Breast Implant Planes

Breast Implants Planes Give Very Different Results

 

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Certification, Affiliation, and Memberships

  • Certified by the American Board of Plastic Surgery
  • Attending Plastic Surgeon at Rush University Medical Center
  • Member of the American Society of Plastic Surgeons
  • Member of the American Society for Aesthetic Plastic Surgery
  • Member of the Illinois Society of Plastic Surgeons
  • Member of the Chicago Medical Society

John Q. Cook, M.D.

Chicago 312-751-2112
Winnetka 847-446-7562

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There Are Several Possible Breast Implant Planes – Each Plane Produces A Very Different Breast Shape and Form

It is very important for you to be fully informed about these choices so that you make the choice that is appropriate for your breast structure and that is in line with your taste.

implant planes

From left to right – breast without implant, breast with subglandular implant, breast with submuscular implant

BREAST IMPLANT PLANES EXPLAINED

With submuscular augmentation the surgeon places the implant beneathe the pec muscle.

With subglandular augmentation the surgeon places the implant in a space that is under the breast structure but above the pec muscle.

With subfascial augmenation the surgeon places the implant underneath the fascia that sits on top of the pec muscle.

There is also the possibility of combining planes so that the top part of the implant is under the pec muscle and the bottom part is under the breast.


SUBPECTORAL BREAST AUGMENTATION HAS SEVERAL IMPORTANT ADVANTAGES

The subpectoral plane is by far the most common choice for my patients because of several distinct advantages.
The anatomy of the pectoral muscle varies from person to person, but for most people its bottom edge lies near or just above the natural fold under the breast. During the breast augmentation procedure I open up the natural space under the pec muscle and release the attachments of the lower edge of the muscle to the underlying ribs.  This maneuver avoids the situation where contraction of the pec muscle pushes the implant up toward the collarbone so that the implant sits too high relative to the breast.

One question that comes up in consultation is whether the release of the lower edge of the pec muscle affects muscle function.
This is important to my patients, many of whom are very athletic.  Fortunately, pec function remains the same after release of the muscle edge.  There is, however, one issue that patients who are to undergo subpectoral augmentation should be aware of:  when the pec muscle contracts, the breast will move.

SUBPECTORAL ADVANTAGES
For most patients this one issue is outweighed by the advantages of having the implant under the muscle.

  1. Natural Slope Subpectoral implants have a natural slope in the upper portion of the breast.  For patients who want to avoid the top-heavy obviously augmented look that is all to common, subpectoral augmentation is a good choice.
  2. Quality Mammograms It is easier to get good quality mammograms when the implant is beneath the pectoral muscle than when implants are just under the breast structure.
  3. Camouflage Imperfections Particularly in thinner patients with a modest amount of natural breast structure, subpectoral implants help to camouflage any imperfections in implants and provide a more natural “feel” to the breast.
  4. Lower Likelihood of Capsular Contracture There is some evidence that submuscular implants have a lower likelihood of developing capsular contracture (hardening) than subglandular implants.

 

SUBPECTORAL DISADVANTAGES
Subpectoral Implants also have disadvantages when compared to Subglandular Implants

  1. Longer Surgery The surgery takes a little longer and requires more skill on the part of the surgeon. This should not be an issue if your surgeon is certified by the American Board of Plastic Surgery and is an experienced breast surgeon.
  2. Initial Discomfort For the first few days you will be more uncomfortable than if you had implants placed in the subglandular plane.
  3. Movement When you activate the pec muscles, such as doing a bench press or pushing down on the edge of a swimming pool to bring yourself out of the water the breasts will move. As a practical measure most patients don’t find this to be an issue. It might be a concern if you  are a competitive body builder.
  4. Technical Challenges If you have very well-developed pec muscles there may be technical challenges in obtaining a nice breast shape.

SUBGLANDULAR IMPLANTS CREATE FULLNESS IN THE UPPER PORTION OF THE BREAST
Some women desire breasts that are full in their upper portion and in the cleavage area. This can be accomplished with the implants in the plane immediately under the breast. The subglandular plane tends to maximize the forward thrust of the implants. From an artistic standpoint this can work reasonably well if you have enough natural breast structure in the upper part of the breast. A decent amount of your own tissue will help to camoflage the upper edge of the implant and avoid an obvious transition in the upper breast that can be a tell-tale sign of an augmented breast.

THERE ARE TWO SITUATIONS THAT YOU SHOULD AVOID WITH SUBGLANDULAR IMPLANTS
A large percentage of patients who come to me for revisional surgery after breast implants have implants in the subglandular plane. A less than ideal outcome from subglandular implants is often associated with two specific situations.

  • First, when very large implants, especially if they are saline-filled, are placed in the subglandular plane.
  • Second, when subglandular implants are placed in a patient with very little thickness of the natural breast tissue in the upper part of the breast.

It mystifies me why some doctors force very large saline filled implants into the subglandular plane. These breasts do not look or feel natural and often develop problems over time. Very large subglandular implants follow a predictable course. The weight of the implants stretches the lower part of the breast and leads to early drooping that only gets worse over time. The mechanical force of the implants leads to a thinning out of the remaining breast tissue, so that there is very little left to camoflage the implant.

This is particularly unfortunate with saline implants, since there will be rippling and irregularity. Surgery to revise this situation, while usually possible, can often be complex and expensive. If you lack sufficient thickness in the upper portion of the breast, it is usually best to avoid subglandular implants. Such implants thrust forward off the chest in a very unnatural way. A soft look is a natural look.

SUBGLANDULAR IMPLANTS HAVE SOME ADVANTAGES
As you can tell from what I have written, I place implants in the subglandular plane infrequently and almost never place saline implants in the subglandular plane.

SUBGLANDULAR ADVANTAGES
That said, here are Some Possible Advantages of the Subglandular Plane:

  1. Structure in Upper Portion For patients who have enough breast structure in the upper portion of the breast and who want a full look the subglandular plane may be a consideration.
  2. Avoid Breast Motion Patients who want to avoid breast motion that occurs when the pec muscles contract might consider subglandular implants. Many of these patients will also have limited amounts of their own natural breast structure, which means the implants may have an artifical look. There are strategies that sometimes help these patients, including the use of form stable implants, the use of the subfascial plane, and with careful discussion, the use of fat transfer to add structure to the upper part of the breast.
  3. Lifting Effect For patients whose breasts are just a little settled or droopy after pregnancy or weight loss, breast implants will provide a limited lift to the breast. This lifting effect is more powerful in the subglandular plane than in the submuscular plane. Another good option is for the surgeon to reposition the lower portion of the pec muscle in a way that preserves muscle coverage in the upper part of the implant but allow the implant to sit under the lower part of the breast.
  4. Shorter Surgery Subglandular augmentation is a little shorter operation that submuscular implants and can be carried out with limited anesthesia techniques in the right patients.
  5. Recovery Period Patients with subglandular implants have a less painful and generally easier recovery than patients with submuscular implants.

 

SUBGLANDULAR DISADVANTAGES
Subglandular Breast Implants Have Significant Disadvantages When Compared to Submuscular Implants

Unless you have a generous amount of natural structure in the upper portion of your breasts, subglandular implants will cause the upper breast to have a very unnatural look.

  1. Greater Likelihood of Irregularties Subglandular implants have a greater likelihood of showing ripples and other irregularties and to have an unnatural feel.
  2. Mammogram Quality It can be more difficult to obtain a good quality mammogram when implants are in the subglandular plane.
  3. Greater Likelihood of Capsular Contracture A number of studies suggest that subglandular implants are more likely to develop significant capsular contracture than submuscular implants.
  4. Greater Likelihood of Thinning Especially if they are large, subglandular implants are more likely to cause a thinning out of the natural breast structure.

SUBFASCIAL IMPLANTS MAY BE HELPFUL FOR WOMEN WITH VERY SPECIFIC BODY TYPES

Like all muscles the pecs are covered by a thin layer of tissue that is known as fascia.
For trim athletic patients who do not want to experience the breast motion that occurs with muscle contraction, the subfascial plane may be a worthy consideration. When a breast implant is placed in the subfascial plane the abrupt transition that occurs at the upper border of the implant is softened. This helps to avoid the tell-tale implant “look.”  Although this is an improvement over what is seen with subglandular implants, the subpectoral plane will provide better camoflage.

One useful strategy is to combine subfascial augmentation with the use of form stable implants and fat transfer in the upper aspect of the breast.
Form stable implants have less fullness in the upper pole, subfascial placement further softens the visual transition at the upper edge of the implant, and fat transfer provides greater thickness over the implant. It is possible to achieve the visual benefits of the combination I have just described with an axillary approach, but the incision needs to be extended in a specific way.


A Blended Approach that Combines Submuscular and Subglandular Implant Placement Will Provide a Modest Breast Lift

If you have a breast that has settled to a lower position on your body than you would like but you want to avoid the scars that occur with a breast lift a blended plane approach may be helpful.
I realized early in my practice that the pectoral muscle could be shifted under the breast so that it camouflages the upper border of the implant, but it allows the implant to fill out the lower portion of the breast. This provides a mild breast lift. I came up with the name “pectoral repostioning” to describe this technique. Many plastic surgeons use the term “biplanar augmentation” to describe this approach.

Remember that a breast augmentation by itself will provide a mild degree of breast lift.
A blended biplanar approach will provide a litlle more breast lift. A structural mastopexy or other breast lift technique will provide much more powerful lifting. It all depends on your needs. Consultation with a highly-experienced board-certified plastic surgeon will help you determine which of these choices is best for you. As a practical measure I tend to use a blended approach to breast augmentation for patients who have experienced a mild degree of breast settling or ptosis after pregnancy or weight loss.

Why do you need the muscle to move?

Submuscular augmentation in a setttled or droopy breast can lead to an undesirable double contour to the breast.
There will be a fullness from the implant and a second area of fullness from the breast that hangs off the implant. Needless to say, this is not desirable. Subglandular augmentation is not restrained by the muscle, so the implant does a better job filling out the breast, thereby avoiding the double contour. Unfortunately, subglandular augmentation has its own set of disadvantages, as I have previously explained. When the pec muscle is freed from its attachments to the under surface of the lower breast it will move to a higher position under the breast. The implant is now able to fill out the lower part of the breast as in a subglandular augmentation, but the upper part of the implant will be hidden by the pec muscle, so there is a smooth transition in the upper breast.

Potential Disadvantages of Biplanar Breast Augmentation

In my opinion biplanar breast augmentation is an easy operation in concept, but it can be difficult to maintain excellent long term results.

As a plastic surgeon who does a considerable amount of revisional breast surgery, here are some of the things I have learned from patients referred to me, as well as from a critical analysis of my own long term results.

  1. Natural Structure of Lower Breast Especially if larger implants are placed, the natural structure of the lower breast will thin out, just the way it does with big implants in a standard subglandular augmentation.
  2. Inframammary Fold It is very important for the surgeon to preserve the natural attachments of the inframammary fold (the fold at the lower edge of the breast). If this is not done the implants tend to drift over time to a position that is too low.
  3. Tendency to Stretch Especially with larger implants there can be a tendency to stretch out the lower portion of the breast. This creates too long of a distance between the bottom of the areola and the fold under the breast, so that the nipples ride too high on the breast.
  4. Pectoral Repositioning A little repositioning of the pec can be a good thing. Too much is too much! I have seen patients for revisional surgery where the pec muscle is sitting near the top of the breast. This is probably due to technical issues with the original surgery.

Biplanar breast augmentation can be a helpful technique for patients who have mildly settled breasts after pregnancy, but the long term results are technique dependent. I would advise any woman considering this operation to make sure that she consults with a board-certified plastic surgeon who is highly experienced in this technique.

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