Breast implants have become one of the most sought-after cosmetic surgery options for breast augmentation and reconstruction. With the different types of implants available today, it’s important to understand the key differences, particularly between smooth vs textured breast implants. These two main types of implants each offer unique benefits, considerations, and risks. We will look into the composition of breast implants, discuss the advantages and drawbacks of smooth and textured implants, and explore scientific research that has influenced the use of each.

What Are Breast Implants Made Of?

Breast implants consist of two primary components:

• Outer Shell: This is made from silicone elastomer, which is durable and flexible.

• Filling Material: The inside of breast implants is typically filled with either:

• Saline: A sterile saltwater solution.

• Silicone Gel: Silicone-filled implants tend to feel more like natural breast tissue.

Silicone gel implants have become the most popular choice due to their natural feel. Over time, developments in silicone technology have led to newer options, such as cohesive gel (commonly known as “gummy bear”) implants, which maintain their shape even when ruptured.

The Difference Between Smooth vs Textured Breast Implants

Breast implants come in two primary surface textures—smooth and textured. Each type has its own characteristics that make it suited to different patient needs.

What Are Smooth Breast Implants?

Smooth breast implants have a completely smooth outer shell, which allows them to move freely within the breast pocket. This mobility often mimics the natural movement of breast tissue, creating a more organic feel and look. Smooth implants tend to be softer to the touch compared to textured implants.

Benefits of Smooth Breast Implants:

• Natural Movement: Due to their free-floating nature, smooth implants move more naturally within the breast pocket.

• Lower ALCL Risk: Smooth implants are generally considered to have a lower risk of ALCL or Anaplastic Large Cell Lymphoma. A meta-analysis paper showed that in 525,475 patients with breast implants, there were 254 patients with BIA-ALCL with a mean duration to the diagnosis of BIA-ALCL of 13.16 years (95% CI 11.7-14.6, P < 0.001). There were 44 patients with textured breast implants and two with smooth implants. Patients with breast implants were 28.86 times more at high risk of BI-ALCL.

Risks of Smooth Breast Implants:

• Higher Risk of Capsular Contracture: Smooth implants are more likely to develop capsular contracture, a condition where the scar tissue surrounding the implant tightens, which can cause pain or a distorted appearance.

• Movement and Shifting: Since they aren’t anchored to the surrounding tissue, smooth implants can shift or rotate, particularly in cases where submuscular placement is used.

• Higher Risk of Rippling: Smooth implants are more likely to develop rippling which is the visible folds on the surface of the breasts.

• Bottoming Out: Smooth implants are more likely to have bottoming out where the implant drops below the natural fold of the breast.

What Are Textured Breast Implants?

Textured breast implants have a roughened surface, designed to adhere to the surrounding tissue. This helps prevent the implant from moving or rotating within the breast pocket. Textured implants are particularly useful for patients choosing anatomical (teardrop-shaped) implants, which need to remain in a fixed position to maintain a natural breast contour.

There are various levels of texture available, each with its own set of properties:

• Nanotextured Implants: Very fine texturing designed to promote tissue adherence with minimal inflammation.

• Microtextured Implants: Slightly rougher than nanotextured implants, aimed at reducing movement while still minimizing complications.

• Macrotextured Implants: These have the most pronounced texture, designed to strongly adhere to tissue and reduce the risk of implant rotation. However, macrotextured implants have fallen out of favour due to an increased association with certain risks. These are now no longer available on the market for use.

Benefits of Textured Breast Implants:

• Stability: The textured surface allows the implant to attach to surrounding tissue, reducing movement or rotation, particularly beneficial for teardrop-shaped implants.

• Reduced Risk of Capsular Contracture: Some studies suggest that textured implants have a lower rate of capsular contracture compared to smooth implants, particularly in subglandular placement.

• Reduced Bottoming Out or Rotation: The textured implants have a lower risk of bottoming out or implant rotation due to their coating.

Risks of Textured Breast Implants:

• Higher Risk of BIA-ALCL: Textured implants, especially macrotextured varieties, have been linked to an increased risk of Breast Implant-Associated Anaplastic Large Cell Lymphoma (BIA-ALCL), a rare type of non-Hodgkin’s lymphoma.

Why Were Allergan Macrotextured Implants Taken Off the Market?

In 2019, Allergan’s Biocell macrotextured implants were globally recalled following an investigation that found a significant link between macrotextured implants and BIA-ALCL. The FDA and other regulatory bodies recommended the recall, as these implants were associated with a higher incidence of this rare lymphoma. Research from the American Society of Plastic Surgeons (ASPS) also highlighted that most BIA-ALCL cases were associated with macrotextured implants.

A 2020 study published in Plastic and Reconstructive Surgery reviewed the incidence of BIA-ALCL and found that the risk was significantly elevated in patients with macrotextured implants compared to smooth or minimally textured implants.

Cohesive Gel or Gummy Bear Implants

A significant advancement in breast implant technology is the development of cohesive gel implants, often called “gummy bear” implants. These implants contain a thicker, form-stable silicone gel that remains intact even if the outer shell is damaged. Gummy bear implants are favoured for their stability, durability, and natural appearance.

Advantages of Cohesive Gel Implants:

• Lower Rupture Risk: Even if the outer shell is compromised, the gel inside does not leak out, reducing the risk of complications.

• Natural Feel and Shape Retention: These implants are firmer and provide more shape retention than traditional silicone implants, making them ideal for patients seeking a stable, natural look.

Smooth vs Textured Implants Around the World

Preferences for smooth or textured implants vary globally, often influenced by regional regulations, surgeon preference, and patient anatomy.

• United States: Smooth implants are more popular due to FDA guidelines and concerns over the risks associated with textured implants. The use of cohesive gel implants has also increased significantly.

• Europe: Textured implants, including anatomical shapes, were historically more common in countries like France and the UK. However, concerns over BIA-ALCL have slowly shifted some preferences towards smooth implants in recent years. In the UK, the use of textured implants remains more popular.

• Asia and Middle East: Both smooth and textured implants are widely used, with textured implants favoured for their stability, especially in breast reconstruction and anatomical implants.

Scientific Research and Literature

Research into breast implants has significantly shaped the recommendations and usage of smooth vs textured implants. A key area of study has been the risk of BIA-ALCL associated with textured implants. A comprehensive review published in the Journal of Plastic, Reconstructive & Aesthetic Surgery in 2021 examined over 300 cases of BIA-ALCL and found a strong correlation between macrotextured implants and the development of the disease .

Additionally, a 2017 study from Aesthetic Surgery Journal compared capsular contracture rates between smooth and textured implants, finding that textured implants had a statistically lower risk of capsular contracture in subglandular placements but not in submuscular placements. This has led to a reconsideration of the use of textured implants, particularly in procedures where capsular contracture is a significant concern.

Conclusion

When considering smooth vs textured breast implants, both types have distinct benefits and risks. Smooth implants offer a more natural feel and movement but may have a higher risk of capsular contracture. Textured implants reduce the risk of movement and capsular contracture but have been associated with BIA-ALCL, particularly in macrotextured forms.

We will discuss the differences during your consultation and Mr Nassab will highlight the pros and cons of smooth vs textured implants. Ultimately, the choice between smooth and textured implants is highly personal and should be made with a full understanding of the potential risks and benefits.

References:

1. Clemens, M. W., Brody, G. S., Mahabir, R. C. (2020). “Breast Implant-Associated Anaplastic Large Cell Lymphoma.” Plastic and Reconstructive Surgery, 145(2), 315-327.

2. Collett, D. J., Rakhorst, H., Lenert, P., et al. (2021). “BIA-ALCL in Europe: Epidemiology and Management.” Journal of Plastic, Reconstructive & Aesthetic Surgery, 74(1), 38-48.

3. Maxwell, G. P., Gabriel, A. (2017). “Breast Implant Surface Texturing: History, Overview, and Safety.” Aesthetic Surgery Journal, 37(3), 293-308.

4. Elameen AM, AlMarakby MA, Atta TI, Dahy AA. The Risk of Breast Implant-Associated Anaplastic Large Cell Lymphoma; A Systematic Review and Meta-Analysis. Aesthetic Plast Surg. 2024 May 9. doi: 10.1007/s00266-024-03956-9. Epub ahead of print. PMID: 38724638.