DR. EPSTEIN’S COMPREHENSIVE Breast Augmentation Guide

Anesthesia – General, Sedation or Local?

Pocket Location: Above Or Below The Muscle

The layers of the breast and chest wall are as follows: breast lies on top of the pectoralis fascia which lies on top of the pectoralis major muscle (the “pecs”) which lies on top of the chest wall (rib cage and rib muscles). The pectoralis muscle is a triangular shaped muscle that has a broad attachment along the sternum (breast bone) and the medial (inner) side of the ribs near the sternum, then spans across the chest to attach on the humerus (upper arm bone).There are basically two places to put the implant: between the breast and the underlying muscle fascia (subglandular or “above the muscle”) or between the muscle and the underlying chest wall (submuscular or “under the muscle”). Either of these pockets can be created by armpit, nipple and breast crease incisions. There are advantages and disadvantages to each.

Subglandular Placement

  • Advantages: Easy dissection. There is a myth that there is less associated pain than placement under the muscle, but in my opinion and experience with the 24 hour recovery technique, this is not true. Many believe that this is the only option in a type II lax breast (this is also not true).
  • Disadvantages: There is less tissue above the implant to pad it so that rippling and wrinkling are more obvious, the implant is more palpable. Many breast radiologists believe that this approach interferes with mammography. With time, the lack of tissue above the upper portion of the implant will often cause a very unnatural look where the upper breast separates from the chest wall.


Anatomy of the breast, pectoralis major muscle and chest wall (ribs) – LAT ©2011 Mark Epstein, MD, FACS

Submuscular Placement

  • Advantages: Easy dissection. Using very gentle techniques of dissection, there is no more discomfort than with a subglandular pocket. Note that the muscle does not completely cover the implant, which is covered only by the breast in the lower, lateral quadrant. For those with a type II sagging breast (mild to moderate), a dual plane II or III approach will correct the bottoming out (see below case example showing the power of the dual plane technique). The dual plane technique involves repositioning the lower portion of the pectoralis muscle upward (see diagram below) so as to allow the implant to better fill out the lower portion of the breast and allow the nipple to rotate upward into a more favorable position. All this without any lift required! In my opinion, I believe that with the advent of the dual plane approach, there is absolutely no indication to ever perform a subglandular augmentation. With more severe sagging, a formal breast lift may still be required.
  • Disadvantages: None that I can think of. Contrary to popular belief, if surgical dissection is performed in a minimally traumatic manner, as with the “One-Day Recovery Breast Augmentation Technique”, recovery time and discomfort are no worse that with a subglandular approach.

The difference between placing the implant above the pectoralis muscle versus below the muscle (front view):
Click on an illustration below for a larger version: p 2002 ac large

Subglandular implants – AP ©2011 Mark Epstein, MD, FACS

p 2002 b glandc large

Partial Retropectoral Submuscular implants (with breast gland shown) – AP ©2011 Mark Epstein, MD, FACS

p 2002 bc large

Partial Retropectoral Submuscular implants (with breast gland removed from drawing) – AP ©2011 Mark Epstein, MD, FACS

The difference between placing the implant above the pectoralis muscle versus below the muscle (side view):


Subglandular implants – LAT ©2011 Mark Epstein, MD, FACS


Retropectoral Submuscular implants – LAT ©2011 Mark Epstein, MD, FACS

Dual-Plane Submuscular Placement 

The technique of dual-plane augmentation, originally described by John Tebbetts, M.D. This technique involves the creation of a pocket below the pectoralis major muscle in which the implant will be placed. A second, smaller pocket is created between the muscle and the above glandular tissue, usually up to about the level of the nipple or upper border of the areola (the pigmented skin around the nipple). Nothing is placed in this pocket, but the separation of tissues serves to separate the tighter muscle with the overlying stretched breast tissue to permit the implant to better fill out the lower pole of the breast, thus preventing the “double-bubble” deformity as described above. This technique leverages the advantages of both a subpectoral approach (pleasing upper beast contour where it takes off from the chest wall) with that of a subglandular technique (pleasing lower breast contours). The dual plane technique adds additional time to the procedure, but can make all the difference in obtaining a beautiful, natural augmentation as opposed to a poor, unnatural look, with breast tissue sliding downward over the front of the breast.


Submuscular implants (Dual plane I) – AP ©2011 Mark Epstein, MD, FACS


Submuscular implants(Dual plane I) – LAT ©2011 Mark Epstein, MD, FACS


Submuscular implants (Dual plane II) – AP ©2011 Mark Epstein, MD, FACS


Submuscular implants Dual plane II) – LAT ©2011 Mark Epstein, MD, FACS


Submuscular implants (Dual plane III) – AP ©2011 Mark Epstein, MD, FACS


Submuscular implants (Dual plane III) – LAT ©2011 Mark Epstein, MD, FACS

The dual plane placement seen below allows the implant to better fill out the lower portion of the breast by re-positioning the lower edge of the muscle upward (note less muscle coverage of the implant in the area of the nipple as compared to the partial retropectoral placement 2 diagrams above, on the right).

Secret tidbit – When the lower edge of the pectoralis muscle is elevated off the chest wall to gain access to the space below the muscle, the muscle naturally retracts upwards for a few cm. This is what Dr. Tebbetts termed a Dual Plane I. So, when you place an implant below the muscle, the lower portion of the implant is actually covered only by breast tissue. This is why, especially with saline implants, the implant is often palpable in the lower portion of the breast. A dual plane II or III is an extension of this concept.

The best way I can explain what a dual plane procedure is: In a sub-muscular pocket, the lower portion of the breast is below the lower edge of the pectoralis muscle, so the majority, but not all of the implant is covered by muscle; perhaps the upper 80% is covered by muscle and the lower 20% by breast tissue only. (If you had 100% muscle coverage of the implant, it would look very unnatural, firm and spherical.) We call this a “Dual Plane I.” So, technically speaking, a sub-muscular (or as it is otherwise known as a partial retropectoral) pocket is really a combination of above and below the muscle, whereas the traditional subglandular pocket is exclusively above the muscle. Now, if you imaging the lower edge of the pectoralis muscle sliding upward and providing, perhaps, coverage of the upper 65% of the implant with muscle and 35% (these numbers are for illustration purposes only) of the implant with breast tissue only, then you have a Dual Plane II pocket. Now, slide the muscle up a little further so that there is muscular coverage of the upper 50% of the implant with muscle and 50% coverage of the implant below with breast tissue only, now you have a Dual Plane III.


Some surgeons talk about a subfascial pocket. The only difference between this and a subglandular pocket is that the thin (1 mm or less) tissue covering the front surface of the pectoralis major muscle, the “pectoralis fascia”, is elevated off the muscle and left attached to the underside of the breast tissue. In my opinion, and that of others, preserving this thin, gossamer layer of tissue affords no specific advantages over a subglandular approach alone.


Subfascial implants (with implant shown under the muscle fascia shown as a blue line) – LAT ©2011 Mark Epstein, MD, FACS


Subglandular implants (with implant shown over the muscle fascia shown as a blue line) – LAT ©2011 Mark Epstein, MD, FACS

How powerful is the dual plane technique? In the example below, if the dual plane technique was not used, the breast tissue would hang off the front of the implant and create a “snoopy dog deformity” as viewed from the side.



So which is better: “above the muscle” or “below the muscle”?

When the implant is placed below the muscle, there is more soft tissue coverage of the implant, which gives the implant (if textured) more support and makes it less palpable. There is a more natural feel to the breast, as there is more tissue covering the implant. This advantage is especially important when saline implants are used, as they do not feel as natural as gel implants. Submuscular implant placement also pushes more of the breast tissue forward, resulting in less interference with mammography. When the implant is placed above the muscle, there is the possibility that some of the breast tissue may not be imaged as well with mammography, and that the implant may be more palpable and visible through thinner breast tissues. When having mammography performed, the mammographer will use techniques such as the Eklund breast displacement technique to better image an augmented breast. Lastly, submuscular placement may lessen the risk of capsule contracture following augmentation (post-operative tightening of scar tissue around the implant – see below). It is believed by many that the disadvantage of placement below the muscle leads to more pain and the possible need for drainage tubes due to more bleeding during the surgery. I have never used drains on a primary augmentation. THIS IS SIMPLY NOT TRUE! See the “One Day Recovery Breast Augmentation” below for more on this.

The fact is that on the lower and lateral portions of the breast, there is rarely muscle coverage of the implant, and thus the implant may be more palpable and even visible in these areas particularly in those individuals with thinner tissue. This is not a contraindication to performing breast augmentation surgery, rather, it is just a point that the prospective patient needs to be made aware of. For those with thinner tissues, silicone gel filled implants may be a better choice.

What if my breasts are sagging? Should the implant be above or below the muscle?

Ptosis means drooping or sagging of the breast. There are two types of ptosis, and they can co-exist in the same breast. The treatment for each type, however, is very different. Women with no (true) ptosis (drooping of the nipple) or pseudoptosis (“false ptosis” or bottoming out of the breast tissue with loss of superior fullness and a drooping bottom contour to the breast), are candidates for either above the muscle (subglandular) or below the muscle (subpectoral) placement of the implant, assuming that they have good quality tissue to drape over the implant.

Women with pseudoptosis present a more challenging problem. Pseudoptosis is more common in women who have been pregnant, and often more pronounced in women who have breastfed their children. In pseudoptosis, the nipple may or may not be at appropriate height (at or above the level of the lower breast crease or inframammary fold). The loss of superior fullness of the breast with shifting of the glandular and fat tissue of the breast to the lower portion of the breast (drooping of the lower portion of the breast as manifested by a longer distance from the crease below the breast to the nipple) is more problematic if one wishes to place the implant below the muscle. In this case, implant placement below the muscle would result in a “snoopy-dog deformity”. The muscle with the underlying implant will project forward; however, the glandular breast tissue will “fall” off the front of the implant (“waterfall deformity”), leading to the appearance of a nice breast mound with a sagging wad of breast tissue at the bottom. It is in these cases that surgeons usually elect to place the implants above the muscle (subglandular). This better fills out the lower breast tissue, and lets the implant descend a little more within the breast envelope to yield a more natural look. However, all the disadvantages of a subglandular augmentation exist. Furthermore, in these cases, the envelope size of the breast (the potential space for the implant) tends to be larger, and requires a larger implant to fill the breast out. While that may make a lot of women happy at least initially, a larger, heavier implant supported by a stretched out, poor quality soft tissue envelope will often times lead to over-stretching of the breast and further descent of the implant.

Here is my opinion, based upon a great deal of experience: I again believe that there is no indication to place an implant above the muscle in a primary (first time) augmentation. The short-term gains are not worth the long-term losses. If the degree of pseudoptosis is mild to moderate, a dual plane procedure is enough to correct the situation and produce an aesthetically pleasing breast. If there is true ptosis, or severe pseudoptosis, a mastopexy (breast lift) is indicated.  A thorough examination and assessment of the breast tissues is required so as a proper surgical plan can be made. This will be discussed in greater depth in the chapter Will I need a breast lift (Mastopexy)?.

How does a Dual-plane technique fit in?

In my practice, many of my patients fall into the category of patients with pseudoptosis as described above. I also have not placed a breast implant into a subglandular location during a primary breast augmentation (excluding revisions of other surgeon’s work) in many years. How is this possible? The dual plane procedure does not eliminate the need for a mastopexy (breast lift) in those that truly need it. In my opinion, with the advent of the dual plane technique, there is no remaining reason to choose placement of a breast implant above the muscle over placement below the muscle. As stated previously, the dual plane technique gives the advantages of both above and below muscle placement, without the disadvantages. Some of the most natural looking results that I have attained were in women who presented with somewhat stretched breasts secondary to pregnancy with mild to moderate pseudoptosis. Both teardrop as well as round implants can produce beautiful results in these patients. There may be some increased risk for implant rotation if a teardrop shaped implant is used in these patients as the tissues are loose and the implant may be more free to turn. As I am currently using only round implants to avoid the risk of the patient developing Anaplastic Large Cell Lymphoma (ALCL), rotation is no longer a concern.

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Chapters – Breast Augmentation Guide

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