Does Under-the-Muscle Placement Reduce Capsular Contracture? It's More Nuanced Than You Think.

A great question came in: "For capsular contracture, are under-the-muscle implants better?"

The honest answer is: in theory, yes — but it's more nuanced than a simple yes or no, because so many other factors matter. And critically, modern technique has lowered contracture rates so dramatically that the old data comparing placements doesn't tell the whole story anymore.

Let me walk through what actually drives capsular contracture risk, and why the "under the muscle is better" framing oversimplifies a much more interesting picture.

When you have a breast augmentation, there are many decisions made, and each one affects your capsular contracture risk:

• Incision location
• Type of implant
• Where the implant sits (under vs. over the muscle)
• OR technique during the procedure

So it's genuinely hard to isolate one variable and say "this is what matters most." The studies that looked at contracture often didn't control well for all the other variables — which is why comparing them is tricky.

Looking across all the studies we have, certain factors appear to increase capsular contracture rates:

• Over the muscle (subglandular) appears to have higher contracture rates than under the muscle
• Subfascial (also a type of over-the-muscle placement) appears to be better than pure subglandular, but still potentially higher than fully under the muscle
• So if we're looking purely at placement, under the muscle does seem to have a theoretical advantage for contracture specifically

• Periareolar incisions (around the areola) appear to increase contracture risk — because they go through the breast tissue and its bacteria
• Transaxillary incisions (armpit) also appear to increase risk
• Inframammary incisions (crease) appear to have lower contracture rates

• Not using a Keller Funnel (no-touch implant insertion) — increases risk
• Not using proper irrigation to clean the area when placing the implant — increases risk
• Not using a Tegaderm or shield over the NAC — misses an opportunity to reduce risk

Here's the part that I think most patients (and even some surgeons) don't fully appreciate:

Look at the contrast:

• Older studies on Allergan and Mentor implants showed contracture rates as high as 14%
• The recent Motiva approval data showed a contracture rate of less than 1%

That's a massive difference. And here's the key point:

The dramatic reduction in contracture rates isn't primarily because Motiva implants are magically better (though the modern implants are good). It's because modern surgery does a whole stack of things that the older studies weren't doing:

• Keller Funnels for no-touch insertion
• Better irrigation solutions (hypochlorous acid, betadine)
• NAC shields
• Glove changes before handling the implant
• Re-prepping the skin before placement
• Modern understanding of biofilm as the driver of contracture

When you do all of these things together, the contracture rate drops dramatically — regardless of placement.

The older capsular contracture studies have two problems:

1. They weren't doing all of the modern techniques — so their baseline contracture rates were higher across the board
2. They were comparing many surgeons doing different things — which muddies the data because you can't isolate what actually mattered

So when someone cites a study showing "under the muscle has 5% contracture and over the muscle has 12%," that comparison is from an era before we figured out how to drive contracture rates below 1% with technique. The placement difference matters less when the overall rate is already low.

Here's my honest synthesis:

In other words:

• The placement difference is real but small in the context of modern technique
• A surgeon using all the modern best practices can achieve a very low contracture rate even with over-the-muscle placement
• So placement alone shouldn't drive your decision — the surgeon's overall technique matters more

This is part of why I've moved many of my patients to over-the-muscle placement despite the theoretical contracture advantage of under-the-muscle — because with modern technique, the contracture risk is low enough that the other benefits of over-the-muscle (no animation deformity, better patient satisfaction) become worth it.

This is the most important takeaway:

Consider the trade-offs:

• Under the muscle = theoretically lower contracture, BUT animation deformity, longer recovery, and the risk of the implant drifting or slipping out from under the muscle over time
• Over the muscle = no animation deformity, easier recovery, BUT theoretically slightly higher contracture (largely mitigated by good technique) and more visible implant edge in thin patients

You have to tailor your augmentation to:

• Minimize the things that are most important to you
• Maximize the things that are most important to you

For one patient, avoiding animation deformity is the top priority. For another, every fraction of a percent of contracture risk matters. There's no universal right answer — it depends on what you care about most.

When you're discussing placement and contracture with your surgeon:

1. "What's your personal capsular contracture rate?" (A surgeon doing modern technique should have a low rate)
2. "What OR techniques do you use to minimize contracture?" (Keller Funnel, irrigation, NAC shields, glove changes)
3. "Given my anatomy and priorities, what placement do you recommend and why?"
4. "What am I trading off if I choose under vs. over the muscle?"

A surgeon who can speak specifically to their technique and their own contracture rate is more reassuring than one who just says "under the muscle is safer" — because the modern reality is that technique matters more than placement.

Does under-the-muscle placement reduce capsular contracture? In theory, yes — the best studies we have suggest under-the-muscle has somewhat lower contracture rates than over-the-muscle.

But the more important truth is that modern technique has changed everything. Contracture rates have dropped from as high as 14% in old studies to under 1% in modern data — and that's due to how we do surgery now (Keller Funnels, proper irrigation, NAC shields, biofilm awareness), not the placement or even the specific implant brand.

So:

• Placement matters, but less than it used to when overall contracture rates are already low
• A surgeon with excellent technique can achieve a very low contracture rate regardless of placement
• Don't decide based on contracture alone — capsular contracture is one of many considerations, and minimizing it may cost you something else you care about
• Tailor your augmentation to your specific priorities, with a surgeon who uses modern best practices

The right question isn't "under or over the muscle for contracture?" It's "which surgeon uses the best modern technique, and which placement fits my overall priorities?"