Clinical Outcomes of Submuscular vs Subglandular Implant Placement in Primary Cosmetic Breast Augmentation: A Systematic Review and Meta-analysis
In brief
Submuscular breast implants show about half the odds of complications
Across 12 studies of 4,534 primary cosmetic augmentations, submuscular or dual-plane placement was associated with about half the odds of overall complications compared with subglandular placement, including fewer cases of capsular contracture, hematoma, and malposition or asymmetry. Satisfaction and reoperation rates did not differ; mostly observational evidence cannot prove cause and leaves other trade-offs uncertain.
- Journal
- Aesthetic surgery journal (Q1)
- Published
- 2 November 2026
- Study design
- Systematic review of cohort studies
- Evidence level
- Level 2, Moderate (CEBM 2a)
- Authors
- Qian Cao, Lin Zhu, Fang Zhou, Jun Ma, Wei Zhai, Wanxiang Zhou, et al.
- PMID
- 42969680
- DOI
- 10.1093/asj/sjag163
Why clinicians should know about it
- Picked for Plastic and Reconstructive Surgery (paper of the day, 7 November 2026): Comparative evidence on cosmetic breast implant placement
Abstract
BACKGROUND: In primary cosmetic breast augmentation, submuscular (including partial submuscular and dual plane) and subglandular implant placement involve distinct trade-offs. Comparative evidence is inconsistent, and no recent meta-analysis has focused exclusively on cosmetic augmentation. METHODS: In this study, the authors conducted a PRISMA-guided systematic review and meta-analysis (PROSPERO: CRD420261385175) comparing submuscular vs subglandular placement exclusively in primary cosmetic augmentation; reconstruction studies were excluded. PubMed, Embase, Cochrane CENTRAL, Web of Science, CNKI, and Wanfang were searched up to June 1, 2026. Risk of bias used Cochrane RoB 2.0 and Newcastle-Ottawa Scale. Dichotomous outcomes were pooled as odds ratios (ORs) with 95% CIs; fixed-effect estimates were primary, with prespecified random-effects and Hartung-Knapp-Sidik-Jonkman sensitivity analyses. RESULTS: Twelve studies (n = 4534; 2884 submuscular/dual plane, 1650 subglandular) were included. Submuscular placement was associated with lower odds of overall complications (OR 0.49, 95% CI, 0.38-0.62), capsular contracture (OR 0.58, 95% CI, 0.38-0.87), hematoma (OR 0.30, 95% CI, 0.15-0.58), and malposition/asymmetry (OR 0.25, 95% CI, 0.07-0.91). Patient satisfaction (OR 1.00, 95% CI, 0.34-2.96) and reoperation (OR 0.80, 95% CI, 0.55-1.15) did not differ significantly. Leave-one-out and random-effects sensitivity analyses supported the primary findings. CONCLUSIONS: Available comparative evidence suggests submuscular and dual-plane placement may be associated with lower odds of selected complications. Given predominantly observational data and absent pooled data for animation deformity, pain, and envelope-related aesthetics, definitive causal conclusions cannot be drawn; pocket selection should remain individualized. LEVEL OF EVIDENCE: 2 (RISK): For image description, please refer to the figure legend and surrounding text.
Abstract as published, via PubMed.
For healthcare professionals. The summary is generated by AI from the published abstract, and the evidence level is assigned automatically from the study design on the Oxford CEBM hierarchy. Neither is medical advice. Read the full paper before changing practice.