The pinch test in the upper pole of the breast can also give additional information in choosing between subglandular or submuscular pocket. If the pinched tissue of upper pole is less than 2 cm, a submuscular dissection should be performed. In MtF patients, total and partial submuscular pocket is not indicated. The stiffness and the strength of the pectoralis muscle due to its development under the influence of testosterone can cause implant displacement in a lateral position or upward when inferior pectoralis origins across the inframammary fold are not divided, even if the risk of capsular contracture is lower than in the case of subglandular pocket. With partial retropectoral (only pectoralis major) or total submuscular (pectoralis major and serratus) location, there is also more postoperative tenderness and a more prolonged recovery.

In order to ensure that greater force does not push the prosthesis below and parenchymal attachment does not give shape distortion like “double-bubble” deformity, it is necessary to detached the lower portion of the pectoralis from the chest wall combined with a subglandular dissection, as described in dual-plane technique [13].

Dual-plane breast augmentation usually allows greater coverage in a wide range of breast in women and gives better cosmetic result in terms of volume and projection. The possibility of the implant going downward is preserved too.

In male patients it is more difficult to identify the muscular plane and prepare the pocket, because the planes are less defined. Bleeding can be a problem. It is also important to fix the space between the two breasts to extend the subglandular pocket more medially toward the sternum.

In our clinical experience, when the gland is firm and more conspicuous, dual-plane type I is more indicated; if it is mobile on the muscular surface (rarely in male), we should choose a type II.

The difference between these two techniques is that in type I, the surgeon creates the pocket only dissecting the muscle at the inframammary fold while in type II, also the glandular tissue is mobilized to the NAC.

In MtF patients, the gland, even if adequately represented, is usually firm on the muscle; this is the reason why dual-plane II is rarely performed.

In MtF the lower pole is often not well represented so the suggested technique is dual-plane type III, in which the mammary gland is elevated from the pectoralis major muscle more cranially. This allows a better downward mobilization of the gland ensuring an adequate coverage of the lower pole of the implant (Figs. 16.3, 16.4, 16.5, and 16.6)

To redistribute the parenchyma and widen the base of this kind of breast, radial or concentric parenchymal scoring is often required. To put pressure on the scored parenchyma and to expand the lower pole, more projecting anatomical implants have to be used.

In those cases of dual-plane type III where the inferior pole of the prosthesis has an insufficient coverage, the use of acellular dermal matrix should be considered. This matrix is sutured in its upper part to the inferior border of the muscle and in its inferior part to the chest wall at the inframammary fold. This technique provides good coverage and protection of the prosthesis and a better cosmetic outcome as the skin flaps become thicker, preventing skin wrinkling.