Dual Plane Breast Augmentation
Breast Implant Placement: An Important Milestone
- [Tebbetts, J.B.: Dual plane (DP) breast augmentation: Optimizing implant-soft tissue relationships in a wide range of breast types”, Plast. Reconstr. Surg.. 107: 1255, April 2001.]
Dual Plane Breast Implant Location
Dr. Tebbetts’ introduction of the dual plane pocket for breast augmentation was an important milestone in the history of breast augmentation, because it:
- Enabled surgeons and patients a solution to address the number one priority in breast augmentation—assuring maximal soft tissue coverage over a breast implant for a patient’s lifetime,
- Enabled surgeons to assure the maximum soft tissue coverage of the traditional subpectoral pocket location, while simultaneously eliminating or minimizing all of the potential tradeoffs associated with traditional subpectoral augmentation, and
- Combined with 24 Hour Recovery® techniques, guaranteed patients a less painful, more rapid recovery that is equivalent to or better than any other implant pocket location.
In 2001, Dr. Tebbetts published a scientific paper in Plastic and Reconstructive Surgery Journal entitled “Dual Plane Augmentation: Optimizing implant-soft tissue relationships in a wide range of breast types.” Understanding why this paper was and is critically important for patients requires some background knowledge.
The number one priority in breast augmentation is assuring maximal, not just adequate, soft tissue coverage over all areas of a breast implant for the patient’s lifetime. This priority is more important than size, shape, recovery, or any other priority in breast augmentation. Why? Because less than maximal soft tissue coverage has been conclusively shown to dramatically increase risks of visible implant edges and rippling that are often uncorrectable, and dramatically increases risks of reoperations to try to correct inadequate tissue coverage, thereby increasing costs and risks for patients, and risking problems that may be uncorrectable.
Over the Muscle and Under the Muscle Breast Implant Placement
During the first decade of his practice, Dr. Tebbetts had extensive experience using both submammary and subpectoral augmentation, and based selection of one pocket location or the other on the thickness of each patient’s tissues. He, like other surgeons, noticed that patients who had their implants placed “under muscle”, sometimes experienced tradeoff that included:
- More discomfort during recovery
- More distortion of the breast when the patient contracted her pectoralis muscle,
- An outward shift of the implants over time due to the pressure of the muscle, causing a widening of the gap between the breasts, and
- Pressure of overlying muscle limiting optimal expansion of the lower breast envelope by the implant compared to a submammary pocket location, and
- Potentially more interference with patients’ mammograms
While the submammary pocket location seemed appealing, Dr. Tebbetts rapidly recognized many tradeoffs of that pocket location, some of which were very serious:
- Less thickness of soft tissue coverage in the upper and middle breast areas allowed implant edges to become visible in the most visible areas of the breast both in and out of clothing
- Visible implant edges and visible rippling caused by inadequate tissue coverage of the implant were often uncorrectable deformities
- The implants in contact with the milk producing tissue of the breast were exposed to more bacteria that are present in every woman’s breasts, resulting in a higher incidence of capsular contracture
- Patients experienced a much higher rate of reoperations as surgeons tried to correct visible implant edges, rippling, and capsular contracture.
Recognizing that providing maximal soft tissue coverage over patients’ implants was the highest priority to avoid reoperations or uncorrectable deformities long-term, Dr. Tebbetts asked a logical question, “Is there a way to provide maximal muscle coverage, and at the same time, minimize the tradeoffs associated with traditional subpectoral augmentation?” The search for a solution began in the cadaver lab at Southwestern Medical School in Dallas, performing a large number of detailed dissections to better understand the variations in the anatomy of the pectoralis major muscle. Armed with that information, Dr. Tebbetts then developed surgical techniques that release a small number of pectoralis muscle attachments beneath the inframammary fold (the fold beneath the breast), and allows the lower edge of the pectoralis muscle to rotate upward a small amount. These simple, but highly effective dual plane techniques had dramatic effects that were all positive for patients:
- Reduced stretch on the pectoralis caused by the underlying implant, dramatically reducing patient discomfort
- Dramatically reduced pressure of the pectoralis on the underlying implant that was causing outward implant displacement, eliminating or dramatically reducing risks of implant displacement and widening of the gap between the breasts,
- Dramatically reduced the amount of distortion of the breast that may occur when a patient contracts her pectoralis,
- Preserved all of the mammography benefits of the subpectoral location, and most importantly,
- Assured maximal soft tissue coverage over the critical upper and middle portions of the implant, while dramatically reducing all of the tradeoffs traditionally associated with subpectoral augmentation.
A large number of peer reviewed and published scientific studies over the past decade have conclusively proved that placing implants in a properly dissected dual plane pocket predictably and consistently deliver all of the advantages listed in the previous paragraph. Today, there are few, if any, logical or scientifically confirmed reasons for surgeons or patients to select any other pocket location for a breast implant.
Anatomy of the Dual Plane Pocket Location for Breast Implants
Another pocket location has recently been described and promoted by a limited number of surgeons—the subfascial pocket location. In a subfascial pocket, the implant is behind breast tissue and behind a very thin layer of fascia that is located between the pectoralis muscle and the overlying breast tissue. Proponents of this pocket location claim less pain compared to subpectoral or dual plane, but this claim is conclusively disproved by Dr. Tebbetts’ published studies. The fascial layer of tissue is less than one millimeter thick in most areas, and does not provide any meaningful additional coverage over the implant compared to submammary augmentation. In addition, the layer is highly variable from patient to patient, not consistent or predictable, and is very difficult for even the most expert surgeons to elevate off the muscle without shredding portions of the fascia, making it useless for coverage. No studies have documented equivalent reoperation rates or rates of visible implant edges or rippling that match Dr. Tebbetts’ published studies using the dual plane pocket location.