How much more of a risk of capsular contracture is there with implants above the muscle?

The evidence for undermuscle placement being protective against caspule contracture is not clear cut in my view and it makes no biological sense anyway because the muscle only covers the upper half of the implant. Modern textured implants in the under-breast plane ('subglandular') have a very low capsule rate and unless you are skinny on the breasts or you have a strong personal preference to have implants under the muscle you should go with the under-breast option. Choose a teardrop implant if you want more of a 'natural' look and choose a round implant if you want a rounder more 'fake' look.

Dear A7183790,
capsular contracture happens. In fact, every implant has a capsule form around it, its just a certain percentage develop thick capsules. There is a lot we don't know about it actually. Some think that bacteria that gets on the implant during insertion can increase the risk. Thats why we use a Keller Funnel in our practice to reduce that possibility. Our capsular contracture rate is less than 2% because we use a keller funnel as well as meticulous operating room techniques.
Daniel Barrett, MDCertified, American Board of Plastic SurgeryMember, American Society of Plastic SurgeryMember, American Society of Aesthetic Plastic Surgery

When it comes to breast augmentation, the risk of capsular contracture can vary depending on whether the implants are placed above (subglandular) or below (submuscular) the pectoralis muscle. Generally, implants placed above the muscle carry a slightly higher risk of capsular contracture compared to those placed beneath the muscle. The risk for subglandular placement tends to range from 10-15%, while for submuscular placement, it's typically around 5-10% (statistics vary among studies and implant types and surgical technique).
The muscle's additional tissue coverage in submuscular placement helps reduce inflammation and tension (factors that can contribute to capsular contracture). However, with advancements in implant technology and surgical techniques, the risk for subglandular implants has significantly decreased. Factors such as implant surface texture (smooth versus textured), surgical technique, and post-surgical care also influence the likelihood of developing capsular contracture. While submuscular placement may be recommended for minimizing this risk, many patients with enough breast tissue opt for subglandular or subfascial implants, as long as they follow proper aftercare to reduce complications. Discuss your preferences and concerns with your surgeon to make an informed decision tailored to your anatomy and aesthetic goals.
Krishna Vyas, MD, PhD, MHSHarvard, Hopkins, & Mayo Clinic Trained Aesthetic Plastic SurgeonNew York, New York