Even a smooth breast implant has a surface that may shape the body's response. Yet inconsistent study designs make the evidence on capsular contracture hard to compare.
Dr. Alicia Billington, founder and lead plastic surgeon at Billington Plastic Surgery in St. Petersburg, Florida, reviewed that evidence at Plastic Surgery The Meeting 2026, organized and hosted by the American Society of Plastic Surgeons (ASPS), in Houston, Texas. She built her talk around 3 questions: Does surface topography influence the foreign body response? Is surface alteration safe? What conflicts exist in the literature?
Studies report capsular contracture over different time periods and sometimes pool smooth and textured implants. Dr. Billington compiled 3- and 10-year data, which varied across studies and between primary and revision procedures, and she uses these rates in shared decision-making with patients.
Surface and the Immune Response
Manufacturing leaves measurable topography even on devices labeled smooth, and the naming system for surfaces has recently changed. She suggested describing surfaces by their variation, including peaks and valleys, in place of a simple smooth-or-textured label. In animal and human studies she reviewed, surface roughness was associated with differences in macrophage, T-cell, and fibroblast activity. Smoother surfaces were linked to thinner capsules, and more textured surfaces to greater inflammation and debris. Surface choice may therefore affect fibrosis and contracture risk.
Safety and Conflicting Evidence
The main safety concern is breast implant–associated anaplastic large cell lymphoma (ALCL). Citing data from Dr. Clemens published on the society's website, she reported an estimated ALCL risk of about 1 in 30,000 for textured implants overall, with estimates for individual textured devices ranging from 1 in 3,300 to 1 in 86,000. Current evidence suggests surface alteration may be safe, she said, but US follow-up for the 4-µm surface is still too short to confirm long-term safety. She recommended continued monitoring and discussing these estimates with patients.
The literature also conflicts. One study found no immune-response difference between 0- and 4-µm surfaces, though she noted its short follow-up and small or assembled implant samples. A large database study did not clearly define "textured." In another study, smooth implants first appeared to have higher contracture rates, but the difference was no longer significant after accounting for implant plane. Procedure type (lift, augmentation, or reconstruction) and mesh use may also confound results.
She concluded that surface topography appears to influence the immune response, especially across very different roughness levels, but that whether a 4-µm surface differs meaningfully from a near-zero surface remains unsettled. With no definitive answer on the best implant or plane, she asked clinicians to report and publish their data.
Key takeaway: Dr. Billington's review suggests implant surface may influence inflammation and capsule formation, but confounders such as implant plane and inconsistent surface definitions limit firm conclusions. She encourages discussing ALCL estimates with patients and publishing outcome data.
Abbreviations: ALCL, breast implant–associated anaplastic large cell lymphoma.