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COSMETIC

Dual Plane Breast Augmentation: OptimizingImplant–Soft-Tissue Relationships in a WideRange of Breast Types

John B. Tebbetts, M.D.

Dallas, TexasSummary: In breast augmentation, surgeons usually choose a pocket locationfor the implant behind breast parenchyma (retromammary), partially behindthe pectoralis major muscle (partial retropectoral), or totally behind pectoralismajor and serratus (total submuscular). Each of these implant pocket locationshas specific indications, but each also has a unique set of tradeoffs. When appliedto a wide range of breast types, each pocket location has limitations. Glandularptotic and constricted lower pole breasts offer unique challenges that often arenot solved without tradeoffs when using a strictly retromammary, partial re-tropectoral, or total submuscular pocket. This article describes specific indica-tions and techniques for a dual plane approach to breast augmentation inseveral different breast types, introducing techniques that combine retromam-mary and partial retropectoral pocket locations in a single patient to optimizethe benefits of each pocket location while limiting the tradeoffs and risks of asingle pocket location. A total of 468 patients had dual plane augmentationbetween January of 1992 and March of 1998 using the specific techniques of dualplane augmentation described in this article. All patients were treated as out-patients and received general anesthesia. Indications, operative techniques,results, and complications for this series of patients are presented. Dual planeaugmentation mammaplasty adjusts implant and tissue relationships to ensureadequate soft-tissue coverage while optimizing implant–soft-tissue dynamics tooffer increased benefits and fewer tradeoffs compared with a single pocketlocation in a wide range of breast types. (Plast. Reconstr. Surg. 107: 1255, 2001.)

Three implant pocket locations are commonlyused in augmentation mammaplasty: (1) be-hind breast parenchyma (retromammary),1

(2) partially behind the pectoralis major muscle(partial retropectoral,2–9 or (3) totally behind pec-toralis major and serratus (total submuscular).10–12

Other authors13–17 have addressed the relative ben-efits and tradeoffs of implant pocket location withrespect to capsular contracture rates. This articlepresents techniques that allow two pocket planes(dual plane) to be developed in a single patient,adjusting the implant and tissue relationships to en-sure adequate soft-tissue coverage while optimizing

implant–soft-tissue dynamics, to offer increased ben-efits and fewer tradeoffs compared with a singlepocket location in a wide range of breast types.

Each of the previously listed implant pocket lo-cations has specific benefits and indications, buteach also has unique tradeoffs in specific breasttypes. For example, in a glandular ptotic breast withthin soft tissues in the superior pole of the breast, apartial retropectoral or total submuscular pocket lo-cation provides the necessary additional soft-tissuecoverage superiorly but risks a “double-bubble” de-formity resulting from parenchyma sliding inferiorlyoff the pectoralis and implant. A constricted lower polebreast in a thin patient needs additional coverage su-periorly, but muscle coverage inferiorly restricts opti-mal expansion of the constricted lower pole.

Because each pocket location has unique ad-vantages and tradeoffs, applying a single pocketlocation to every primary augmentation may riskunnecessary compromises. Patients vary widely insoft-tissue characteristics, breast tissue, and theirwillingness to accept specific tradeoffs. When asurgeon uses only one pocket location for all pri-

Received for publication August 4, 2000.Dr. Tebbetts is a consultant to McGhan Medical Corpora-tion, manufacturer of one of the types of saline-filled breastimplants used in this study.Reprinted and reformatted from the original article publishedwith the April 2001 issue (Plast Reconstr Surg. 2001;107:1255–1272).Copyright ©2012 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e318269b129

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mary breast augmentations, it is logical that com-promises, complications, or less-than-optimal re-sults will occur, because a single pocket locationdoes not completely address the range of ana-tomic variations and implant–soft-tissue dynamicsthat occur in a wide range of breast types. Even ifa surgeon chooses the most appropriate of thethree pocket locations (retromammary, partialretropectoral, total submuscular) for a given pa-tient, tradeoffs can still occur. For example, noneof the three common pocket locations is optimalfor the glandular ptotic breast or a constrictedlower pole breast in a thin patient. Even in routinebreast types without specific deformities, a surgi-cally controlled combination of pocket locationscan potentially maximize the benefits and mini-mize the tradeoffs of a single pocket location.

This article addresses two questions:

1. Can a combination of pocket locations in the samebreast (dual plane; combination of retromammaryand partial retropectoral) increase the benefitsand decrease the tradeoffs of a single pocketlocation, increase surgical control and pre-dictability of the result, and minimize thetradeoffs, risks, and complications?

2. When additional muscle coverage is indi-cated, can the surgeon adjust the anatomicposition of the pectoralis major muscle relative tothe implant to better control the implant–soft-tissue dynamics for an optimal result?

DEFINITION OF DUAL PLANEAUGMENTATION

Dual plane augmentation is defined as anyaugmentation that meets the following threecriteria:

1. The implant lies partially behind the pecto-ralis major muscle and partially behind thebreast parenchyma (in dual planes simulta-neously).

2. A specific group of pectoralis major muscleorigins are totally divided in a specific area toalter implant–soft-tissue dynamics by ana-tomically repositioning portions of the pec-toralis major relative to the implant (thiscriterion distinguishes dual plane from par-tial retropectoral augmentation).

3. The parenchyma-muscle interface is specificallyaltered to change the soft-tissue relationships be-tween pectoralis major and parenchyma and tochange the implant-parenchyma dynamics.

Two anatomic entities largely control the posi-tion of the pectoralis major muscle relative to a

breast implant: (1) the origins of the muscle alongthe inframammary fold inferiorly and the sternummedially, and (2) the attachments of the pectoralisto the breast parenchyma at the parenchyma-muscleinterface. To alter the position of the pectoralis ma-jor muscle relative to the implant, the surgeon di-vides origins of the pectoralis along the inframam-mary fold. The muscle then retracts superiorly untilits superior retraction is stopped by attachments atthe parenchyma-muscle interface or by remainingmuscle origin attachments along the sternum.

In dual plane augmentation, the surgeon al-ters the position of portions of the pectoralis ma-jor muscle by (a) selectively dividing the inferiororigins of the pectoralis along the inframammaryfold only, with no muscle division along the sternum;and (b) freeing the attachments of parenchyma tomuscle at the parenchyma-muscle interface bydissecting in the retromammary plane between theparenchyma and the pectoralis. These two ma-neuvers are performed at different times and to dif-ferent degrees, depending on incisional approach,breast type, tissue characteristics, implant–soft-tis-sue dynamics, and the surgeon’s preferences.

CLINICAL CRITERIA AND METHODSEach patient’s preoperative breast-envelope

characteristics were clinically characterized as tight,normal, or excessively compliant (genetically orpostpregnancy). Areola-to-inframammary-fold dis-tance, sternal-notch-to-nipple distance, base width ofthe breast, and intermammary distance were mea-sured and recorded preoperatively and at each post-operative visit. Soft-tissue pinch thicknesses of theupper pole and at the inframammary fold was mea-sured with calipers. The position of the lower borderof the pectoralis was noted pre-operatively and post-operatively by palpation and visualization while thepatient contracted the pectoralis. The pocket loca-tion for the implant was chosen based on the criteriadescribed below in order of priority.

Adequacy of Soft-Tissue CoverAdequate soft-tissue cover over an implant is

mandatory in both primary and reoperation cases.In primary cases, adequacy of soft-tissue cover inthe upper breast was assessed clinically by isolatingthe breast parenchyma inferiorly and firmly pinch-ing the soft tissues superior to the parenchyma(Fig. 1, left) to quantitate soft-tissue pinch thick-ness of the upper pole. If this pinch thickness was 2cm or greater, the patient was offered a retromammarypocket location, provided that an adequatelyfilled, textured, anatomic implant was used. Soft-

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tissue pinch thickness was also measured imme-diately inferior to the inframammary fold (Fig. 1,right). If this pinch thickness was less than 0.4 cm,pectoralis major origins along the inframammaryfold 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 col-lapse of the round implant filled to the manufac-turer’s recommendations necessitated a partialretropectoral pocket to minimize risks of visibleunderfill rippling. If the patient requested a mark-edly bulging upper breast with a step-off (the “Bay-watch” breast), she was encouraged to select eitheran overfilled round implant, a larger round im-plant filled to the manufacturer’s recommenda-tions, or a larger anatomic implant. Tradeoffs thatall patients were required to accept by informedconsent included the possibility of an increased(a) risk of a visible or palpable implant edge, (b)capsular contracture rate resulting from increasedimplant exposure to parenchyma, and (c) inter-ference with mammographic interpretation as im-plant contact with parenchyma increased.

Patient PreferenceIf a patient preferred one pocket location over

another, the tradeoffs and risks of that pocketlocation were discussed with the patient, and thepatient’s wishes were honored provided that ad-equate soft-tissue cover was present. If �2 cm ofpinch thickness was present superior to the breastparenchyma, the patient was required to acceptmuscle coverage in the upper breast to ensure

adequate coverage with any type of implant, or thepatient was not operated on. Pocket locations withpotential benefits and tradeoffs included in theinformation materials and discussed with each pa-tient are listed in Table 1.

Table 2 lists the potential benefits and tradeoffsof the dual plane pocket location compared withstrict retromammary or partial retropectoral pocketlocations described in Table 1.

In this series of patients, when inadequate soft-tissue coverage (�2 cm pinch thickness) was presentsuperior to the breast parenchyma, upper pole mus-cle coverage was mandatory. When muscle coveragewas indicated or preferred by the patient, three op-tions were discussed: (1) partial retropectoral (withpectoralis origins intact along the inframammaryfold and sternum), (2) total submuscular (addingserratus laterally for total muscle coverage), and (3)dual plane (with complete division of pectoralis or-igins along the inframammary fold, not along thesternum). The goal of the dual plane approach wasto optimize the benefits while limiting the tradeoffsof the retromammary, partial retropectoral, and to-tal sub-muscular approaches. Patients who electedthe dual plane pocket location after consideringall alternatives were included in this study. Pre-operatively, all patients, regardless of tissue thick-ness, 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 yourbreast, you will be able to feel the edge ofyour implant beneath your breast and at theside of your breast.

Fig. 1. Soft-tissue pinch thickness of the upper pole (left) and immediately inferior to the in-framammary fold (right) is caliper-measured with a firm pinch of the skin and subcutaneoustissue.

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2. Currently manufactured implants that strive toachieve durability of the shell have a thickershell to prolong the life of your implant, and athicker shell may be easier for you to feel.

3. If feeling an edge of an implant shell couldbe a problem for you, do not have an aug-mentation.

4. We cannot change the quality or thicknessof your tissues. If you are thin or have verylittle breast tissue, you will be more likely tofeel your implant.

5. The larger your implant, the worse yourbreast will look over time. A larger implantwill stretch your tissues over time and willcause more tissue-thinning and sagging thana smaller implant. Your tissues do not im-prove with age, and they will be less able tosupport the additional weight of any im-plant, especially a larger implant.

6. Any implant, if filled adequately to preventcollapse and possible folding of the shellwhen you stand, will feel firmer than a nor-mal breast, regardless of the filler material.If the implant shell folds, it could fail soonerand require you to have a reoperationsooner18 (most patients accept a firmerbreast in exchange for a possibly longer lifeof the implant shell).

7. If you want a totally natural breast, youshould not have a breast augmentation.

Three Types of Dual Plane AugmentationThree variations of muscle division and pa-

renchyma-muscle interface dissection were usedin this study:

1. Type I dual plane: complete division of pec-toralis origins across the inframammary fold,

Table 1. Alternative Pocket Locations with Potential Tradeoffs

Pocket Tradeoffs Potential Benefits

Retromammary 1. Increased risk of edge visibility orpalpability.

2. Possible increased interference withmammography.

3. Possible increased incidence of capsularcontracture.

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 andshape.

Partial retropectoral (withoutdividing pectoralis originsalong the inframammaryfold)

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. Thispotential tradeoff is minimized oreliminated by division of pectoralis originsalong the inframammary fold in patientswho have adequate soft-tissue coverage.

6. Increased risk of superior implantmalposition or displacement (wheninferior pectoralis origins acrossinframammary fold are not divided).

7. Longer time required for deepening ofthe inframammary fold (when pectoralisorigins along the inframammary fold arenot divided).

1. Muscle coverage mandatory ifpinch thickness �2 cm abovebreast parenchyma.

2. Possibly more accuratemammograms.

3. Less risk of palpable or visibleimplant edges.

4. Possible decreased risk of capsularcontracture (small difference withsaline-filled implants, greaterdifference with silicone gel-filledimplants).

Total submuscular 1. All tradeoffs listed above for partialretropectoral, plus:

2. Highest risk of superior implantdisplacement or malposition.

3. Longer operative time.4. Longest postoperative recovery and

morbidity.5. Least accurate and predictable

inframammary fold and longest to achievedepth.

6. Greatest risk of inframammary foldirregularities, lateral flattening, and foldlevel inaccuracies.

1. Possible increased coverageinferolaterally but clinically nosignificant additional coverlong-term.


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stopping at the medial aspect of the infra-mammary fold, with no dissection in the retro-mammary plane to free the parenchyma-muscleinterface (Fig. 2, above).

2. Type II dual plane: complete division of pec-toralis origins across the inframammary fold,stopping at the medial aspect of the infra-mammary fold (Fig. 2, center), followed bydissection in the retromammary plane to approxi-mately the inferior border of the areola.

3. Type III dual plane: complete division ofpectoralis origins across the inframammaryfold, stopping at the medial aspect of theinframammary fold (Fig. 2, below), followedby dissection in the retromammary plane to ap-proximately the superior border of the areola.

The medial origins of the pectoralis along the sternumwere not completely divided in any patient to avoidfour potential problems: (1) visible deformitiesthat can occur along the sternum from cut mus-cle edges adhering to subcutaneous fat and ex-cessive risk of visible implant edges beneath thinparasternal skin; (2) visible implant edges be-

neath thin skin and subcutaneous tissue in theintermammary space; (3) visible traction-ripplingmedially that can occur with any implant whenthe implant places traction on a capsule attached tothin, overlying tissue; and (4) possible synmastia.The distinct, isolated, white, tendinous-looking me-dial origins of the pectoralis that are located lateralto the main body of parasternal origins along thesternum in some patients were divided to maximallyenlarge the medial pocket without risking thetradeoffs of complete division along the sternum.Complete division of the medial origins of pectora-lis along the sternum allows slightly greater narrow-ing of the intermammary distance but greatly in-creases the risks described previously, and the risksfar outweigh the potential benefits.

Selection of Technique by Breast TypeOne of the three dual plane techniques was

selected for each patient, according to the require-ments dictated by the patient’s anatomy and de-sired implant–soft-tissue dynamics required for anoptimal result. The goal was to match the surgical

Table 2. Potential Benfits and Tradeoffs of the Dual Plane Pocket Location

Pocket Tradeoffs Potential Benefits

Dual plane (compared withretromammary)

1. Preserves the potential increased control oflower breast shape with retromammary.

2. With proper techniques can have similarrecovery as with retromammary.

3. Reduced risk of edge visibility or palpability ofretromammary by providing more upper polecoverage.

4. Reduced interference with mammography byretromammary.

5. Reduced possibility of capsular contracture ofretromammary by reducing contact withparenchyma compared with retromammary.

Dual plane (compared withpartial retropectoral)

1. Possible increased risk of palpableor visible implant edges inferiorly

1. Provides same mandatory muscle coverage if pinchthickness �2 cm above breast parenchyma.

2. Reduced risk of lateral implant displacementover time; dividing inferior origins decreasespectoralis pressure on implant.

3. Better control of upper medial fill with divisionof inferior origins to decrease pectoralis tensionand pressure on upper pole of implant.

4. Reduced postoperative tenderness and recoveryperiod with proper technique.

5. Reduced distortion of breast shape withpectoralis contraction.

6. Decreased risk of superior implant malpositionor displacement by decreasing pressure ofpectoralis on lower pole of implant by dividinglower pectoralis origins.

7. Increased control of inframammary foldposition, depth, and configuration by decreasingpressure of pectoralis on lower pole of implantalong inframammary fold.

8. Retains possibility of more accurate mammograms,depending on position of muscle.

9. Possible decreased risk of capsular contracture(small).


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technique to the needs of the breast to (1) max-imize soft-tissue coverage and minimize forces thatcould cause undesirable implant displacement,(2) avoid restricting optimal expansion of thelower pole, and/or (3) reduce the risks of inferior

displacement of breast parenchyma sliding off thepectoralis.

A type I dual plane technique was selected formost routine breasts that fit the following three cri-teria (Fig. 3):

Fig. 2. Extent of dissection at the parenchyma-muscle interface (above), the position of the inferior edge of divided pectoralisorigins (center), and pectoralis position relative to the implant (below) for types I, II, and III dual plane augmentation techniques.


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1. all of the breast parenchyma located abovethe inframammary fold

2. tight attachments at the parenchyma-muscleinterface

3. minimally stretched lower pole envelope,with an areola-to-inframammary fold dis-tance under stretch between 4.0 and 6.0 cm.

The goal in this type of breast was to minimizedissection at the parenchyma-muscle interfaceand divide the inferior pectoralis origins to opti-mize inframammary fold accuracy while preserv-ing maximal muscle cover over the implant.

A type II dual plane technique was selected forbreasts that had highly mobile parenchyma and fit thefollowing criteria (Fig. 4):

1. most of the breast parenchyma locatedabove the inframammary fold, but

2. looser attachments at the parenchyma-muscle interface (breast tissue much moremobile relative to the anterior surface of thepectoralis major)

3. lower pole envelope more stretched with anareola-to-inframammary fold distance understretch between 5.5 and 6.5 cm.

The goal in this type of breast was to performmore dissection at the parenchyma-muscle inter-face to allow the muscle to retract more superiorly,reducing the risks of highly mobile parenchymasliding off the anterior surface of the pectoralispostoperatively.

A type III dual plane technique was selectedfor glandular ptotic and constricted lower pole breaststhat fit criteria 1, 2, and 3 or criterion 4, below(Fig. 5):

1. breasts with glandular ptosis or true ptosis whenone-third or more of the breast parenchymalies below the level of the projected inframam-mary fold with the patient standing

2. very loose attachments at the parenchyma-muscle interface (breast parenchyma readilyslides off the surface of the pectoralis)

3. markedly stretched lower pole envelope withan areola-to-inframammary fold distance un-der stretch of 7.0 to 8.0 cm

4. constricted lower pole breasts (Fig. 6) of all de-grees, from mild to marked, including tuber-ous breasts, characterized by any combinationof a (a) tight, constricted lower-breast enve-lope with a transversely short, tight inframam-mary fold; (b) parenchymal maldistribution,with parenchyma tightly concentrated cen-

Fig. 3. A type I dual plane technique is selected for mostroutine breasts with the following characteristics: all breast pa-renchyma located above the inframammary fold, tight attach-ments at the parenchyma-muscle interface, and a minimallystretched lower pole envelope with an areola-to inframammaryfold distance under maximal stretch between 4.0 and 6.0 cm.

Fig. 4. A type II dual plane technique is selected for breasts withthe following characteristics: most breast parenchyma locatedabove the inframammary fold but looser attachments at theparenchyma-muscle interface (the breast tissue is much moremobile relative to the anterior surface of the pectoralis major),and a more stretched lower pole envelope with an areola-to-inframammary fold distance under stretch between 5.5 and 6.5 cm.

Fig. 5. A type III dual plane technique is selected for glandularptotic breasts with the following characteristics: one-third ormore of the breast parenchyma lying below the level of the pro-jected inframammary fold with the patient standing, very looseattachments at the parenchyma-muscle interface (the breast pa-renchyma readily slides off the surface of the pectoralis), and amarkedly stretched lower pole envelope with an areola-to-infra-mammary fold distance under stretch of 7.0 to 8.0 cm.


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trally, producing a narrow base width; or (c)short areola-to-inframammary fold distanceunder stretch of 2.0 to 5.0 cm.

The goal in both glandular ptotic and con-stricted lower pole breasts was to maximallyfree the pectoralis inferiorly and to incremen-tally free the parenchyma from the pectoralismajor at the parenchyma-muscle interface toallow the inferior edge of the pectoralis to movesuperiorly. All medial pectoralis origins alongthe sternum were totally preserved to avoid exces-sive upward retraction, visible superior bandingof the pectoralis, and visible implant edges ortraction-rippling medially. In both constrictedlower pole and glandular ptotic breasts, the im-plant must maximally contact parenchyma andproject anteriorly without muscle restriction to op-timally correct the deformities. In all glandularptotic breasts, the parenchyma-muscle interfacemust be altered to prevent parenchyma from slid-ing off the anterior surface of the pectoralis. Inconstricted lower pole breasts, the implant mustcontact large areas of parenchyma to achieve paren-chymal redistribution after scoring and to optimallyexpand the inferior envelope.

Patient Follow-Up and EvaluationThe patients were scheduled for follow-up at 2

days, 3 weeks, 3 months, and 1 year, and at 2-yearintervals thereafter. The overall results were eval-uated clinically and were subjectively rated accord-ing to the following levels and criteria for thebreast types defined previously:

• Excellent (5): Near-perfect symmetry and form,straight-sloping upper pole with no excessive ordeficient fill, excellent nipple-areola position onthe breast mound, no visual parenchymal-implantstep-off or double-bubble, and near-perfect infra-mammary fold depth and definition without ir-regularities.

• Very good (4): Very good symmetry and form,aesthetic upper pole but very slight inward oroutward sloping, very good nipple-areola posi-tion on the breast mound, no visual parenchy-mal-implant step-off or double-bubble, andvery good inframammary fold depth and defi-nition without irregularities.

• Satisfactory (3): Satisfactory symmetry andform, aesthetic upper pole but very slight in-ward or outward sloping, good but not perfectnipple-areola position on the breast mound,minimal visual parenchymal-implant step-offor double-bubble, and satisfactory inframam-mary fold depth and definition without irreg-ularities.

• Fair (2): Fair symmetry and form, apparentinward or outward sloping at the upper pole,good but not perfect nipple-areola position onthe breast mound, mild visual parenchymal-implant step-off or double-bubble, and fair in-framammary fold depth with minimal-to-mildirregularities.

• Poor (1): Poor symmetry and form, upper polewith significantly excessive or deficient fill, excel-lent nipple-areola position on the breast mound,moderate-to-marked parenchymal-implant step-off or double-bubble, and compromised infra-mammary fold depth or definition with moder-ate-to-marked fold distortions.

All patients were questioned at each postop-erative visit about their perceived firmness of theirbreasts, any visible deformities, any change in pec-toralis major function, and time required beforereturning to normal activities.

Dual Plane Surgical TechniquesInframammary and periareolar incisional ap-

proaches facilitate dual plane techniques, butthese techniques can also be applied endoscopi-cally through the axillary approach.

Through an inframammary incision, dissectdirectly to the surface of the pectoralis directlybeneath the incision. For type I dual plane pro-cedures, do not dissect at all in the retromammaryplane. Retract anteriorly to lift the pectoralis offthe chest wall (use of adequate muscle relaxantfacilitates retropectoral dissection). With the pec-

Fig. 6. A type III dual plane technique is selected for constrictedlower pole breasts (all degrees from mild to marked, includingtuberous breasts) characterized by any combination of (1) a tight,constricted lower-breast envelope with a transversely short,tight inframammary fold; (2) parenchymal maldistribution, withthe parenchyma tightly concentrated centrally, producing anarrow base width; (3) a short areola-to-inframammary fold dis-tance under stretch of 2.0 to 5.0 cm.


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toralis tented, use needlepoint electrocautery dis-section to incise the pectoralis just above the skinincision, parallel to the inframammary fold and 1cm above it (Fig. 7), entering the subpectoralspace on a line toward the medial border of the

areola. In this direction, the space is easiest toenter because there are no attachments to pecto-ralis minor or serratus anterior. The large perfo-rator that is usually located 2 to 3 cm above theinframammary fold (Fig. 8) is controlled withunipolar, hand-switching, needlepoint electrocau-tery forceps, and the remainder of the pocketdissection and muscle division are completed withthese same forceps. Dividing pectoralis originsalong the inframammary fold, with no additionalseparation of pectoralis from parenchyma at theparenchyma-muscle interface, allows the inferiorcut edge of pectoralis to move 2 to 4 cm superiorly.Leaving a 1-cm stump of pectoralis origins alongthe inframammary fold (1) facilitates control ofintramuscular blood vessels, (2) provides a “shelf”that may offer some support for the inferior edgeof the implant in some cases, and (3) leaves attach-ments of deep subcutaneous fascia to the anteriorsurface of the muscle stump along the fold to reducethe risk of excessively lowering the fold.

With the needlepoint forceps in the closedposition, using a blended cut and coagulation cur-rent, continue dissection medially to the sternumand inferiorly to the desired inframammary foldlevel. Using the longer end of a double-endedretractor to expose the pectoralis origins at theinframammary fold, incrementally and com-pletely divide pectoralis origins from the incisionmedially to the sternum (Fig. 9). Divide muscle insmall increments from the undersurface to thesuperficial surface of the muscle, using the forcepslike an electrocautery needle until subcutaneousfat is visible and controlling intramuscular vesselsas they are encountered. Check topographicallandmarks frequently to ensure accuracy, and stopmuscle division medially where the inframammary foldmeets the sternum. Deep subcutaneous fascia over-

Fig. 7. Electrocautery incision of the tented pectoralis major toenter subpectoral space.

Fig. 8. Location and control of the large subpectoral perforatingartery and vein.

Fig. 9. (Left) Retraction for exposure and division of pectoralis major origins across and 1 cm above the inframammary fold.(Right) Unipolar, hand-switching, needlepoint electrocautery forceps divides pectoralis major origins.


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lying the pectoralis at the inframammary fold doesnot provide meaningful additional coverage andcan restrict fold accuracy, so it is also divided tovisualize subcutaneous fat (Fig. 10) except forwhen the soft-tissue pinch thickness at the infra-mammary fold is �0.4 cm.

Medially, along the sternum, divide only the iso-lated, white, tendinous origins that lie lateral to the mainbody of the pectoralis, if tendinous origins are visible.Do not divide any of the main body of medialpectoralis origins along the sternum to avoid dif-ficult or uncorrectable medial deformities, asmentioned earlier. Before removing the retractor,palpate the undersurface of the pocket along theinframammary fold to ensure complete, even re-lease of inferior pectoralis origins and deep sub-cutaneous fascia. In exceedingly thin patients, thesurgeon may choose to preserve muscle originsand fascia intact along the fold, accepting thetradeoffs of a less predictable fold location andconfiguration in exchange for thicker soft-tissuecoverage for the implant at the inframammaryfold.

With inferior pectoralis origins divided, sweepthe pocket dissection from medial to lateral, liftingthe pectoralis off the pectoralis minor and serratusanterior (Fig. 11). Completely divide any remain-ing pectoralis major origins lateral to the incisionalong the inframammary fold. Stop dissection atthe lateral border of the pectoralis minor to avoidover-dissection of the lateral pocket, and enlargeit after the implant is in place by using a double-ended retractor and a spatula or malleable retrac-tor for exposure.

Change to a longer, fiber-optic retractor withsmoke-evacuation capabilities, and dissect superi-orly, opening the superior subpectoral pocket untilthe thoracoacromial pedicle is visible, dissecting

from lateral to medial (Fig. 12). Finally, open themedial pocket from superior to inferior alongthe sternum. Isolated, white, tendinous origins ofthe pectoralis lateral to the main body of originsalong the sternum medially can be safely divided toexpand the medial pocket. Preserve all medial ori-gins along the sternum intact to avoid the deformi-ties that occur in a small percentage of patients andare difficult or impossible to correct. Narrowing theintermammary distance to �3 cm in a subpectoralplane requires pectoralis division, risks leaving onlythin skin and subcutaneous tissue over the implantedge medially, and should be avoided in all cases.

For types II and III dual plane procedures, enterthe subpectoral plane, divide pectoralis muscle ori-gins along the inframammary fold only, and com-plete the retropectoral pocket dissection exactly asdescribed previously for the type 1 procedure. Withthe tissues now mobilized, place a double-ended re-tractor with the tip immediately inferior to the in-

Fig. 10. Division of pectoralis major origins extended throughthe deep subcutaneous fascia to expose subcutaneous fat.

Fig. 11. Zone 2 subpectoral pocket dissection, sweeping later-ally to separate pectoralis major from pectoralis minor and ser-ratus muscles.

Fig. 12. Zone 3 subpectoral pocket dissected superiorly to visu-alize the thoracoacromial pedicle.


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ferior cut border of the pectoralis at its attachmentto the overlying parenchyma. Using upward tractionon the retractor and traction with the fingers to keepthe overlying tissues pulled onto the retractor bladeexposes and defines the plane of attachments ofpectoralis to the overlying parenchyma at the cutmuscle edge (Fig. 13). With the closed needlepointelectrocautery forceps, free the muscle from theoverlying parenchyma incrementally, sweepingthe dissection from side-to-side and repositioningthe retractor as necessary. Continue the separationat the parenchyma-muscle interface far enough lat-erally to free the lateral muscle adequately to allowit to move superiorly, but do not disrupt any medialpectoralis origins at the junction of the sternum withthe inframammary fold. For the type II dual planeprocedure, continue the dissection until the inter-face is free to approximately the inferior border of theareola, and for the type III procedure, to approxi-mately the superior border of the areola. Free theinterface in 1-cm increments, then insert the fingersand lift anteriorly to determine the precise muscleedge position relative to the topographical land-marks (Fig. 14). Continue freeing the muscle fromthe parenchyma until no muscle banding is felt inter-nally that could restrict full implant projection. Leav-ing the medial origins of pectoralis intact along thesternum prevents excessive upward retraction andbanding of the pectoralis superior to the implant.

Before irrigating the pocket and placing the im-plant, lift the skin envelope anteriorly to ensurethere is no restriction to free movement of the tissuesanteriorly. If any banding or restriction is felt at thelevel of the inferior border of the pectoralis, separate

the muscle from the overlying parenchyma with elec-trocautery forceps dissection in additional 1-cm in-crements superiorly. Recheck the free excursion an-teriorly, and stop when the parenchyma movesanteriorly without restriction by the lower border ofthe pectoralis.

Implant placement follows basic guidelines,but it is imperative to bring the patient to a sittingposition and to check the implant position. Re-gardless of implant type, the implant must be po-sitioned adequately inferiorly, with its inferior edgeat the desired inframammary fold. Leaving an implantin an excessively high position is a common errorthat precludes optimal results.

Through the periareolar approach in the type Idual plane procedure, dissection is carried over thebreast parenchyma to the inframammary fold,where the pectoralis is divided as described previ-ously for the inframammary approach. For types IIand III procedures using the periareolar approach,dissection is directed through the breast paren-chyma to the desired level of separation of the pa-renchyma from muscle, either the lower or upperborder of the areola, respectively. When the muscleis visualized, dissection proceeds inferiorly in theretromammary plane to the desired new fold level,and the muscle is then divided 1 cm above the de-sired fold level to enter the subpectoral plane.When areolar asymmetry and/or pseudoherniationare a component of the breast deformity, the peri-areolar approach is the most logical to allow simul-taneous correction of the areolar deformities.

The axillary incisional approach with endo-scopic control is excellent for type I dual planeprocedures but impractical for types II and III. Fortype I, the pocket is created in the subpectoral

Fig. 13. Retraction for exposure of cut pectoralis muscle edgeat the parenchyma-muscle interface, lifting anteriorly and pull-ing overlying tissue onto the retractor blade. Exposure for elec-trocautery forceps dissection to separate the pectoralis from theoverlying parenchyma at the parenchymamuscle interface intypes II and III dual plane techniques.

Fig. 14. Anterior traction for palpation to define the locationof the inferior edge of the pectoralis and ensure no restrictionto the anterior movement of the parenchyma and overlyingenvelope.


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plane with endoscopic assistance, and the pecto-ralis origins along the inframammary fold are thendivided 1 cm above the desired fold with a nee-dlepoint electrocautery endoscopic dissector.

CLINICAL EXPERIENCE AND RESULTSA total of 468 patients (936 breasts) had dual

plane augmentation between January of 1992 andMarch of 1998. All patients in this series under-went primary breast augmentation under generalanesthesia as outpatients. All were female with anage range of 18 to 64 years (average, 28 years). Inthe series, 281 patients (60 percent) had type Ibreasts and received the type I dual plane proce-dure, 108 patients (23 percent) had type II breastsand received the type II procedure, and 79 pa-tients (17 percent) had type III breasts and re-ceived the type III procedure.

The inframammary approach was used in 316patients (67.5 percent), the periareolar approachin 55 patients (11.8 percent), and the axillary ap-proach in 97 patients (20.7 percent). Round, tex-tured silicone shell saline implants were used in 34patients (7.3 percent); round, smooth shell salineimplants were used in eight patients (1.7 percent);and textured, full-height anatomic saline implants(McGhan Style 468) were used in 426 patients (91percent). The type of implant for all of the typesI and II breasts was selected by patient choice.Patients with type III breasts were encouraged toselect between a high-profile round implant anda high-profile anatomic implant.

Follow-up ranged from 3 months to 6 years.The patients were scheduled for follow-up at 2days, 3 weeks, 3 months, and 1 year, and at 2-yearintervals thereafter. Follow-up at 3 months wasobtained in 92 percent of patients, at 6 to 23months in 78 percent of patients, and at 2 years orlonger in 46 percent of patients.

Results by breast type, graded according to thecriteria described previously, are listed in Table 3.Representative results of corrections in four breasttypes using the three variations of dual plane tech-niques are shown in Figures 15 through 18.

Capsular ContractureTen patients (12 breasts) developed capsular

contractures (two bilateral, eight unilateral) thatwere clinically significant with moderate-to-severebreast firmness, shape distortion and/or implantdisplacement, and discomfort (10 of 468 patients,2.1 percent; 12 of 936 breasts, 1.3 percent). Allwere treated with complete capsulectomy (excepton the posterior surface of the pectoralis) andplacement of new implants. Two patients experi-enced a recurrence of the condition but receivedno additional surgery. One bilateral and four uni-lateral capsules (50 percent of the capsules) oc-curred in type III breasts, in which the implant wasexposed to more parenchyma. Two capsules oc-curred with smooth implants (two of 16 breasts,12.5 percent) in type II breasts, and the remaining10 capsules occurred with textured implants (10 of920 breasts, 1.1 percent).

Other ComplicationsTwo hematomas occurred unilaterally, one in

a patient with type III breasts who required ex-tensive parenchymal scoring, the other in a pa-tient with type II breasts (two of 936 breasts, 0.2percent; two of 468 patients, 0.4 percent). No se-romas occurred, and no patient developed visiblerippling in any portion of the breast in the uprightposition. Six patients (six of 468, 1.3 percent)could demonstrate visible rippling laterally (trac-tion rippling) when they leaned forward 90 de-grees at the waist. Two of the six had round,smooth implants filled to the manufacturer’s rec-ommendations; one had a round, textured im-plant filled to the manufacturer’s recommenda-tions; and three had full-height textured,anatomic implants. Two unilateral infections oc-curred (two of 936 breasts, 0.2 percent; two of 468patients, 0.4 percent). One infection (Staphylococ-cus aureus) occurred in a patient with type IIIbreasts, and a second (Staphylococcus epidermidis)occurred in a patient with type II breasts. Bothwere treated with implant removal, and the infec-tions resolved rapidly.

Table 3. Results Graded by Breast Type

Breast Type

Grade 1:Excellent

Grade 2:Very Good

Grade 3:Satisfactory

Grade 4:Fair

Grade 5: Poorn % n % n % n %

I (n � 281) 107 38 132 47 42 15 0 0 0II (n � 108) 37 34 42 39 28 26 1 1 0III (n � 79) 21 26 46 58 10 13 2 3 0


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DISCUSSION

Implant–Soft-Tissue DynamicsImplant–soft-tissue dynamics affect the short-

term and long-term results of augmentation inboth primary and reoperation cases. The im-plant exerts pressure on the overlying soft tis-

sues to shape the breast. The overlying soft tis-sues exert counterpressure on the implant,depending on the compliance of the envelope,the layers of tissue (parenchyma and/or mus-cle) interposed between implant and envelope,the projection and compliance (firmness) of theimplant,and other factors such as genetic tissue

Fig. 15. Preoperative (above) and 20-month postoperative (below) views of an inframammary, type I dual plane augmentation ina 38-year-old, gravida 3, para 3 patient with McGhan Style 468 textured, anatomic implants, 240 cc bilaterally.

Fig. 16. Preoperative (above) and 28-month postoperative (below) views of an inframammary, type II dual planeaugmentation in a 38-year-old, gravida 1, para 1 patient with McGhan Style 468 textured, anatomic implants, 285 cc bilaterally.


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characteristics. All patients’ tissues age withtime, usually becoming thinner and more com-pliant, which results in envelope stretch evenwithout the additional weight of a breast im-plant. The interaction of tissue and implantforces over time, combined with the inevitable

aging changes of the soft tissues, determines thelong-term result in breast augmentation.

Placement of an implant in any pocket lo-cation initiates a complex series of events (an-atomic, mechanical, and biological) that varysignificantly from patient to patient over time.

Fig. 17. Preoperative (above) and 24-month postoperative (below) views of an inframammary, type III dual plane augmentation ina 31-year-old, gravida 2, para 2 patient with McGhan Style 468 textured, anatomic implants, 315 cc bilaterally.

Fig. 18. Preoperative (above) and 20-month postoperative (below) views of a 24-year old, gravida 0, para 0 patient with breastasymmetry and a constricted lower pole left breast. The patient had an inframammary, type III dual plane augmentation withMcGhan Style 468 textured, anatomic implants, 240 cc right, 270 cc left.


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Wide anatomic variations exist in the soft-tissueenvelope, parenchyma, and tissue interfaces be-tween envelope and parenchyma and betweenparenchyma and underlying muscle, resultingin a wide range of breast types. The interactionof the implant with adjacent tissues in each ofthese widely varying breast types (implant–soft-tissue dynamics) varies in each patient accord-ing to anatomy, implant type, and soft-tissuecharacteristics. By focusing on soft-tissue character-istics and implant–soft-tissue dynamics instead of se-lecting a single-technique solution for all breasts, thesurgeon can better select appropriate surgicaltechniques and adjust those techniques for op-timal control and predictability in a wide rangeof breast types.

In general, a surgeon cannot change the ge-netic and aging characteristics of a patient’s tis-sues. The surgeon can, however, recognize howthese factors influence the choice of a breast im-plant to achieve optimal long-term results withminimal tradeoffs, risks, and compromises. Manyof the limitations that are associated with eachpocket location are mechanical. Modifications oftissue layers that contact the implant (the pocket)and implant selection allow adjustment of soft-tissue mechanics relative to the implant, enablingthe surgeon to better control the implant–soft-tissue dynamics and the relative positions of theimplant and soft tissues within the envelope. Con-trolling implant–soft-tissue dynamics short-termand long-term is a key to optimal long-term results.

ImplantsType I breasts do not require a highly project-

ing implant, and a wide variety of implants canproduce satisfactory results. Types II and IIIbreasts with mobile parenchyma or constrictedlower poles require a more projecting implant foroptimal correction, because the implant mustmaximally expand the lower pole and/or provideprojection for optimal nipple lift. Highly project-ing round or anatomic implants provide bettercorrection for breasts with highly mobile paren-chyma, glandular ptotic breasts, and constrictedlower pole breasts. Anatomic implants with aheight slightly greater than their width providebetter upper pole fill. Over the long term, anybreast with a larger implant in a stretchy envelopewill lose some upper fill.

The Nulliparous Breast with Minimally MobileParenchyma

In most nulliparous breasts or parous breastswith tight envelopes (Fig. 3) that require addi-

tional soft-tissue coverage superiorly (softtissuepinch thickness of the upper pole �2.0 cm), thesurgeon can avoid many of the tradeoffs of partialretropectoral placement by completely dividingthe origins of the pectoralis major from the lateralborder of the pectoralis at the inframammary foldto the medial extent of the inframammary fold.Division of pectoralis origins across the inframam-mary fold reduces several tradeoffs associated withpartial retropectoral placement:

1. Reduced pressure on the implant lower polereduces the risk of superior displacement ormalposition of the implant.

2. Pectoralis release decreases pressure on theupper implant to reduce lateral implant dis-placement over time.

3. The implant can rest more precisely at thelower border of the pocket, forming adeeper and more precise fold more quicklyand obliterating dead space that can fill withfluid, undergo fibrous replacement, andcause fold distortions.

In exceedingly thin patients (soft-tissue pinchthickness at the inframammary fold �0.4 cm), thesurgeon may elect to accept all of the potentialtradeoffs listed above to maintain additional cov-erage at the inframammary fold level. Many cur-rent implants are designed with thicker shells foradditional urability, and shell palpability (with orwithout lower pole muscle cover) is greater in bothtextured and smooth implants. Preserving the verythin layer of deep subcutaneous fascia when di-viding the pectoralis origins along the inframam-mary fold did not provide clinically significant cov-erage long-term in this series. Usually, exceedinglythin patients can feel the edges of any implantshell inferolaterally, whether or not the pectoralisorigins are preserved, so in most cases, a palpableshell accepted preoperatively by the patient is pref-erable to the other potential tradeoffs of preserv-ing muscle origins along the inframammary fold.

Therefore, in most nulliparous patients whoneed additional upper pole implant coverage,complete division of pectoralis origins along theinframammary fold with no undermining in theretromammary plane (type I dual plane) allowsoptimal accuracy and depth of the inframammaryfold by allowing the inferior edge of the pectoralisto move superiorly 2 to 4 cm, decreasing pressureon the lower pole of the implant. In the type Ibreast, when the parenchyma is not sliding off theanterior surface of the pectoralis, it is unnecessaryto further release the pectoralis by retromammaryundermining to allow it to move more superiorly.


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The position of the parenchyma relative to themuscle remains the same in the middle and upperpole as the implant exerts pressure on the paren-chyma through the overlying pectoralis. Clinically,in most cases, less breast distortion occurs withpectoralis contraction than when inferior originsare left intact. Although difficult to document,lateral implant displacement also seemed to occurless, but such factors as thickness of the lateralenvelope and size of the implant complicate thisdetermination.

“Bottoming” of the breast long-term seems torelate more to the genetic characteristics of thepatient’s tissues and the size of the implant thanto the integrity of pectoralis overlying the implantat the inframammary fold. In this series, dividingthe pectoralis inferiorly did not increase the nip-ple-to-inframammary fold distance significantly inpatients with similar-sized implants and tissuecharacteristics.

The Parous Breast with Mobile ParenchymaIn the routine parous breast (Fig. 4), implant–

soft-tissue dynamics are similar to those of thenulliparous breast, except that the envelope is usu-ally more compliant and the parenchyma is oftensofter. The parenchyma is often more mobile atthe parenchyma-muscle interface and has agreater tendency to slide inferiorly off the anteriorsurface of the pectoralis when the patient is up-right. The advantages of a dual-plane approachwith respect to the inframammary fold are similarto those in the nulliparous breast. Freeing someattachments at the parenchyma-muscle interface(freeing parenchyma from muscle) allows the in-ferior border of the pectoralis to move more su-periorly to approximately the lower border of theareola. As a result, the implant has more contactwith the parenchyma in the lower pole and there-fore can place more direct pressure there to re-duce any tendency to slide off the anterior surfaceof the pectoralis.

The Breast with Highly Mobile Parenchyma:The Glandular Ptotic Breast

In breasts with highly mobile parenchyma(Fig. 5), the parenchymal attachments to the pec-toralis are insufficient to prevent the parenchymafrom moving inferiorly in a stretched envelope. In-ferior movement of the glandular tissue produces aglandular ptotic or truly ptotic breast. The larger themass of breast parenchyma and the weaker the at-tachments to the pectoralis at the parenchyma-mus-cle interface, the more stretching force the paren-

chyma transmits to the lower pole skin envelope. Asthe lower skin envelope stretches, the distance fromthe nipple or from the inferior border of the areolato the inframammary fold increases. This distance,measured under maximal stretch, is an excellentobjective parameter to assess the degree of ptosisand whether an implant or a mastopexy is likely toachieve the best correction. When the areola-to-in-framammary-fold distance is 7 cm or less under max-imal stretch, regardless of the position of the nipplerelative to the inframammary fold, the ptosis can becorrected by an appropriate implant alone withoutmastopexy by using dual plane techniques. To op-timally correct any degree of ptosis, the implant mustadequately expand the pocket anteriorly, which re-quires an implant with adequate projection. Equallyimportant is that the implant is wide enough toexpand the pocket mediolaterally for optimal cor-rection and the patient is willing to accept thetradeoffs of a larger implant that meets these criteria.

Optimal correction of glandular ptosis with animplant requires maximal contact of the anteriorsurface of the implant with the posterior surface ofthe parenchyma. With this degree of contact, animplant of adequate width and projection ex-pands the lower-breast envelope in all directions(Fig. 17). For this reason, and to avoid a double-bubble deformity, a retromammary placement hastraditionally been the pocket of choice to correctglandular ptosis. As the envelope expands underthe influence of an adequate base width and pro-jection implant, the nipple position moves antero-superiorly. Tradeoffs that the patient must acceptare that (1) the nipple position will be higher, butthe breast will not necessarily appear higher onthe torso; (2) a larger implant is required to fullyexpand the envelope for correction; and (3) alarger implant in a skin envelope that has alreadyshown a tendency to stretch may require a mas-topexy in the future.

Glandular ptosis in a thin patient (�2-cmpinch thickness superior to the parenchyma) pres-ents the greatest challenge. A retromammary aug-mentation in this type of breast risks a visible im-plant edge or traction-rippling superiorly ormedially. A type III dual plane approach, bydividing pectoralis origins inferiorly and freeingthe parenchyma-muscle interface up to approxi-mately the superior border of the areola, accom-plishes two objectives. First, it disrupts the paren-chyma-muscle interface, so that the parenchymacan no longer slide inferiorly off the anteriorpectoralis. Second, by allowing the muscle toretract superiorly, it allows maximal contact ofthe anterior surface of the implant with the pa-


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renchyma at the implant’s point of maximal pro-jection to provide an anterior force that “lifts”the nipple-areola complex. The pectoralis mus-cle no longer restricts maximal implant projec-tion, and the implant can then optimally expandthe lower-breast envelope for optimal correc-tion while reducing the possibility of the paren-chyma sliding off pectoralis and causing a dou-ble-bubble deformity.

The Constricted Lower Pole BreastConstricted lower pole breasts represent a

wide range of deformities, from mild constrictionto a tubular or tuberous breast. Common charac-teristics are variable but often include (1) a narrowbase width of the breast parenchyma; (2) constric-tion of the lower pole breast envelope mediolat-erally, producing (3) a transversely short, oftentight, and high inframammary fold; (4) varyingdegrees of areolar stretch or asymmetry caused byparenchymal pseudoherniation. Optimal correc-tion must address all of these components of thedeformity. Radial, and often concentric, paren-chymal scoring are required to redistribute thecentrally concentrated parenchyma and widen thebase of the breast. The degree and depth of scor-ing required depend on the degree of deformitypresent. In severe deformities, radial and concen-tric parenchymal scoring completely throughbreast parenchyma and deep subcutaneous fasciamay be necessary for optimal correction.

In a constricted lower pole breast, for optimalcorrection the implant must (1) increase the basewidth of the breast, (2) put pressure on the scoredparenchyma to redistribute it over a wider basewidth of the implant, and (3) transmit pressure tostretch the lower pole skin envelope to expand theconstricted area.

In a thin patient (�2 cm pinch thickness su-perior to the parenchyma) with a constrictedlower pole breast, additional upper pole coverageis helpful to avoid visible implant edges or possiblerippling with saline implants. However, a retropec-toral pocket location has been undesirable in thepast, because the muscle restricts full expansion ofthe lower-breast envelope by the implant, the pa-renchyma is not redistributed and the old fold isnot stretched, and a double-bubble deformity of-ten results. With type III dual plane dissection,upper muscle coverage is preserved, but the infe-rior border of the pectoralis moves superiorly tothe top of the areola, removing any muscle re-striction of lower pole expansion. The surgeon hasideal access to the posterior surface of the paren-

chyma for scoring and redistribution, and an ap-propriate implant is more likely to optimally re-distribute the parenchyma, expand the envelope,correct the constricted lower pole, and avoid thedouble-bubble deformity.

Pectoralis Function and AppearancePectoralis major muscle function postopera-

tively was evaluated only by examining the pa-tient’s history. The patients were encouraged toreturn to full normal activity immediately but tolimit aerobic activity for 2 weeks. No patient in theseries had drains or bandages postoperatively orreported any complaints related to pectoralisfunction. Many of the athletically active women,including professional athletes, in the series re-ported no functional compromise. The visiblebanding of the pectoralis at rest that sometimesoccurs, with marked window-shading of the pec-toralis, did not occur. Regardless of the degree ofparenchyma-muscle interface separation, main-taining all medial pectoralis origins intact alongthe sternum to its junction with the inframammaryfold definitely retards window-shading.

Dual plane techniques have limitations andtradeoffs. In glandular ptotic breasts, parenchymamay displace inferiorly despite disrupting the pa-renchyma-muscle interface and achieving optimalcontact of the implant with parenchyma. If ade-quate implant pressure is not present (an implantwith inadequate projection or width) or the pa-renchyma slides at the parenchyma-capsule inter-face, parenchyma can displace inferiorly. This oc-curred in two patients with type III breasts in theseries. The capsular contracture rate was definitelyhigher in more severely constricted lower polebreasts that required maximal, radial, and con-centric deep parenchymal scoring to redistributeparenchyma and correct the deformity. Decreasedsoft-tissue coverage from dividing pectoralis ori-gins along the fold has benefits and tradeoffs.

CONCLUSIONS1. Dual plane augmentation mammaplasty is a

logical approach to realize the benefits ofretromammary and partial retropectoral im-plant placement while minimizing thetradeoffs of each pocket location, and thetechnique offers surgeons increased versatil-ity in augmentation mammaplasty.

2. Dual plane augmentation improves im-plant–soft-tissue relationships by adjustingthe positions of the pectoralis muscle and


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breast parenchyma relative to the implant tooptimize implant–soft-tissue dynamics.

3. Dual plane augmentation techniques addsurgical options for more predictable cor-rection of breasts with highly mobile paren-chyma, glandular ptotic breasts, and con-stricted lower pole breasts.

4. Dual plane augmentation techniques allowthe surgeon to take advantage of additionalsoft-tissue coverage provided by the pectora-lis major superiorly while reducing thetradeoffs of a purely partial retropectoral ortotal submuscular pocket location.

John B. Tebbetts, M.D.2801 Lemmon Avenue West

Suite 300Dallas, Texas 75204

[email protected]

REFERENCES1. Cronin TD, Gerow RM. Augmentation mammaplasty: A new

“natural feel” prosthesis. In Translations of the Third Interna-tional Congress of Plastic Surgery. Amsterdam: Excerpta Medica,1964. Pp. 41–49. Excerpta Medica International CongressSeries, No. 66.

2. Griffiths CO. The submuscular implant in augmentationmammaplasty. In Translations of the Fourth International Con-gress of Plastic Surgery. Amsterdam: Excerpta Medica Founda-tion, 1967. P. 1009.

3. Dempsey WC, Latham WD. Subpectoral implants in aug-mentation mammaplasty: Preliminary report. Plast ReconstrSurg. 1968;42:515.

4. Regnault P. Partially submuscular breast augmentation. PlastReconstr Surg. 1977;59:72.

5. Mahler D, Ben-Yakar J, Hauben DJ. The retropectoral routefor breast augmentation. Aesthetic Plast Surg. 1982;6:237.

6. Tebbetts JB. Transaxillary subpectoral augmentation mam-maplasty: Long-term follow-up and refinements. Plast Recon-str Surg. 1984;74:636.

7. Mladick RA. “No-touch” submuscular saline breast augmen-tation technique. Aesthetic Plast Surg. 1993;17:183.

8. Papillon J. Pros and cons of subpectoral implantation. ClinPlast Surg. 1976;3:321.

9. Pickrell KL, Puckett, CL, Given KS. Subpectoral augmenta-tion mammaplasty. Plast Reconstr Surg. 1977;60:325.

10. Truppman ES, Ellenby JD. A 13-year evaluation of subpec-toral augmentation mammaplasty. In J. Q. Owsley and R. A.Peterson (Eds.), Symposium on Aesthetic Surgery of the Breast. St.Louis: Mosby, 1978.

11. Seckel BR, Costas PD. Total versus partial musculofascialcoverage for steroid-containing double-lumen breast im-plants in augmentation mammaplasty. Ann Plast Surg. 1993;30:296.

12. Spear SL, Matsuba H, Little JW III. The medial periareolarapproach to submuscular augmentation mammaplasty un-der local anesthesia. Plast Reconstr Surg. 1989;84:599.

13. Biggs TM, Yarish RS. Augmentation mammaplasty: Retropec-toral versus retromammary implantation. Clin Plast Surg1988;15:549.

14. Biggs TM, Yarish RS. Augmentation mammaplasty: A com-parative analysis. Plast Reconstr Surg. 1990;85:368.

15. Biggs TM, Cukier J, Worthing LF. Augmentation mamma-plasty: A review of 18 years. Plast Reconstr Surg. 1982;69:445.

16. Mahler D, Hauben, DJ. Retromammary versus retropectoralbreast augmentation: A comparative study. Ann Plast Surg.1982;8:370.

17. Vazquez B, Given KS, Houston GC. Breast augmentation: Areview of subglandular and submuscular implantation. Aes-thetic Plast Surg. 1987;11:101.

18. Tebbetts JB. Patient acceptance of adequately filled breast im-plants using the tilt test. Plast Reconstr Surg. 2000;106:139.


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