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

Question

Hi. I want a breast augmentation but only above the muscle, I've been told by surgeons before I have enough breast tissue to have the above the muscle placement, how much more of a risk of capsular contracture above then below? As I wouldn't have the surgery if below as for me I'm not comfortable with the idea of manipulation of a muscle. Just a personal preference.

Daniel Barrett, MD · Answer

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

Donovan Rosas, MD · Answer

When undergoing breast augmentation there are a number of choices which need to be made: saline or silicone? Volume: Larger or smaller? Incision? However, one of the most commonly debated choices is that of implants placement: subglandular/ submammary vs. subpectoral/ submuscular? While many surgeons recommend submuscular placement there are distinct differences to each approach. Subglandular Augmentation (“overs”): • Subglandular augmentation means place of the implant underneath the breast tissue but above the pectoralis muscle. Subglandular placement spares the pectoralis muscle which leads to reduced post operative pain/discomfort and no impact on muscle function post augmentation. Recovery is also faster when compared to subpectoral augmentation. • Subglandular augmentation can impact mammographic evaluation of the breast. However, as dedicated breast radiography has become more prevalent this has become less of an issue. Fellowship trained radiologists have become familiar with evaluating breasts post augmentation. It is also important to note that implant position does not interfere with visualization of breast tissue via contrast enhanced MRI (the most sensitive and specific study available for breast cancer detection). • Studies suggest there is an increased risk of capsular contracture when implants are placed in a subglandular space. • Aesthetically, implants placed superficial to the pectoralis major create a rounded, convex appearing breast profile. This effect is camouflaged, at least initially in larger breasted patients. However, as a woman ages fat atrophies and breast tissue descends. The result is a more noticeable implant specifically in the upper pole. Similarly, patients who have thin coverage superiorly are more likely to be able to perceive the implants and at higher risk of visible rippling. Subpectoral Augmentation (“unders”): • Subpectoral augmentation is technically a bit of a misnomer. Traditionally, subpectoral augmentation involves the release of the pecotralis major muscle from its lower attachments. This allows the muscle to “window-shade.” The upper hemisphere of the implant sits underneath the muscle (dual plane). This release contributes much of the discomfort encountered postoperatively by patients. • Subpectoral implants have a lower rate of capsular contracture. The difference is significant with some studies quoting a 38% rise in contracture risk with subglandular placement. • Aesthetically, in contrast to submammary implants (which are prominent in the upper pole- especially in thinner patients), the pectoralis muscle both conceals the underlying implant and flattens the upper pole. This flattening effect creates a natural sloping as one proceeds from the upper portion of the implant to the lower portion. • The most commonly cited drawback to sub-muscular augmentation is the animation deformity associated with contraction of the overlying muscle. Each approach has both costs and benefits. Patients are unique and so too is each operative plan. A potential augmentation candidate may be better suited for one approach or the other. As always, your board certified plastic surgeon can help guide you in your decision making process.

Krishna Vyas, MD, PhD, MHS · Answer

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

Jeffrey M. Darrow, MD · Answer

While it is generally accepted that capsular contracture rates for breast implants put underneath the breast is in the range of 10 to 15% and capsular contractor rates for implants placed underneath the pectoral muscle is 2 to 8%, there have been some studies, showing capsular`contrature rates of 1-2% for implants placed underneath the breast.  These low rates are achieved using a 14 step protocol for skin, cleaning, pocket irrigation, and a no touch technique for the implants utilizing a sterile introduction sleeve for placing the implant.  Discuss this with your plastic surgeon to see if they follow these protocols. One other option is the possibility of a sub fascial breast augmentation, where the implant is placed underneath the pectoral fascia, but above the muscle. This introduces an additional layer of protection between the breast and the implant and also carries a very low capsular contraction rate.

Benjamin Baker, BMBS MBA FRCS(Plast) · Answer

Thanks for your question, which is a good one. All breast implants will form a capsule around them, and the degree to which this is likely to contract is thought to be related to a number of factors including implant surface, placement, and implant contamination. 
Lower rates of capsular contracture have previously been reported with implants put underneath the muscle, but this is partly due to the implants having more coverage and therefore when capsular contracture does occur it is less likely to be reported by the patient. Implant technologies have moved on significantly, and the risk of capsular contracture, even with a subglandular augmentation (in front of the muscle) is low. There are a number of advantages of subglandular placement that you may feel outweigh this risk. 
In my practice, getting the implant placement right for the individual patient is important, and the risk of capsular contracture is one of a number of factors that will feed into this - the risk/benefit profile of each of the decisions that you make about your implants (surface / shape / dimensions / placement) should be discussed with your surgeon and individualised depending upon your priorities.

Ronald J. Edelson, MD · Answer

Although most surgeons agree that abive the muscle has higher risk of capsular contracture there are no really good studies that have determined what the percent risk is for above vs below the muscle

Zoran Potparic, MD · Answer

A capsular contracture is the most frequent complication of breast surgery in the life time starting several weeks to 30-40 years after surgery. There is a small difference in incidence based on placement of implant, underneath or on top of the muscle which is not the reason to avoid one or another. It is very difficult to collect solid data on this topic since this condition may occur in such a long time frame. I hope this helps.

Oliver Harley, FRCSEd(Plast) · Answer

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.

Mauricio Castano, MD · Answer

Previous evidence stated that subfascial or subglandular pockets, had a higher rate of capsular contracture, specially with smooth surface implants. With all new generation implants specially Motiva implants (which have a capsular contracture rate less than 1%), the pocket placement, isn't that much of a concern, but not all surgeons use this brand, other brands that have a lower rate of capsular contracture are the ones that have a polyurethane surface. 
Things to consider as well for a capsular contracture are: incision placement (IMF or areola), implant type, use of drains, and implant manipulation (I always do no touch technique) 
Hope this helps

Camille Cash, MD · Answer

Capsular contracture can occur with implants placed both above and below the muscle, but below the muscle simply carries a slightly lower risk.  If you want implants above the muscle and you are a good candidate then it's fine to proceed as planned.  I've included a video on capsular contracture that I hope you find helpful.

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

Answers (12)

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