Breast Augmentation Plane: Dual Plane

DEFINITION

According to the American Society for Aesthetic Plastic Surgery (ASAPS) 2016 statistics, breast augmentation was the second most common aesthetic surgical procedure performed in the USA, with approximately 311 000 procedures performed.¹
A thorough physical examination of the prospective breast augmentation candidate is imperative.
Any asymmetry of breast size, nipple position, and inframammary fold is documented.
The most commonly used implant locations are partial subpectoral and subfascial.
A combination of two pocket locations in the same breast (dual plane) can address the implant-soft tissue dynamics that may occur.

ANATOMY

In dual plane augmentation, the implant lies partially behind the pectoralis major muscle, and partially behind the breast parenchyma (in dual planes simultaneously).²
The parenchyma-muscle interface is specifically altered, and a specific group of pectoralis major muscle origins are totally divided.
- The inferior origins of the muscle are only divided without any division of the sternal attachments.
- A plane between the parenchyma and the anterior surface of the muscle is formed to a varying degree, resulting in three different types of dual plane: type I, type II, and type III.

PATHOGENESIS

Micromastia occurs as a developmental phenomenon either as primary mammary hypoplasia or due to chest wall pathology such as Poland syndrome.
It may also present as an involutional process, due to weight loss or after pregnancy and lactation.
Micromastia may lead to a negative body image and have a negative effect on quality of life.

PATIENT HISTORY AND PHYSICAL FINDINGS

Goals and expectations of the patient are discussed in detail during consultation.
A thorough personal and family history is performed focusing on:
- History of any breast disease and breast cancer
- History of pregnancy
- Desire for future pregnancy
- Mammogram: Screening mammogram is obtained for any patient over 35 years old.
Physical examination focuses on:
- Current height and weight
- Current breast size and desired breast size
- Palpation for any breast masses, lymph nodes, or nipple discharge
- Observation of breast ptosis and degree of ptosis, and the need for synchronous mastopexy
- Observation of chest wall and breast asymmetries, such as differences in inframammary fold height, nipple-areola complex (NAC) height, breast volume, and breast shape

IMAGING

The authors use the VECTRA 3D imaging and simulation system for all patients interested in breast augmentation. The device takes a three-dimensional photograph that can then be visualized in the monitor, with the addition of breast measurements.

Differences between the two breasts, such as breast volume and sternal notch to nipple distance, can be depicted (FIG 1).

FIG 1 • Three-dimensional photograph of a 27-year-old female using the VECTRA 3D imaging device. Breast measurements are shown. Differences between right and left breast in terms of volume and sternal notch to nipple distance are recorded.

Using different implant shapes and sizes, the surgeon produced a simulated postsurgical result, allowing the patients to have a visual image of the outcome. It has been shown that the use of the VECTRA 3D imaging system may provide a high degree of accuracy for breast volume (90%) and contour (98.4%).³

SURGICAL MANAGEMENT

The main objectives of breast augmentation are as follows:
- Enhancement of breast shape and volume
- Improving self-esteem and quality of life.⁴ A prospective analysis using the BREAST-Q showed that breast augmentation is associated with high patient satisfaction and significant improvements in quality of life.⁵

Preoperative Planning

Breast measurements
- Breast width at its widest point
- Nipple to inframammary fold (N-IMF) distance
- Sternal notch to nipple distance
- Breast height
Assessment of breast parenchyma and skin
- Elasticity: This is performed with deflection of the skin, and observation for resistance.
- Pinch test: This is performed at the superior and medial portion of the breast, between the examiner’s thumb and index finger. A result of less than 2 cm is most of the times an indication for placement of the implant in the subpectoral plane.
Choice of implant volume. Sizers are placed in a bra and compared to the images obtained by the three-dimensional imaging.
The patient is marked preoperatively in the upright standing position (FIG 2).
- Midline, from sternal notch to xiphoid
- Inframammary fold
- Superior, medial, and lateral borders of the breast. The medial borders are marked 1.5 cm lateral to the midline, so as to prevent synmastia.
- Breast meridian
- Incision. For an inframammary approach, the marking is placed below the inframammary fold, centered at the breast meridian, most often 4 cm in length, 2 cm medial and 2 cm lateral to the meridian.