Does above or below muscle placement of implants matter in avoiding a repeat episode of capsular contracture?

does placement of breast implants matter when trying to avoid a repeat episode of capsular contracture?

Doctor Answers 23

Subglandular or submuscular?

Thank you for your question.  The choice of pocket (over or under the muscle) depends on many factors including patient anatomy, lifestyle, and patient choice.  The most common location is submuscular.  There are many studies to suggest that a submuscular location decrease the rate of capsule contracture.   Some other studies suggest that an acellular dermal product such as Stratttice can decrease capsule formation as well.  These products are generally reserved for revisionary surgeries.  In patients with an established capsule contracture with a subglandular implant, most surgeons would recommend conversion to a  submuscular pocket in an effort to reduce the capsule recurrence rate.

Capsular Contracture and Breast Implants

     Most implants are placed under the muscle, particularly if they are smooth.  If the first implant was placed over the muscle, then a change of plane to under the muscle could be performed.  If the original implant was placed under the muscle, a new implant can be placed in a new pocket between the anterior capsule and the muscle or total capsulectomy can be performed.  Anterior capsulectomy alone results in greater recurrence rates, and open capsulotomy is not recommended to treat capsular contracture due to high recurrence rates.  There are many variations on this and always find the expert with best credentials.

Typically yes...

Typically yes. It is generally accepted that after a capsular contracture the new breast implant should be placed in a new pocket if possible. This is achieved either by converting subglandular to subpectoral placement or in the case of a previous subpectoral placement, a capsulectomy can be performed to freshen the pocket for the new implant.

Submuscular for subglandular for cc

In general, submuscular placement has been shown in multiple studies to have a lower rate of CC.

However, I would also need to know your personal history - how many surgeries for breast augmentation have you had, which plane were the earlier implants in, what revisional procedures were performed, were there complications, etc. - before recommending the best approach for you.

You may want to consider more advanced alternatives, such as placement of Strattice, or even implant removal and replacement with fat grafting, if you have already had many episodes of CC.

Hello Beth and thanks for asking about possible recurring capsular contracture and breast implant placement

It would be so great to know your current implant position-  maybe come back and share that with me.  I would hold off on the decision about where to place the next implant until I assessed the quality of the contracture, the quality of your skin, the volume of your breast tissue and the type of implant to be used for the replacement. As a woman surgeon,  I like to discuss at the consultation the goal that each woman has for breast implant surgery.  Once I have that information, the physical examination provides to me additional information related to the the quality of your skin, volume of breast tissue and the position of your nipple.  As an example:  is the nipple above or below the crease/fold below your breast?  Then, I like the ladies I see to try on breast implant sizers so that she and I better understand what impact the implant size may have on the skin, breast tissue and position of the nipple.  Only at that time, do I feel comfortable sharing my thoughts on the position of the implant- above or below the muscle.

When possible, I prefer to place the implant below the musle as the risk of capsular contracture is less.  Also, in ladies with only a small volume of breast tissue, the muscle provides an extra layer of soft tissue over the implant which in those cases may contribute to a more natural 'look.'  It takes a woman to woman conversation to make the best decisions, both short and long term.

Thanks for asking!  Ellen Mahony, MD

Ellen A. Mahony, MD
Westport Plastic Surgeon
5.0 out of 5 stars 20 reviews

Reducing capsular contracture with breast implants

Most plastic surgeons, as I, would agree that submuscular breast implants have a lower rate of capsular contracture.  I use the submuscular or dual plane techniques as my methods of choice. 

Raffy Karamanoukian, MD, FACS
Los Angeles Plastic Surgeon
4.8 out of 5 stars 93 reviews

Capsular Contracture

Placement of breast implants under the muscle has the lowest rate of capsular contracture.  So, if you have subglandular implants, it is best to convert to submuscular placement if you development capsular contracture.  Newer evidence shows that placement of Acellular products such as Alloderm can help decrease contracture rate.


Good Luck.

David Shafer, MD
New York Plastic Surgeon
4.9 out of 5 stars 72 reviews

Capsular Contracture

Placing breast implants below the chest wall muscles has been shown to reduce the incidence of capsular contracture (hardening of the breast).In cases of recurrent capsular contracture, sewing in a piece of acellular matrix (such as strattice) can also help to reduce the contracture from coming back again.

Location of implant

The choice of submuscular and subglandular is based on the patients anatomy, lifestyle, and understanding the pros and cons of each.  The most common approach is submuscular.  There is evidence that the rate of capsular contracture is less.  I would not say the subglandular should never be done as has been posted here.  If you have recurrent capsule problems from subglandular, I would suggest changing to submuscular, and possibly including acellular matrix.

Steven S. Carp, MD
Akron Plastic Surgeon
4.5 out of 5 stars 28 reviews

Capsular Contracture is common after breast implant surgery

The most common problem after breast implant surgery is capsular contracture. Our bodies recognize the breast implants as a foreign object and try to protect us from this "invader" by walling it off with a scar tissue like substance.  This happens 100% of the time, but in only 10-20% of the time does it become noticeable by squeezing the implant causing shape distortion, firmness and even pain.  If it deforms the breast severely and there is pain then surgical intervention is necessary. 

However, surgery is only successful 50% of the time, that is why you see so many solutions offered by all the physicians on this website.  No one knows what will work, so many solutions are suggested to try to solve the problem.  Since we don't know what causes the capsule, we are just guessing on how to fix it.  We do know that you need to change the environment around the implant.  If you are above the muscle, go below, saline implant changed to silicone, smooth implant change to textured, capsulotomy, capsulectomy, alloderm, do something different and keep your fingers crossed.

I personally believe prevention and medical management are a better approach to keep our patients out of the operating room again.  I like to start a program of aggressive breast implant massage starting 1 week after surgery on a daily basis.  And, at the first sign of firmness start the patients on 2,000 IU of Vitamin E daily combined with Montelukast (Singulair) 10 mg daily for 3 months.  If that fails then I start Trental 400 mg three times/day for 6 months.  If that fails then we talk about surgery to fix the capsules as a last resort.

David Finkle, MD
Omaha Plastic Surgeon
4.9 out of 5 stars 70 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.