Abstract Background Implant pocket selection is a key determinant of safety and aesthetic outcomes in primary breast augmentation. Despite the widespread use of subglandular, subfascial, submuscular, and dual-plane techniques, no clear consensus exists on the optimal approach. Methods A PRISMA-guided systematic review and meta-analysis of PubMed, Embase, Scopus, and Web of Science identified studies on implant pocket-related complications in primary breast augmentation from inception to February 2025. One-arm and pairwise random-effects meta-analyses were performed, with heterogeneity assessed by I 2 , publication bias by Egger’s test, and risk of bias by ROBINS-I. Results Ninety one studies (51,524 patients; mean age 33.0 years, BMI 21.6 kg/m 2 ) were included. Submuscular placement was most common ( n = 22,764), followed by dual-plane (15,480), subglandular (7,870), and subfascial (5,410). Capsular contracture (CC) was highest with subglandular implants (6.85%) compared to subfascial (2.80%), dual-plane (1.99%), and submuscular (1.83%) implants. Pairwise analysis revealed an increased CC risk with subglandular versus submuscular placement (RR = 2.84; p = 0.041) and a protective effect of subfascial versus subglandular placement (RR = 0.24; p = 0.013). Hematoma did not differ between subglandular and submuscular (RR = 0.88; p = 0.70) but was lower with subfascial versus subglandular (hematoma (RR = 0.21; 95% CI 0.02–2.31; p = 0.2004; I 2 = 65.3%) although this failed to reach statistical significance. Other complications were infrequent: seroma (0.5–1.4%), infection (0.5–1.0%), reoperation (2.3–4.1%), and displacement (0.8–1.7%). Conclusions All pocket planes demonstrated low complication rates with notable variation. Submuscular and dual-plane showed the most favorable profiles, while subfascial may represent a balanced alternative. These findings may help refine surgical decision-making, offering tailored pocket selection strategies to optimize both safety and aesthetic outcomes in primary breast augmentation. Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Alderhali et al. (2026) studied this question.