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Michael Law MD Aesthetic Plastic Surgery

Why are there textured and smooth breast implants?

The answer to that question depends on a number of factors, including your preop breast appearance, what your lifestyle is like, what breast volume you would like to have and what is pleasing to you aesthetically. Sientra, Mentor and Allergan all have silicone gel breast implant product lines for cosmetic breast augmentation that include the traditional round implants in both smooth and textured surfaces, and shaped / form-stable implants all of which have textured surfaces. For a number of reasons this practice offers only round implants for breast augmentation; our decision to stop placing shaped implants as of 2016 is discussed in another section.

Traditional, single-chamber saline implants are also available from Sientra, Mentor and Allergan. All available saline implants have a smooth shell, as saline-filled implants with a textured surface shell have a higher failure rate and are therefore no longer produced. Textured surface silicone gel implants, on the other hand, do not have a higher failure rate than smooth surface silicone gel implants. The newest implant to market is the structured Ideal Implant; this saline-filled implant has a smooth shell and is designed with two separate saline-filled chambers with internal ‘baffles’ (sheet of smooth silicone elastomer shell material) between the chambers.

So if you go with traditional or structured saline implants, your implants will by default have a smooth shell. If you go with a shaped silicone gel implant, your implants will by default have a textured shell. If you prefer round silicone gel implants, which is the most commonly placed implant around the world today, you and your surgeon will need to decide between smooth surface and textured surface implants.

Textured surface implants were originally developed with the hope in mind of reducing the rate of capsular contracture (CC). The general consensus in the plastic surgery literature for many years has been that there does not seem to be a significant difference in the contracture rate between smooth and textured surface implants, but some recent data from the implant companies shows that some textured surface implants do have a slightly lower rate of capsular contracture. The difference in the CC rate is small, however, and one needs a large study with many patients enrolled to observe a difference.

So for a single patient any potential small difference in CC rates in smooth vs textured implants, in my opinion, is not that relevant. There are a number of steps that a surgeon can take to reduce the risk of capsular contracture that are much more significant than the type of implant shell that is selected. Read more about the things we do to prevent capsular contracture at The Plastic Surgery Center here: What can be done to prevent capsular contracture?

Up until recently, most U.S. plastic surgeons have preferred to use smooth / round silicone gel implants. This bias comes from years of using primarily smooth / round saline implants, during the fourteen year (1992-2006) FDA-mandated moratorium on silicone gel breast implants, until the FDA gave approval to the new generation of cohesive silicone gel implants in 2006. Saline implants were previously available in smooth and textured versions, however the textured shell saline implants had a higher deflation rate and fell out of favor.

So the primary implant used in the United States for almost a decade and a half was a smooth-surface saline implant, and when the FDA lifted the moratorium in 2006 most American surgeons transitioned to using smooth-surface silicone gel implants. Again, it is important to understand that the ‘smooth vs. textured’ decision only applies to silicone gel implants; if you seek a saline implant breast augmentation then smooth shell implants are the only option.

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 potentially beneficial feature of textured implants, but the surface texture 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.

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%.

Making the Decision with your Plastic Surgeon

These are general concepts and not necessarily absolute preferences, and many additional factors are evaluated when selecting the best implant for each patient. The thought process behind implant selection takes into consideration not only what is likely to contribute to a successful outcome immediately postop, but also what is likely to remain stable and aesthetically ideal over time. For example, an athletic patient who is a distance runner is often best served, in my opinion, by textured surface breast implants, as the textured surface provides a greater likelihood of the implants remaining in an aesthetically ideal position over years of sustained, high-impact exercise.

The take-home message is this: there are more available breast implant options than ever before, so you want to see a surgeon who has experience with (and therefore some expert opinions about) all of the implants that you are considering. The best decision is always a well-informed decision that takes into consideration all of the currently available options and all of the latest, scientifically-based information about those options. You are best-served, without question, by a board-certified plastic surgeon who is up-to-date on the current breast implant literature and who has a working relationship with all of the FDA-approved implant companies.

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