Are smooth or textured implants the best choice for me?

Cohesive round silicone gel breast implants are appealing in that the gel inside is cohesive (i.e. it is in a solid state and sticks together, as opposed to the liquid silicone gel of older silicone gel implants) but not highly cohesive (that’s what is inside ‘gummy bear’ implants), which makes them the softest and ‘squishiest’ breast implants that are available, and which also makes them the most popular implants with patients. Cohesive (not highly cohesive) implants best mimic natural breast tissue. Highly-cohesive or ‘gummy bear’ implants feel much firmer than natural breast tissue.

Smooth shell breast implants, in patients with thin breast tissue, are perhaps a little less likely to be palpable (and outwardly visible) than textured surface breast implants. This slight difference is less relevant when the implants are placed behind the pectoralis major muscle, which enhances concealment of the implants in the upper pole and cleavage area.

Another important difference is the interaction between the implant shell and the fibrous capsule that one’s body forms around the implants. This fibrous capsule which forms around any implanted medical device does not adhere to a smooth implant shell, so smooth implants are mobile within the implant pocket – which has the advantage of nicely simulating the feel and behavior of natural breasts, but has the potential downside of contributing to implant displacement (‘bottoming out’, ‘lateral drift’) over time.

Textured surface implants are intended to promote friction between the implant shell and the body’s fibrous capsule around the implant, or even adherence of the fibrous capsule (which the body naturally creates) to the surface of the implant. Friction and/or adherence to the implant surface, if it occurs, helps to stabilize implant position and reduce the likelihood of unfavorable implant position changes over time – such as ‘bottoming out’ and ‘lateral drift’. Friction/adherence may also reduce the rate of capsular contracture, which is a positive, but may also increase the risk of postoperative seroma (a fluid collection around the implant).

The process for creating the textured surface of the implant shell varies significantly between the three companies, and as you might expect the performance of each company’s textured surface implants varies as a result of these differences. The least aggressively textured implants (the smallest ‘bumps’ on the implant surface when you image it using a microscope) have the least adherence to the fibrous capsule, but also the lowest risk of seroma. The most aggressively textured implants (the biggest ‘bumps’ on the implant surface) have the highest degree of adherence but also the highest rate of seroma. My personal textured implant preference is to not use aggressively textured implants.

In patients with good breast skin tone and adequate breast tissue to conceal the implants, I think that textured surface round implants are a great choice. I prefer smooth surface round implants when the breast tissues are thin, or when there is some skin laxity but not enough to absolutely require a simultaneous mastopexy. Why? If the breasts are a little droopy, you want an implant that will settle into the somewhat droopy breasts, not one that may tend to stay in a higher position on the chest wall because of the surface texturing.

I also prefer smooth surface implants for patients having an augmentation mastopexy. With breast skin laxity and thinning there is a slightly greater chance of implant palpability and visibility, so my preference is for smooth implants in those patients. If there is better skin and breast tissue tone, then textured surface breast implants are fine for augmentation mastopexy.

You may have read about or heard discussed in the media a form of lymphoma (lymphatic system cancer) called ALCL that is now known to occur rarely in patients with breast implants. ALCL stands for ‘atypical large cell lymphoma’ and it is discussed in detail on another page on this website entitled ALCL: what you need to know. While this very rare (and treatable) cancer appears to be more common with textured surface implants compared to smooth surface implants, the majority of cases have been associated with aggressively textured implants (and older generation implants) which are not used in this practice. </p.

Additionally, implant bacterial colonization and low-grade infection also appear to be a likely causative factor or at least promoting factor for ALCL. In my opinion, less aggressively textured implants remain a perfectly acceptable implant option. As with any breast augmentation procedure, they should be placed using techniques that drastically reduce the possibility of bacterial colonization: triple antibiotic irrigation, insertion using a sterile funnel, use of a nipple barrier, not using a periareolar incision, etc. In a study published in 2017 that included 42,000 patients in whom theses anti-infection strategies were used, the rate of ALCL was 0%.

Schedule a consultation with board-certified plastic surgeon Michael Law MD.