Purpose: Textured round gel implants have several potential advantages when compared to smooth devices, including lower rates of capsular contracture, reduced implant mobility under the breast, and less long term stretch of lower pole tissues. Disadvantages of textured implants include greater potential for contamination during insertion, increased seroma rate, and traction rippling. No prior direct comparison of textured versus smooth gel implants has been made. This study sought to compare the experience and clinical outcomes associated with textured versus smooth round gel implants in primary breast augmentation. Methods: A consecutive series of patients undergoing primary bilateral breast augmentation with round silicone gel implants (2004-2009) were identified from two breast augmentation practices. Patients receiving textured versus smooth implants were compared on demographics, operative and implant characteristics, and outcomes (complications, reoperations). A stratified comparison of complications and reoperations by implant pocket was also performed. Parametric (Student's t test, chi square test) and nonparametric tests were utilized for statistical comparisons, as appropriate. Results: 336 patients (mean age 32.0 years; mean f/u 8.2 months) were included. Patients receiving smooth (n=165) and textured (n=171) round gel implants were similar with respect to demographics and indications for augmentation. Moderate profile implants were most common in both study groups, but median implant size was slightly smaller in the textured group (300 vs. 325, p=0.003). Textured devices were more frequently placed in a subpectoral pocket (63.7% vs. 40.0%, p<0.0001), and through an inframammary fold incision (87.1% vs. 77.6%, p=0.053). Total number of complications (p=0.004) and reoperations (p=0.017) was lower in patients with textured versus smooth implants. Patients receiving textured implants had fewer capsular contractures than patients receiving smooth implants when implants were placed in the subglandular position (5.0% vs. 14.7%, p=0.059). This effect was lost for implants placed in a subpectoral pocket. Other complications (e.g. seroma, rippling) were infrequent in this series. Conclusions: In this series, complications and reoperations were less frequent with textured implants. Our findings support existing evidence that textured implants are associated with decreased capsular contracture rates, and that this benefit exists mainly for subglandular augmentation.