July 17th, 2009 Dr. McKane
Today in clinic, I had a patient who was an aerobics instructor ask,”Can putting the implant behind the muscle cause distortion of my breast during exercise?” The answer to her question is yes, but I want to qualify this answer.
In patients where implants are positioned behind the pectoralis muscle, contraction of the muscle can change the shape of the breast. This distortion in shape is called an animation deformity and is graded on a scale ranging from no deformity to severe. It is something that occurs during contraction of the muscle and then resolves with relaxation. A recent study by Spear et al. looked at this issue and reported that muscle related distortion was not a problem during normal activities of daily living. In this patient cohort, interference occurred during weight training, exercise, yoga, and sexual activity. Interestingly, only 3% of patients reporting this problem would not consider subpectoral placement again. It is apparent that these patients accept animation deformity in return for improved breast cancer detection, less risk of capsular contracture, less problems with visible rippling, and a better chest/breast/implant interface. Although there are several techniques designed to help with this problem, the only definitive solution is to replace the implants into the subglandular (in front of the muscle) position. However, this is at the expense of increased risk of capsular contracture, implant visibility and rippling problems, and greater difficulty with mammography.
Our website www.drmckane.com has additional information and before and after photographs of breast augmentation for review. I invite you to schedule a consultation with me if you would like to learn more about breast augmentation or animation deformity. Please feel free to contact our office at (972) 566-3939 if you have any questions.
-Brice W. McKane, M.D.
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July 17th, 2008 Dr. McKane
I have received an email today from a nurse considering breast augmentation. She writes…”I have recently become aware of a new position for breast implants. I understand what subglandular and submuscular breast augmentations are. Would you explain to me what a dual plane breast augmentation is?”
There are several sites that implants can be positioned in the breast. I’ll review them all for you:
Subglandular – is a site where the implant is positioned immediately behind the breast gland and in front of the pectoralis muscle. This is a reasonable position for patients that have a fair amount of breast tissue. The greatest benefit for it is that patients generally have a faster recovery period and it can be beneficial for some types of breast shape. If a women is active, this position is not associated with any significant breast distortion with pectoralis contraction. One downside of this site is that there is increased implant visibility and the breast has a more augmented appearance. Other downsides include probable increased risk of capsular contracture (firm breast formation), and greater interference with mammography and breast cancer detection.
Subfascial – A fascial layer is a sheet of connective tissue that binds together or separates muscles. An implant can be placed beneath the fascial layer of the pectoralis muscle. This position in theory has some of the benefits of each of the more common positions – subglandular and subpectoral. It has some ability to provide more coverage for an implant and make it less visible than the subglandular plane. The problem is that the pectoralis fascia is a very thin structure in some patients and may be less than 1/2 of a millimeter in thickness. In this type of patient, the benefit of using the subfascial plane remains to be seen and further study will need to be conducted before we have a definitive answer.
Subpectoral– This site usually means partial muscle coverage of the implant by the pectoralis muscle. Due to the anatomy of the muscle and the nature of the dissection, the upper portion of the implant is covered by the muscle and the lower portion is behind the breast gland. This site generally has better upper pole breast contour as the muscle serves to soften the transition between the breast and the implant. This position also has a lower rate of capsular contracture associated with it and improved visualization of the breast on mammograms. The downside of this position is that it generally requires a longer recovery period, and it may cause an increased risk of a double bubble deformity in patients with specific breast types.
Total submuscular– total coverage of the implant was used in the past to reduce the risk of capsular contracture and implant visibility. This involved not only using the pectoralis muscle to cover the implant, but also recruited other muscle groups to assist with this as well such as the serratus muscles or in some instances the rectus muscles. This procedure had a very lengthy recovery period and was associated the highest risk of superior implant malposition and double bubble deformities. The lower pole of the breast and breast fold also had poor shape and definition due to the muscle’s inability to fully expand. This position is not commonly used for primary breast augmentation, but may be used in patient undergoing breast reconstruction.
Dual plane– this site was originally described by Dr. Tebbetts as a variation of the subpectoral position. It has several advantages over the previously mentioned sites and is the plane that I prefer to place implants into. A dual plane augmentation has several variations defined by division of the pectoralis muscle along the breast fold and varying degrees of dissection in the subglandular plane. The implant sits both behind the pectoralis muscle and behind the breast gland. That is, it lies in two planes or the “dual plane.” It has several advantages in that it allow for reduced visibility of the implant at the upper pole of the breast, reduced risk of capsular contracture, reduced interference with mammography, reduced muscle distortion of the implant, and decreased risk of double bubble deformity with certain breast types. It has a similar recovery period to the subpectoral plane.
Here is an example of a patient who underwent a dual plane breast augmentation in my practice. She is a 30 y/o woman who presented wanting a breast augmentation. She was a B cup and wanted to have a proportional for her frame augmentation. She had some early descent of her right breast causing her mild breast asymmetry. This is the preoperative view:
During our consultation she decided to use a 325 cc saline implant. Due to the breast asymmetry that she had and due to her concerns about implant visibility, capsular contracture, and breast cancer detection she decided that she would like to use the dual plane. I performed one of the variations of the operation on the right side to help her asymmetry. Here is the postoperative result:
The operation achieved her goal of a natural, proportional augmentation. By performing the dual plane augmentation and one of its sub types on the right side, her asymmetry was improved.
Our websites www.beauty-surgeon.com and www.drmckane.com have additional information about breast augmentation and before and after photographs for review. I invite you to schedule a consultation with me if you would like to learn more about dual plane breast augmentation. Please feel free to contact our office at (713) 661-5255 if you have any questions.
-Brice W. McKane, M.D.
Posted in Breast Augmentation, Breast Implant Positions, Home | No Comments »
