What is the dual plane technique? A guide to the combined subglandular-submuscular approach in breast augmentation

What does “dual plane” mean?

The term “dual plane” refers to a surgical technique that combines two different anatomical planes to place the breast implant: one part is covered by the pectoralis major muscle and the other lies in direct contact with the breast tissue, just beneath the gland.

In other words, the implant sits partly under the muscle and partly under the breast gland. This hybrid approach makes it possible to draw on the benefits of both positions without taking on the limitations of either.

How is the dual plane technique carried out?

During the operation the surgeon makes an incision (usually in the inframammary fold or in the areola) and creates a breast pocket divided into two planes:

1. The upper part of the implant is placed beneath the pectoralis major muscle, which gives extra cover and reduces the risk of the implant being visible or palpable.
2. The lower part sits beneath the breast tissue, with no muscle involved, which lets the implant fill the lower pole of the breast better and define the natural shape of the cleavage.

The technique requires partly releasing the pectoralis muscle at its lower attachment in order to free the breast pole and allow the implant to settle downwards in a controlled way.

What advantages does the dual plane offer?

The dual plane technique has proved one of the most effective ways of achieving natural, aesthetically balanced results, particularly in patients with demanding anatomy or with certain pre-existing breast conditions.

Among its advantages:

• A more natural-looking breast, both at rest and in movement.
• Better definition of the lower pole, which in a pure subpectoral plane can end up compressed.
• Better cover of the upper part of the implant, which reduces the risk of the edges showing in slim women or in those with little breast tissue.
• Lower risk of capsular contracture compared with the subglandular plane.
• Better adaptation to breasts with ptosis (mild drooping) without the need, in certain cases, for an additional breast lift.
• Longer-lasting results, since the implant stays well positioned over time.

Which patients is this technique indicated for?

The dual plane is particularly suitable in:

• Patients who are slim or who have little breast tissue in the upper part of the breast.
• Women with slight drooping of the breast (grade I or II ptosis), where the implant needs to follow the natural position of the tissue.
• Cases where the aim is a result that is natural but with projection and definition of the cleavage.
• Patients with mild breast asymmetry or with moderately tuberous breasts.
• Women who want to correct previous deformities or replace poorly positioned implants.

Where breasts are very firm, with good projection and sufficient tissue, or where a very marked result is wanted, other techniques such as the subglandular or the pure submuscular may be considered instead, on medical assessment.

What sets the dual plane technique apart from the others?

To understand its usefulness better, it is worth comparing the dual plane with the other traditional options:

• Subglandular plane: the implant sits entirely beneath the gland. Recovery is quicker, but there is a greater risk of visibility and of capsular contracture.
• Subpectoral plane (entirely beneath the muscle): it gives good cover, but can look artificial if the muscle compresses the implant too much, particularly in the lower part.
• Dual plane (combined): it offers the best of both. A natural look, cover above, definition below and gentle movement.

The dual plane technique provides a balance that adapts precisely to most women’s bodies today, and that is why it has taken on such a prominent place in modern clinical practice.

Where the dual plane came from

It is not a marketing label. The technique was described by Tebbetts in 2001 from a series of 468 patients operated on between 1992 and 1998, and the idea is exactly what the name says: combining the two classic pockets in the same patient — the retromammary and the partial retropectoral — instead of having to choose one.

The reason that combination was needed appears in the paper itself: breasts with glandular droop and a constricted lower pole pose a problem that a single pocket cannot solve without a price. With the whole implant beneath the muscle, the lower pole does not expand and the gland tends to slide down in front of the implant; entirely in front of the muscle, shape is gained below but cover is lost above, exactly where the edge of the implant shows. The dual plane is the attempt to keep what is good about each.

What the muscle gains you, and what it costs

This is worth saying plainly, because the idea circulates that “under the muscle is better” with no further qualification: the plane is not a choice between better and worse but a trade-off. A 2019 meta-analysis comparing subpectoral with prepectoral placement found that the subpectoral plane was associated with less capsular contracture and fewer haematomas, but also with more implant displacement and more animation deformity — that movement of the breast that appears when the pectoralis contracts.

The dual plane sits right in the middle of that debate: it keeps the muscle cover high up, which is where it is really needed to conceal the edge of the implant, and releases the lower attachment of the pectoralis so that the lower pole can expand. To be precise: that is the logic of the technique, not something that meta-analysis demonstrates. What it does make clear is that no plane wins on every count, and that the choice depends on the breast in front of you.

Which implants are used in the dual plane technique?

In the dual plane both round and anatomical implants can be used, although the final choice will depend on the patient’s aesthetic goals and on the surgeon’s recommendations.

• Round implants give more projection in the upper pole and a more evident cleavage.
• Anatomical implants, teardrop in shape, give a softer transition and a more natural result in profile.

The type of surface (smooth or textured) and the cohesiveness of the silicone gel also come into the choice. All these factors are discussed at the pre-operative consultation so that the best decision can be made.

What is recovery like after a dual plane augmentation?

Recovery is similar to that of a conventional augmentation with implants, although there may be slight muscle tension in the first few days because of the handling of the pectoralis. The most usual advice includes:

• Wearing a post-surgical bra for several weeks.
• Avoiding upper-body exercise for 3 or 4 weeks.
• Not sleeping face down or making sudden movements with the arms.
• Attending the scheduled follow-up appointments to check that the implant is settling properly.

Going back to work depends on the type of job, but generally happens between 5 and 7 days.

What results can you expect?

Results with the dual plane technique tend to be highly satisfactory, both for their natural appearance and for the stability of the implant over time. The breast moves softly, with no stiffness and no abrupt changes in shape.

What is more, with individual planning and precise surgical execution it is possible to avoid common complications such as displacement, rotation of the implant or visibility of its edge.

The dual plane technique represents one of the greatest advances in breast augmentation surgery. Its ability to give natural, stable results adapted to each type of body makes it an excellent option for many patients.

At the Instituto de Cirugía Plástica del Mediterráneo, in Valencia, we apply this technique on rigorous medical criteria, backed by years of experience and continuing professional development. If you are considering breast augmentation and looking for a balanced result, we invite you to a first individual consultation where we can assess whether the dual plane is the best option for you.

Frequently asked questions

What does “dual plane” mean?

That the implant is placed in two planes at once: the upper part is covered by the pectoralis major muscle and the lower part sits in direct contact with the breast tissue, just beneath the gland. It is a hybrid approach that takes the benefits of the two classic positions without their limitations.

How is that achieved in theatre?

The incision is made — usually in the inframammary fold or the areola — and a pocket divided into two planes is created. To do that, the pectoral muscle has to be partially released along its lower portion, which frees the lower pole and allows the implant to fill it without being compressed.

What advantages does it have over the pure planes?

A more natural appearance at rest and in movement; better definition of the lower pole, which in the pure subpectoral plane can end up compressed; better cover of the implant edge in slim women or those with little tissue; a lower risk of capsular contracture than the subglandular plane; better adaptation to breasts with slight droop; and a result that stays well positioned over time.

Which patients is it indicated for?

Above all slim patients or those with little breast tissue in the upper part of the chest, with grade I or II ptosis, with mild breast asymmetry or moderately tuberous breasts, and those looking for a natural result but with projection in the cleavage. Also to correct previous deformities or replace badly positioned implants.

Are there cases where it is not the best option?

Yes. In very firm breasts, with good projection and enough tissue, or where a more marked result is wanted, other techniques such as the subglandular or pure submuscular plane may be considered. That is decided by medical assessment.

Isn’t it always better to put the implant under the muscle?

No: the plane is not a choice between better and worse but a trade-off. A 2019 meta-analysis found that subpectoral placement is associated with less capsular contracture and fewer haematomas, but also with more implant displacement and more animation deformity. No plane wins on everything, and the choice depends on the breast in front of you.

Where does this technique come from?

It is not a marketing label. Tebbetts described it in 2001 from a series of 468 patients operated on between 1992 and 1998, designed for breasts with glandular droop and a constricted lower pole, which are the ones a single pocket cannot resolve without a cost.

What type of implant is used?

Round or anatomical. Round implants give greater projection in the upper pole and a more evident cleavage; anatomical, teardrop-shaped ones give a smoother transition. The surface (smooth or textured) and the cohesiveness of the gel also come into it, and all of it is decided at the pre-operative consultation.

What is recovery like?

Similar to any augmentation with implants, although there may be slight muscular tension in the first few days from handling the pectoral muscle. A post-surgical bra for several weeks, no upper-body exercise for 3 or 4 weeks, no sleeping face down or sudden arm movements, and scheduled check-ups. Returning to work depends on the activity, generally between 5 and 7 days.

Sources

• Tebbetts JB. Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types. Plast Reconstr Surg. 2001;107(5):1255-1272. PMID 11373572 — the original description of the technique across 468 patients, conceived for breasts with glandular droop and a constricted lower pole.
• Li S, Mu D, Liu C, Xin M, Fu S, Xu B, Li Z, Qi J, Luan J. Complications Following Subpectoral Versus Prepectoral Breast Augmentation: A Meta-analysis. Aesthetic Plast Surg. 2019;43(4):890-898. PMID 31139912 — the submuscular plane reduces capsular contracture and haematomas, but increases implant displacement and animation deformity.