Many social subsets of women with various motivations seek this device, especially for cosmetic purposes. However, the prototypical recipient is in her early 30s and is secure and successful in most of her activities, except for this single focus of concern. She is fully aware of the unique ambivalence that society and often family and friends have to an artificial bosom (ie, that breasts are sexy and attractive if natural but somehow frivolous and vain if sought through surgery).
Thus, in contrast to the common cliche, these women seek augmentation despite, rather than because of, social pressures. The depth of this personal need and the importance of this procedure to their sense of wholeness and self-esteem are difficult for even their loved ones and their personal physicians to appreciate. Only the woman and perhaps the plastic surgeon who hears these stories over and over again can understand the power of this need and the significant enhancement of quality of life that these devices provide.
Several surveys consistently have demonstrated that 90-95% of women who have undergone cosmetic augmentations are pleased that they did so, even if the results were less than ideal or were accompanied by complications. At the height of the negative media information in 1991, a survey of 300 plastic surgeons revealed that approximately 3% of these women made inquiries about removal due to concern over safety. Less than one half followed through, which is a measure of the great value of this operation.
This estimate is similar to the percentage of women who took advantage of the implant manufacturers’ offer of financial support for implant removal or replacement. Plastic surgeons suspected that the number of requests for removal of gel devices, usually with saline replacement, increased commensurately with the publicity over the multibillion-dollar class action settlement.
The desire of most women to replace their implants with saline (76% according to a recent study by Spear and Bowen) reflects their satisfaction with the enlargement. More recently, as reassuring research on safety has become available, interest in removal appears to have fallen significantly. Current estimates suggest that 85% of removed implants are replaced. A 1998 attempt to study explantation prospectively failed for lack of candidates. Some women, having experienced both gel and saline, are requesting a return to the gel as they felt that it provided a superior result.
More implants are sold on either coast, suggesting the existence of regional differences in body image. This becomes moot when one realizes that women in the Midwest buy larger bras on average than those that are sold on the coasts.
The anxiety generated by the 1990s media scare and dramatic litigation awards has diminished the significant psychological benefit that accrues from implants. This concern seems to be diminishing; as noted below, the number of cosmetic augmentations now appears to exceed premoratorium estimates following the significant dip of the early and mid-1990s. Therefore, all caring physicians must share the truth with their implant patients and reassure those who have chosen to accept whatever risk may be present.
Table 1. Annual Implant Sales by Pairs (Open Table in a new window)
1990-1996 figures represent manufacturer’s estimates for all implant sales, including augmentation, reconstruction, and replacement. American Society of Plastic Surgeons (ASPS) and American Society for Aesthetic Plastic Surgery (ASAPS) data represent separately collected and analyzed membership statistics on cosmetic augmentation using different methodologies. These do not include patients of nonmembers, which is substantial. All numbers are approximations.
Aside from the usual medical conditions that would increase the risk of anesthesia, surgery and/or infection, the most significant red flag, as in all cosmetic surgery, is an unrealistic expectation. Women who are emotionally unstable or are requesting the surgery to please another person should be discouraged from undergoing the procedure. However, this should not be considered a blanket contraindication.
Each patient must be individually evaluated and a decision made as to whether the procedure will enhance the quality of her life, her sense of self, and her sense of well-being. Plastic surgeons must develop the skills to evaluate these intangibles and take the time for a proper evaluation. Because it is so subjective, do not expect 100% accuracy in predicting the outcome; guessing correctly 95% of the time is the best that can be expected.