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Breast Augmentation
72. Tebbetts JB. Achieving a predictable 24-hour return
to normal activities after breast augmentation: Part II.
Patient preparation, refined surgical techniques, and
instrumentation. Plast Reconstr Surg. 2002;109:293 – 305;
discussion 306 – 297.
73. Alderman AK, Collins ED, Streu R, et al. Benchmarking out-
comes in plastic surgery: National complication rates for
abdominoplasty and breast augmentation. Plast Reconstr
Surg. 2009;124:2127 – 2 1 3 3 .
74. Pitanguy I,
Relative implant volume and sensibility alterations after breast augmentation. Aesthetic Plast Surg.
2007;31:238 – 243.
75. Okwueze MI, Spear ME, Zwyghuizen AM, et al. Effect of
augmentation mammaplast
Reconstr Surg. 2006;117:73 – 83; discussion 84.
76. Ghaderi B, Hoenig JM , Dado D, Angelats J, Vandevender D.
Incidence of intercostobrachial nerve injury after transaxillary breast augmentation. Aesthet Surg J. 2002;22:
26 – 32.
77. Center for Devices and Radiological Health, U.S. Food
and Drug Administration. FDA update on the safety of
silicone gel-filled breast implants, June 2011. Available
at: http://www.fda.gov/downloads/MedicalDevices/Pro
ductsandMedicalP
BreastImplants/UCM260090.pdf. Accessed February 21,
2012.
78. Cunningham B. The Mentor core study on Silicone
MemoryGel breast implants. Plast Reconstr Surg. 2007;
120:19S – 2 9 S; discussion 30S – 3 2 S.
79. Cunningham B
Mentor’s MemoryGel implants at 6 years. Aesthetic Plast
Surg. 2009;33:440 – 444.
8 0 . Spear SL, Low M, Ducic I. Revision augmentation masto-
pexy: Indications, operations, and outcomes. Ann Plast
g. 2003;51:540 – 546.
Sur
8 1 . Chasan PE. Breast capsulorrhaphy revisited: A simple
technique for complex problems. Plast Reconstr Surg.
2005;115:296 – 301; discussion 302.
8 2 . Shestak KC. Acellular dermal matrix inlays to c orrect signif-
icant implant malposition in patients with compromised
local tissues. A
8 3 . Maxwell GP, Gabriel A. Acellular dermal matrix in aes-
thetic revisionary breast surgery. Aesthet Surg J. 2011;31
(7 Suppl):65S – 76S.
8 4 . Stev
ens WG, Pacella SJ, Gear AJ, et al. Clinical experience
with a fourth-generation textured silicone gel breast
Vaena M, Radwanski HN, Nunes D, Vargas AF.
y on breast sensation. Plast
rocedures/ImplantsandProsthetics/
, McCue J. Safety and effectiveness of
esthet Surg J. 2011;31(7 Suppl):85S – 9 4 S.
implant: A review of 1012 Mentor MemoryGel breast
implants. Aesthet Surg J. 2008;28:642 – 647.
8 5 . Collis N, Sharpe D
implant capsular contracture: Anterior versus total cap-
sulectomy. Plast Reconstr Surg. 2000;106:792 – 797.
8 6 . Maxwell GP, Gabriel A. The neopectoral pocket in revi-
sionary breast surgery. A
8 7. Spear SL, Carter ME, Ganz JC. The correction of capsular
contracture by conversion to “dual-plane” positioning:
Tec hnique and outcomes. Plast Reconstr Surg. 2006;118
(7 Suppl):103S – 1 1 3 S; discussion 114S.
Lee HK, Jin US, Lee YH. Subpectoral and precapsular
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implant repositioning technique: Correction of capsular
contracture and implant malposition. Aesthetic Plast Surg.
2011;35:1126 – 1132.
8 9 . Baker JL Jr, Chandler ML, LeVier RR. Occurrence and
activity of myofibroblasts in human capsular tissue
surrounding mammary implants. Plast Reconstr Surg.
1981;68:905 – 912.
9 0 . Scuderi N, Mazzocchi M, Rubino C. Effects of zafirlukast
on capsular contracture: Controlled study measuring the
mammary compliance. Int J Immunopathol Pharmacol.
2007;20:577 – 5 8 4 .
9 1 . Reid RR, Gr
(Accolate) on early capsular contracture in the primary
augmentation patient: A pilot study. Aesthet Surg J.
2005;25:26 – 30.
9 2 . Schlesinger SL, Ellenbogen R, Desvig
Heck R. Zafirlukast (Accolate): A new treatment for capsular contracture. Aesthet Surg J. 2002;22:329 – 336.
9 3 . Huang CK, Handel N. Effects of Singulair (montelu-
kast) treatment for capsular contractur
2010;30:404 – 408.
9 4 . Gryskiewicz JM. Investigation of Accolate and Singulair
for treatment of capsular contracture yields safety concerns. Aesthet Surg J. 2003;23:98 – 101.
9 5 . Cash TF, Duel LA, Perkins LL. Women’s psychosocial out-
comes of br
implants: A 2-year prospective study . Plast Reconstr Surg.
2002;109:2112 – 2121; discussion 2122.
9 6 . Young VL, Watson ME, Boswell CB, Centeno RF. Initial
results from an online breast augmentation sur
Aesthet Surg J. 2004;24:117 – 1 3 5 .
9 7. Pusic AL, Reavey PL, Klassen AF, Scott A, McCarthy C,
Cano SJ. Measuring patient outcomes in breast augmentation: Introducing the BREAST-Q augmentation module.
Clin Plast Surg. 2009;36:23 – 32, v.
eve SD, Casas LA. The effect of zafirlukast
east augmentation with silicone gel-filled
T. Recurrence of subglandular breast
esthet Surg J. 2008;28:463 – 467.
ne MN, Svehlak S,
e. Aesthet Surg J.
vey.
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Breast Augmentation
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APPENDIX
BREAST AUGMENTATION: INFORMED
CONSENT (SAMPLE)
This information is provided to inform you of the
risks and potential pr
oblems associated with breast augmentation. A complete discussion includes advising you
of the alternative treatments available, which in the case
of breast augmentation consists only of wearing padded
bras. Please initial this paragraph and each one that follows as you read through this information.
Initial: ______
There are a variety of potential problems associated
with breast augmentation. Some of these, like bleeding
and infection, occur in the early postoperative period and
are rare. Anesthesia related problems can occur although
none have in my personal experience. Most other
problems are associated with the implants themselves.
While the surgeon has control over implant placement,
least six months to be certain the infection is eradicated
and all inflammation in the tissues has subsided. The
implant can usually be successfully replaced when conditions are optimal.
Initial: ______
Scar tissue, which normally forms internally around
the breast implant, can sometimes tighten and make the
breast round, firm, and even painful. Excessive firmness
of the breasts is called capsular contracture. It can occur
soon after surgery or years later and happens in approximately 5percent of women. There are no known factors
on which its development can be predicted. Treatment
for capsular contracture may require surgery to remove
the scar tissue and replace the implant. This treatment
is usually but not always successful. The need to permanently remove implants because of persistent capsular
contracture is rare.
Initial: ______
size selection, and implant positioning, factors such as
how you heal, how much tissue you have to help conceal
the implants, and your skin elasticity can all influence
the final result. Sometimes these factors can have a
delayed adverse eect on an excellent early result. While
any of these problems can occur, the chance of having
a problem that requires additional surgery is small,
approximately 5%. The majority of problems that can
occur and require further surgery are correctable. The
likelihood of having to remove the implants and not
replace them is very rare. Implant problems are aesthetic
in nature and generally do not have health implications
beyond this.
Initial: ______
Bleeding within the implant pocket after surgery may
result in a hematoma if it accumulates in sucient volume.
This requires return to the operating room to remove it.
The occurrence of a hematoma has been linked to the
later development of capsular contracture (see below)
in some cases. The cause for most hematomas is rarely
found although asymptomatic bleeding disorders such as
von Willebrand’s disease or the lingering eects of cer-
Some change in nipple sensation is not unusual right
after surgery. After several months, most patients have
normal sensation. Partial or permanent loss of nipple
and skin sensation may occur occasionally. The larger
the implant, the more chance of overstretching the nerve
to the point where sensation is lost. Numb skin following breast augmentation generally resolves completely
after several months but may be permanent. Women
who have armpit incisions may develop small areas of
numbness on the inside of the upper arm.
Initial: ______
Excessive incision scarring is very uncommon. Most
scars heal as fine white lines. They are inconspicuous
but never disappear completely. Scars may be red, thick,
and/or lumpy in rare cases. They may benefit from
surgical scar revision at the appropriate time (after one
year). A band of scar tissue that looks like a cord can
develop in the armpit in those having armpit incisions.
This results from failure to stretch the arms adequately
after surgery and can be treated.
Initial: ______
tain medications such as aspirin, ibuprofen, or homeopathics can be causative.
Initial: ______
All breast implants eventually require replacement.
Most last 10 years although sometimes they last much
longer. Breast implants, like other medical devices,
can fail. Sometimes this happens prematurely, before
Infection is unusual after breast augmentation but
can occur. Antibiotics are given intravenously during
surgery to prevent it. If an infection should develop it
usually requires removal of the implant in order to treat
it eectively. The implant is usually not replaced for at
45
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10 years. When a saline-filled implant deflates, the
salt water it contains will be harmlessly absorbed by
the body. Deflation can occur as a result of an injury
or from no apparent cause. Theoretically they can be
ruptured during mammography although I have never
Breast Augmentation
seen this. Deflated saline implants require surgery for
replacement.
Initial: ______
Lack of adequate tissue coverage or infection may
result in exposure of the implant. This means that a
small portion of the implant is directly visible through
the skin incision. This is most likely to occur in thin
women having a lift combined with an augmentation.
The reason for this is that the implant pocket lies close
to the overlying incisions used to lift the breast and this
constitutes a potentially weak area of the wound. Smoking has an adverse eect on wound healing. It may contribute to the development of implant exposure and to
capsular contracture.
Initial: ______
may require insertion of a chest tube. Clots can develop
in the leg veins during surgery and possibly lead to the
development of a pulmonary embolus (1 in 10,000).
Inflatable boots are placed on the legs during surgery to
help minimize the chance of developing leg vein clots.
Initial: ______
Current research indicates that the risk of breast
cancer is not increased in women who have breast augmentation. However, breast disease can occur independently of breast implants. It may be more dicult for
mammograms to fully visualize the breast tissue following breast augmentation. The implant compresses the
normal breast tissue which may make it more dicult
to see detail and the implant itself may obscure some
tissue from being seen at all. However, most experienced
radiologists can obtain a satisfactory exam using special
Visible and palpable wrinkling of implants can occur,
most commonly in very thin women with little breast
tissue. Almost all women can feel the implants close to
the skin on the side and bottom of the breast. This is
normal. Cases of extreme wrinkling, which are rare,
may require surgery to exchange saline implants for a
silicone gel type. While this yields an improved result in
most, it may not solve the problem completely in very
thin women.
Initial: ______
It is not believed that breast implants aect the ability to breast feed. The implants are located behind the
breast tissue and do not interfere with the duct system in
the gland. Most women who have breast implants have
a small amount of breast tissue to begin with and my
not be able to breast feed even without implants.
techniques. Self-examination of the breast is not aected
by the presence of breast implants. Other methods to
detect breast disease such as ultrasound and MRI are
not aected by breast implants. Studies have been done
comparing women with breast implants who develop
breast cancer with those who do not have implants.
There is no increase in severity of the disease or long
term prognosis in those who have implants compared to
those who do not.
Initial: ______
A rare form of lymphoma called anaplastic large cell
lymphoma (ALCL) has been reported in patients with
breast implants (34 known cases worldwide out of as
many as 5 to 10 million patients). This appears to be
a low grade malignancy that responds to a variety of
treatments. There have not been any deaths reported
Initial: ______
Displacement or migration of a breast implant from
its original position may occur. This most commonly
occurs in women over thirty years of age who have had
multiple pregnancies. The bottom of the breast may
stretch in these cases due to either thin or poor quality
skin or lack of bra support. The breasts look too low
when this happens and may require further surgery to
correct the problem.
Initial: ______
Both local and general anesthesia involve risk, though
small. The risk of death from anesthesia is estimated to
be one in 250,000. A collapsed lung (pneumothorax)
can occur during the course of creating an implant
pocket as a result of a small tear in the very thin tissue
from this rare entity and the exact nature of the association with breast implants is under active investigation.
Initial: ______
Fluid may accumulate around an implant (seroma)
following surgery and make the breast larger on one
side. This most commonly occurs in patients who are
having more involved surgery to replace old, neglected
implants. Treatment of seroma often requires additional surgery that may include temporary removal of
the implant until the fluid buildup resolves.
Initial: ______
Some women with breast implants have reported
symptoms similar to those of known diseases of the
immune system, such as systemic lupus erythematosis, rheumatoid arthritis, scleroderma, and other
that lies between the ribs. Treatment of this condition
46
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arthritis-like conditions. To date, there is no scientific
Breast Augmentation
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evidence that women with either silicone gel-filled or
saline-filled breast implants have an increased risk of
developing these diseases.
Initial: ______
It is possible that you may be disappointed with the
results of surgery. Asymmetry in implant placement,
breast shape, and size may occur after surgery. Unsatisfactory surgical scar location or displacement may occur. Pain
may occur following surgery. It may be necessary to perform additional surgery to improve your results. Women
with breasts that hang, are flat, and have very downward
pointing nipples are extremely challenging cases and are
the type most likely to require revisional surgery.
Initial: ______
Implant size selection is guided by a preoperative siz-
of various sizes into a larger bra to simulate a spectrum of
possible results. This method is very helpful but is not infallible. Fortunately, second procedures to change implant
size prove necessary in less than onepercent of patients.
Initial: ______
Other very rare problems can occur with breast augmentation that are impossible to predict or enumerate
completely. Despite all of the issues discussed above, most
women have one operation until the time of eventual
implant replacement, and are pleased with their results.
Initial: ______
I have read all of the above and have had the opportunity to discuss these issues to my satisfaction.
Signature: ___________________________________
ing technique where the patient places sample implants
Date:_____________
47
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COSMETIC
Journal
e
Vie
cle
View Article
Dual Plane Breast Augmentation: Optimizing
Implant – Soft-Tissue Relationships in a Wide
Range of Breast Types
John B. Tebbetts, M.D.
Dallas, Texas
Summary: In breast augmentation, surgeons usually choose a pocket location for the implant behind breast parenchyma (retromammary), partially
behind the pectoralis major muscle (partial retropectoral), or totally behind
pectoralis major and serratus (total submuscular). Each of these implant
pocket locations has specific indications, but each also has a unique set of
tradeos. When applied to a wide range of breast types, each pocket location has limitations. Glandular ptotic and constricted lower pole breasts oer
unique challenges that often are not solved without tradeos when using a
strictly retromammary, partial retropectoral, or total submuscular pocket.
This article describes specific indications and techniques for a dual plane
approach to breast augmentation in several dierent breast types, introducing techniques that combine retromammary and partial retropectoral pocket
locations in a single patient to optimize the benefits of each pocket location
while limiting the tradeos and risks of a single pocket location. A total of 468
patients had dual plane augmentation between January of 1992 and March
of 1998 using the specific techniques of dual plane augmentation described
in this article. All patients were treated as outpatients and received general
anesthesia. Indications, operative techniques, results, and complications for
this series of patients are presented. Dual plane augmentation mammaplasty
earch
ind a Previous Issu
w Arti
hree implant pocket locations are commonly used
in augmentation mammaplasty: (1) behind breast
T
the pectoralis major muscle (partial retropectoral,
(3) totally behind pectoralis major and serratus (total
submuscular).
Received for publication August 4, 2000.
Dr. Tebbetts is a consultant to McGhan Medical Corporation,
manufacturer of one of the types of saline-filled breast implants
used in this study.
Reprinted and reformatted from the original article published
with the April 2001 issue ( Plast Reconstr Surg.
2001;107:1255 – 1272).
Copyright ©2012 by the American Society of Plastic Surgeons
parenchyma (retromammary),1 (2) partially behind
10 – 12
Other authors
13 – 17
adjusts implant and tissue relationships to ensure adequate soft-tissue coverage while optimizing implant – soft-tissue dynamics to oer increased benefits
and fewer tradeos compared with a single pocket location in a wide range
of breast types. (Plast. Reconstr. Surg. 107:1255,2001.)
2 – 9
or
have addressed the
relative benefits and tradeos of implant pocket location with respect to capsular contracture rates. This
article presents techniques that allow two pocket planes
(dual plane) to be developed in a single patient, adjusting
the implant and tissue relationships to ensure adequate
soft-tissue coverage while optimizing implant – soft-tissue
dynamics, to oer increased benefits and fewer tradeos
compared with a single pocket location in a wide range
of breast types.
Each of the previously listed implant pocket locations
has specific benefits and indications, but each also has
unique tradeos in specific breast types. For example,
in a glandular ptotic breast with thin soft tissues in the
superior pole of the breast, a partial retropectoral or
total submuscular pocket location provides the neces-
DOI: 10.1097/PRS.0b013e318269b129
48
sary additional soft-tissue coverage superiorly but risks a
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Dual Plane Breast Augmentation
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“double-bubble” deformity resulting from parenchyma
sliding inferiorly o the pectoralis and implant. A constricted lower pole breast in a thin patient needs additional coverage superiorly, but muscle coverage inferiorly
restricts optimal expansion of the constricted lower pole.
Because each pocket location has unique advantages
and tradeos, applying a single pocket location to every
primary augmentation may risk unnecessary compromises. Patients vary widely in soft-tissue characteristics,
breast tissue, and their willingness to accept specific
tradeos. When a surgeon uses only one pocket location for all primary breast augmentations, it is logical
that compromises, complications, or less-than-optimal
results will occur, because a single pocket location does
not completely address the range of anatomic variations
and implant – soft-tissue dynamics that occur in a wide
range of breast types. Even if a surgeon chooses the
the implant (this criterion distinguishes dual plane
from partial retropectoral augmentation).
3. The parenchyma-muscle interface is specifically
altered to change the soft-tissue relationships
between pectoralis major and parenchyma and to
change the implant-parenchyma dynamics.
Two anato mic e nti tie s lar gel y con trol the po sit ion o f
the pectoralis major muscle relative to a breast implant:
(1) the origins of the muscle along the inframammary fold
inferiorly and the sternum medially, and (2) the attachments of the pectoralis to the breast parenchyma at the
parenchyma-muscle interface. To alter the position of
the pectoralis major muscle relative to the implant, the
surgeon divides origins of the pectoralis along the inframammary fold. The muscle then retracts superiorly until
its superior retraction is stopped by attachments at the
most appropriate of the three pocket locations (retromammary, partial retropectoral, total submuscular) for
a given patient, tradeos can still occur. For example,
none of the three common pocket locations is optimal
for the glandular ptotic breast or a constricted lower
pole breast in a thin patient. Even in routine breast
types without specific deformities, a surgically controlled
combination of pocket locations can potentially maximize the benefits and minimize the tradeos of a single
pocket location.
This article addresses two questions:
1. Can a combination of pocket locations in the same breast
(dual plane; combination of retromammary and partial retropectoral) increase the benefits and decrease the trad-
eos of a single pocket location, increase surgical
control and predictability of the result, and minimize the tradeos, risks, and complications?
2. When additional muscle coverage is indicated, can
the surgeon adjust the anatomic position of the pectora-
lis major muscle relative to the implant to better control the
implant – soft-tissue dynamics for an optimal result?
parenchyma-muscle interface or by remaining muscle
origin attachments along the sternum.
In dual plane augmentation, the surgeon alters the
position of portions of the pectoralis major muscle by
(a) selectively dividing the inferior origins of the pectoralis along the inframammary fold only, with no muscle
division along the sternum; and (b) freeing the attachments
of parenchyma to muscle at the parenchyma-muscle
interface by dissecting in the retromammary plane between
the parenchyma and the pectoralis. These two maneuvers are performed at dierent times and to dierent degrees,
depending on incisional approach, breast type, tissue
characteristics, implant – soft-tissue dynamics, and the
surgeon’s preferences.
CLINICAL CRITERIA AND METHODS
Each patient’s preoperative breast-envelope characteristics w
ere clinically characterized as tight, normal,
or excessively compliant (genetically or postpregnancy).
Areola-to-inframammary-fold distance, sternal-notchto-nipple distance, base width of the breast, and intermammary distance were measured and recorded
preoperatively and at each postoperative visit. Soft-
DEFINITION OF DUAL PLANE
AUGMENTATION
Dual plane augmentation is defined as any augmen-
tation that meets the following three criteria:
tissue pinch thicknesses of the upper pole and at the
inframammary fold was measured with calipers. The
position of the lower border of the pectoralis was noted
pre-operatively and postoperatively by palpation and
visualization while the patient contracted the pectoralis.
1. The implant lies partially behind the pectora-
lis major muscle and partially behind the breast
The pocket location for the implant was chosen based
on the criteria described below in order of priority.
parenchyma (in dual planes simultaneously).
2. A specific group of pectoralis major muscle ori-
gins are totally divided in a specific area to alter
implant – soft-tissue dynamics by anatomically repositioning portions of the pectoralis major relative to
49
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Adequacy of Soft-Tissue Cover
Adequate soft-tissue cover over an implant is mandatory in both primary and reoperation cases. In primary cases, adequacy of soft-tissue cover in the upper
Dual Plane Breast Augmentation
breast was assessed clinically by isolating the breast
parenchyma inferiorly and firmly pinching the soft tissues superior to the parenchyma (Fig.1, left) to quantitate soft-tissue pinch thickness of the upper pole. If
this pinch thickness was 2 cm or greater, the patient was
oered a retromammary pocket location, provided that
an adequately filled, textured, anatomic implant was
used. Soft-tissue pinch thickness was also measured
immediately inferior to the inframammary fold (Fig.1,
right). If this pinch thickness was less than 0.4 cm, pectoralis
major origins along the inframammary fold were left
intact for additional soft-tissue coverage, and the patient
was excluded from this study.
If the patient preferred a round implant, smooth or
textured, the potential upper pole collapse of the round
implant filled to the manufacturer’s recommendations
necessitated a partial retropectoral pocket to minimize
were honored provided that adequate soft-tissue cover
was present. If <2 cm of pinch thickness was present
superior to the breast parenchyma, the patient was
required to accept muscle coverage in the upper breast
to ensure adequate coverage with any type of implant,
or the patient was not operated on. Pocket locations with
potential benefits and tradeos included in the information materials and discussed with each patient are listed
in Table1.
Tab le 2 lis ts the pot ential b enefits an d t rad eos of
the dual plane pocket location compared with strict retromammary or partial retropectoral pocket locations
described in Table1.
In this series of patients, when inadequate soft-tissue
coverage (<2 cm pinch thickness) was present superior
to the breast parenchyma, upper pole muscle coverage
was mandatory. When muscle coverage was indicated
risks of visible underfill rippling. If the patient requested
a markedly bulging upper breast with a step-o (the
“Baywatch” breast), she was encouraged to select either
an overfilled round implant, a larger round implant
filled to the manufacturer’s recommendations, or a
larger anatomic implant. Tradeos that all patients were
required to accept by informed consent included the
possibility of an increased (a) risk of a visible or palpable implant edge, (b) capsular contracture rate resulting
from increased implant exposure to parenchyma, and
(c) interference with mammographic interpretation as
implant contact with parenchyma increased.
Patient Preference
If a patient preferred one pocket location over
another, the tradeos and risks of that pocket location
were discussed with the patient, and the patient’s wishes
or preferred by the patient, three options were discussed:
(1) partial retropectoral (with pectoralis origins intact
along the inframammary fold and sternum), (2) total
submuscular (adding serratus laterally for total muscle
coverage), and (3) dual plane (with complete division
of pectoralis origins along the inframammary fold, not
along the sternum). The goal of the dual plane approach
was to optimize the benefits while limiting the tradeos
of the retromammary, partial retropectoral, and total
sub-muscular approaches. Patients who elected the dual
plane pocket location after considering all alternatives
were included in this study. Preoperatively, all patients,
regardless of tissue thickness, were advised of the following
in informed-consent documents:
1. If you can feel your ribs with your finger, beneath
the breast or at the side of your breast, you will be
50
Fig. 1. Soft-tissue pinch thickness of the upper pole (left)andimmediatelyinferiortothein-
framammary fold (right)iscaliper-measuredwithafirmpinchoftheskinandsubcutaneous
tissue.
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Dual Plane Breast Augmentation
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Table 1. Alternative Pocket Locations with Potential Tradeoffs
Pocket Tradeoffs Potential Benefits
Retromammary 1. Increased risk of edge visibility or
palpability.
2. Possible increased interference with
mammography.
3. Possible increased incidence of capsular
contracture.
Partial retropectoral (without
dividing pectoralis origins
along the inframammary
fold)
Total submuscular 1. All tradeoffs listed above for partial
1. Lateral implant displacement over time,
widening the space between the breasts.
2. Less control of upper medial fill.
3. More postoperative tenderness and a more
prolonged recovery.
4. Distortion of breast shape with pectoralis
contraction.
5. Less precise control of inframammary fold
position, depth, and configuration. This
potential tradeoff is minimized or
eliminated by division of pectoralis origins
along the inframammary fold in patients
who have adequate soft-tissue coverage.
6. Increased risk of superior implant
malposition or displacement (when
inferior pectoralis origins across
inframammary fold are not divided).
7. Longer time required for deepening of
the inframammary fold (when pectoralis
origins along the inframammary fold are
not divided).
retropectoral, plus:
2. Highest risk of superior implant
displacement or malposition.
3. Longer operative time.
4. Longest postoperative recovery and
morbidity.
5. Least accurate and predictable
inframammary fold and longest to achieve
depth.
6. Greatest risk of inframammary fold
irregularities, lateral flattening, and fold
level inaccuracies.
1. Increased control of breast shape.
2. Usually a more rapid
postoperative recovery.
3. Minimal or no distortion with
pectoralis contraction.
4. Increased control of
inframammary fold position and
shape.
1. Muscle coverage mandatory if
pinch thickness !2 cm above
breast parenchyma.
2. Possibly more accurate
mammograms.
3. Less risk of palpable or visible
implant edges.
4. Possible decreased risk of capsular
contracture (small difference with
saline-filled implants, greater
difference with silicone gel-filled
implants).
1. Possible increased coverage
inferolaterally but clinically no
significant additional cover
long-term.
able to feel the edge of your implant beneath your
breast and at the side of your breast.
2. Currently manufactured implants that strive to
achieve durability of the shell have a thicker shell
to prolong the life of your implant, and a thicker
shell may be easier for you to feel.
3. If feeling an edge of an implant shell could be a
problem for you, do not have an augmentation.
4. We cannot change the quality or thickness of your
tissues. If you are thin or have very little breast tissue, you will be more likely to feel your implant.
5. The larger your implant, the worse your breast
will look over time. A larger implant will stretch
your tissues over time and will cause more tissuethinning and sagging than a smaller implant. Your
tissues do not improve with age, and they will be
less able to support the additional weight of any
6. Any implant, if filled adequately to prevent collapse and possible folding of the shell when you
stand, will feel firmer than a normal breast, regardless of the filler material. If the implant shell folds,
it could fail sooner and require you to have a reoperation sooner18 (most patients accept a firmer
breast in exchange for a possibly longer life of the
implant shell).
7. If you want a totally natural breast, you should not
have a breast augmentation.
Three Types of Dual Plane Augmentation
Three variations of muscle division and pa-renchyma-
muscle interface dissection were used in this study:
1. Type I dual plane: complete division of pectoralis
origins across the inframammary fold, stopping at
implant, especially a larger implant.
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the medial aspect of the inframammary fold, with
Dual Plane Breast Augmentation
Table 2. Potential Benfits and Tradeoffs of the Dual Plane Pocket Location
Pocket Tradeoffs Potential Benefits
Dual plane (compared with
retromammary)
Dual plane (compared with
partial retropectoral)
1. Possible increased risk of palpable
or visible implant edges inferiorly
1. Preserves the potential increased control of
lower breast shape with retromammary.
2. With proper techniques can have similar
recovery as with retromammary.
3. Reduced risk of edge visibility or palpability of
retromammary by providing more upper pole
coverage.
4. Reduced interference with mammography by
retromammary.
5. Reduced possibility of capsular contracture of
retromammary by reducing contact with
parenchyma compared with retromammary.
1. Provides same mandatory muscle coverage if pinch
thickness !2cmabovebreastparenchyma.
2. Reduced risk of lateral implant displacement
over time; dividing inferior origins decreases
pectoralis pressure on implant.
3. Better control of upper medial fill with division
of inferior origins to decrease pectoralis tension
and pressure on upper pole of implant.
4. Reduced postoperative tenderness and recovery
period with proper technique.
5. Reduced distortion of breast shape with
pectoralis contraction.
6. Decreased risk of superior implant malposition
or displacement by decreasing pressure of
pectoralis on lower pole of implant by dividing
lower pectoralis origins.
7. Increased control of inframammary fold
position, depth, and configuration by decreasing
pressure of pectoralis on lower pole of implant
along inframammary fold.
8. Retains possibility of more accurate mammograms,
depending on position of muscle.
9. Possible decreased risk of capsular contracture
(small).
no dissection in the retromammary plane to free the parenchyma-muscle interface (Fig.2, above).
2. Type II dual plane: complete division of pectoralis origins across the inframammary fold, stopping at the medial aspect of the inframammary
fold (Fig. 2, center), followed by dissection in the ret-
romammary plane to approximately the inferior border of
the areola.
3. Type III dual plane: complete division of pectoralis origins across the inframammary fold, stopping at the medial aspect of the inframammary
fold (Fig. 2, below), followed by dissection in the ret-
romammary plane to approximately the superior border of
the areola.
The medial origins of the pectoralis along the sternum were
not completely divided in any patient to avoid four poten-
intermammary space; (3) visible traction-rippling medially that can occur with any implant when the implant
places traction on a capsule attached to thin, overlying
tissue; and (4) possible synmastia. The distinct, isolated,
white, tendinous-looking medial origins of the pectoralis that are located lateral to the main body of parasternal
origins along the sternum in some patients were divided
to maximally enlarge the medial pocket without risking
the tradeos of complete division along the sternum.
Complete division of the medial origins of pectoralis
along the sternum allows slightly greater narrowing of
the intermammary distance but greatly increases the
risks described previously, and the risks far outweigh the
potential benefits.
Selection of Technique by Breast Type
One of the three dual plane techniques was selected
tial problems: (1) visible deformities that can occur
along the sternum from cut muscle edges adhering to
subcutaneous fat and excessive risk of visible implant
edges beneath thin parasternal skin; (2) visible implant
edges beneath thin skin and subcutaneous tissue in the
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for each patient, according to the requirements dictated
by the patient’s anatomy and desired implant – softtissue dynamics required for an optimal result. The
goal was to match the surgical technique to the needs
of the breast to (1) maximize soft-tissue coverage and
Dual Plane Breast Augmentation
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Fig. 2. Extent of dissection at the parenchyma-muscle interface (above), the position of the inferior edge of divided pectoralis
origins (center), and pectoralis position relative to the implant (below) for types I, II, and III dual plane augmentation techniques.
minimize forces that could cause undesirable implant
1. all of the breast parenchyma located above the
displacement, (2) avoid restricting optimal expansion
of the lower pole, and/or (3) reduce the risks of infe-
2. tight attachments at the parenchyma-muscle
rior displacement of breast parenchyma sliding o
the pectoralis.
3. minimally stretched lower pole envelope, with
A type I dual plane technique was selected for most
routine breasts that fit the following three criteria (Fig.3):
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inframammary fold
interface
an areola-to-inframammary fold distance under
stretch between 4.0 and 6.0 cm.
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