However, though the dual plane technique provides a very natural result in these cases, the patient may feel that they are now more droopy and have a "rock-in-a-sock" appearance to their breasts. A breast lift or mastopexy should be performed at the same time if the patient is amenable to the extra scarring.
What is the dual plane method for breast augmentation?
Great question ! It looks like you are really doing your homework. 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. Good luck
Not ideal for all patients, but helpful if you have mild sag.
Dual plane breast augmentation is one of the many options
available for patients undergoing breast augmentation surgery.This procedure offers significant benefits
for patients with specific anatomic findings and aesthetic goals.
not unusual for plastic surgeons to encounter patients who have breast
hypoplasia associated with mild breast sag.These patients want larger breasts but don’t want the scarring that’s
frequently seen with breast lift surgery.
these circumstances, dual plane breast augmentation offers significant
advantages.This procedure creates a
pocket beneath the pectoralis muscle as well as a separation between the muscle
and the overlying breast tissue.This
results in the implant having muscle coverage superiorly and breast tissue
covering the implant inferiorly.
configuration allows the breast tissue to cover the implants in a more natural
way.It avoids the need for a breast
lift and avoids a snoop dog or double bubble deformity.In addition, the patient continues to have
the advantages of submuscular implant placement including a decreased risk of
you’re considering breast augmentation and have mild breast sag, you may be an
excellent candidate for this procedure.Under these circumstances, it’s important to consult a board certified
Dual plane breast augmentation
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.
What is the dual plane method for breast Augmentation?
We commonly choose to place the implant under the pectoralis muscle in order to provide more coverage over the upper portion of the implant and hide potential implant edges and wrinkles from being visible. The pectoralis muscle does not extend all the way down to the inframammary crease, where the bottom of the implant rests. Therefore, the muscle may only cover the upper 2/3 to 3/4 of the implant, depending on your anatomy, but this is where the extra coverage is most important. However, there are times when a patient needs the implant to "expand" into the lower pole of the breast and the muscle and the connections between the muscle and the overlying breast tissue may prevent the implant from fully doing this. One example is in patients who have loose, mobile breast tissue and it may tend to "hang" off of the underlying implant if the muscle is not released a bit from the overlying breast tissue by the "dual plane" technique and the implant allowed to expand into the lower pole of the breast. Another example is in patients who have a constricted or tuberous breast with a deficient, tight lower pole. The dual plane release allows the muscle to move up a bit and encourages the implant to stretch and expand that tight lower pole of the breast.