LAUSR

Dual-plane breast augmentation was described by Tebbetts in 2001,1 in which submuscular implant placement is combined with a variable amount of dissection in the subglandular plane. The technique is subdivided into 3 types, depending on the extent of this dissection and the degree of release of pectoralis major (PM) fibers. These key maneuvers allow repositioning of the PM muscle relative to the implant.1 It has become an effective technique to improve the implant–soft tissue relationship in a wide range of breast types.2,3 A recent survey4 showed that 79.5% of members of the American Society of Plastic Surgeons (ASPS) use it as their primary technique. A problem that may arise with type II or III dual-plane technique is the superior displacement of the muscle and even the possibility of its sliding under the implant.5 The risk of this complication is potentially higher in patients in whom PM is (vertically) short or (horizontally) narrow. Anatomical variations in the origin of PM predispose to this malposition.1,2,6 In patients with a vertically short and/ or horizontally narrow PM,7 a relatively smaller separation between muscle–gland interface can result in shortening of the PM in the cephalad direction (Figure 1). This movement may impede the implant’s placement in the intended position as the free portion of PM “window shades” over the implant. This anatomical variation in the PM cannot be easily identified preoperatively. It is an intraoperative finding that requires an intraoperative decision. Clinically, this complication can present itself as an upper pole deformity (eg, a bulgy upper pole) that may be visible immediately postoperatively or can be discovered in the early postoperative period. One option2,5 is to gradually separate the muscle from the gland in 0.5 cm increments in order to have more control on PM position. This may not always be easy and, in certain cases, a small extra dissection can produce an uncontrolled displacement of PM. Another option is to use sutures between the free margin of PM and the posterior surface of the gland to prevent cephalad malposition of PM. Ramirez and Heller5 described placement of 3 VicrylTM 4-0 sutures at the muscle–gland interface, for all of their textured implants, to minimize the risk of PM rolling over. However, the placement of polyfilament sutures adjacent to a textured implant can increase the risk of subclinical infection and its long-term sequelae.3 In our experience, the combination of a short and narrow PM along with a high type of dual plane increases the risk of pectoralis retraction. Additional risk may be conferred if the PM is hypertrophic (eg, in patients who