Implant Selection
For two decades, the breast implant market has been split into two camps: round implants — preferred by the majority of surgeons globally — and anatomical (teardrop) implants — championed by a smaller group as more "natural." The truth is more nuanced than the marketing on either side.
Walk into ten different plastic surgeon consultations in London, Berlin, or Istanbul, and you will hear ten slightly different answers. Some surgeons will tell you anatomical implants give the only "natural" result. Others will say round implants do exactly the same thing in 95% of patients, with fewer complications. Most patients leave the consultations more confused than when they arrived.
This article cuts through the marketing and gives you what the international literature actually says, what I personally use in my practice, and how the decision should be made for your specific anatomy — not based on what's popular this year.
A round implant is symmetrical in every direction. Whether you rotate it, flip it, or stand it on its edge, it looks the same. Once placed under the breast, it distributes volume evenly between the upper and lower poles.
An anatomical (teardrop) implant has more volume at the bottom and less at the top, mimicking the natural slope of a breast in standing position. The flat side faces up, the rounded fuller portion faces down. To prevent the implant from rotating inside the pocket, anatomical implants must have a textured surface that grips the surrounding tissue.
The most quoted argument for anatomical implants is that they produce a more natural shape. This was supported by early 2000s anecdotal observation, but rigorous comparative studies have repeatedly failed to confirm it.
The landmark study is from Hidalgo and Weinstein (2010, Plastic and Reconstructive Surgery): a randomized intra-patient comparison where 75 women received a round implant in one breast and an anatomical implant in the other, in the same operation, by the same surgeon. After surgery, neither plastic surgeons nor patients could reliably tell which side had which implant. The conclusion: in the upright position, a round implant placed correctly takes on the same anatomical shape due to gravity and the soft tissue envelope.
This finding has been replicated in subsequent studies. Friedman et al. (2014) and Doren et al. (2016) reached the same conclusion: for the vast majority of women with reasonable breast tissue and skin elasticity, the final aesthetic outcome with round and anatomical implants is essentially indistinguishable.
This is the dealbreaker for many surgeons. An anatomical implant only works correctly if it stays in the position it was placed. If it rotates 30, 60, or 90 degrees inside the pocket, the breast becomes visibly deformed — the fullness ends up in the wrong place.
Reported rotation rates in the literature range from 1% to 14% depending on the study, surface texturization, and pocket dissection technique. The Tebbetts and Adams 2005 paper reported rates as low as 0.4% with meticulous pocket creation, but real-world registry data suggests 3-5% is more typical. A round implant that rotates 90 degrees looks exactly the same — it cannot be malpositioned by rotation, by definition.
Until 2019, this was not part of the discussion. After the FDA's recall of Allergan's BIOCELL textured implants due to BIA-ALCL (a rare lymphoma associated specifically with macro-textured surfaces), the calculus changed.
BIA-ALCL is associated almost exclusively with aggressively textured surfaces. Smooth implants have not been linked to ALCL in any reliable case series. Because anatomical implants must be textured to prevent rotation, choosing anatomical means accepting the lifetime BIA-ALCL risk that comes with texturization — even with the safer micro-textured surfaces still on the market.
For me, this is a serious consideration when counseling patients. The absolute risk of BIA-ALCL is low (1 in 3,000 to 1 in 30,000 over a lifetime, depending on the texture grade), but for a purely cosmetic procedure, asking whether that risk is justified by a shape advantage that double-blind studies cannot detect is a fair question.
I do not believe round implants are universally correct. There are specific situations where anatomical implants offer a real advantage:
While patients fixate on round vs teardrop, the more clinically relevant decision is profile — how much projection the implant has for a given base width.
Modern round implants come in low, moderate, moderate-plus, high, and extra-high profiles. The right profile depends on your chest wall width, existing breast base, and desired projection. A correctly chosen moderate-plus profile round implant in a patient with reasonable tissue often looks more natural than an anatomical implant placed at the wrong base width.
In my consultations, I spend more time on profile and base width selection than on round-vs-teardrop, because the former has a much bigger impact on the final result.
One implant family deserves separate mention: Motiva Ergonomix. These are technically round implants, but they have a unique gel formulation (TrueMonobloc gel) that responds to body position. Standing up, the gel shifts downward and the implant takes on an anatomical shape; lying down, it spreads evenly.
This bypasses the round-vs-teardrop debate entirely: you get round implant safety (smooth or nano-textured surface, no rotation risk) with adaptive shape behavior. In my own practice, Motiva Ergonomix accounts for the majority of my primary augmentations, and patient satisfaction has been very high.
When patients ask me which is "better," I tell them honestly: for 85% of women undergoing standard cosmetic augmentation, round smooth implants — particularly Motiva Ergonomix — give an excellent result with the lowest risk profile and the best long-term safety data.
The 15% of women who genuinely benefit from anatomical implants are those with specific anatomical challenges: tuberous deformity, severe asymmetry, or post-mastectomy reconstruction. For those patients, the rotation and texture trade-offs are worth it.
If a surgeon tells you that anatomical implants are always more "natural" or always the "premium" choice — be skeptical. The peer-reviewed comparative literature does not support that claim. Choose your surgeon first, choose your implant brand second, and let your specific anatomy guide round-vs-teardrop — not marketing.