Operative Technique in Plastic Surgery – Kevin C.Chung

■ The advantages of subglandular implant placement include the following:
■ It avoids implant deformation or distortion that can be seen in the subpectoral
position
■ Enhances the improvement in the constricted or ptotic breast
■ Allows an easier dissection plane
■ Decreased postoperative discomfort
■ Allows access to the inframammary fold (IMF) as the superficial and deep
fascial components merge
■ There are some disadvantages of the subglandular pocket, which include the
following:
■ Pocket with the least soft tissue coverage to disguise the implant
■ Increased visibility or palpability of implant with wrinkling or rippling
■ Higher capsular contracture rate
■ Less support and stabilization of the implants, especially shaped devices,
compared to subfascial or submuscular pockets
Subfascial Implant
■ Advantages to placing the implant in a subfascial pocket (FIG 2) include the
following1,3:23
■ It avoids implant deformation or distortion (animation deformity) that can be
seen in the subpectoral position.
■ This position provides additional soft tissue coverage between the implant
and the skin as compared to the subglandular pocket.
■ Fascia provides additional support to minimize implant edge visibility and
palpability seen most commonly with subglandular placement.
■ Fascia provides support of implant especially in the upper pole minimizing
excess implant movement and potential rotation with shaped implants.
■ Less postoperative pain as compared to submuscular placement
■ Fascia provides a distinct layer separating the implant from the overlying
breast parenchyma.
■ The disadvantages of a subfascial pocket include the following:
■ Less soft tissue coverage compared to submuscular coverage

FIG 1 • Subglandular implant placement is deep to the
breast tissue but superficial to the pectoralis fascia.

FIG 2 • Subfascial implant placement is deep to the
breast tissue and the pectoralis major fascia but
superficial to the muscle.
■ More challenging dissection to separate deep pectoral fascia from underlying
muscle while keeping fascia intact.
■ Higher rate of capsular contracture compared to submuscular
Submuscular Implant
■ Advantages to placing the implant in a submuscular pocket (FIG 3) as
compared to placement in the subglandular or subfascial pocket include the
following:
■ Lower capsular contracture rates1,4
■ Enhanced coverage of the implant
■ Reduced issues with wrinkling

■ Sloping natural upper pole
■ Enhanced support for the breast implant
■ Enhanced radiographic imaging with mammogram5,22
■ The disadvantages of a submuscular pocket include the following:
■ Animation deformity
■ Increased risk of implant superior malposition with waterfall deformity
■ Increased postoperative pain
■ Limited expansion of the lower pole of breast (required to expand constricted
and ptotic breasts)
■ The most significant attribute of the submuscular pocket is in providing
maximum soft tissue coverage for the implant. The widespread use of saline
implants and wrinkling issues led to surgeons looking for improved implant
coverage. After the moratorium on silicone was lifted, surgeons in the United
States continued to use the submuscular pocket with mostly smooth and to a
limited extent textured silicone implants.6
ANATOMY
■ An understanding of the breast blood and nerve supply is critical when
performing breast surgery (FIG 4AB).
■ Muscular attachments are shown in FIG 4C.
■ The breast is a skin appendage contained within layers of the superficial
fascia.
■ The superficial layer of this fascia is near the dermis and is not distinct from
it.
■ The deep layer of the superficial fascia is more distinct and is identifiable on
the deep surface of the breast when the breast is elevated in a subglandular
augmentation mammoplasty.

FIG 3 • A. Submuscular position of the implant with
overlying pectoralis muscle and breast parenchyma.
Note that the released inferior edge of the pectoralis
major allows lower pole expansion (arrow). B. Anterior
view of the implant placement below the pectoralis
major.

Thoracoacromial artery Axillary artery Subclavian artery Pectoral branch of thoracoacromial artery Lateral thoracic artery Lateral mammary branches of posterior intercostal arteries - - Superior thoracic artery Internal thoracic artery Perforating branches Medial mammary branches Lateral mammary branches Thoracoacromial artery Axillary artery Lateral pectoral nerve Medial pectoral nerve Median nerve Medial brachial cutaneous nerve Intercostobrachial nerve Pectoralis major Pectoralis minor Thoracodorsal nervel Long thoracic nerve

FIG 4 • A. Arterial blood supply of the breast. B. Nerve
branches supplying the breast. C. Muscular
attachments to the chest. The pectoralis major is
removed on the right side of the picture revealing the
underlying pectoralis minor.
■ There is loose areolar tissue between the deep layer of the superficial fascia
and the fascia to cover the pectoralis major that and to cover the adjacent rectus
abdominis, serratus anterior, and external oblique muscles.
■ The deep pectoralis fascia has its origin on the clavicle and sternum, extending
toward the lateral border of the muscle to form the axillary fascia (FIG 5).
■ It continues down to cover the latissimus dorsi muscle, rectus abdominis,

serratus anterior, and external oblique.
FIG 5 • Breast anatomy showing pectoralis fascia
posterior to the breast tissue.

FIG 6 • Histologic slide of the inframammary fold (IMF)
showing the superficial and deep fascia fusing
together.7
■ The subfascial pocket is deep to this deep pectoral fascia but superficial to the
underlying muscle.
■ This fascia is thin and more fragile in the lower two-thirds of the pectoralis
muscle and becomes denser and substantial in the upper third of the muscle.
■ The thin fascia in the lower aspects of the breast can make the initial subfascial
dissection more challenging, which becomes easier as the dissection proceeds
toward the upper pectoralis muscle.
■ The deep fascia overlying the pectoralis and the deep layer of the superficial
fascia underlying the breast unite with the dermis to form the IMF (FIG 6).7
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Initial consultation should evaluate the patient’s goals and anticipated results
with the breast augmentation.
■ A thorough history and physical should be done to identify any risk factors for
the procedure, including bleeding or clotting disorders.
■ Any history of breast lumps, masses, or breast disease should be elicited.

■ A family history is required.
■ In planning for optimal implant pocket selection, it is important to determine
the desired appearance or “look” the patient is seeking.
■ The submuscular pocket is more likely to create a smooth, sloping upper pole
with minimal roundedness in the upper pole.
■ A patient desiring a more rounded upper pole with a more obvious “implant
appearance” with implant shape visibility may prefer a subglandular implant,
provided there is adequate soft tissue coverage.
■ The subfascial approach can provide a compromise between the two; the
implant will be in a plane similar to the subglandular, but the additional
fascia layer will minimize implant edge visibility and palpability that can be
seen with the subglandular pocket.
■ The preoperative exam of the breast augmentation patient will guide the
surgeon’s implant selection and pocket placement. The physical exam
measurements should include the following (FIG 7):

FIG 7 • Necessary physical exam breast
measurements.
■ Breast width (BW)
■ Sternal notch to nipple (SSN:N)
■ Breast height (BH)
■ Nipple to IMF (N:IMF) at rest and under maximal stretch.
■ Upper pole pinch (UPP), medial pinch (MP), and lateral pinch (LP)
■ Intermammary distance (IMD)
Pinch Test
■ A key point of the exam is the upper pole pinch test.
■ A pinch test of less than 2 cm indicates the need for a submuscular placement
of the implant to avoid noticeable rippling (FIG 8A).
■ If the pinch test is more than 2 cm (1 cm of soft tissue thickness), the patient
is a candidate for a subglandular or subfascial pocket (FIG 8B). (The deep
fascial layer will provide additional coverage over the implant to allow for
subfascial placement.)
■ Implant selection impacts adequacy of soft tissue coverage. Keep in mind the
thinner the soft tissue, the greater the risk of implant palpation and rippling.
■ Some implants are prone to more wrinkling, including underfilled saline
implants and textured devices.
■ We require a pinch test of more than 2 cm if placing the implant subfascially
or subglandularly, where the soft tissue coverage is firm and good quality.
■ If the soft tissue coverage is lax and poor quality or if the implant selected is
deemed at risk for wrinkling, a pinch test greater than 3 cm is more reliable in
providing adequate coverage and minimizing the risk of rippling.
■ Adequate soft tissue coverage in the upper pole in a subglandular
augmentation will camouflage the transition between the breast and implant,
aiding to a smooth natural upper pole.
■ The deep fascia overlying the implant in the subfascial pocket will provide
additional support and coverage in the upper pole and minimize the implant
edge visibility, which can be seen if implants are placed in the subglandular
pocket with limited upper pole coverage.
■ If the patient prefers a full, rounded upper pole with an obvious transition
between her implant and soft tissue, a subglandular implant would be

preferred even if the pinch test is less than 2 cm.
• One must have a discussion regarding visible and palpable rippling of the
implant if placing the implant subglandular and the pinch test is less than 2
cm.
■ Capsular contracture can be reduced by using a textured implant in the
subglandular position, but one must consider the risks of rippling with
textured implant in a patient with inadequate upper pole coverage with a
pinch test of less than 2 cm.1
Physical Assessment
■ Assess for all asymmetries, including breast volume, IMF, nipple-areolar
complex (NAC), and chest wall.
■ Chest wall (skeletal and muscle) abnormalities or asymmetries are often
underappreciated and can significantly alter the final result (FIG 9).8
■ Pectus excavatum occurs occasionally, whereas pectus carinatum and Poland
syndrome are rare.9
■ Central deformities are typically ameliorated sufficiently by breast
augmentation alone.
■ Deep pectus excavatum deformities can be treated simultaneously with a
custom solid silicone implant made from a plaster mold, although most
patients decline this option.
■ Poland syndrome (absence of sternal head of pectoralis muscle) is best
addressed with subglandular augmentation as the sternal head of the pectoralis
major muscle is absent. When more severe, more extensive adjunctive
procedures, such as tissue expansion, fat grafting, and latissimus muscle
transfer, may be required.10
■ Hemithorax asymmetry due to differences in shape, protrusion, or regression
can create an uneven breast foundation, suggesting different size implants
despite equivalent breast volumes.

FIG 8 • A. Upper pole pinch test less than 2 cm and (B)
more than 2 cm.

FIG 9 • Examples of chest wall abnormalities.
■ Unilateral prominence of the chest wall is often associated with scoliosis
(FIG 10).
■ Subtle unilateral pectoralis hypertrophy should not affect subglandular or
subfascial implant placement, but it could affect subpectoral placement and
overall implant projection.
IMAGING
■ Screening mammography per the American College of Surgeons is
recommended for patients over 40 years of age.

■ Many plastic surgeons recommend a baseline mammogram at 35 or older prior
to a breast augmentation, especially if a family history is present.
■ Any additional diagnostic studies are guided by the preoperative exam.
FIG 10 • Left chest wall prominence compared to the
right chest wall.
■ Any palpable mass requires evaluation, usually with a diagnostic ultrasound
and/or mammogram.
SURGICAL MANAGEMENT
■ The preoperative evaluation and decision-making are a critical step in
achieving optimal outcomes in breast augmentation.
■ Capsular contracture is the leading indication for revision breast surgery after
a breast augmentation and every effort should be made during planning and
execution to minimize the risk of capsular contracture postoperatively.
Placement of breast implants in the submuscular pocket has consistently
demonstrated reduction in capsular contracture rates compared with the other
pocket choices.1,4
■ Validated steps to reduce this risk include the following:
■ Nipple shields11
■ No-touch technique12
■ Use of an insertion sleeve13
■ Pocket irrigation with triple antibiotics14
■ Inframammary incisions4
■ Use of textured implants1,4

Preoperative Planning
Incision
■ The decision on incision placement is based on a variety of variables:
■ Patient and surgeon preferences
■ Anatomic considerations
■ Implant type and size
■ Issues of capsular contracture, breast-feeding, and NAC sensation
■ There are many potential advantages of the inframammary approach, including
the following:
■ Well-hidden scar in the fold of the breast
■ Incisional length is unlimited, thus can accommodate any and all implant
choices
■ Excellent visualization for dissection of the implant pocket
■ The ability to control the IMF position during incision closure
■ Can be used for any complication revision
■ Lower capsular contracture
■ Minimal issue of a scar contracture creating deformity
■ Potentially less nipple sensation changes
■ Potential disadvantages of the inframammary incision include the following:
■ The scar is located on the breast
■ Scar may be more visible if breast fold is absent or if the scar becomes
pigmented
■ Must determine final IMF position preaugmentation and place scar precisely
in planned new fold.
■ Scar position more vulnerable to irritation from the bra
■ There are many potential advantages of the periareolar approach, including the
following:
■ Scar can be camouflaged in the areolar border
■ Direct visualization and access into the breast pocket
■ Can lower the IMF to any location without predetermining location
■ Central access allows use in most revision cases with optimal visualization
and access to the upper pole of the breast
■ Access for parenchymal breast scoring in constricted breast deformities
■ Potential disadvantages of the periareolar incision include the following:
■ The scar is located on the breast

■ Access is through a tunnel and may limit visualization in dense, heavy
breasts
■ Cannot use if areolae are too small
■ Poor scarring possible and can create significant deformities
■ IMF control sutures not possible when IMF is lowered
■ Transection of breast ducts may increase bacterial contamination
■ Potentially higher capsular contracture rates15
■ Good candidates for the inframammary approach may include the following:
■ Small areola
■ When controlling IMF is desired
■ Indistinct areolar border
■ Desire for no scar on the breast
■ Potentially when placing larger implants
■ Desire future breast feeding as interference with lactation has been implicated
with periareolar incision.5
■ Concerns with nipple sensation, although no strong data to support this
concern.3,16
■ Good candidates for the periareolar approach may include the following:
■ Very distinct areolar borders present
■ When areola large enough to accommodate implant and avoid implant trauma
■ When performing a concurrent mastopexy
■ Indistinct or absence of IMF to hide scar
■ When lowering IMF (IMF position does not need to be predetermined)
■ Treatment of tuberous breasts (parenchymal scoring, IMF lowering)
■ The incision should be as small as possible but large enough to dissect the
pocket and place the implant without distorting or injuring the device.
■ Incision length ranges include 3 to 4.5 cm for saline implants, 4 to 6 cm for
silicone round implants, and 4.5 to 7 cm for shaped cohesive silicone
implants.17
■ The length of the incision would be smaller with saline than with silicone
implants. Factors requiring increased incision length include the following:
• Implant volume
• Implant texture
• Silicone compared to saline
• Increased gel cohesiveness (silicone gel firmness)
• Increase implant projection

• Shaped implants (cohesiveness and gel distribution)
■ When using the periareolar approach, the incision is made around the areola
and the dissection is carried inferiorly the appropriate distance to accommodate
the selected breast implant.
■ However, when the approach is through an IMF incision, the final position of
the fold postaugmentation must be predetermined so the incision can be
placed accurately in that location.
■ Before surgery, the IMF is identified and marked in the sitting position (FIG
11A). To determine the true IMF position, the breast is autorotated inferiorly
to identify the inferior extent of the attachments of the IMF (FIG 11B).
■ The distance measured from the nipple to the true fold under maximal stretch
assesses the amount of lower pole skin available to accommodate the selected
implant.
■ The amount of lower pole skin required and the ultimate position of the fold is
a function of many factors, including the type of implant (saline vs silicone,
round vs shaped), size of implant, pocket location, and the strength and
stability of the soft tissue of the lower pole.
■ An acceptable standard that can be used is to follow the guidelines that an
implant with a base diameter of 11 cm requires 7 cm, a base diameter of 12 cm
requires 8 cm, and a base diameter of 13 cm requires 9 cm from nipple to
fold.18
■ Another useful method of estimating fold position is based on implant height
and projection and can be used for round or shaped implants17:
■ Optimal nipple to IMF distance = (1/2 implant projection) + (1/2 implant
height)
■ IMF lowering = (optimal nipple to IMF distance) − (measured nipple to IMF
distance)
■ If the measured nipple to fold distance is less than the desired or optimal
distance, the fold will need to be lowered.
■ Keep in mind that textured and smooth implants have different effect on the
lower pole skin and fold over time. A larger smooth implant will lead to more
stretch on the lower pole compared to a smaller or textured implant.

FIG 11 • A. The inframammary fold is a natural
boundary where the chest and the breast meet. B.
Autorotation of the breast. N:IMF is 6 cm at rest. N:IMF
is 8 cm on stretch/autorotation.
Pocket Control
■ Pocket control is key and begins during preoperative markings to design the
pocket size necessary to accommodate the selected implant.
■ Controlling the pocket involves placement of the IMF, defining the medial and
lateral pocket margins.
■ This creates the desired cleavage and prevents lateral migration or
malposition of the implant.
■ Whereas smooth implants often are designed with a larger pocket to allow for
implant mobility and perceived softness, pocket design should be more limited
when using a textured implant.
■ Excess movement can lead to irritation and seroma formation.
■ When using a shaped textured implant, a controlled pocket is even more
essential to minimize the risk of implant rotation postoperatively.
■ This requires defining the lateral, medial, and inferior as well as the superior
border and limiting the pocket to only what is required to accommodate the

shaped device.
■ The implant and pocket should ultimately have a “hand-in-glove” fit.19
Positioning
■ Patients are placed on the operating room table in the supine position.
■ The arms are secured to the arm board at approximately 45 degrees to stabilize
the patient in the upright position. Actual arm placement is between 45 and 60
degrees (FIG 12).
■ Some surgeons place the arms directly by the patient’s side.
■ Having the arms abducted to 90 degrees should be avoided because this does
not allow the breasts to be in a relaxed position when sitting the patient up to
check adequacy of implant placement and soft tissue redraping.
Approach
■ Before surgical preparation, 50 mL of a local field block of 1/4% lidocaine,
1/8% bupivacaine, and 1:400 000 epinephrine is injected into breast (Table 1).
■ A 20-mL syringe with a 22-gauge spinal needle is used to inject the anesthetic
into the dermis along the planned incision line, deep to the dermis along the
IMF, the medial pectoral border, the anterior axillary line, and deep to the
breast parenchyma, in a fanning fashion throughout the area of planned pocket
creation (FIG 13).
■ These injections provide assistance not only in operative hemostasis but also
in the management of postoperative pain.
■ This is less important in the subglandular augmentation as postoperative pain
is significantly less than with a submuscular augmentation.

FIG 12 • Arms abducted at approximately 45 to 60
degrees in supine position.
Table 1 Breast Local Anesthetic Formula
Drug
Amount
½% lidocaine plain
25 mL
½% lidocaine/1:200 000 epinephrine
25 mL
½% bupivacaine/1:200 000 epinephrine
25 mL
Injectable saline
25 mL
Total concentration: ¼% lidocaine, 1/8% bupivacaine,
1:400 000 epinephrine
100 mL

FIG 13 • Breast infusion with 20-cc syringe and a 22-
gauge spinal needle.
T E C H N I Q U E S
■ Subglandular and Subfascial Placement
■ The distinction between the subglandular and the subfascial plane is subtle
and opinions differ on whether it is of clinical importance.
■ The common aspect is both involve dissection superficial to the muscle and
avoid both, the animation deformity associated with the muscle and the
limitation the muscle plays on the ability of the implant to expand the breast
envelope.
Inframammary Fold Incision
■ A variety of incisional approaches to the subglandular, subfascial, or
submuscular pocket are possible, the inframammary fold (IMF) being the
most common.
■ This incision is performed the same for both subglandular or subfascial

pockets.
■ After determining the IMF position (either the native true fold position or the
planned lowered position), a paramedian line is drawn through the center of
the breast and bisects the newly drawn IMF.
■ The incision’s medial extent begins 1 cm medial to the paramedian line and
extends laterally for the appropriate distance, as previously described based
on the implant type (TECH FIG 1A).
■ The incision is made with a no. 15 blade through the skin to the mid-
dermis (TECH FIG 1B).
■ Dissection is then carried out with electrocautery through the skin and
subcutaneous tissue, beveling superiorly while rotating the breast off of the
chest wall.
■ Once dissection has been carried superiorly for 1 cm, the dissection is
carried through the superficial fascia and toward the chest wall.
■ The beveling preserves a small cuff of superficial fascia at the incision,
which ensures the fold is not inadvertently lowered and also provides a cuff
of Scarpa fascia that will prove useful during closure (TECH FIG 1C).
■ As dissection proceeds toward the chest wall, a constant upward retraction of
the breast tissue is maintained, exposing the pectoralis major with its
overlying fascia (TECH FIG 1D).
■ The upward retraction of the breast tissue is key, as the suspensory
ligaments of the breast concomitantly elevate the muscle to expose the
muscle edge.
■ The only distinguishing characteristic is at the level of the IMF incision,
dissection begins over the pectoralis fascia for the subglandular pocket or
deep to the fascia for a subfascial pocket.
■ The elevation of the subglandular pocket is superficial to the pectoralis
fascia, and the elevation of the subfascial is deep to the breast and fascia,
but superficial to the muscle.

TECH FIG 1 • A. Paramedian line drawn from the
nipple to the IMF. Note the 5 cm incision length. B. 5-
cm inframammary incision. C. Cuff of Scarpa fascia.
D. Upward rotation of the breast with retractor
exposes the underlying pectoralis muscle.
Periareolar Incision
■ Development of the periareolar incision differs slightly based on either
subglandular or subfascial implant placement is intended. The differences are
distinguished below.
■ The planned incision location is marked directly on the border of the inferior
areolar and breast skin with a series of dots.
■ The dots are used instead of a line for more accurate visualization of the
exact areolar border.
■ It is most important to follow the exact outline of the areolar border even if
irregular because any deviation off the border to smooth the incision outline
leads to a more visible scar (TECH FIG 2A).
■ The planned incision should extend equidistance medial and lateral from the
midline but not to exceed half of the circumference of the areola.
■ With the skin placed under tension by the assistant, the incision is made
precisely on the areolar border with a no. 15 blade through the skin to the
mid-dermis (TECH FIG 2B).
■ Dissection then proceeds through the deep dermis and breast parenchyma
with electrocautery.
■ The skin edges are retracted inferiorly and superiorly, and dissection is
carried down through the parenchyma toward the pectoralis fascia (TECH
FIG 2C).

TECH FIG 2 • A. Periareolar incision noted with dark
purple line. B. Periareolar incision along inferior
border of NAC. Solid black line is the IMF. C.
Periareolar incision along inferior border of NAC with
counter tension. Be careful not to aggressively
undermine the NAC. Solid black line is the IMF. D.
Schematic of the transparenchymal and subcutaneous
approach. E. Periareolar transparenchymal approach
with electrocautery. Solid black line is the IMF.
■ The dissection should be directed in an inferior direction to ensure that the
nipple-areolar complex (NAC) is not inadvertently undermined during
dissection and the blood supply compromised.
■ Dissection proceeds either directly through the breast tissue

(transparenchymal) to the pectoralis fascia or inferiorly under the skin
(subcutaneous) until the fascia is reached at the fold. The authors prefer the
transparenchymal approach (TECH FIG 2D,E).
Subglandular Pocket
■ With the subcutaneous periareolar approach (like the IMF approach), the
breast elevation and pocket creation begins at the fold and proceeds
superiorly in the subglandular plane.
■ The IMF is a fusion of the deep fascia attached to the pectoralis and the
superficial fascia of the breast.
■ Care is taken to prevent disruption of the IMF as the breast is elevated off
the pectoralis fascia.
■ If the transparenchymal periareolar approach is used, the dissection is
directed through the breast down to the pectoralis fascia.
■ The subglandular pocket is then developed as an inferior flap and superior
flap with its overlying breast tissue, creating a continuous pocket
superficial to the pectoralis muscle fascia.
TECH FIG 3 • A. Elevation of the overlying breast
tissue with underlying pectoralis muscle and fascia. B.
Subglandular pocket with pectoralis muscle/fascia
visible posterior to the pocket.
■ If the fold is inadvertently disrupted and the IMF lowering is not planned,
the fold must be controlled with deep fascial sutures at the time of incision
closure.

■ Continued upward retraction of the breast will elevate the breast and its
underlying superficial fascia as a single unit, leaving the deep pectoralis
fascia attached to the muscle.
■ The dissection is carried superiorly, medial and lateral to create the desired
pocket (TECH FIG 3).
Subfascial Pocket
■ With the subcutaneous periareolar approach (like the IMF approach), the
breast elevation and pocket creation begins at the fold and proceeds
superiorly in the subfascial plane.
■ The IMF is a fusion of the deep fascia attached to the pectoralis and the
superficial fascia of the breast.
■ Care is taken to prevent disruption of the IMF as the breast and underlying
pectoralis fascia are elevated off the underlying pectoralis muscle.
■ If the transparenchymal periareolar approach is used, then dissection is
directed through the breast down to the pectoralis fascia.
■ The subfascial pocket is then developed as an inferior flap and superior
flap of fascia with its overlying breast tissue, creating a continuous pocket
superficial to the pectoralis muscle but beneath the fascia.
■ If the fold is inadvertently disrupted and the IMF lowering is not planned,
the fold must be controlled with deep fascial sutures at the time of incision
closure.
■ The inferior extent of the pectoralis fascia is thin and elevation is best carried
out with the cut current of the electrocautery. The superior fascia is thicker
and more developed providing more easily dissected plane.
■ Continued upward retraction of the breast will elevate the fascial plane.
■ The fascia is left attached to the overlying breast tissue and elevated as a
single unit.
■ The dissection is carried superiorly, medial and lateral to create the desired
pocket (TECH FIG 4).
Pocket Control
■ As with any breast augmentation, pocket control is key.
■ Avoid overdissection of the pocket laterally to optimize medial projection of
the implant and minimize lateralization of the implant.
■ Subglandular implants have less lateral drift compared with submuscular

implants because they lack the lateral action of the forceful pectoralis
muscle contraction.
TECH FIG 4 • Creation of the subfascial plane. The
deep pectoralis fascia is elevated with the breast
tissue exposing the underlying pectoralis major
muscle.
■ As one carries the subglandular dissection medially, the midline can
quickly be violated due to the lack of sternal muscle attachments that
usually limit the dissection in the submuscular plane.
■ The fascia is adherent to the underlying pectoralis muscle as the sternum is
approached in the subfascial dissection and will provide some limitation to
medial overdissection compared to the subglandular pocket.
■ Overdissection can lead to implant medialization and the potential for
postoperative symmastia. This is especially true when the chest wall is
concave or slanting medially. Special caution with limited medial
dissection is warranted in these cases.
■ Remember if IMF lowering is needed, the dissection is in the subglandular
pocket, as the attachments creating the fold are superficial to the deep
pectoral fascia.20
Implant Placement
■ Once dissection is complete, the pocket is irrigated with triple antibiotic
solution (1 g cefazolin sodium, 80 mg gentamicin, 50 000 units bacitracin
mixed in 500 mL of normal saline) and hemostasis is assessed (TECH FIG
5A).

■ The authors as a personal preference generally remove bacitracin and add
betadine solution (50 cc) to the irrigation mixture if no allergy exists.14
■ The implants are soaked in the irrigation solution before insertion. Gloves
are changed and rinsed with the irrigation solution to remove any residue.
■ In the authors’ practice, the implant is placed into the pocket with the
assistance of an insertion sleeve such as the Keller funnel (TECH FIG 5B).
■ The opening of the funnel should be cut large enough to allow easy egress
of the implant through the funnel. This is confirmed by passing the implant
with irrigation solution through the funnel before insertion.
■ The implant orientation is confirmed in the funnel, and a maneuver of
squeezing the implant through the funnel with pressure exerted on the back
of the funnel slips the implant into the breast pocket.
■ These maneuvers provide a “no-touch” technique, which has been
associated with lower capsular contracture rates.13
TECH FIG 5 • A. Irrigation of breast pocket prior to

implant placement. B. Insertion of breast implant into
subglandular pocket with Keller funnel. C. Hand-
assisted implant pocket assessment and breast tissue
redraping. D. Note the pocket control and the medial
projection of the implant in the supine position.
■ Once the implant is in the pocket, a finger-assisted assessment and
manipulation of the implant within the pocket is necessary to confirm its
proper placement and assure appropriate redraping of the breast parenchyma
over the implant (TECH FIG 5C).
■ This maneuver is especially important with textured devices, as these
implants are less mobile and less likely to stretch the pocket and, thus, a
distortion or wrinkling of the implant in a tight pocket may be permanent if
not resolved before closure.
■ Repeated removal and insertions of the implant should be avoided to
minimize implant or incision damage, potential contamination, and pocket
overdissection. This is especially important with shaped implants, as a
stretched pocket from over manipulation could lead to implant rotation
postoperatively (TECH FIG 5D).
Pocket Closure
■ Before incision closure, the patient should be placed in the upright position
to assess implant position, fold position, and symmetry (TECH FIG 6A).
■ The inframammary approach is useful to control the fold position during the
final closure.
■ The cuff of superficial Scarpa fascia that was preserved during the initial
incision is used to secure the fold during closure.
■ If the IMF structure is stable, and was not violated or lowered during the
pocket formation, reapproximation of the superficial fascia during closure is
usually adequate.
■ If the fold is mobile from inherent weakness or was disrupted with fold
lowering, the pocket closure should include stabilization of the fold.
■ Fold stabilization is accomplished by incorporating the deep fascia in the
closure.
■ The Scarpa fascia cuff is sutured to the deep fascia in the lower incisional
edge during the closure of the IMF (TECH FIG 6B).

■ Both the periareolar and inframammary incision are closed in three layers:
deep fascia/parenchyma (2-0 Vicryl running), deep dermis (4-0 PDS
interrupted), and subcuticular (4-0 PDS running) (TECH FIG 6C).
■ Periareolar incisional closures do not stabilize the fold structure as it does
with an IMF incision closure.
■ If using a textured device, the implant must be seated at the desired
position at the base of the breast pocket because it is less likely to settle in
the pocket postoperatively as can be seen with smooth breast implants
(TECH FIG 6D).
TECH FIG 6 • A. Patient sitting upright prior to final
closure to assess for symmetry and final aesthetic
result. B. Fold stabilization with a 2-0 Vicryl
incorporating the deep fascia in the Scarpa fascial
closure. C. Image of the final closure incorporating
superficial Scarpa fascia and deep fascia as one

consistent layer without the presence of an incisional
step off. D. Downward pressure on the implant/breast
demonstrates a locked and stable IMF.
■ Submuscular (Subpectoral) Implants
Inframammary Fold Incision
■ Although the submuscular pocket can be accessed by any incision
(periareolar, inframammary, transaxillary, transumbilical), the most common
approach is through the inframammary incision.
■ After determining the IMF position (either the native true fold position or the
planned lowered position), a paramedian line is drawn through the center of
the breast and bisects the newly drawn IMF.
■ The incision’s medial extent begins 1 cm medial to the paramedian line and
extends laterally for the appropriate distance, as previously described based
on the implant type (see TECH FIG 1A).
■ The incision is made with a no. 15 blade through the skin to the mid-
dermis (see TECH FIG 1B).
■ Dissection is then carried out with electrocautery through the skin and
subcutaneous tissue, beveling superiorly while rotating the breast off of the
chest wall.
■ Once dissection has been carried superiorly for 1 cm, the dissection is
carried through the superficial fascia and toward the lateral pectoral border
deep on the chest wall.
■ The beveling preserves a small cuff of superficial fascia at the incision,
which ensures that the fold is not inadvertently lowered and also provides a
cuff of fascia that will prove useful during closure (see TECH FIG 1C).
■ Dissection is carried down toward the chest wall while maintaining a
constant upward retraction of the breast tissue, ultimately exposing the lateral
edge of the pectoralis muscle.
■ The upward retraction of the breast tissue is key as the suspensory
ligaments of the breast will concomitantly elevate the muscle (see TECH
FIG 1D).
■ It is imperative to not cut the muscle unless you can elevate the muscle off
the chest wall.

■ Inability to elevate the muscle most likely indicates that the identified
muscle is actually not the pectoralis, but rather the serratus, rectus, or an
intercostal muscle.
■ Dissection through an intercostal could lead to penetration of the pleural
space and pneumothorax.
■ Once the lateral border of the pectoralis is identified, the fascia is incised to
expose the underlying muscle. Continued upward retraction of the breast will
elevate the lateral border, allowing further dissection and placement of the
retractor beneath the overlying pectoralis muscle.
Periareolar Incision
■ The planned incision location is marked directly on the border of the inferior
areolar and breast skin with a series of dots. The dots are used instead of a
line to allow more accurate visualization of the exact areolar border.
■ It is most important to follow the exact outline of the areolar border even if
irregular as any deviation off the border in order to smooth the incision
outline leads to a more visible scar.
■ The planned incision should extend equidistance medial and lateral from the
midline but not to exceed half of the circumference of the areola (see TECH
FIG 2A).
■ With the skin placed under tension by the assistant, the incision is made
precisely on the areolar border with a 15 blade through the skin to the mid-
dermis.
■ Dissection then proceeds through the deep dermis and breast parenchyma
with electrocautery (see TECH FIG 2B,C).
■ The skin edges are retracted inferiorly and superiorly, and dissection is
carried down through the parenchyma toward the pectoralis fascia.
■ The dissection should be directed in an inferior direction to insure that the
NAC is not inadvertently undermined during dissection and blood supply
compromised.
■ Dissection proceeds either directly through the breast tissue
(transparenchymal) to the pectoralis fascia or inferiorly under the skin
(subcutaneous) until the fascia is reached at the fold. The authors prefer the
transparenchymal approach (see TECH FIG 2D).
■ With the subcutaneous periareolar approach (like the IMF approach), the
breast elevation and pocket creation begins at the fold and proceeds
superiorly in the subpectoral pocket.

■ The IMF is a fusion of the deep fascia attached to the pectoralis and the
superficial fascia of the breast (see FIG 6). Take care to prevent disruption of
the IMF as the breast and pectoral fascia are elevated.
■ If creating a subpectoral dual plane pocket, dissection proceeds
subcutaneously or transparenchymal down to the lateral border of the
pectoralis muscle.
■ If accessing the submuscular pocket, the lateral border of the pectoralis is
identified and the fascia is incised to expose the underlying muscle.
Continued upward retraction of the breast will elevate the lateral border,
allowing further dissection and placement of the retractor beneath the
overlying pectoralis muscle
■ When creating the submuscular pocket, it is imperative to not cut the
muscle unless it can be elevated off the chest wall.
■ Inability to elevate the muscle most likely indicates that the identified
muscle is actually not the pectoralis, but rather the serratus, rectus, or an
intercostal muscle.
■ Dissection through an intercostal could lead to penetration of the pleural
space and pneumothorax.
Pocket Dissection
■ After the subpectoral space is entered, dissection is carried upward centrally
to the superior extent of the pocket.
■ Dissection is then carried laterally just superficial to the pectoralis minor
until the lateral border of the pocket is reached.
■ Keep lateral dissection of the pocket to a minimum with the cautery
because the breast/nipple neural supply from the lateral cutaneous nerves
can be inadvertently cut.
■ Blunt dissection of the lateral edge of the pocket decreases the chance of
nerve transection.
■ Carry the dissection inferiorly along the lateral border of the pocket,
identifying and staying superficial to the serratus muscle until the inferior
extent of the pocket at the IMF is reached.
■ Avoid overdissection of your pocket laterally to facilitate optimal medial
projection of the implant.
■ The pectoralis is then released along the planned IMF, staying 1 cm superior
to the fold to account for caudal muscle descent.
■ Dissection directly at the fold will often lead to a fold that is lower than

planned as the muscle retracts inferiorly (TECH FIG 7A).
■ As the dissection is carried medially along the IMF, it is critically important
to stop it at the most medial extent along the sternum (TECH FIG 7B).
■ Preservation of the most caudal attachment of the pectoralis muscle at the
transition point (TP) along the sternum is critical to minimize the chance of
window shading of the pectoralis with subsequent medial implant exposure
and animation deformities (TECH FIG 7C,D).
■ A transition zone (TZ) of tapered muscle release connects the transition
point to the main body of medial pectoral muscle along the sternum.
■ The extent of the pocket is completed by defining the medial pectoral border
and dividing all of the accessory slips of pectoralis muscle that insert along
the ribs, preserving only the main body of the muscle as it inserts along the
sternum.

TECH FIG 7 • A. Inferior/lateral border of the
pectoralis major after it was released along the IMF. B.
Inferior release of the pectoralis major heading
medially toward the sternum. C. Transition zone (TZ)
and transition point (TP). Dashed line reveals
pectoralis muscle release medially up to the TP. Solid
line represents the inframammary fold (IMF). D.

Schematic demonstrating the release of the pectoralis
off of the chest wall to the transition point (TP). Notice
the transition zone (TZ) which is a zone of thinning of
the muscle at the caudal end of the sternum just
medial to the TP.
■ Dividing these muscle slips with electrocautery instead of blunt dissection
improves postoperative cleavage and maintains hemostasis. Although
completely dividing all accessory slips is required to achieve maximal
cleavage, division of the main body of medial pectoralis muscle should be
preserved, other than conservative thinning at the transition zone, to
minimize the risk of postoperative wrinkling or implant show.
■ This division of the inferior pectoralis muscle just above the IMF during
initial pocket dissection creates a level 1 dual plane. Thus, all subpectoral
pockets where the muscle is released inferiorly are actually dual-plane
pockets, as the segment between the caudal edge of the divided muscle and
the IMF is subglandular.21
■ The level of dual plane required varies, and each surgery can be tailored to
provide the optimal level based on soft tissue requirements and implant
selection.
■ The greater the amount of breast parenchyma or breast laxity, the greater
the level of dual plane.
■ It is this creation of a lower pole subglandular pocket that allows for an
optimal breast-implant interface and soft tissue redraping.
■ Failure to optimize the breast-implant interface can lead to a waterfall
deformity, with the breast sliding off of the implant.
■ When submuscular, IMF lowering can be more challenging as it is tempting
to carry the dissection under the muscle inferiorly to lower the fold.
■ The dissection along the chest wall at the level of the fold is deep to the
suspensory ligament structures that create the IMF.
■ IMF lowering in the subpectoral pocket requires transitioning into a more
superficial plane above the pectoralis fascia to lower the IMF.20
■ Dissection deep to the pectoral fascia will likely result in a lowered fold with
persistence of the fold structure, resulting in a double-bubble deformity.
■ This is more likely when dissection begins from above, such as a
periareolar or transaxillary approach.

■ When using an IMF incision, the dissection below the native fold begins in
the subcutaneous plane until the pectoralis muscle is reached, resulting in
appropriate obliteration of the native fold at the correct level.
Implant Placement
■ The implants are bathed in the irrigation solution before insertion. Gloves
are changed and rinsed with the irrigation solution to remove any residue (see
TECH FIG 5A).
■ In the authors’ practice, the implant is placed into the pocket with the
assistance of an insertion sleeve such as the Keller funnel (see TECH FIG
5B).
■ The opening of the funnel should be cut large enough to allow easy egress
of the implant through the funnel. This is easily confirmed by passing the
implant with irrigation solution through the funnel prior to pocket insertion.
■ The implant orientation is then confirmed in the funnel, and a maneuver of
squeezing the implant through the funnel with gentle pressure exerted on
the back of the funnel allows the implant to slip effortlessly into the breast
pocket.
■ These maneuvers provide a “no-touch” technique, which has been
associated with lower capsular contracture rates.12,13
■ Once the implant is in the pocket (see FIG 3A), a finger-assisted assessment
and manipulation of the implant within the pocket is necessary to confirm its
proper placement and ensure appropriate redraping of the breast parenchyma
over the implant (see TECH FIG 5C).
■ This maneuver is especially important with textured devices, as these
implants are less mobile and less likely to stretch the pocket and, thus, a
distortion or wrinkling of the implant in a tight pocket may be permanent if
not resolved before closure.
■ Repeated removal and insertions of the implant should be avoided to
minimize implant or incision damage, potential contamination, and pocket
overdissection.
■ This approach is especially important with shaped implants, as a stretched
pocket from overmanipulation could lead to implant rotation
postoperatively.
Pocket Closure
■ Before incision closure, the patient should be placed in the upright position

to assess implant position, fold position, and symmetry, and the adequacy of
the dual plane (see TECH FIG 6A).
■ The IMF approach for submuscular implant placement is useful to control
the fold position during the final closure. The cuff of superficial Scarpa fascia
that was preserved during the initial incision is used to secure the fold during
closure.
■ If the IMF structure is stable and has not been violated or lowered during
the procedure, reapproximation of the superficial fascia during closure is
usually adequate.
■ If the fold is mobile and unstable from either inherent weakness or from
disruption during fold lowering, the pocket closure should include
stabilization of the fold.
• Fold stabilization is accomplished by incorporating the deep fascia in the
closure.
• The Scarpa fascia cuff is sutured to the deep fascia in the lower incisional
edge during the closure of the IMF (see TECH FIG 6B,C).
■ Both the periareolar and inframammary incision are closed in three layers:
deep fascia/parenchyma (2-0 Vicryl running), deep dermis (4-0 PDS
interrupted), and subcuticular (4-0 PDS running).
■ If using a textured device, the implant must be seated at the desired position
at the base of the breast pocket because it is less likely to settle in the pocket
postoperatively as can be seen with smooth breast implants (see TECH FIG
6D).
PEARLS AND PITFALLS
Live by the
pinch
■ A pinch test of less than 2 cm should guide the surgeon away
from subglandular and subfascial pocket creation.
■ Implants that are more prone to rippling (eg, textured implants,
saline implants) or poor quality soft tissue might require an even
thicker soft tissue coverage and a pinch test of more than 3 cm
may be warranted.
Avoid midline
overdissection
■ No muscle sternal attachments encountered in subglandular or
subfascial plane. Symmastia prevention is important.

Control the
fold
■ If IMF is mobile, disrupted or lowered, the closure must
incorporate the deep fascia to secure the fold.
Reduce
capsular
contracture
risk
■ Textured implants in the subglandular/subfascial pocket, no-
touch technique, nipple shields, pocket irrigation with triple
antibiotics, insertion sleeve, submuscular implant pocket,
inframammary incision, and cohesive-shaped implants.
Pocket control
■ Precise pocket dissection to minimize malposition, rotation,
lateral drift.
Periareolar
incision
■ Avoid undermining the NAC to minimize disruption of the blood
supply to the nipple.
Subfascial
pocket entry
■ Use the cut current to facilitate elevation of the thin fascia. Fascia
thickens as you move superiorly.
Submuscular
pocket entry
■ If you cannot lift the muscle (pectoralis major) off the chest wall,
do not cut it.
Respect the
transition
point and zone
■ Divide pectoralis muscle 1 cm above the fold to the transition
point, thin along the transition zone, and release only accessory
muscle slips along sternum to prevent wrinkling and window
shading of muscle.
Optimize
submuscular
dual plane
■ Place implants submuscular and create a subglandular pocket in
the lower pole with a dual plane to optimize breast tissue-implant
relationship.
POSTOPERATIVE CARE
■ Incisions are covered with Steri-strips.
■ Contour tape is placed along the fold and lateral breast.
■ Breasts are wrapped with a Kerlix and Ace wrap for 24 hours.
■ For textured implants, a breast band is worn for 1 week.
■ Early range of motion, beginning in the recovery room, is initiated for all
patients, which includes shoulder rolls in both directions in addition to
elevation of the arms outward to the sides and over the head.
■ With smooth devices, implant massage begins postoperatively on day 4 and
includes displacing the implant upward and downward in the pocket, crossing
the arms and pulling the implants inward to create cleavage, and downward
pressure on the implants to stretch the lower pole.

■ With textured implants, both round and shaped, limited arm movement other
than range of motion is recommended for the first week.
■ Implant massage with textured implants is contraindicated, because the
textured surface can irritate the pocket and potentially create serous fluid
around the implant. Likewise, the implants are placed in a controlled pocket
with the implant positioned appropriately at the base of the pocket;
displacement could lead to implant malposition or, in the case of shaped
devices, rotation of the implant.
■ Patients are allowed to resume wearing regular bras after 4 weeks but should
continue with sports bras during bedtime for an additional 2 to 4 weeks to limit
lateral implant movement during pocket formation.
■ Normal activity resumes within a few days after surgery, but exercise and
high-impact activity should be delayed for 3 to 4 weeks for subfascial and
subglandular implants and 4 to 6 weeks for submuscular implants.
■ If a variety of smooth and textured (round or shaped) breast implants are being
used within a practice, it is extremely important to communicate to ancillary
staff the type of device placed with each patient to initiate the appropriate
postoperative protocol, as inappropriate instructions can lead to postoperative
problems such as seromas, malposition, and rotational deformities.
■ Whereas smooth implants often seem high initially and often require
downward massage and the use of breast bands or bandeaus, textured devices
that are appropriately seated in the base of the breast pocket should only
occasionally require such maneuvers.
■ Whereas smooth implants will seem more mobile and softer in the first few
weeks after surgery in comparison with textured devices, the textured
implants will soften with modest movement often present after 4 to 6 weeks.
OUTCOMES
■ Preoperative and postoperative photos of bilateral subglandular breast
augmentation are shown in FIG 14.
COMPLICATIONS
■ Capsular contracture
■ Infection
■ Malposition (symmastia, double-bubble, lateral drift, superior malposition
with waterfall) (FIG 15)

FIG 14 • Preoperative and postoperative photos of a 31-
year-old woman who underwent bilateral subglandular
breast augmentation through an IMF incision, with 355
cc moderate profile textured implants.
FIG 15 • A. Waterfall deformity with the breast tissue
falling off of the implant. Black curvilinear line
represents the breast-implant interface. B, C. Double-
bubble deformity resulting from overdissection deep to

the pectoralis major muscle attachments on the chest.
■ Double capsule/seroma
■ Nipple and breast sensation changes
■ Implant failure (leak rupture, fracture)
■ Implant extrusion
■ Neuropraxia
■ Poor scarring
REFERENCES
1. Stevens WG, Nahabedian MY, Calobrace MB, et al. Risk factor analysis for
capsular contracture: a 5-year Sientra study analysis using round, smooth and
textured implants for breast augmentation. Plast Reconstr Surg.
2013;132(5):1115-1123.
2. Strasser EJ. Results of subglandular versus subpectoral augmentation over
time: one surgeon’s observations. Aesthet Surg J. 2006;26:45-50.
3. Okwueze MI, Spear ME, Zwyghuizen AM, et al. Effect of augmentation
mammoplasty on breast sensation. Plast Reconstr Surg. 2006;117(1):73-83.
4. Namnoum JD, Largent J, Kaplan HM, et al. Primary breast augmentation
clinical trial outcomes stratified by surgical incision, anatomical placement and
implant device type. J Plast Reconstr Aesthet Surg. 2013;66(9):1165-1172.
5. Michalopoulos K. The effects of breast augmentation surgery on future ability
to lactate. Breast J. 2007;13(1):62-67.
6. Calobrace MB, Kaufman DL, Gordon AE, et al. Evolving practices in
augmentation operative techniques with Sientra HSC round implants. Plast
Reconstr Surg. 2014;134(suppl 1):57S-67S.
7. Muntan CD, Sundine MJ, Rink RD, et al. Inframammary fold: a histological
reappraisal. Plast Reconstr Surg. 2000;105:549-556.
8. Gabriel A, Fritzsche S, Creasman C, et al. Incidence of breast and chest wall
asymmetries: 4D photography. Aesthet Surg J. 2011;31:506-510.
9. Rohrich RJ, Hartley W, Brown S. Incidence of breast and chest wall
asymmetry in breast augmentation: a retrospective analysis of 100 patients.
Plast Reconstr Surg. 2006;118(7 suppl):7S-13S.
10. Hodgkinson DJ. The management of anterior chest wall deformity in patients
presenting for breast augmentation. Plast Reconstr Surg. 2002;109:1714-1723.
11. Wixtrom RN, Stutman RL, Burke RM, et al. Risk of breast implant bacterial
contamination from endogenous breast flora, prevention with nipple shields,

and implications for biofilm formation. Aesthet Surg J. 2012;32:956-963.
12. Mladick RA. “No-touch” submuscular saline breast augmentation technique.
Aesthetic Plast Surg. 1993;17:183-192.
13. Flugstad NA et al. Does implant insertion with a funnel decrease capsular
contracture? A preliminary report. Aesthet Surg J. 2016;36(5):550-556.
14. Adams WP, Rios JL, Smith S. Enhancing patient outcomes in aesthetic and
reconstructive breast surgery using triple antibiotic breast irrigation: six-year
prospective clinical study. Plast Reconstr Surg. 2006;118(suppl 7):46S-52S.
15. Wiener TC. Relationship of incision choice to capsular contracture. Aesthetic
Plast Surg. 2008;32(2):303-306.
16. Mofid MM, Klatsky SA, Singh NK, Nahabedian MY. Nipple-areola complex
sensitivity after primary breast augmentation: a comparison of periareolar and
inframammary incision approaches. Plast Reconstr Surg. 2006;117(6):1694.
17. Calobrace MB. Teaching breast augmentation. Clin Plast Surg. 2015;42:493-
504.
18. Teitelbaum S. The inframammary approach to breast augmentation. Clin
Plast Surg. 2009;36:33-43.
19. Hammond DC. Technique and results using Memory-Shape implants in
aesthetic and reconstructive) breast surgery. Plast Reconstr Surg.
2014;134(suppl 3):16S-26S.
20. Schusterman MA. Lowering the inframammary fold. Aesthet Surg J.
2004;24:482-485.
21. Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue
relationships in a wide range of breast types. Plast Reconstr Surg.
2001;107:1255-1272.
22. Handel N. The effects of silicone implants on the diagnosis, prognosis, and
treatment of breast cancer. Plast Reconstr Surg. 2007;120(7):81S-93S.
23. Munhos AM, Gemperli R, Goes JCS. Transaxillary subfascial augmentation
mammoplasty with anatomic form-stable silicone implants. Clin Plast Surg.
2015;42:565-585.
24. Tebbetts JB, Adams WP. Five critical decisions in breast augmentation using
five measurements in 5 minutes: the high five decision support process. Plast
Reconstr Surg. 2005;116:2005-2016.

3
CHAPTER
Breast Augmentation Plane:
Dual Plane
Bill Kortesis and Charalambos “Babis” Rammos
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.

FIG 2 • The markings are made in the preoperative area
and reviewed with the patient.
Positioning
■ The patient is brought to the operating room and placed in the supine position
on the operating table with the arms extended up to 90 degrees and well
secured to the arm boards. Both shoulders should be at the same height.
Approach
■ Inframammary incision placement
■ Wide exposure, better visualization
■ Easier manipulation of the inframammary fold position
■ Easier placement of the implant
■ Submuscular pocket and retromammary plane creation
■ Dual plane augmentation6 (FIG 3).
■ Type I dual plane: Complete division of pectoralis major muscle origin across
the inframammary fold, stopping at the medial aspect, with no separation of
the parenchyma-muscle interface
• Most routine breasts
• All of the parenchyma should be above the inframammary fold
• Minimally stretched lower pole envelope. Areola to inframammary fold
distance under stretch between 4 and 6 cm
• Maximal muscle cover over the implant, compared to all types