Dual Plane versus Subpectoral Breast Augmentation: Is There a Difference?

Supplemental Digital Content is available in the text.

Sir:

Most plastic surgeons prefer subpectoral over subglandular implant placement to achieve greater tissue coverage, a more natural appearance, less wrinkling, and possibly less risk of capsular contracture.[1,2] A subpectoral pocket is really partially subpectoral; the inferolateral portion is subglandular. Today, many surgeons describe their implant placement as “dual plane.” How does this approach differ from a subpectoral plane?

Dual-plane modification by Tebbetts[2] was meant to “combine retromammary and partial retropectoral pocket locations in a single patient to optimize the benefits of each pocket location while limiting the tradeoffs and risks of a single pocket location.” In theory, surgeons could have their cake (a submuscular plane) and eat it too (still expand the breast skin envelope to treat women with glandular ptosis). In all patients, the implant is placed subpectorally. In type 1, there is no prepectoral dissection, so that type 1 (representing 60% of patients[2]) is not really a dual-plane dissection. In types 2 and 3, a prepectoral dissection extends around the pectoralis border to the level of the inferior (type 2) or superior (type 3) areola margin. The pectoralis origin is released along the inframammary fold but not from the lower sternum.[2]

Conceptually, a subglandular implant can expand a deflated skin envelope without being limited by the pectoralis muscle, avoiding a snoopy deformity (sometimes inaccurately called double bubble[3]), which is characterized by breast tissue that appears to slide off the implant.[3] In practice, however, even large implants fail to prevent a snoopy deformity in women with glandular ptosis.[3] These women require augmentation/mastopexy.[3,4]

Tebbetts[2] believes that a partial prepectoral dissection elevates the pectoralis border, improves the breast shape in patients with glandular ptosis or constricted lower poles, and also elevates the nipple. An unfilled prepectoral dissection plane no doubt scars together shortly after surgery. It is possible, although unproven, that the pectoralis border moves up as a result of the dissection. It remains unclear whether the breast shape is affected by elevating the pectoralis border. In a patient treated with a traditional subpectoral dissection (Fig. 1), horizontal and vertical breast dimensions are substantially increased, but the nipple is only slightly elevated. These changes are similar to a patient treated with a type 3 dual-plane dissection (See pdf, Supplemental Digital Content 1, http://links.lww.com/PRSGO/A324). There is no evidence that the pectoralis muscle, released at the inframammary fold and partially released from its lower sternal origin[1] (to avoid a wide intermammary space), restricts breast expansion.

Fig. 1.

This 28-year-old woman with 2 children is seen before (A) and 3 years after (B) a subpectoral breast augmentation performed by the author using a 400-cm3 smooth, round Moderate Plus profile silicone gel implant (Mentor; Santa Barbara, Calif.) on the left side. Her original breast shape was constricted. Upper pole projection, breast projection, and the vertical dimension of the lower pole are all increased. This case demonstrates the expansion of the breast envelope without a prepectoral dissection. Parenchyma scoring was not performed. Photographs have been matched for size and orientation.

A recent survey[5] interpreted dual-plane responses as synonymous with subpectoral; the methods do seem equivalent in their effect on the breast shape (Fig. 1 and See pdf, Supplemental Digital Content 1, http://links.lww.com/PRSGO/A324). The dual plane, which implies 2 planes, is really a misnomer—the implant inhabits only 1 plane. A plane that starts under one tissue and continues under another is not a dual plane. For example, a sub–superficial musculoaponeurotic system face lift dissection starts subcutaneous and continues under the superficial musculoaponeurotic system. Surgeons call it a deep plane, not a dual plane. Correct wording is important. Clarity of language leads to clarity of thought and vice versa.