How much higher is the risk of capsular contracture with subglandular than submuscular?

Question

How much higher is the risk of capsular contracture with subglandular breast implants than submuscular implants?

Jeffrey M. Darrow, MD · Answer

The rate of capsular contracture in sub glandular implants is generally higher than in sub muscular implants due to the highly vascularized muscle protecting the implant from the back side of the breast.  Closely comparable rates of capsule contracture in the sub muscular placement can be achieved with a sub fascial placement of the implant, which adds a layer of fascia between the backside of the breast and the implant and can be an excellent option for patients who don’t want a sub muscular placement.  Have a detailed discussion with your plastic surgeon about the best options for you. Best wishes.

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.

Azita Madjidi, MD, MS, FACS · Answer

The risk is over double. The reason is that in subglandular plane the implant is in direct contact with the breast tissue which contains milk ducts and bacteriae live in milk ducts. So there is more risk of chronic contamination and development of a reactive capsule.

Ted Eisenberg, DO, FACOS, FAACS · Answer

Exactly how much is difficult to be agreed upon, some say twice as much. Dr. Ted Eisenberg, Board Certified Plastic Surgeon and Author. RealSelf Distinguished Hall of Fame Inductee. Philadelphia, Pa., USA

Gerald Minniti, MD, FACS · Answer

But beyond excess risk of cc, placement of implants over the muscle puts you at risk of implant visibility, rippling, and tissue atrophy in the upper and medial poles of the breasts, especially over time. The new rage of 'subfascial' implant position is no different, and will soon come tumbling down as we see these patients 5, 10, or 15 years later. Subpectoral placement will give the most durable results.

John L. Burns Jr., MD · Answer

The risk of capsular contracture with smooth round implants is higher in the subglandular plane.  The newly approved Motive implants have a unique surface that resists capsular contracture and would be a better choice in the subglandular plane.

Ronald J. Edelson, MD · Answer

You will have a hard time finding an accurate answer to this question.  It has been difficult to accurately study so you can expect different answers from different surgeons

Daniel Barrett, MD · Answer

Dear LexieCooper,
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

Zoran Potparic, MD · Answer

Many papers dealing with this issue would state that there is slightly larger frequency of breast implant related contracture when implants are placed in subglandular position, above the muscle. However, most plastic surgeons would select that location in well selected patients dispute this fact in order to achieve benefits of better shape control, for example. Hope this helps.

James Knoetgen, III, MD · Answer

The risk of capsular contracture is notably higher with subglandular (over the muscle) implants compared to submuscular (under the muscle) placement.
Why the Risk is Higher with Subglandular
•	Less tissue coverage, more direct contact between the implant and breast tissue.
•	Higher chance of bacterial contamination.
•	More exposure to the body’s immune response.
•	Less implant mobility, which can contribute to the development of a tight capsule.
Summary
•	Subglandular implants may have 2 to 3 times higher risk of capsular contracture compared to submuscular placement.
•	Submuscular placement is generally preferred for reducing this risk, especially in primary augmentations.

How much higher is the risk of capsular contracture with subglandular than submuscular?

Answers (13)

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