A comparative assessment of three planes of implant placement in breast augmentation: A Bayesian analysis

Published:September 24, 2019DOI:



      Techniques based on three planes of implant placement, including the subglandular (SG), subpectoral (SP), and subfascial (SF) planes are used for breast augmentation. The placement that offers the greatest balance of risks and benefits is unclear. This study presents a systematic review with a Bayesian network meta-analysis to compare different implant placement techniques for augmentation mammaplasty.


      A systematic literature search was performed. We estimated the odds ratios (ORs) for capsular contractures, hematomas, seromas, infections, reoperation rates, rippling, nipple numbness, malplacements, ruptures, and asymmetry among the different interventions. Muscle movement events and satisfaction rates were also evaluated.


      A total of 19 studies (25,744 cases) were included. SG placement significantly increased the incidence of capsular contractures (SP vs. SG: OR 0.42; 95% credible interval [CrI] 0.28–0.63; SF vs. SG: OR 0.41; 95% CrI 0.17–0.97), hematomas (SF vs. SG: OR 0.22; 95% CrI 0.06–0.63), and seromas (SF vs. SG: OR 0.04; 95% CrI 0.00–0.81) compared to other placement techniques. Muscle movement only occurred in the SP group, but it did not increase the risk of subsequent malplacements, asymmetries, or ruptures. Most patients were highly satisfied with their surgical results. Comparisons did not show significant differences in the remaining results.


      Our evidence suggests that SG placement increases the risk of capsular contractures, hematomas, and seromas. The SP and SF planes were safe and effective for controlling total complication rates and achieving high satisfaction rates; however, the long-term benefits of the SF technique require further research.


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      1. American Society of Plastic Surgeons. 2018 Plastic surgery statistics. Available at: Accessed February 27, 2019.

        • Hidalgo D.A.
        • Spector J.A
        Breast augmentation.
        Plast Reconstr Surg. 2014; 133: 567e-583e
        • Handel N.
        • Cordray T.
        • Gutierrez J.
        • Jensen J.A
        A long-term study of outcomes, complications, and patient satisfaction with breast implants.
        Plast Reconstr Surg. 2006; 117 (discussion 768–72): 757-767
        • Biggs T.M.
        • Yarish R.S
        Augmentation mammaplasty: a comparative analysis.
        Plast Reconstr Surg. 1990; 85: 368-372
        • Henriksen T.F.
        • Fryzek J.P.
        • Holmich L.R.
        • et al.
        Surgical intervention and capsular contracture after breast augmentation: a prospective study of risk factors.
        Ann Plast Surg. 2005; 54: 343-351
        • Khan U.D
        Muscle-splitting, subglandular, and partial submuscular augmentation mammoplasties: a 12-year retrospective analysis of 2026 primary cases.
        Aesthetic Plast Surg. 2013; 37: 290-302
        • Kjøller K.
        • Hölmich L.R.
        • Jacobsen P.H.
        • et al.
        Capsular contracture after cosmetic breast implant surgery in Denmark.
        Ann Plast Surg. 2001; 47: 359-366
        • Kulmala I.
        • McLaughlin J.K.
        • Pakkanen M.
        • et al.
        Local complications after cosmetic breast implant surgery in Finland.
        Ann Plast Surg. 2004; 53: 413-419
        • Li C.R.
        • Xie D.C.
        • Mu F.G.
        • Li Y
        Approach of clinical application of augmentation mammaplasty by the plane inferior to fascia pectoralis.
        Chin J Aesth Med. 2013; 22: 1834-1836
        • Li S.F.
        • Li J.M.
        • Zhang X.X
        A retrospective study on breast augmentation with silicone gel prosthesis implant via 4 different planes: report on 450 cases.
        Chin J Aesth Plast Surg. 2013; 24: 355-357
        • Mahler D.
        • Hauben D.J
        Retromammary versus retropectoral breast augmentation-a comparative study.
        Ann Plast Surg. 1982; 8: 370-374
        • Namnoum J.D.
        • Largent J.
        • Kaplan H.M.
        • Oefelein M.G.
        • Brown M.H
        Primary breast augmentation clinical trial outcomes stratified by surgical incision, anatomical placement and implant device type.
        J Plast Reconstr Aesthet Surg. 2013; 66: 1165-1172
        • Niechajev I.
        • Jurell G.
        • Lohjelm L
        Prospective study comparing two brands of cohesive gel breast implants with anatomic shape: 5-year follow-up evaluation.
        Aesthetic Plast Surg. 2007; 31: 697-710
        • Pereira L.H.
        • Sterodimas A
        Transaxillary breast augmentation: a prospective comparison of subglandular, subfascial, and submuscular implant insertion.
        Aesthetic Plast Surg. 2009; 33: 752-759
        • Puckett C.L.
        • Croll G.H.
        • Reichel C.A.
        • Concannon M.J
        A critical look at capsule contracture in subglandular versus subpectoral mammary augmentation.
        Aesthetic Plast Surg. 1987; 11: 23-28
        • Seify H.
        • Sullivan K.
        • Hester T.R
        Preliminary (3 years) experience with smooth wall silicone gel implants for primary breast augmentation.
        Ann Plast Surg. 2005; 54 (discussion 235): 231-235
        • Shi H.
        • Cao C.
        • Li X.
        • Chen L.
        • Li S
        A retrospective study of primary breast augmentation: recovery period, complications and patient satisfaction.
        Int J Clin Exp Med. 2015; 8: 18737-18743
        • Spear S.L.
        • Murphy D.K
        Natrelle round silicone breast implants: core study results at 10 years.
        Plast Reconstr Surg. 2014; 133: 1354-1361
        • Calobrace M.B.
        • Stevens W.G.
        • Capizzi P.J.
        • et al.
        Risk factor analysis for capsular contracture: a 10-year sientra study using round, smooth, and textured implants for breast augmentation.
        Plast Reconstr Surg. 2018; 141: 20s-28s
        • Stoff-Khalili M.A.
        • Scholze R.
        • Morgan W.R.
        • Metcalf J.D
        Subfascial periareolar augmentation mammaplasty.
        Plast Reconstr Surg. 2004; 114 (discussion 1289–91): 1280-1288
        • Stutman R.L.
        • Codner M.
        • Mahoney A.
        • Amei A
        Comparison of breast augmentation incisions and common complications.
        Aesthetic Plast Surg. 2012; 36: 1096-1104
        • Vazquez B.
        • Given K.S.
        • Houston G.C
        Breast augmentation: a review of subglandular and submuscular implantation.
        Aesthetic Plast Surg. 1987; 11: 101-105
        • Jacobson J.M.
        • Gatti M.E.
        • Schaffner A.D.
        • Hill L.M.
        • Spear S.L
        Effect of incision choice on outcomes in primary breast augmentation.
        Aesthet Surg J. 2012; 32: 456-462
        • Benito-Ruiz J.
        • Manzano M.L.
        • Salvador-Miranda L
        Five-year outcomes of breast augmentation with form-stable implants: periareolar vs transaxillary.
        Aesthet Surg J. 2017; 37: 46-56
        • Brown T
        Subfascial breast augmentation: is there any advantage over the submammary plane?.
        Aesthetic Plast Surg. 2012; 36: 566-569
        • Yang Y.Q.
        • Guo N.Q.
        • Sun J.M.
        • et al.
        Comparison study of clinical effect and complications between subfascial and submammary breast augmentation.
        Zhonghua Zheng Xing Wai Ke Za Zhi. 2013; 29: 12-14
        • Gutowski K.A.
        • Mesna G.T.
        • Cunningham B.L
        Saline-filled breast implants: a plastic surgery educational foundation multicenter outcomes study.
        Plast Reconstr Surg. 1997; 100: 1019-1027
        • Handel N.
        • Jensen J.A.
        • Black Q.
        • Waisman J.R.
        • Silverstein M.J
        The fate of breast implants: a critical analysis of complications and outcomes.
        Plast Reconstr Surg. 1995; 96: 1521-1533
        • Tebbetts J.B
        Dual plane breast augmentation: optimizing implant-soft-tissue relationships in a wide range of breast types.
        Plast Reconstr Surg. 2001; 107: 1255-1272
        • Strasser E.J.
        Results of subglandular versus subpectoral augmentation over time: one surgeon's observations.
        Aesthet Surg J. 2006; 26: 45-50
        • Mofid M.M.
        • Singh N.K
        Pocket conversion made easy: a simple technique using alloderm to convert subglandular breast implants to the dual-plane position.
        Aesthet Surg J. 2009; 29: 12-18
        • Tebbetts J.B
        Does fascia provide additional, meaningful coverage over a breast implant?.
        Plast Reconstr Surg. 2004; 113 (author reply 779–80): 777-779
        • Graf R.M.
        • Bernardes A.
        • Rippel R.
        • et al.
        Subfascial breast implant: a new procedure.
        Plast Reconstr Surg. 2003; 111: 904-908
        • Siclovan H.R.
        • Jomah J.A.
        Advantages and outcomes in subfascial breast augmentation: a two-year review of experience.
        Aesthetic Plast Surg. 2008; 32: 426-431
        • Moher D.
        • Liberati A.
        • Tetzlaff J.
        • Altman D.G
        Preferred reporting items for systematic reviews and meta-analyses: the Prisma statement.
        Ann Intern Med. 2009; 151 (w64): 264-269
        • Stroup D.F.
        • Berlin J.A.
        • Morton S.C.
        • et al.
        Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis of Observational Studies in Epidemiology (MOOSE) group.
        JAMA. 2000; 283: 2008-2012
        • Hutton B.
        • Salanti G.
        • Caldwell D.M.
        • et al.
        The Prisma extension statement for reporting of systematic reviews incorporating network meta-analyses of health care interventions: checklist and explanations.
        Ann Intern Med. 2015; 162: 777-784
        • Spear S.L.
        • Baker Jr., J.L.
        Classification of capsular contracture after prosthetic breast reconstruction.
        Plast Reconstr Surg. 1995; 96 (discussion 1124): 1119-1123
      2. Wells G.A., Shea B., O'Connell D., et al. The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomized studies in meta-analysis. Available at: Accessed February 27, 2019.

        • Jadad A.R.
        • Moore R.A.
        • Carroll D.
        • et al.
        Assessing the quality of reports of randomized clinical trials: is blinding necessary?.
        Control Clin Trials. 1996; 17: 1-12
        • Higgins J.P.
        • Thompson S.G.
        • Deeks J.J.
        • Altman D.G
        Measuring inconsistency in meta-analyses.
        BMJ. 2003; 327: 557-560
        • Begg C.B.
        • Mazumdar M.
        Operating characteristics of a rank correlation test for publication bias.
        Biometrics. 1994; 50: 1088-1101
        • Egger M.
        • Davey Smith G.
        • Schneider M.
        • Minder C
        Bias in meta-analysis detected by a simple, graphical test.
        BMJ. 1997; 315: 629-634
        • DerSimonian R.
        • Kacker R.
        Random-effects model for meta-analysis of clinical trials: an update.
        Contemp Clin Trials. 2007; 28: 105-114
        • Marques M.
        • Brown S.A.
        • Oliveira I.
        • et al.
        Long-term follow-up of breast capsule contracture rates in cosmetic and reconstructive cases.
        Plast Reconstr Surg. 2010; 126: 769-778
        • Bachour Y.
        • Ritt M.
        Risk factors for developing capsular contracture in women after breast implant surgery: a systematic review of the literature.
        J Plast Reconstr Aesthet Surg. 2018; 71: e68
        • Peters W.
        • Keystone E.
        • Smith D
        Factors affecting the rupture of silicone-gel breast implants.
        Ann Plast Surg. 1994; 32: 449-451
        • Yalanis G.C.
        • Liu E.W.
        • Cheng H.T
        Efficacy and safety of povidone-iodine irrigation in reducing the risk of capsular contracture in aesthetic breast augmentation: a systematic review and meta-analysis.
        Plast Reconstr Surg. 2015; 136: 687-698
        • Steiert A.E.
        • Boyce M.
        • Sorg H
        Capsular contracture by silicone breast implants: possible causes, biocompatibility, and prophylactic strategies.
        Med Devices (Auckl). 2013; 6: 211-218
        • Egeberg A.
        • Sorensen J.A.
        The impact of breast implant location on the risk of capsular contraction.
        Ann Plast Surg. 2016; 77: 255-259
        • Ma S.L.
        • Gao W.C.
        Capsular contracture in breast augmentation with textured versus smooth mammary implants: a systematic review.
        Zhonghua Zheng Xing Wai Ke Za Zhi. 2008; 24: 71-74
        • Headon H.
        • Kasem A.
        • Mokbel K
        Capsular contracture after breast augmentation: an update for clinical practice.
        Arch Plast Surg. 2015; 42: 532-543
        • Blount A.L.
        • Martin M.D.
        • Lineberry K.D.
        • Kettaneh N.
        • Alfonso D.R
        Capsular contracture rate in a low-risk population after primary augmentation mammaplasty.
        Aesthet Surg J. 2013; 33: 516-521
        • Hand F.
        • Barry M.
        • Kell M.R
        A meta-analysis of optimum plane placement and related morbidity in primary breast augmentation.
        Eur J Plast Surg. 2010; 33: 241-244
        • Handel N.
        • Silverstein M.J.
        • Jensen J.A.
        • Collins A.
        • Zierk K
        Comparative experience with smooth and polyurethane breast implants using the Kaplan-Meier method of survival analysis.
        Plast Reconstr Surg. 1991; 88: 475-481
        • Schaub T.A.
        • Ahmad J.
        • Rohrich R.J
        Capsular contracture with breast implants in the cosmetic patient: saline versus silicone—a systematic review of the literature.
        Plast Reconstr Surg. 2010; 126: 2140-2149
        • Benito-Ruiz J.
        • Raigosa M.
        • Manzano M.
        • Salvador L
        Subfascial breast augmentation: thickness of the pectoral fascia.
        Plast Reconstr Surg. 2009; 123: 31e-32e
        • Baxter R.A
        Subfascial breast augmentation: theme and variations.
        Aesthet Surg J. 2005; 25: 447-453
        • Nahabedian M.Y.
        • Patel K.
        Management of common and uncommon problems after primary breast augmentation.
        Clin Plast Surg. 2009; 36 (vii): 127-138
        • Giot J.P.
        • Paek L.S.
        • Nizard N.
        • et al.
        The double capsules in macro-textured breast implants.
        Biomaterials. 2015; 67: 65-72
        • McGuire P.
        • Reisman N.R.
        • Murphy D.K
        Risk factor analysis for capsular contracture, malposition, and late seroma in subjects receiving natrelle 410 form-stable silicone breast implants.
        Plast Reconstr Surg. 2017; 139: 1-9
        • Hadad E.
        • Klein D.
        • Seligman Y.
        • Wiser I.
        • Heller L
        Sub-muscular plane for augmentation mammoplasty patients increases silicone gel implant rupture rate.
        J Plast Reconstr Aesthet Surg. 2019; 72: 419-423
        • Swanson E
        Dual plane versus subpectoral breast augmentation: is there a difference?.
        Plast Reconstr Surg Glob Open. 2016; 4: e1173
        • Roxo A.C.
        • Nahas F.X.
        • Pinheiro Rodrigues N.C.
        • et al.
        Functional and volumetric analysis of the pectoralis major muscle after submuscular breast augmentation.
        Aesthet Surg J. 2017; 37: 654-661
        • Serra-Renom J.
        • Garrido M.F.
        • Yoon T
        Augmentation mammaplasty with anatomic soft, cohesive silicone implant using the transaxillary approach at a subfascial level with endoscopic assistance.
        Plast Reconstr Surg. 2005; 116: 640-645