BACKGROUND: Implant-based breast reconstruction is the most common technique after mastectomy. Breast implants are categorized by surface type as smooth, textured, or polyurethane-covered, each with specific attributed advantages and complication profiles. High-quality comparative studies are, however, limited. This study compared revision incidence and indications for revision among these implant types. METHODS: A prospective, nationwide cohort from the Dutch Breast Implant Registry was analysed. Permanent implants used between 2017 and 2022 for direct-to-implant or two-stage reconstruction were included. Surface-related revision was the primary outcome. Cumulative incidences were estimated using a competing risk model. Cause-specific hazard ratios (HRcs) were calculated using univariable and multivariable models, accounting for implant clustering and confounders. Subgroup analyses examined revisions for specific complications. RESULTS: Of 3996 implants, 76.9% were textured, 12.4% smooth, and 10.8% polyurethane-covered. At 4 years, the cumulative incidence of revision surgeries did not differ between textured (11.1%; 95% c.i. = 9.9 to 12.5), smooth (13.0%; 95% c.i. = 8.5 to 18.4), and polyurethane-covered (16.1%; 95% c.i. = 12.4 to 20.2) implants. Multivariable analysis found no association between surface type and surface-related revision. Subgroup analysis however revealed that polyurethane-covered implants had increased hazards of revision for capsular contracture (HRcs = 2.49; 95% c.i. = 1.24 to 5.01) and asymmetry (HRcs = 2.31; 95% c.i. = 1.33 to 4.02). CONCLUSION: After adjusting for confounders and clustering, surface-related revision in a reconstructive setting did not significantly different among breast implant surface types overall. Polyurethane-covered implants may, however, require more revisions due to capsular contracture and asymmetry.