Why does Europe primarily use textured implants whereas the US still primarily uses smooth?

I love your question, I think it is an important one and one that you will find a variety of opinions on.   For what it is worth, here is my journey as a plastic surgeon regarding texture, this will explain why and how I feel about texture. 
2003 - Started practice, only saline available in which case smooth MUCH better regarding rupture and rippling2006 - Silicone moratorium ended, silicone available.   Common sense transition was from smooth saline to smooth round silicone2012 - Sientra becomes FDA approved including the first FDA approved shaped device in the U.S.    Shaped implants are always textured so at this point many of us had to reconsider pros and cons of texture.   For the benefits of reduced CC and improved stability of implants I started using more and more textured implants and by 2014 was using upwards of 80% textured (round and shaped).Current - Over time I have seen a few cases where a textured implant was more palpable that I would like or had some degree or rippling.   I have also seen an uptick in seroma (non-ALCL) and implants not dropping into the pocket with texture.   Additionally there are the ALCL concerns (VERY small risk but higher with texture than smooth).   For these reasons I have decreased my rate of texture a bit, I am currently only using textured implants in those cases where it has the most benefit.   In my practice I have not seen a difference in CC with submuscular textured vs smooth (I have seen less than 1% CC with either) so this is not a strong consideration for me.  I would consider the largest benefit in implant stability in the extreme weight lifter and patients with chest wall shape and soft tissue support that would have a higher risk of lateralization or bottoming out of the implant.   I am currently using texture approximately 30% of the time. 

Still a hot topic at all of the Plastic Surgery Conferences.  You can get an ideal result with both textured and smooth.  Cost becomes an issue, as well as motion of the implant. I recommend an in-office examination as well as a detailed discussion with a surgeon who you are comfortable.  Additionally, make sure your surgeon is a Double-Board Certified Plastic Surgeon certified by the American Board of Plastic Surgery, a member of the American Society of Plastic Surgery (ASPS) and the American Society of Aesthetic Plastic Surgery (ASAPS).
Best,Dr. DesaiBeverly Hills Institute for Aesthetic Plastic SurgeryHarvard Educated, Beverly Hills & Miami Beach Trained, Double-Board Certified Plastic Surgeon 

It is very difficult to determine the best lift you will need (recommended based on your photos) or the exact size and shape implant you will require to best match your ideal breast image without an examination by a board certified plastic surgeon. Not just any board certified plastic surgeon, but one with many years of frequently performing breast augmentation surgery including different approaches, techniques and implant choices. This is because several measurements not to mention your breast characteristics are needed to determine the optimal implant size to obtain your goals. Without knowing these dimensions it would be difficult to make this determination. For example, the existing base width of your breast will determine, in many cases, the maximal volume per implant profile that you can accommodate. To illustrate; a 100 cc difference may make a significant difference with a narrow base width breast, but much less of a difference if you have a wide chest wall and wide breast “foot print”. Therefore, just because your friend may have a great result with let’s say a 300 cc implant to make her go from a “A” cup to a “C” cup size does not mean that you will have the same result with the same size implant. The same process goes for just filling in the upper part of your breast without becoming much larger. Further simply placing implants in a bra to determine the size best for you is not always accurate as the bra often distorts the size, is dependent on the pressure the bra places plus the implant is outside your breast and not under it among other variables. Computer software morphing programs that automatically determine the best implant size can be helpful in some but not all cases (e.g. doesn’t work well in my experience with existing implants, sagging or asymmetric breasts). Using “want to be” photos however are useful if simply provided to the surgeon as I will further explain in the link below including silicone vs saline implant
#toobig #breastimplant

There is a lot of debate in the US about this, but, imo, there is no doubt that txt implants DECREASE capsular contracture (CC) rates by 2/3--~10% for smooth, and ~3% for txt! Given that CC is the most common complication, and if I can decrease the rate by 2/3 just by changing the implant, I think it only makes sense to do so--for the patients' benefit. Why not use a simple change in implant to decrease the risk of something by 70%? There just seems to be no feasible argument to me. Bottoming-out is relatively common with smooth as well. I used to fix about 5-6 'bottomed-out' cases/yr when I used smooth; I think I've fixed a total of 3 since I started with txt implants about 10 yrs ago.Smooth implant advocates will tell you there is an increase in rippling, and that is false as well. I actually had more rippling complaints from smooth implant clients than txt implants--I believe that rippling is an issue when the implant is too big for the skin envelope and the breast tissue is very thin. If you take care to not stretch the breast tissue too much, and beware of skin envelope characteristics, the risk of rippling is minimized in both implants.There is a reason why, worldwide, 90% of people use txt implants--they are better, have a lower side-effect profile and give a longer lasting result, period.Best.

Smooth implants usually have thinner shells and move more freely in their pocket than their textured counterparts. Many plastic surgeons believe that the thinner shell allows smooth implants to feel more natural. Implants with smooth surfaces are less likely to ripple. Textured implants were designed to lower the risk of capsular contracture, but whether it achieves that is open to debate. Capsular contraction can occur no matter what type of implant is used.
 
The textured implants may have a greater chance of leakage or deflation and may be associated with a very rare form of lymphoma called anaplastic large cell lymphoma (ALCL).  Currently, most plastic surgeons in the U.S. prefer smooth implants. You should discuss your concerns with your plastic surgeon, who should be certified by the American Board of Plastic Surgery and ideally a member of the American Society for Aesthetic Plastic Surgery (ASAP).

Robert Singer, MD FACS 

La Jolla, California

Thank you for the question.
The difference between these types of implants is the feel and surface characteristics of the outer surface of the implants. I do not think that there are any advantages of using textured implants and use the smooth round implants almost exclusively. Personally, I think that the surface coating of the breast implants are probably the least important factor when it comes to a successful outcome achieved with breast augmentation surgery. Much more important, will be careful selection of your plastic surgeon and careful communication of your goals.  Ultimately, careful communication of your goals (in my practice I prefer the use of goal pictures, direct examination/communication in front of a full-length mirror, and computer imaging) will be critical. 
 
Generally speaking, the best online advice I can give to ladies who are considering breast augmentation surgery ( regarding breast implant size/profile selection) is:
1. Concentrate on choosing your plastic surgeon carefully. Concentrate on appropriate training, certification, and the ability of the plastic surgeon to achieve the results you are looking for. Ask to see lots of examples of his/her work.
2. Have a full discussion and communication regarding your desired goals with your plastic surgeon. This communication will be critical in determining breast implant size/type/profile will most likely help achieve your goals. 
In my practice, the use of photographs of “goal” pictures (and breasts that are too big or too small) is very helpful. For example, I have found that the use of know words such as “natural” or "C or D cup” etc means different things to different people and therefore prove unhelpful.
Also, as you know, cup size varies depending on him who makes the bra; therefore, discussing desired cup size may also be inaccurate. Again, the use of computer imaging has been very helpful during the communication process, in our practice.
3. Once you feel you have communicated your goals clearly, allow your plastic surgeon to use his/her years of experience/judgment to choose the breast implant size/profile that will best meet your goals. Again, in my practice, this decision is usually made during surgery, after the use of temporary intraoperative sizers.
I hope this (and the attached link, dedicated to breast augmentation surgery concerns) helps. Best wishes for an outcome that you will be very pleased with. 

Textured vs smooth has long been debated in the plastic surgery community. In my experience there is basically no benefit of a textured implant if placed beneath the muscle. Also I believe that smooth implants feel softer. All implants feel and look more natural beneath the muscle in my opinion as well. Some food for thought. 

You are correct that textured implants are primarily used in Europe -- not sure why! It may have to do with the placement (many implants in South America are placed above the muscle and so a textured implant may reduce the risk of capsular contracture in those women).  In the US, most of the implants are placed below the muscle because that is the only way you can truly reduce the risk of contracture and in provides less interference with mammograms.  When the implant is under the muscle, there is no added benefit to the implant being textured, so we use smooth.  There is a new concern with textured implants as well -- Anaplastic Large Cell Lymphoma.  This is a rare form of cancer that has been linked only with textured implants.  I have always only used smooth implants and will continue to do so in light of this newer development.  Good luck!

As you'll see, each of us has an opinion based on personal professional experience.  I tried textured implants years ago due to the hype over decreased capsular contracture and found no improvement.  Some patients just failed to soften with them leading me to abandon them.  I also feel that the incidence of rippling is higher (of course especially with saline) and the data suggests no benefit in the submuscular plane over smooth implants for cc prevention.
The recent reports of approximately 100 cases of ALCS all associated with patients who had or in the past had textured implants concerns me although this is admittedly very rare.
In Europe the majority of implants are textured, here in the US the majority of surgeons prefer smooth.
My last point is that you're better off IMHO following the recommendations of your chosen surgeon for implant type. We all benefit from our years of experience and feel that we get the best results from the implants that we prefer. If those choices didn't work well for us and our patients in the majority of cases we would of course change.
Enjoy your results and best wishes,

There was a time when the texturing was important to promote a soft result. It makes little difference now and either can give a nice result. The textured however remain fixed in position (if they work the way they are designed which does not always happen) and don't "flow" with movement as the smooth do. Americans are far more demanding of perfection than the Europeans so most of us prefer smooth in most patients in order to get the best mimicry of natural.