Textured or smooth, under or over the muscle? Implant choice and BIA-ALCL
Medical editor: Dr. Semih Yıldız, plastic, reconstructive and aesthetic surgeon (FEBOPRAS) · Last updated: October 2026
The implant is chosen according to your breast tissue, the degree of sagging and the operation planned. For breast lifts and implant exchanges, our routine choice is a textured implant: its surface grips the tissue and reduces shifting and renewed sagging. Because a smooth implant shifts more easily, it is used in breasts with no sagging and firm skin, or when it is specifically requested. For a natural transition in the upper part of the breast, the implant is placed under the muscle; if a round cleavage is deliberately wanted, it is placed over the muscle. A textured surface is associated with a very rare lymphoma called BIA-ALCL; this risk is low but not zero.
These choices determine how the breast will look not only straight after surgery but also years later. A surface or placement that does not suit the tissue can lead to the implant shifting, the pocket widening and the breast sagging early. Below we explain which implant we choose in which situation, and why; the operation itself and the recovery are covered on our breast augmentation page.
What is the difference between textured and smooth implants?
Both implants are filled with silicone gel; the difference is in the surface. A textured implant has a slightly rough surface that grips the surrounding tissue. This grip reduces downward movement of the implant, sideways shifting and widening of the pocket over time; in the long term, the breast also sags later. A smooth implant, by contrast, does not grip the tissue and moves around more within the pocket; this is why shifting and pocket widening are more likely with it.
The surface does not make a difference you can feel from the outside: the two implants are similarly soft and both look natural. We particularly recommend a textured implant in the following situations:
Implants placed together with a breast lift
Implant exchanges and revisions
Implants placed over the muscle
Large, heavy implants
What these situations have in common is that it is harder for the implant to stay in place. In a breast with no sagging and firm skin, however, a smooth implant is also a suitable option. If you are having breast augmentation for the first time, we decide together which surface suits you by assessing your tissue and your priorities.
Why a textured implant for breast lifts and implant exchanges?
In a breast that needs a lift, the skin has stretched and the tissues have become lax. A smooth implant placed in such a breast can slip down over time, and the breast can sag again. A textured surface helps keep the implant in place; this is why we use textured implants as standard in operations that include a lift. This grip reduces the likelihood of renewed sagging and shifting but does not eliminate it; the quality of the skin and the weight of the implant also affect the result.
The same rule applies to implant exchange. An implant that is not noticeable when you are standing but shifts to the side when you lie down shows that the pocket has widened. The main reason for this is often that the implant is smooth and sits over the muscle. In such a breast, we carry out the exchange with a textured implant and, if necessary, move the implant under the muscle.
A breast lift does not make the breast bigger: because tissue is removed, the breast usually becomes between half a cup and one cup smaller, and no fullness is created in the upper part. If you want to keep the same volume or want fullness in the upper part, an implant or fat is needed; a pronounced cleavage, however, comes from an implant, not from fat. That said, the volume of an implant placed together with a lift is decided by the surgeon on safety grounds; not every volume used in a standard augmentation will fit here. The plan for this operation is explained on our breast lift with implants page.
How high is the BIA-ALCL risk, and when is a smooth implant chosen?
BIA-ALCL is not breast cancer; it is a very rare type of lymphoma linked to the capsule tissue and fluid around the implant. We explain the signs by which it is recognised in Breast augmentation safety: the risks and how they are reduced. What matters for implant choice is this: the risk increases with how textured the surface is. It is higher with coarsely textured surfaces and lower with a fine micro-textured surface; with smooth implants, this lymphoma is seen far more rarely.
We most often use a fine microtextured surface; coarse textured or polyurethane-coated implants are not our routine choice. With this surface, the risk is very low but not zero. If you are very worried about this, you can choose a smooth implant, knowing that the likelihood of shifting and displacement is higher; this is also a common and reasonable option. If there is a history of lymphoma in your family, we discuss this separately at the consultation.
Should the implant go under or over the muscle?
The decision depends on your breast tissue and the look you want. If your breast tissue is thin and elastic and you also want a natural transition in the upper part, we place the implant under the muscle; the muscle covers the upper edge of the implant. If you have enough tissue and deliberately want a sharp, round cleavage, the implant is placed over the muscle. Breasts with a distinctly round, full upper part are often achieved with a round implant over the muscle; this look cannot be achieved with placement under the muscle.
An implant over the muscle has a greater tendency to shift; this is why we prefer a textured implant for placement over the muscle. There is also an upper limit to the size of implant that can fit under the muscle, and this limit is only confirmed during the operation. If you want a larger volume, an over-the-muscle plan and a textured implant are needed; the look will also be somewhat sharper. We explain how placement affects the movement of the breast and a natural look in Natural-looking breast augmentation: what makes the difference.
Teardrop or round? What does high profile mean?
In most patients we prefer a round implant; a teardrop (anatomical) implant is not our first choice. A teardrop implant can rotate inside the breast, and when it rotates, the shape of the breast is distorted; teardrop implants already have a textured surface to reduce rotation. A round implant placed under the muscle, on the other hand, settles into place over time and often takes on a teardrop-like appearance. Even so, in some patients who do not want pronounced fullness in the upper part, a teardrop implant may be chosen, with the risk of rotation understood; the decision is based on your tissue and the look you want. A teardrop implant can also be a good option for transgender women with very little breast tissue; a round implant can look more noticeably round in this situation. In a revision where the pocket has widened, however, we do not recommend a teardrop implant, because the risk of rotation remains even if the pocket is tightened.
Profile describes how far the implant projects forwards when seen from the side; diameter describes the width of its base. At the same volume, a higher profile means a narrower diameter. A high profile does not mean that the implant will sit higher on the chest.
How is the implant size decided?
We choose the size at the consultation, not by message: we take your chest measurements and go through the options with you using a 3D simulation. The simulation gives an idea but is not an exact copy of the result; this is why we do not make promises in advance based on a photo or a requested cc. Smaller implants put less strain on the skin in the long term; the choice is made by balancing safety against your expectations. You can find out how the measurements guide this decision in How do you choose the right breast implant size?.
Reducing the load the implant places on the skin comes before supporting it from the inside. Internal support can be provided with your own tissue or absorbable mesh when needed, including at a first revision. However, it is not our routine preference. We consider it mainly for recurrent sagging and in revisions where the lower pocket needs extra support. For the load of a large implant, our first step is to choose a lighter implant.
Frequently asked questions
Does a smooth implant look softer and more natural than a textured one?
No. Whether the surface is textured or smooth relates to how the implant grips the tissue; it is not a difference you can feel from the outside. The two implants are similarly soft and both look natural. How natural the breast looks depends less on the surface than on placement, size and how well your tissue covers the implant.
I definitely want saline (water-filled) implants; is that possible?
At our clinic, we currently use only silicone gel-filled implants; saline implants are not our preference. A saline implant can give a sloshing sensation as you move and does not look natural. If you previously had saline implants, we switch to silicone gel implants at the exchange.
My nipples are far apart; will implants make my breasts look closer together?
Yes; one of the aims of an implant is to create cleavage and bring the breasts closer together. However, there is a limit to how far the gap between the breasts can be narrowed, and your chest structure determines this. Which volume suits you becomes clear after measurements and a 3D simulation.
Can a very large implant, such as 800 cc, be placed to get closer to my former breast size?
In some cases this is possible; but at these sizes the main problem is the weight of the implant: it strains the skin and can cause the breast to sag again. We do not recommend a smooth implant at such a volume because it would shift quickly; we choose a textured or lighter model and place the implant over the muscle. Lighter models can feel slightly firmer than a classic implant. If the skin cannot take a large volume in one go, the volume is left for a second session.
Is a natural DD cup with upper fullness and cleavage realistic for me?
It may be possible; however, the largest volume that can be achieved is determined by the volume your skin and chest structure can carry. With heavy implants, a textured surface helps the implant stay in place. Because there is no conversion between cup size and cc that fits everyone, we choose the size together after measurements and a simulation.
We can discuss your implant choice together in a preliminary assessment. Send us by message photos of your breasts without a bra, with your arms down, taken from the front and from both sides; tell us your height, weight and the look you would like. If you have had implants before, please also add a photo of your implant card, or the volume and surface details you remember, and whether the implant is under or over the muscle.
This article provides general information and does not replace a medical consultation. Results vary from person to person.
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