COSMETIC

Round versus Anatomical Implants in Primary

Cosmetic Breast Augmentation: A Meta-Analysis
and Systematic Review
Fengrui Cheng, M.D.
Background: Choosing implant shape (round or anatomical) is one of the
Ying Cen, M.D., Ph.D.
most essential yet controversial decisions in cosmetic breast augmentation.
Chuanqi Liu, M.D.
Many surgeons choose implant shape based on personal experience or expert
Ruolin Liu, M.D. opinion. This is the first systematic review and meta-analysis comparing the
Cheng Pan, M.D. aesthetic effect between anatomical and round implants in primary cosmetic
Shuiping Dai, M.D. breast augmentation.
Methods: The authors searched the PubMed, MEDLINE, Embase, ScienceDi-
Downloaded from http://journals.lww.com/plasreconsurg by BhDMf5ePHKbH4TTImqenVHjXcsSv/g1E0bIPateuoKRX+vm53jRriDbbzpi2Dau4hnBtJ9aq30k= on 03/05/2019

Chengdu, Sichuan, People’s

Republic of China rect, Web of Knowledge, Scopus, and Cochrane Central Register of Controlled
Trials databases for studies that compared anatomical and round implants in
primary cosmetic breast augmentation. Primary outcomes were postoperative
aesthetic effect and correct identification rate of implant shape. Random ef-
fects models were used to obtain pooled standardized mean difference and 95
percent confidence intervals.
Results: One randomized comparative and four observational comparative
studies met the inclusion criteria. No aesthetic superiority was found in the
anatomical implant group with regard to overall appearance (standardized
mean difference, 0.06; 95 percent CI, −0.40 to 0.53), naturalness (standardized
mean difference, 0.18; 95 percent CI, −1.51 to 1.15), projection, upper pole
contour, and lower pole contour. Pooled correct identification rate of implant
shape by plastic surgeons was 52 percent (95 percent CI, 0.46 to 0.58).
Conclusions: Generally, anatomical implants do not seem to have an aesthetic
superiority compared to round implants. Plastic surgeons seemed to be un-
able to accurately differentiate the two implant shapes in vivo. Further studies
should focus on identifying the specific indications for the use of anatomical
implants. (Plast. Reconstr. Surg. 143: 711, 2019.)

C
osmetic breast augmentation is one of the
most popular plastic surgery operations
worldwide. Since first introduced in 1960s,
breast implants have been one of the most pop-
ular materials for augmentation mammaplasty.1
The evolution of implants offers surgeons and
their patients a variety of implant shapes (i.e.,
round and anatomical).2,3 Choosing implant
From the Department of Plastic and Burn Surgery, West
China School of Medicine, West China Hospital, Sichuan
University.
Received for publication April 18, 2018; accepted September
10, 2018.
This trial is registered under the name “Anatomical ver-
sus round implants for primary aesthetic breast augmenta-
tion,” Prospero registration number CRD 42017079948
(http://www.crd.york.ac.uk/PROSPERO/display_record.
php?ID=CRD42017079948).
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005371
shape (round or anatomical) is one of the key
and controversial decisions in cosmetic breast
augmentation.4
Anatomical implants were believed to give a
more natural outcome than round implants.4–8
However, some surgeons do not recommend ana-
tomical implants because of their malrotation
potential, higher cost, and lack of proof for aes-
thetic superiority compared to round implants.8–16
Even though several articles have discussed
the aesthetic effect of implant shape, most of them
were author opinions and not able to be further
scrutinized.3,4,12,17–21 To provide better evidence for
choosing implant shape, we conducted the first
systematic review and meta-analysis targeted at
Disclosure: None of the authors has a financial in-
terest in any of the products or devices mentioned in
this article.

www.PRSJournal.com 711
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • March 2019
studies comparing the aesthetic effect of anatomi-
cal versus round implants in women who under-
went primary cosmetic breast augmentation.
PATIENTS AND METHODS
Design and Setting
A literature search was conducted of the
PubMed, MEDLINE, Embase, ScienceDirect, Web
of Knowledge, Scopus, and Cochrane Central Reg-
ister of Controlled Trials databases. Search date
was through November 11, 2017. We used the fol-
lowing search terms: “breast implant,” “mamma-
plasty,” “mammoplasty,” “breast surgery,” “breast
enlargement,” “breast augmentation,” “type,”
“anatom*,” “shape*,” “round,” “teardrop,” “biodi-
mensional,” “oval,” and “natural shape.” Both sub-
ject headings and key words were applied. There
was no restriction imposed on the search. In addi-
tion, we hand-searched the reference lists of rel-
evant articles to supplement the electronic search.
Sample
Studies were included if they met the follow-
ing criteria: (1) participants were women undergo-
ing primary cosmetic breast augmentation surgery
without a history of breast diseases or other types
of breast surgery operations; (2) intervention was
different types of breast implants used in primary
cosmetic breast augmentation surgery (i.e., round
versus anatomical implants); (3) outcomes were
postoperative aesthetic effect and correct identifi-
cation rates of implant shape; and (4) randomized
controlled trials and observational comparative
studies. We excluded the following: (1) reviews,
case reports, case series, and export comments; (2)
reconstruction surgery, breast augmentation com-
bined with a skin expander, acellular dermal matrix,
fat graft, flap graft, or negative-pressure devices; and
(3) participants who were pregnant or lactating.
Measurement
Two reviewers independently assessed the study
quality and risk of bias of included studies. For ran-
domized controlled trials, reporting of blinding,
allocation concealment, withdrawals, and loss to
follow-up was assessed according to the criteria in
the Cochrane Handbook 5.1.0.22 We used the nine-
star Newcastle-Ottawa Scale23 for observational
comparative studies. Study quality was assessed by
selection of the study groups, comparability of the
groups, and assessment of outcomes; the highest
quality studies were awarded up to nine stars. Dis-
agreement was resolved by consensus.
712
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Data Collection
Data were extracted by two independent review
authors. Discrepancies were resolved through
discussion or by consulting a third review author.
Characteristics of included articles, such as author
name, publication year, study interval, country,
study design, follow-up, number of patients, out-
comes, level of evidence, and study quality, were
recorded on a standard form. The outcomes were
postoperative aesthetic effect comparing round
to anatomical implants and correct identification
rates of implant shape.
Statistical Analysis
We used Review Manager Version 5.3
(Copenhagen, The Nordic Cochrane Centre,
The Cochrane Collaboration) for meta-analysis.
Weighted mean difference and 95 percent con-
fidence interval were used in continuous data in
the same measurement unit; standardized mean
difference and its 95 percent confidence inter-
val were used when different measurement units
were applied. Noncomparative binary data were
converted as reported by Chen et al.,24 shown
as the risk difference with the 95 percent con-
fidence interval. Heterogeneity among studies
was evaluated using the chi-square test and I2
statistics. Heterogeneity was detected when the
chi-square value was less than or equal to 0.10.
Values of I2 ranging from 75 to 100 percent were
interpreted as considerable heterogeneity; 50 to
90 percent represented substantial heterogene-
ity; 30 to 60 percent was moderate heterogene-
ity; and less than 50 percent was regarded as not
important.22 When I2 was less than or equal to 50
percent, we used a fixed-effects model, whereas
when values of I2 were greater than 50 percent,
we used a random-effects model, explored the
sources of heterogeneity, and conducted a sen-
sitivity analysis by excluding studies with distinc-
tive design to confirm the stability of the result.
Values of p ≤ 0.05 were considered statistically
significant.
RESULTS
Characteristics of Included Studies
The initial search yielded 9224 citations. Seven
additional studies were identified by reviewing the
references of relevant articles. After eliminating
duplications, titles and abstracts of the remaining
5640 citations were screened; full texts of 259 cita-
tions were obtained. According to the predefined
inclusion and exclusion criteria, one randomized
 Volume 143, Number 3 • Round versus Anatomical Implants

Fig. 1. Flow diagram of included studies.

controlled trial and four observational compara-
tive studies were enrolled in this systematic review
(Fig. 1).
There were a total of 297 participants who
underwent primary cosmetic breast augmenta-
tion, with 155 having round implants and 142
having anatomical implants. Characteristics of
the included studies are listed in Table 1.9,10,25–27
Demographic and clinical characteristics of the
participants are listed in Table 2.9,10,25–27
Aesthetic Effect
Four of the five included studies comparing
the aesthetic effect between round and anatomical

713
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 714
Table 1.  Characteristics of Included Studies
No. of Patients/
Breasts
Study
Study Interval Country Study Design Follow-Up Round Anatomical Review Panel Outcomes Study Quality
Hidalgo and 2013–2015 United RCT Intraoperative 75/75 75/75 Ten plastic surgeons and Aesthetic effect: overall Low risk of bias*
Weinstein, States 10 lay individuals appearance, projection,
201710 upper pole contour,
lower pole contour,
nipple position; correct
identification rate of
implant shape
Al-Ajam et al., 2007 United Observational >8 mo postopera- 33/66 27/54 Twenty-two plastic sur- Aesthetic effect: overall 7
20159 Kingdom comparative tively geons (14 male and appearance, natural-
study eight female) ness, upper pole con-
tour; correct identifica-
tion rate of implant
shape
Rubi et al, 2010–2013 Spain Observational >1 yr since inter- 15/30 15/30 Fifteen plastic surgeons Correct identification 6
201725 comparative vention, on two (10 men and five rate of implant shape
study occasions with women) and 15 plastic
an interval of surgery nurses (four
12 wk men and 11 women)
Friedman et al., NA Israel Observational >1 yr postopera- 15/30 15/30 Eleven male plastic sur- Aesthetic effect: overall 6
201626 comparative tively geons, and 235 female appearance, natural-
study lay respondents ness, upper pole con-
tour; correct identifica-
tion rate of implant
shape
Kovacs et al., 2004–2010 Germany Observational Before and 6 mo 17/34 10/20 — Three-dimensional evalu- 8
201227 comparative after surgery ations of the preopera-
study tive and postoperative
breast shapes: breast
projection, linear
distance measurements
between specific land-
marks (SN, N, IMF, lBF,
mBF), breast surface,
breast volume
RCT, randomized controlled trial; NA, data not available; SN, sternal notch; N, nipple; IMF, inframammary fold; IBF, lateral breast fold; mBF, medial breast fold.
Plastic and Reconstructive Surgery • March 2019

Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Table 2.  Demographic and Clinical Characteristics Comparing Participants with Round and Anatomical Implants
Age (yr) BMI (kg/m2) Breast Volume Device Volume Pocket Plane
Study (R/A) (R/A) (cc) (R/A) Device Type (R/A) (cc) (R/A) (R/A) Incision (R/A) Others (R/A)
Hidalgo and 39.2 20.3 Right breast: Mentor Moderate 277.6 (range, Subpectoral/sub- Inframammary/ Breast base diameter
Weinstein, 144.9 ± 41.0; Classic (n = 40) and 170–375)/277.6 pectoral inframammary (left, 9.9 ± 0.7 cm;
201710 left breast: Moderate Plus (range, right, 9.8 ± 0.7 cm),
145.7 ± 39.0 profiles (n = 35)/ 170–375) nipple to clavicle (left,
Allergan Natrelle 19.9 ± 1.9 cm; right,
Style 410 (n = 25), 19.7 ± 1.9 cm)
Mentor
MemoryShape
(n = 25), and Sientra
(n = 25).
Al-Ajam et al., 32.8 (range, 20.6 (range, NA INSPIRA round 300 (range, Dual-plane/dual- Inframammary/ Tissue pinch thickness
20159 19–57)/ 16.6–24.6)/ cohesive gel 210–450)/278 plane inframammary of 17 mm (range,
32.4 (range, 20.0 (range, implants/Allergan (range, 6–39 mm)/17 mm
18–41) 14.2–21.6) Style 410 cohesive 240–320) (range, 10.0–
gel anatomical 25.0 mm); implant
implants base diameter, 11.7 cm
(range, 10.5–
13.0 cm)/11.8 cm
(range, 11.0–12.5 cm),
parity 1.3 (range,
0–4)/0.9 (range, 0–3)
Rubi et al, 201725 NA NA NA
Round implants/ana- 295 (range, Subpectoral/sub- NA —
tomical moderate- 220–340) pectoral
plus profile cohesive
silicone gel implants
Friedman et al., NA NA NA Sebbin Laboratories 265–375/255–360 NA NA —
201626 highly cohesive
gel-filled round
Volume 143, Number 3 • Round versus Anatomical Implants

implants regular
(low) projection/
Arklow highly
cohesive gel-filled
Inamed style 410
moderate to extra
full projection
Kovacs et al., 33.2 ± 9.1 21.6 ± 222.3 ± Round silicone 193.0 ± Subpectoral/sub- Inframammary (n Preoperative linear dis-
27
2012 (range, 23– 3.4/20.6 ± 74.75/195.0 ± implants/anatomical 48.66/218.0 ± pectoral = 10) and axillary tance measurements
58)/31.2 ± 2.8 109.06 silicone implants 59.01 (n = 24)/ between specific land-
4.7 (range, inframammary (n marks (SN, N, IMF,
19–50) = 12) and axillary lBF, mBF) and breast
(n = 8) surface area were
comparable
R, round implant group; A, anatomical implant group; BMI, body mass index; NA, data not available; SN, sternal notch; N, nipple; IMF, inframammary fold; lBF, lateral breast fold; mBF,
medial breast fold.

715
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • March 2019
implants were reviewed. In the randomized
controlled trial by Hidalgo and Weinstein,10 75
patients had a round implant of optimal volume
and model placed in one breast and an anatomi-
cal implant of similar volume and optimal model
placed in the other. The procedure was then
completed with two round implants. Ten plastic
surgeons and 10 lay reviewers blindly evaluated
the intraoperative photographs. In the prospec-
tive cohort study by Friedman et al.,26 two expe-
rienced plastic surgeons chose the 30 best results
from patients undergoing breast augmentation
using anatomical implants or round implants.
Postoperative photographs of the patients were
assessed by 235 female lay respondents and 11
male plastic surgeons. Breast beauty, naturalness,
and upper pole contour were scored blindly using
a Likert scale ranging from 1 to 7 (where 1 = poor
and 7 = excellent). In another prospective study
by Al-Ajam et al.,9 data of 60 consecutive patients
undergoing breast augmentation (33 round and
27 anatomical) performed by a single surgeon
were reviewed by 22 plastic surgeons. Overall aes-
thetic result, upper pole contour, and naturalness
were scored using a modified Likert scale (where
1 = poor and 4 = excellent). Kovacs et al.27 evalu-
ated breast shape changes of 34 patients undergo-
ing subpectoral breast augmentation (17 round
and 10 anatomical) using three-dimensional sur-
face breast scans preoperatively and at 6 months
postoperatively.
Outcomes of Overall Appearance
In the randomized controlled trial by Hidalgo
and Weinstein,10 neither plastic surgeons nor
lay individuals reported any difference in breast
aesthetics between the anatomical and round
implants. When rating the aesthetic superiority
Fig. 2. Forest plot comparing the overall appearance of women with round and anatomical implants. IV, interval variable.
Fig. 3. Forest plot comparing naturalness of women round and anatomical implants. IV, interval variable.
716
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
of their preferred side, both implant shapes
obtained similar grades according to plastic sur-
geons (anatomical side superior on average, 1.9;
versus round side superior, 1.9; p = 0.793) and lay
individuals (anatomical side superior on average,
2.2; versus round side superior, 2.2; p = 0.528).
Given that this randomized controlled trial rated
only the preferred side and reported only the
mean value, it does not fit into the meta-analysis.
Two studies investigating plastic surgeons
using Likert scales were included in the meta-
analysis. The pooled data showed no significant
difference in overall appearance between women
with round and anatomical implants (standard-
ized mean difference, 0.06; 95 percent CI, 0.40 to
0.53; p = 0.89) (Fig. 2).
The heterogeneity was substantial (p < 0.10;
I2 = 75 percent) and might come from differ-
ent study populations. In the study by Friedman
et al.,26 each plastic surgeon selected the 15 best
results from patients with anatomical or round
implants. Al-Ajam et al.9 recommended anatomi-
cal implants to patients with thin upper pole tis-
sues and little breast parenchyma.
Outcomes of Naturalness
Studies by Friedman et al.26 and Al-Ajam et al.9
investigated the postoperative breast naturalness
of women with two implant shapes. A random-
effects model yielded no significant difference
in naturalness between women with round and
anatomical implants (standardized mean differ-
ence, −0.18, 95 percent CI, −1.51 to 1.15; p = 0.79)
(Fig. 3). The heterogeneity was substantial (p <
0.10; I2 = 89 percent) and might come from differ-
ent study populations.
 Volume 143, Number 3 • Round versus Anatomical Implants
Outcomes of Breast Projection
In the observational comparative study by Kovacs
et al.,27 the preoperative breast volume, implant
volume, and breast projection of participants were
comparable (p > 0.05). The mean implant projec-
tion was significantly different between the round
(2.9 ± 0.25 cm) and anatomical (4.0 ± 0.26 cm)
implants. After augmentation surgery, women with
anatomical implants showed a remarkably larger
projection than women with round implants (4.8
± 0.60 cm versus 4.2 ± 0.89 cm; p < 0.05). In the
randomized controlled trial by Hidalgo and Wein-
stein10 regarding breast characteristics accounting
for perceived aesthetic superiority, plastic surgeons
who preferred the anatomical side chose “better
projection” more frequently (20.8 percent) than
those who preferred the round side (11.6 percent).
After Bonferroni correction, the difference was not
statistically significant.
Outcomes of Upper Pole Contour
Regarding the breast characteristics account-
ing for the aesthetic superiority, “better upper
pole contour” was not selected more frequently
by plastic surgeons comparing the anatomical
and round implant sides (anatomical side, 65.2
percent; round side, 60.6 percent; p > 0.05). In
Al-Ajam et al.’s study,9 scores for upper pole con-
tour were higher in the anatomical implant group
(2.80 ± 0.44 versus 2.60 ± 0.38). This difference
did not achieve significance (p > 0.05). In the
study by Friedman et al.,26 a significant difference
in assessments regarding upper pole between
the two implants was found. The round implant
group presented a better aesthetic effect in breast
Table 3.  Identification of Implant Shape
Study Resource
Hidalgo and Intraoperative photographs (one Ten plastic surgeons
Weinstein, frontal and two lateral views)
201710
Al-Ajam et Preoperative and postoperative
al., 20159 photographs (one frontal and
two lateral views, postoperative
photographs were assessed a
minimum of 6 mo after surgery)
Rubi et al., A PowerPoint (Microsoft Corp.,
201725 Redmond, Wash.) presentation
with the preoperative and postop-
erative photographs (frontal and
oblique views on two occasions, >1
yr since intervention, on two occa-
sions with an interval of 12 wk)
Friedman Five postoperative photographs,
et al., using standardized views (>1 yr
201626 postoperatively)
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
upper pole among plastic surgeons (too full, 17.87
percent; proper fullness, 69.83 percent; and too
empty, 12.29 percent for round implants; versus
too full, 19.44 percent, proper fullness, 49.44 per-
cent, and too empty, 31.11 percent for anatomical
implants; p < 0.001) and lay individuals (too full,
13.77 percent; proper fullness, 63.17 percent; and
too empty, 23.05 percent for round implants; ver-
sus too full, 17.7 percent; proper fullness, 58.84
percent; and too empty, 23.43 percent, for ana-
tomical implants; p < 0.001).
Other Outcomes
In the randomized controlled trial by Hidalgo
and Weinstein10 regarding breast characteristics
accounting for perceived aesthetic superiority, nei-
ther “better nipple position,” nor “better projec-
tion,” nor “better lower pole contour” was selected
more frequently in the anatomical implant side
than in the round implant side (p > 0.05).
Identification of Implant Shape
As shown in Table 3, four studies investigated
the ability to identify implant shape. Pooled cor-
rect identification rate by plastic surgeons was
52 percent (95 percent CI, 0.46 to 0.58) (Fig. 4).
Heterogeneity among studies was substantial (p
< 0.10; I2 = 87 percent). Hidalgo and Weinstein10
had reviewers to identify cases only if there was
a perceived aesthetic superiority, whereas other
studies identified all cases. This difference may
account for the heterogeneity. We conducted a
sensitive analysis excluding this study. The het-
erogeneity decreased from 86.7 percent to 0 per-
cent, and the pooled correct identification rate
Review Panel Result
Round implants identified correctly, 59 of 207
cases (28.5%); anatomical implants identified
correctly, 53 of 216 cases (24.5%); “I don’t
know,” 148 of 423 cases (35.0%)
Twenty-two plastic Correct identification of implants was 55.9%
surgeons (14 male (62.7% round and 49.0% anatomical)
and eight female)
Fifteen plastic surgeons Round implants identified correctly, 435 of 900
(10 men and five (48.3%; 95% CI, 45.03–51.65%); anatomical
women) and 15 plastic identified correctly, 471 of 900 (52.3%;
surgery nurses (four 95% CI, 49.01–55.65%); plastic surgeons’
men and 11 women) correct rate, 487 of 900 (54.1%; 95% CI,
50.8–57.42%); nurses’ correct rate, 419 of 900
(46.5%; 95% CI, 43.24–49.87%)
Eleven male plastic Round implants identified correctly, 63.89%;
surgeons anatomical identified correctly, 46.69%;
correct identification rate of implants, 55%
717
 Plastic and Reconstructive Surgery • March 2019

Fig. 4. Forest plot showing the pooled correct identification rate of implant shape by plastic surgeons. IV, interval variable.

Fig. 5. Forest plot showing the pooled correct identification rate using sensitive analysis. IV, interval variable.

increased slightly to 55 percent (95 percent CI,
0.54 to 0.57) (Fig. 5).
DISCUSSION
Both implant shapes achieved similar satisfy-
ing aesthetic effects. In this systematic review, no
aesthetic superiority was found in the anatomical
implant group. Although the study of Kovacs et
al.27 used anatomical implants with higher pro-
jection than round implants, the resulting breast
shapes also demonstrated a higher projection
(mean, 6 mm) when the anatomical implants
used were compared to round implants in vivo.
In the study of Al-Ajam et al.,9 scores for upper
pole contour were not statistically higher in the
anatomical implant group than in the round
implant group. Moreover, in the randomized
controlled trial by Hidalgo and Weinstein,10 pro-
jection, as a breast characteristic accounting for
perceived aesthetic superiority, was not selected
more frequently when the preferred side had an
anatomical implant, indicating that the poten-
tial outcome difference depending on the use of
anatomical or round implants could hardly be
detected with the naked eye or cause an aesthetic
difference.
Caplin28 reported high patient satisfaction
levels (>94 percent; p > 0.05) in both implant
shapes at 9 years across cohorts. Hamas29 com-
pared radiographic images of saline-filled round
and anatomical implants in vivo. The two implant
shapes had similar teardrop shapes when people
were upright. Round implants were even more
natural—when people were supine, they would
settle back evenly, acting like normal breasts.
For cohesive gel–filled implants, using three-
dimensional magnetic resonance imaging scans,
Nipshagen et al. demonstrated that both shapes
in vivo largely maintained their original in vitro
configuration.30 However, no aesthetic difference
was detected between both cohesive gel–filled
implant shapes under the breast tissue cover.9,10,25
The mean pooled correct identification rate
was 52 percent, which was very close to what chance
would predict. Plastic surgeons were unable to
accurately differentiate the two implants in vivo
through their appearance, which was consistent
with the results in this study; currently, no differ-
ence in aesthetic effect was found between women
with the two implant shapes.
Some researchers regarded anatomical
implants as a better choice based on expert
opinion or personal experience. They believe
that the teardrop shape and asymmetric projec-
tion give anatomical implants a shape similar to
a real breast and a more natural appearance in
vivo than round implants.4 Anatomical implants
adjust women’s breasts in height, width, and pro-
jection and provide more personalized selection
and greater versatility than round implants with
two parameters.31 Moreover, anatomical implants
may give greater control in women with certain
chest wall and parenchymal maldistribution
deformities.32 For women with a very small breast
volume, without adequate tissue to hide the edge
of implants, the breast implant contour will solely
determine the final shape of the breast. Therefore,

718
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 143, Number 3 • Round versus Anatomical Implants
the anatomical implants are preferred for their
natural shape.27 With greater projection in the
caudal part, anatomical implants are also thought
to compensate for lower pole deficiency.32 Other
conditions favoring anatomical implants include
significant mammary asymmetry, a prominent
thorax, or the constriction of the lower pole.21,33
In the study by Al-Ajam et al.,9 patients with thin
upper pole tissues and little breast parenchyma
were advised to consider anatomical implants. Aes-
thetic scores of overall aesthetic result, upper pole
contour, and natural appearance were higher in
the anatomical implant group than in the round
implant group, with no statistical significance.
However, individual data were not available for
subgroup analysis. As there is no comparative study
targeting women in the above-mentioned cases,
more research is needed to confirm these opin-
ions. Moreover, the included studies compared the
appearance of breasts with two implants in only the
erect position, whereas surgeons had observed a dif-
ference between saline-filled implant shapes in the
supine position.29,34 In addition, aesthetic outcome
measurements were mostly subjective. Thus, deter-
mining which kind of implant achieves a more nat-
ural outcome or a more aesthetic upper pole varied
with the observer’s judgment. Probably Mallucci
and Branford35 provided a more accurate descrip-
tion, with their proposed proportion of 45 and 55
percent relation between upper and lower poles
when describing an aesthetic breast. Another limita-
tion is that all included studies applied subpectoral
plane or dual-plane during operations, whereas the
subglandular plane was not applied. Muscular cov-
erage and contraction would probably diminish the
difference in appearance. Further studies should
also take these aspects into consideration.
Anatomical implants also have some disad-
vantages. Apart from their higher cost, as a result
of the asymmetric shape, women with anatomi-
cal implants are at risk of malrotation. Previous
studies reported malrotation rates ranging from
1.1 to 3.6 percent.13,14,28,36 A textured surface is
crucial for anatomical implants, to prevent mal-
rotation. The surface texturing increased friction
between the implant and surrounding tissue, con-
sequently holding the device in position.37 How-
ever, concerns on the association of the textured
surface with anaplastic large cell lymphoma have
been raised recently, despite the fact that breast
implant-associated anaplastic large cell lymphoma
rarely occurs.38–41 This possibility or risk should be
known by the patients who are considering a tex-
tured surface implant.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Although we searched seven mainstream data-
bases with no restriction on language or date, we
identified only one randomized controlled trial
and four observational comparative studies com-
paring the aesthetic effect between anatomical
and round implants in primary breast augmen-
tation. Not all of the outcome parameters—aes-
thetic effect, overall appearance, naturalness (of
breast shape), breast projection, and upper pole
contour—were available for investigation, creat-
ing a potential bias of results. The eligible studies
varied in study populations, surgical approaches,
and methods of assessment. These methodo-
logic differences might have caused a consider-
ably high heterogeneity among studies. Atlan et
al.42 performed a three-dimensional analysis that
revealed significant shape differences among
breast implants (especially the upper pole projec-
tion) from different manufacturers despite simi-
lar dimensions on width, height, and projection.
Given that anatomical implants have been proven
to generally maintain their shapes in vivo,30 and
the wide range of shapes and projections from dif-
ferent manufacturers involved in this study, these
difference might influence the aesthetic results,
contributing to the heterogeneity as well. As data
were inadequate for further analysis, we used ran-
dom-effects meta-analysis to incorporate heteroge-
neity among studies.
Tebbetts reported more than 50 tissue and
surgeon factors,43 including chest wall and breast
dimensions. Apart from Friedman et al., who
reported only device volume and type, most stud-
ies investigated the comparability of the main
confounding factors (i.e., age, body mass index,
breast volume, device volume, pocket plane, and
incision). However, the uncontrolled confound-
ing factors (e.g., soft-tissue thickness or quality)
might hide the potential aesthetic difference, lim-
iting the interpretation of study results. A prop-
erly designed study evaluating the result of breast
augmentation should compare similar patients
regarding the preoperative anatomical shape of
the breast and the thorax. This is evident in the
study of Al-Ajam et al.,9 who suggested the use of
anatomical implants in patients with thin upper
pole tissues and little breast parenchyma. Given
that randomized controlled trials are the best
solution to these biases, more high-quality ran-
domized controlled trials are needed.
CONCLUSIONS
Both round and anatomical implants in pri-
mary cosmetic breast augmentation achieved
719
 Plastic and Reconstructive Surgery • March 2019
similar aesthetic effects. Generally, anatomical
implants do not seem to have an aesthetic supe-
13. Hammond DC, Migliori MM, Caplin DA, Garcia ME, Phillips
riority compared to round implants. Likewise,
plastic surgeons seemed to be unable to accu-
rately differentiate both implant shapes in vivo.
Given the unique risks associated with anatomical
implants, round implants would be a sure choice.
For women with certain chest wall and parenchy-
mal maldistribution deformities, the correlation
of implant shape with aesthetic superiority is still
unclear. Further studies focusing on identifying
the specific indications for their use are expected.
Ying Cen, M.D., Ph.D.
Department of Plastic and Burn Surgery
West China Hospital
Sichuan University
No. 37, Guoxue Alley
Chengdu, Sichuan 610041, People’s Republic of China
cen_ying@126.com
ACKNOWLEDGMENT
The authors thank Yinmeng Zhang (School of Inter-
national Studies, Communication School of China) for
English language assistance.
REFERENCES
1. Takayanagi S. Augmentation mammaplasty using implants:
A review. Arch Plast Surg. 2012;39:448–451.
2. Maxwell GP, Gabriel A. The evolution of breast implants.
Plast Reconstr Surg. 2014;134(Suppl):12S–17S.
3. Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr
Surg. 2012;130:597e–611e.
4. Hedén P, Montemurro P, Adams WP Jr, Germann G, Scheflan
M, Maxwell GP. Anatomical and round breast implants:
How to select and indications for use. Plast Reconstr Surg.
2015;136:263–272.
5. Mira JA. Anatomic asymmetric prostheses: Shaping the
breast. Aesthetic Plast Surg. 2003;27:94–99.
6. Nipshagen MD, Beekman WH, Esmé DL, de Becker J.
Anatomically shaped breast prosthesis in vivo: A change of
dimension? Aesthetic Plast Surg. 2007;31:540–543.
7. Kreymerman PA, Rotemberg SC. Augmentation mam-
moplasty. In: Siemionow MZ, Eisenmann-Klein M, eds.
Plastic and Reconstructive Surgery. London: Springer Verlag;
2010:447–460.
8. Mallucci P, Branford OA. Concepts in aesthetic breast dimen-
sions: Analysis of the ideal breast. J Plast Reconstr Aesthet Surg.
2012;65:8–16.
9. Al-Ajam Y, Marsh DJ, Mohan AT, Hamilton S. Assessing the
augmented breast: A blinded study comparing round and ana-
tomical form-stable implants. Aesthet Surg J. 2015;35:273–278.
10. Hidalgo DA, Weinstein AL. Intraoperative comparison of ana-
tomical versus round implants in breast augmentation: A ran-
domized controlled trial. Plast Reconstr Surg. 2017;139:587–596.
11. Derby BM, Codner MA. Textured silicone breast implant use
in primary augmentation: Core data update and review. Plast
Reconstr Surg. 2015;135:113–124.
12. Lista F, Tutino R, Khan A, Ahmad J. Subglandular breast
augmentation with textured, anatomic, cohesive silicone
720
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
implants: A review of 440 consecutive patients. Plast Reconstr
Surg. 2013;132:295–303.
CA. Mentor Contour Profile Gel implants: Clinical outcomes
at 6 years. Plast Reconstr Surg. 2012;129:1381–1391.
14. Jewell ML, Jewell JL. A comparison of outcomes involving
highly cohesive, form-stable breast implants from two manu-
facturers in patients undergoing primary breast augmenta-
tion. Aesthet Surg J. 2010;30:51–65.
15. Namnoum JD, Largent J, Kaplan HM, Oefelein MG,
Brown MH. Primary breast augmentation clinical trial
outcomes stratified by surgical incision, anatomical place-
ment and implant device type. J Plast Reconstr Aesthet Surg.
2013;66:1165–1172.
16. Heidekrueger PI, Sinno S, Hidalgo DA, Colombo M, Broer
PN. Current trends in breast augmentation: An international
analysis. Aesthet Surg J. 2019;28:133–148.
17. Bronz G. A comparison of naturally shaped and round
implants. Aesthet Surg J. 2002;22:238–246.
18. Tebbetts JB. The greatest myths in breast augmentation. Plast
Reconstr Surg. 2001;107:1895–1903.
19. Adams WP Jr, Small KH. The process of breast augmentation
with special focus on patient education, patient selection
and implant selection. Clin Plast Surg. 2015;42:413–426.
20. Hedén P, Brown MH, Luan J, Maxwell GP, Munhoz AM,
Carter M. Delphi study consensus recommendations: Patient
selection and preoperative planning measurements for
Natrelle 410. Plast Reconstr Surg Glob Open 2015;3:e556.
21. Cárdenas-Camarena L, Encinas-Brambila J. Round gel breast
implants or anatomic gel breast implants: Which is the best
choice? Aesthetic Plast Surg. 2009;33:743–751.
22. Higgins JP, Green JP. Chapter 9. Analysing data and under-
taking meta-analyses. Cochrane Handbook for Systematic
Reviews of Interventions Version 5.1.0. Available at: www.
cochrane-handbook.org. Accessed November 19, 2017.
23. Wells GA, Shea B, O’Connell D, et al. The Newcastle-Ottawa
Scale (NOS) for assessing the quality if nonrandomized
studies in meta-analyses. Available at: http://www.ohri.ca/
programs/clinical_epidemiology/oxford.htm. Accessed
November 19, 2017.
24. Chen YH, Liang DU, Geng XY, Liu GJ. Implement meta-anal-
ysis with non-comparative binary data in RevMan software.
Zhongguo Xun Zheng Yi Xue Za Zhi 2014;14:889–896.
25. Rubi CG, Lozano JA, Pérez-Espadero A, Leache ME.
Comparing round and anatomically shaped implants in aug-
mentation mammaplasty: The experts’ ability to differenti-
ate the type of implant. Plast Reconstr Surg. 2017;139:60–64.
26. Friedman T, Davidovitch N, Scheflan M. Comparative dou-
ble blind clinical study on round versus shaped cohesive gel
implants. Aesthet Surg J. 2006;26:530–536.
27. Kovacs L, Eder M, Zimmermann A, et al. Three-dimensional
evaluation of breast augmentation and the influence of
anatomic and round implants on operative breast shape
changes. Aesthetic Plast Surg. 2012;36:879–887.
28. Caplin DA. Indications for the use of MemoryShape breast
implants in aesthetic and reconstructive breast surgery: Long-
term clinical outcomes of shaped versus round silicone breast
implants. Plast Reconstr Surg. 2014;134(Suppl):27S–37S.
29. Hamas RS. The postoperative shape of round and teardrop
saline-filled breast implants. Aesthet Surg J. 1999;19:369–374.
30. Nipshagen MD, Beekman WH, Esmé DL, de Becker J.
Anatomically shaped breast prosthesis in vivo: A change of
dimension? Aesthetic Plast Surg. 2007;31:540–543.
31. Mallucci P. Discussion: Intraoperative comparison of anatomi-
cal versus round implants in breast augmentation: A random-
ized controlled trial. Plast Reconstr Surg. 2017;139:599–600.
 Volume 143, Number 3 • Round versus Anatomical Implants
32. Tebbetts JB. Breast augmentation with full-height ana-
39. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large
tomic saline implants: The pros and cons. Clin Plast Surg.
2001;28:567–577.
33. Vera Cucchiaro J. Comparing round and anatomically shaped
implants in augmentation mammaplasty: The experts’ abil-
ity to differentiate the type of implant. Plast Reconstr Surg.
2017;140:758e.
34. Kisner WH. Round versus tear-drop breast prostheses: Their
superiority when supine. Br J Plast Surg. 1977;30:284–286.
35. Mallucci P, Branford OA. Population analysis of the per-
fect breast: A morphometric analysis. Plast Reconstr Surg.
2014;134:436–447.
36. Doren EL, Pierpont YN, Shivers SC, Berger LH. Comparison
of Allergan, Mentor, and Sientra contoured cohesive gel
breast implants: A single surgeon’s 10-year experience. Plast
Reconstr Surg. 2015;136:957–966.
37. Calobrace MB, Hammond D. Anatomic gel implants: From
concept to device. Plast Reconstr Surg. 2014;134(Suppl):4S–9S.
38. Swanson E. Textured breast implants, anaplastic large-
cell lymphoma, and conflict of interest. Plast Reconstr Surg.
2017;139:558e–559e.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
cell lymphoma occurring in women with breast implants:
Analysis of 173 cases. Plast Reconstr Surg. 2015;135:695–705.
40. Kim B, Predmore ZS, Mattke S, Van BK, Gidengil CA. Breast
implant-associated anaplastic large cell lymphoma: Updated
results from a structured expert consultation process. Plast
Reconstr Surg Glob Open 2015;127:209–210.
41. Thompson PA, Prince HM. Breast implant-associated ana-
plastic large cell lymphoma: A systematic review of the lit-
erature and mini-meta analysis. Curr Hematol Malig Rep.
2013;8:196–210.
42. Atlan M, Bigerelle M, Larreta-garde V, Hindié M, Hedén
P. Characterization of breast implant surfaces, shapes,
and biomechanics: A comparison of high cohesive ana-
tomically shaped textured silicone, breast implants
from three different manufacturers. Aesthetic Plast Surg.
2016;40:89–97.
43. Tebbetts JB. A system for breast implant selection based on
patient tissue characteristics and implant-soft tissue dynam-
ics. Plast Reconstr Surg. 2002;109:1396–1409; discussion
1410–1415.
721