One of the most common questions in breast augmentation is whether implants should be placed subglandularly or submuscularly. Both techniques can be appropriate, but the choice should be based on the patient’s anatomy, tissue thickness, and aesthetic goals rather than on dogma alone.
For many years, the prevailing surgical dogma favored submuscular breast implant placement. The reason this idea became established is that peer-reviewed studies showed a tendency toward lower rates of capsular contracture when implants were placed beneath the pectoralis muscle rather than directly under the breast tissue. This led many surgeons to adopt submuscular placement as a default strategy.
Why Capsular Contracture Happens
Capsular contracture is one of the most important long-term complications of breast implant surgery. A capsule normally forms around every implant as part of the body’s natural response to a foreign material. The problem arises when that capsule becomes abnormally tight, thick, or distorted, causing firmness, discomfort, visible distortion, or an unnatural feel.
A leading explanation is that capsular contracture is often related to low-grade bacterial contamination, sometimes referred to as biofilm contamination, on the implant surface. Even after careful prepping and sterile draping, microorganisms that normally persist on the skin may still be present. Among the organisms frequently discussed in this setting is Staphylococcus epidermidis, which may contribute to chronic subclinical inflammation around the implant.
Because of this, we exclusively use a no-touch breast augmentation technique in which the implant is delivered directly into the surgical pocket using a Keller funnel. This allows the implant to be inserted without touching the patient’s skin or the surgeon’s gloves, helping minimize microcontamination during implantation.
Pros and Cons of Subglandular Breast Implant Placement
In the subglandular approach, the implant is placed beneath the breast tissue but above the pectoralis muscle.
In appropriately selected patients, the advantages of subglandular breast augmentation include a more natural-looking result, a faster recovery, and significantly less postoperative pain. Because the pectoralis muscle is not elevated or released, patients generally experience less discomfort and a quicker return to normal activities.
The main disadvantage of subglandular implant placement is that there is less tissue coverage over the upper portion of the implant. In a patient with very thin breast tissue, the upper edge of the implant may be more visible or palpable along the chest wall.
Pros and Cons of Submuscular Breast Implant Placement
In the submuscular approach, the implant is positioned partially beneath the pectoralis muscle.
The main advantage of submuscular breast implants is the extra thickness of tissue over the implant, which can help camouflage its presence in patients with very thin soft tissue coverage. In selected cases, this may make the upper edge of the implant less visible.
The disadvantages, however, are significant. Submuscular breast augmentation is usually associated with more postoperative pain and a longer recovery because the muscle must be divided or released to accommodate the implant. In addition, submuscular placement may lead to animation deformity, a condition in which the implant moves unnaturally with contraction of the pectoralis muscle. When this happens, the implant may shift upward or distort during muscular activity.
Our Philosophy on Implant Placement
For these reasons, I seldom use the submuscular technique. In my practice, the subglandular approach is the default implant position unless the breast tissue is extremely thin and the upper edge of the implant would be likely to show on the chest wall. In that specific subgroup of patients, submuscular placement may offer a meaningful camouflage benefit.
In other words, the choice between subglandular vs. submuscular breast implants should be individualized. The goal is not to follow a rigid formula, but to choose the implant plane that provides the best balance of appearance, tissue coverage, comfort, and long-term result.
Why Capsular Contracture Can Recur After Revision Surgery
Patients are often surprised to learn that capsular contracture recurrence after capsulectomy and reimplantation can be common. The reason is that the underlying cause may not be the scar capsule alone. If low-grade biofilm contamination has not been fully eradicated, the cycle may repeat itself.
We frequently see patients who have already undergone capsulectomy and reimplantation elsewhere and then developed recurrent contracture, sometimes two or three times. We use a specific treatment protocol for this subgroup of patients and have had encouraging success with subsequent reimplantation without recurrence thus far.
Schedule a Consultation
If you are considering breast augmentation, or if you have developed capsular contracture after breast implants, we invite you to contact our office to schedule a consultation. We can evaluate your tissue characteristics, implant history, and surgical options to determine the most appropriate strategy for prevention, revision, and long-term implant success.
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