Textured silicone expanders are alleged to be less painful in the filling process, to have less capsular contracture, and to stay in position better than smooth silicone expanders. To test these three hypotheses, 6 patients undergoing bilateral simultaneous expander implant placement for breast reconstruction after mastectomy were studied. In a double-blind fashion, after smooth and textured implant placement (one in each side) and initial wound healing, each patient was sequentially expanded with equal volumes of saline. In each patient, at each expansion, pressure data, discomfort scores, and implant placement measurements were made. At implant removal, smooth and textured capsule tissues were studied for collagen type content and ability to contract the patient's own fibroblast-populated collagen lattice. In 4 of 6 patients the smooth expander was associated with lower injection pressures and less discomfort. In all patients the expanders maintained their position, except in 1 patient whose smooth implant shifted laterally. The capsular collagen typing and fibroblast-populated collagen lattice studies demonstrated no difference between smooth and textured capsules. In this double-blind clinical study in simultaneous bilateral breast reconstruction patients we could not confirm the suggestion that textured silicone expanders produce less capsular contracture and cause less pain with injection.