A Head-To-Head Meta-Analysis of 35,052 Smooth Versus Textured Implants in Breast Reconstruction and Augmentation

Abstract

Abstract Background Whether texturing confers clinical advantages over smooth breast implants remains debated, especially in the wake of BIA-ALCL concerns with textured implants. Objectives To compare complications, implant-specific events, and patient-reported outcomes between smooth and textured implants across augmentation and reconstruction. Methods Following PRISMA 2020, we synthesized head-to-head comparative studies through January 15, 2025. Random-effects models estimated risk ratios for dichotomous outcomes and mean differences for BREAST-Q domains; heterogeneity (I²) guided prespecified subgroup and sensitivity analyses (e.g., implant plane; exclusion of overlapping or historical cohorts). Review Manager 5.4 was used for statistical analysis. Results Thirty-three studies comprising 35,052 implants met inclusion. In the initial pooled analysis, smooth implants showed higher capsular contracture (RR = 1.69, 95% CI 1.36–2.11, p < 0.00001; with significant heterogeneity, I² = 79%, p < 0.00001); nonetheless, after stratifying by plane (subpectoral and prepectoral) and conducting sensitivity analyses that excluded overlapping/historical cohorts, the difference was no longer statistically significant (RR = 1.13 95% CI 0.82, 1.56, p = 0.46) with no subgroup differences (I² = 0%, p = 0.92). Infection was lower with smooth implants (RR = 0.51, 95% CI 0.30–0.89, p = 0.02). No differences were detected for seroma, hematoma, rippling, rupture, malposition/rotation, explantation, or BREAST-Q domains. Conclusions In contemporary, plane-matched comparisons with appropriate sensitivity analyses, smooth implants did not demonstrate a higher capsular contracture risk and were associated with lower infection risk compared with textured implants. Other complications and patient-reported outcomes were similar among both groups.