… but on the fourth night, Ormond chancing to praise the fine shape of one of her very dear friends, Miss Darrell whispered, “She owes that fine shape to a finely padded corset.”
— MARIA EDGEWORTH,
Ormon
BREASTS MIGHT EXIST FOR THE PURPOSE OF FEEDING infants, but let’s face it, for most women these days, breasts fulfill that destiny only briefly, if at all. The rest of the time, they sit around trying, sometimes desperately, to look nice. In other primates, “breasts” exist only while lactating. For us, lactating is beside the point. Many of us will think nothing of jeopardizing lactation at that other altar of evolution: beauty. Throughout the ages, women have alternately flattened them, buttressed them, veiled them, decorated them, and bared them, sometimes in the course of a day. Now, with enough cash or credit, we can change them for life.
According to the American Society for Aesthetic and Plastic Surgery, 289,000 women went under the knife to enlarge their breasts in 2009, vaulting it to the country’s most popular cosmetic surgery ahead of nose jobs, eyelid lifts, and liposuction. That figure does not include 113,000 breast reductions in women, 17,000 breast reductions in men, 87,000 “breast lifts,” and 20,000 implant removals. The history of how we got from A to B, or DD, as it were, is a sordid and fascinating tale of marketing, mass hysteria, and environmental disease. To see where we’ve ended up, as well as where it all began, I went to boob job ground zero: houston.
At the swank office suite of Dr. Michael Ciaravino, over eight hundred pairs of breasts a year get the full Texas treatment: silicone, mostly, and a smattering of saline. Ciaravino is a true scion of a storied boob-job lineage, having trained with the doctor who trained with the inventor of implants. An energetic forty-five-yearold, he performs more augmentations by far than any doctor in Texas. His office is where Trump Plaza meets Jiffy Lube. I walked into the white marble sanctum on a crisp winter day. Reflecting the notion that boob jobs are as much about consumerism as medicine, tasteful displays of cosmetics, Ciaravino T-shirts, and a giant poster advertising MemoryGel by Mentor for “superlative enhancement” met me just inside the glass doors. Add to this soft lighting, spotless white and taupe furniture, and arresting megaphotos of women in expensive lingerie.
Dr. C, as he’s known affectionately by staff and patients, had agreed to walk me through the experience as if I were a regular patient. It was all so real, so slick and seductive, so full of metaphorical lotuses that I almost left with a new titanic rack. First, I was greeted by Katye, who genuinely fits the description of blonde bombshell. Like many of the curvy and silken-haired assistants here, she’s been either a swimsuit model or a professional cheerleader. We practically sashayed to a corner office overlooking leafy west Houston, not far from the Galleria mall. Several curvy vases accented the room’s modernist décor, suggesting shapelier times ahead.
“Welcome to the practice!” Katye began. She told me that Dr. C has been practicing for fourteen years and “has been able to perfect the technique.” She showed me a book of before and after photos, in which (mostly) perfectly nice breasts end up looking like water balloons on a skinny rib cage. These headless torsos did, I have to admit, look much more sexed up in the after shots, since by now we’ve all been conditioned to associate big fake breasts with sex. More on that later.
Katye walked me next door to the 3-D imaging room, where, in the name of journalism, I disrobed. After I comfortably settled into my white waffle-weave robe, she showed me implant samples. They were about the size of a large Krispy Kreme. Both the silicone and saline ones were cased in a round, clear, silicone bag. The silicone implant felt nice and soft in a detached way, like bread dough through Saran Wrap. The saline one felt like a bag of water, which is what it is. Women who wear these sometimes make sloshing noises, and ripples can show through the skin. They are less expensive, though, and may be safer if the implant ruptures. In that case, the breast deflates like a flat tire. When a silicone implant ruptures, it is supposed to stay in place since it has the viscous properties of a gummy bear. This is a vast improvement over the more syrup-like silicones of old.
Dr. Ciaravino came in and introduced himself. He has a broad, tanned face and shoulder-length brown hair. He wore a white lab coat and a thick neck chain. I could easily see him relishing his pastimes, which, according to the office literature, include driving a Porsche and playing electric guitar. I channeled my inner Houston housewife. I told him I’d borne two children, had breast-fed for years, and after going through life as a size B, was now curious as to what life might be like as a C. He nodded sympathetically. “Let’s have a look,” he said.
The robe came off, and Ciaravino pulled out a small tape measure. He measured me from collarbone to nipple, from nipple to under-breast fold, and from nipple to nipple, calling out numbers to Katye. He took a step back and mashed my breasts together with his hands, then squeezed each one like a club sandwich. I felt like I was awaiting the word of St. Peter. I was secretly hoping one of the world’s foremost experts on flawed breasts would be so vexed by my nice, very normal breasts that he’d tell me he had nothing to offer.
“Well, first off,” he began, “let me say you’d be a great candidate for breast augmentation.” He assessed me some more. “Where you’re lacking a little is some upper fullness here,” he said, referring to the slope above my nipples. “You actually have a decent amount of breast tissue to begin with. We just need to give it a little boost. Silicone would really serve you best. What I would say if we were truly just trying to gain a little upper fullness and enhance its look, we would want to work with implants in a 250 to 275 cc range. This would move you into an average C size.” (Silicone implants from Mentor, for which Ciaravino is a paid consultant, come in a range of about 100 to 800 ccs, or cubic centimeters. Most women in Texas go much bigger than what he was recommending for me. “Big breasts are part of the Texas tradition,” he said. For perspective, some women test sizes by filling sandwich bags with rice: 275 cubic centimeters is the equivalent of 11/5 cups of rice; 800 cubic centimeters is almost 31/2 cups of rice.)
Ciaravino then led me to his new $40,000 Vectra imaging machine, which would simulate how the implants would look in my breasts. He ducked out, and I, still half-naked, stood motionless in front of the small-saguaro-sized device, with its white plastic trunk and arms, while it captured me in 3-D. Katye clicked a mouse on a computer and then told me I could get dressed behind a small curtain. Soon an image of my torso popped up on her monitor, and together we watched while she punched in some magic codes. Two images appeared on the monitor, me with my real B-plus breasts and then me with big breasts getting bigger and bigger.
“Oh my God,” I said to the screen. I was va-va-voom. But not in a good way. My breasts were big and pendulous and pointing outward. My nipples had the strabismic look of a walleye.
Dr. C popped back into the room and looked at the monitor.
“Oh, that’s huge,” he said.
“I kind of have a sideways thing going on,” I said.
“Yeah, that doesn’t look too good. I would back it up to about half of that,” he told Katye at the controls. “Keep going, keep going.” My cyber boobs were shrinking before my eyes. “Sometimes the machine distorts things,” he explained. “Your nipples won’t really go out like that.” Katye next brought up the profile images, which looked much better. Instead of my breasts having the regrettable ski slope above the nipple (something I never noticed before), now they had the curves of an upside-down cereal bowl.
“You’ll do wonderful,” said Dr. C.
THERE’S NOTHING LIKE AMERICA’S CONSUMER CULTURE TO convince us that what we have isn’t quite good enough. We didn’t used to be this way. Americans have traditionally been toughskinned and self-reliant. At the same time, of course, we’ve been great reinventors of the self. Hollywood may celebrate the heroes of the former, but its images reinforce the latter. In breasts, these two strains of character found a new tension by the middle of the last century. Somewhere along the line, lured by Jean Harlow and Jayne Mansfield and the technological promise of postwar America, American women tossed out the make-do-with-what-you-have mentality and embraced a burning desire for outsized nose-cones.
Highly engineered bras helped, but only if you had something to put in them. Kleenex was popular, and so were socks. Falsies, made out of wire, sheet metal, papier-mâché, rubber, cork, elk hair, or cotton, became a multimillion-dollar industry. In its 1951 catalog, Sears offered twenty-two different versions. At that time, surgical solutions to a larger bust were dangerous and rare. Many more breast reductions were performed than breast augmentations. For much of Western history, large breasts were considered a burden and a handicap. Consider the case of poor Elisabeth Trevers, a young Englishwoman who, according to her surgeon, woke up one morning in 1669 “and attempted to turn herself in bed, [but] she was not able … Then endeavoring to sit up, the weight of the breasts fastened her to her bed; where she hath layn ever since.”
Augmentation came later. Although inserting foreign objects into the body was known to be dangerous, there were always some surgeons and women willing to experiment. The first boob job is attributed to Vincenz Czerny, a Heidelberg physician. He transplanted a benign fatty growth from the backside of a forty-one-year-old singer to her chest in 1895. It was a good idea, since the material came from her own body and was less likely to cause an immune-system rejection, but the result was lumpy and, because the fat liquefied, temporary. That was failure number one.
From that point on, the backstory of implants reads like a horror novel.
In the early twentieth century, implant materials included glass balls, ivory, wood chips, peanut oil, honey, goat’s milk, and ox cartilage. What became of the (thankfully few) women who volunteered for these leaps of science? The parable of paraffin offers a glimpse. From the mid-nineteenth century, paraffin injections had been used on facial deformities. Sadly, there was plenty of opportunity; both war and syphilis—which depressed the nose—were great for advancing the art of plastic surgery. Inevitably, the wax was injected into the breast. But by 1920, its limitations were well known. It melted in the sun, for one. It also created lumps and tumors called paraffinomas that eventually had to be excised out, leaving scars. Beyond that, other problems were puss, hardness, blue skin, and feverish rheumatism. At least one woman’s infected breasts had to be amputated. As one historian put, the disadvantages of paraffin ranged from aesthetic failure to death.
Of course, women going to dangerous extremes for beauty was hardly new. For a thousand years Chinese women crippled themselves and their daughters to have tiny, deformed feet. Western women literally suffocated while wearing corsets, some of which punctured their internal organs. Women have painted their faces with lead and arsenic and ripped their body hair off with hot wax. Oh, wait, we still do that.
Into this sorry milieu came the plastics revolution and a new breed of unholy implant contenders: Teflon, nylon, and Plexiglas. Several surgeons were moved by the shape of plastic kitchen sponges. In 1957 a Johns Hopkins surgeon implanted a polyvinyl and polyethylene sponge (also made with “foaming agents” and formaldehyde) called the Ivalon into thirty-two women. As one magazine reported at the time, “The material’s one drawback is that when it dries inside the breast it becomes a hard lump.”
Meanwhile, toiling in a laboratory in Midland, Michigan, chemists were experimenting with different uses for a versatile material called silicone. Corning Glass Works had begun fooling around with the stretchy composite in the 1930s, making it from silicon (an element) left over from its glass production. To this they added organic carbon-based chemicals in various configurations, resulting in a material that was pretty close to miraculous: hardy, inert, and heat resistant, yet soft and flexible. It was a glass-and-plastic hybrid, with the best properties of both. The company thought it might make a good mortar for its trendy glass bricks (they were wrong, but the failed formulation found new life two decades later as Silly Putty). At the beginning of World War II, U.S. Navy officials coveted a similar formulation of silicone, finding it perfect for insulating airplane ignitions (it made long flights to Europe possible) and for lubricating machinery. To guarantee larger supplies of the carbonbased ingredients, Corning partnered with Dow Chemical in 1943 to form a new war-christened giant, Dow Corning, in the American heartland.
When the war ended, Dow Corning was eager for new civilian markets for wartime products. The company began ardently filing patents for silicone polishes and paints, adhesives, silicone shoe rubber (astronaut Neil Armstrong would take a giant step in it in 1969), caulking, and other applications. The medical profession was intrigued by silicone’s strength, flexibility, and apparent non-reactivity, and slowly the material made its way into catheters, stents, tubing, and blood bags.
In American-occupied Japan, another, less orthodox use was found for silicone. Drums of the stuff, needed for cooling transformers, went missing from the docks of Yokohama harbor. It turned up in the breasts of Japanese prostitutes, who were being injected with it to better attract enlisted farm boys. The technique spread through eastern Asia and became one of Japan’s most popular exports to the United States. But as with paraffin, the industrial caulk-like material was known to migrate throughout the body, form hard lumps, and cause serious infections.
Back in Houston, plastic surgeon Thomas Cronin was holding a new silicone bag of warm blood in St. Joseph Hospital. It was 1959, and the blood bags were a nice change from glass bottles. My, he thought, that feels good. That feels like a breast.
The era of the boob job was about to arrive.
AT FIRST GLANCE, THIS HARD CITY OF OIL DERRICKS, PIPELINES, and banks might seem an unlikely place for such a defining moment in the natural history of breasts. But in addition to its status as the oil and gas capital of the country, Houston in the 1950s was emerging as a major medical hub, in no small part because of the city’s oil and gas wealth. MD Anderson Cancer Center had been created in 1941 as part of the University of Texas system. Houston’s Texas Medical Center, including several nonprofit hospitals and schools, was well on its way to becoming the largest medical center in the world. At Baylor College of Medicine, where Cronin worked, a cardiologist named Michael DeBakey had just pioneered a procedure called patch-graft angioplasty with a Dacron swatch, a celebrated technique still used today. Plastics and chutzpah were revolutionizing medicine.
Add to this a lively burlesque scene, the city’s embrace of petro-fueled commerce and technology, and its particular brand of cowboy entrepreneurialism, and Houston was perfect for the Future Boob mantle. Cronin was ambitious, and he’d been thinking about the breast for some time. He was aware of the practice of silicone injections and dismissed it as no good. But when he saw the new blood bags, he reasoned that if the filler substance could be contained in a sac, many of the collateral problems would be solved. He and his chief resident, Frank Gerow, found a receptive audience at Dow Corning. Working with the company, they designed an implant using a silicone rubber bag filled with silicone gel. On the back of the bag, they added several patches of Dacron in the hope that it would bind to the chest wall and keep the sac from ending up in an armpit. Accounts vary about how they tested it. Some authors say they tested it in six dogs, but Dr. Tom Biggs, who was another resident of Cronin’s at the time, told me they tested the implant in only one. She was, he recalled, a pound mutt named Esmerelda. When Esmerelda survived the surgery, the doctors called it good. (Esmerelda was not as delighted by her new profile, however. She soon chewed the implant out.)
Next, they needed a human volunteer.
IN 1962, TIMMIE JEAN LINDSEY WAS A TWENTY-NINE-YEAR-OLD woman with a hard life behind her. After her mother died of cancer, she dropped out of high school at the age of fifteen, left home, and married a gas-station attendant. Six kids and twelve years later, she kicked him out for being a slouch and an alcoholic. She then fell hard in love with a steelworker, who talked her into getting a big tattoo. A red rose on her right breast said, “Fred,” one on her left breast, “Timmie,” and in between bloomed yet another rose. But Fred was a womanizer and things didn’t work out. At a checkup, Timmie Jean’s doctor audibly gasped when he saw her chest. Feeling ashamed and depressed, she went to Houston’s public hospital, Jefferson Davis, for dermabrasion. That’s where she met Cronin’s chief resident, Frank Gerow. He was another man with a plan for her breasts.
I found Timmie Jean in a small unincorporated town east of Houston. With both Cronin and Gerow dead, she is, on the fiftieth anniversary of her historic implant surgery, the best remaining artifact of the era. Nothing in Houston commemorates the event or the hundreds of millions of dollars that breast implants would soon be pumping into the medical and legal communities. But then again, Houston is not a looking-back kind of place.
“That’s how it all started,” said Timmie Jean, who’s now seventynine and, to my jaundiced eyes, surprisingly healthy for having been a surgical guinea pig. A robust and gracious redhead, she works the night shift at a nearby nursing home that no doubt houses a few people considerably younger than she. She welcomed me to the same house in which she has lived for the last fifty years, though the house, much like her chest, has undergone some augmentation, including a couple of small additions to the original shotgun floor plan. Tan with red shutters, it sits not far off Interstate 10, next to a boat-and-generator repair shop and across the street from two large chemical holding tanks. We sat on a couch covered with crocheted afghans in a room crowded with pictures of her children and grandchildren. A straw-hat collection decorated one wall, and in the next room, an upside-down pink umbrella served as chandelier above the dining table. Now a widow, Timmie Jean shares the house with her daughter Pamela.
“Unbeknownst to me, implants were in development and they were looking for young women to be the first to have them,” she told me in a gravelly Texas twang. “So they brought it up to me. They asked me, would I like to be in a study to have implants? I’d never even dwelled on [my breasts]. I was okay with what I had. After six children I guess they were kind of saggy. I said, ‘You know, what I really want is to have my ears pinned back.’ My brother had teased me my whole life. They said, ‘Yeah, we’ll fix your ears too.’ ”
So in a move that would never pass today’s institutional review boards, Timmie Jean got a cosmetic surgery she didn’t want in exchange for one she did. She went from a size A or B cup to a size C. “I have to tell you,” she said, “they said it would boost my confidence, but I had plenty of confidence.” With new breasts and new ears, though, more men did notice her. But there were drawbacks. At the time, she worked in a dress factory, and as a perfect size 12, she was the in-house model. But her new breasts no longer fit into the shirtwaist dresses of the time. And within five or ten years, she said, her implants hardened and sometimes caused shooting pains in her chest. She wasn’t able to do aerobics or certain exercises because of the pain. She is self-conscious if anyone hugs her. She has also suffered from rheumatism, and has had two knees and a thumb joint replaced, but she doesn’t know if her immunesystem troubles were caused by the silicone in her body or by a life of unceasing hard work.
Around the time of her surgery, the doctors asked her if she knew anyone else for their study, and so she recruited her sister-in-law and her sister-in-law’s sister-in-law. Over the years, like many women, they also had problems with hardness, pain, ruptures, and symptoms of illness they believed were related to the implants. Her relatives eventually joined a class-action lawsuit against Dow Corning and other makers of silicone implants. But despite her ailments, Timmie Jean never publicly complained about the implants. She even testified before Congress, on Dow Corning’s dime, that she was a healthy and pleased customer. One of her daughters went on to get implants, and so did a granddaughter.
Natural breasts have a shelf life. So do fake ones, and it’s a lot shorter. Silicone implants, even today, last only ten to twenty years, but, amazingly, Timmie Jean is still walking around with the original specimens. She is a living museum. She knows they’ve ruptured, because she’s been screened, but she doesn’t want them removed. “I don’t want to go through that,” she said. (Surgery to remove implants, known as explantation, can be considerably more involved than the original if it requires cutting away dense scar tissue, calcifications, and hard nodules called siliconomas.) Plus, she said, “I fell on my boobs and they saved me.”
Would she do it all again? She’s not sure.
“I’d have to look at my options.”
For now, she’s trying to decide whether or not to return a request from Tom Biggs to examine her. She knows her breasts are of great medical interest. “I suppose I should call him,” she said.
“Would you donate your body to science?” I asked.
She laughed. “No, but they can have ‘em if they want ‘em.”
THE 1962 ENLARGEMENT OF TIMMIE JEAN LAUNCHED TWO CULtural tsunamis: a clamor for implants and then, in the 1990s, a clamor against them. Presenting their work to the third Interwnational Conference of Plastic Surgery in 1963, Frank Gerow, Cronin’s right-hand man, held a cigar and coffee cup in one hand and Dow Corning’s Silastic gel breast “prosthesis” in the other. He reflected the beliefs of the audience when he said, “Many women with limited development of the breast are extremely sensitive about it, apparently feeling that they are less womanly and therefore, less attractive. While most such women are satisfied, or at least put up with ‘falsies,’ probably all of them would be happier if, somehow, they could have a pleasing enlargement from within.”
It soon became the fervent stance of the plastic surgery profession that such women were legitimately diseased, either because of “micromastia”—small breasts—or because of their severe psychic inferiority complexes, a handy Freudian concept in vogue at the time. And where there’s a disease, there’s a cure. One surgeon’s autobiography was filled with slump-shouldered, depressive “before” pictures and gleeful, exuberant “after” shots. The message was clear: bigger breasts could change you from a loser to a winner. As recently as 1982, the American Society of Plastic and Reconstructive Surgery told the U.S. Food and Drug Administration that “there is a substantial and enlarging body of medical information and opinion … to the effect that these deformities [small breasts] are really a disease which in most patients result in feelings of inadequacy, lack of selfconfidence, distortion of body image and a total lack of well-being, therefore due to a lack of self-perceived femininity. The enlargement of the female breast is often very necessary to insure an improved quality of life for the patient.”1
For three decades, Cronin and Gerow and their colleagues rushed to fill (as well as to create) the demand for larger breasts. Mastectomy patients represented 20 percent of the total. For them, implants would stand in for what had been brutally cut away with the cancer. For the rest, though, implants promised youth, a certain kind of confidence, and lots of attention. The implants came in three sizes, small, medium, and large. The largest was called “the Burlesque.” (It’s worth noting that at 340 cubic centimeters, it is now merely the average size used in Houston. Implants in the Midwest and East tend to be smaller, as well as less popular.) Gerow reputedly liked big breasts, and it apparently wasn’t unusual for him to take a look at an unconscious woman on the operating table in whom he had just placed implants, decide she could handle bigger ones, and redo the whole thing.2 With royalties on the devices, the men made a lot of money. So did a lot of other surgeons. One Houston doctor boasted that he could perform as many as seventeen breast augmentations a day. He built a breast-shaped swimming pool for himself, with a Jacuzzi for the nipple. If it were up to me, that would be the site of the nation’s implant museum.
By 1985, one hundred thousand women were getting breast augmentations a year, adding some thirteen thousand gallons of silicone gel annually to the nation’s mammary capacity. By 1992, two million women had implants, fueling a $450 million industry.
Especially in the beginning, women from the entertainment industry represented an outsized portion of patients. These were also the women clamoring for silicone injections, a practice that continued well into the 1970s and was mostly performed by “cosmeticians.” It was cheaper and easier than undergoing implant surgery. From its illicit origins in Japan, the option was popularized in the United States by San Francisco’s Carol Doda, credited with being the country’s first topless go-go dancer. In 1964, while dancing at the Condor Club, she underwent forty-four injections of silicone, turning herself into an overnight sensation and winning the title of “the new Twin Peaks of San Francisco.” It is no understatement to say that Doda changed the landscape of breasts. By 1965, she was appearing in Las Vegas and insuring her mammary assets for $1.5 million. In 1968, Tom Wolfe immortalized her anatomy in The Pump House Gang: “Carol Doda’s breasts are up there the way one imagines Electra’s should have been, two incredible mammiform protrusions, no mere pliable mass of feminine tissues and fats there but living sculpture—viscera spigot—great blown-up aureate morning-glories.”
Doda dangled her glories before San Francisco’s power brokers while dancing the Swim, the Twist, the Frug, and the Watusi. She did this to live music from a white hydraulic piano that moved up and down. Now that’s entertainment. (A word about that piano: it once again made headlines in 1983 when a bouncer shtupping a stripper after hours on said piano was crushed to death after accidentally activating the hydraulic system. The trapped woman waited several hours to be freed by a janitor.)
Thanks to Doda’s volcanic success, the pneumatic look became de rigueur for any self-respecting topless dancer, and patrons came to expect it. The strippers instantly saw their tips increase. Corresponding with the popularity of hometown implants, Houston became the strip-club capital of the world. Rick’s Cabaret anchored the city’s club scene. The club’s average bust size was a 38D, according to the Texas Monthly. Founded in 1983, it supplied more models to Playboy than any other club. At one point, it was American Express’s largest charge customer. Setting up franchises across the country, it went on to become the first publicly traded strip joint. Big breasts were going national.
I looked up Doda, half expecting her to be a tenderloin junkie long dead from some sort of silicone poisoning. But once again, my knockered preconceptions were knocked upside down. Doda went on to live a long and rather fabulous life. Now well into her seventies, she currently owns a lingerie store in a fashionable San Francisco neighborhood and makes occasional appearances with her band, The Lucky Stiffs.
Despite the contribution by Doda and her followers to the GDP, federal regulators were not on board with silicone injections. Because the substance was being injected, the FDA classified silicone as a drug in 1965. Alarmed by its poor quality, the agency then prohibited Dow Corning from selling industrial-grade silicone to medical or beauty practitioners and restricted the use of the “medical-grade” stuff to only eight doctors for controlled studies. Even so, an underground trade flourished. An investigation revealed that by 1975, more than twelve thousand women had received injections in Las Vegas alone. There were reports of infection, gangrene, necrosis, and amputations. By 1971, at least four women had died from silicone embolisms, clumps of silicone that had lodged in their lungs or brain. The press covered stories of “Tijuana silicone rot.”
While injections were regulated, implants were not. They were classified as a “medical device,” not a drug, and the FDA did not have authority to regulate medical devices until 1976. Even then, lobbyists ensured the implants were grandfathered in, meaning they did not need to go through an approval process as long as the manufacturer kept the agency updated on any safety problems. It was an eerie parallel to the sixty-two thousand chemicals also grandfathered in that same year under the new Toxic Substances Control Act (for more on that, see chapter 5). In both cases, the lure and power of technology—technology that would alter women’s bodies in wholly unexpected ways—trumped consumer protection.
From the beginning, Cronin and Gerow knew they had some problems on their hands. The sac did not, in fact, prevent the breast from hardening, and the silicone gel proved harder to contain than they’d hoped. The first-generation implants had a ridgelike seam that could be felt on the sides of the breast. Many patients—41 percent, according to a 1979 study—experienced loss of nipple sensation. An enormous percentage of patients—around 25 to 70 percent by ten years—suffered “capsular contracture” in which the body walled off the implant by creating fibrous scar tissue around it. The scar shell then tightened and shrank, contributing to a visual that became known as “the doorknob effect.” If silicone injections came to look like a bag of rocks, the implant resembled one big shriveled stone. A Houston neurologist, who was openly critical of implants, told me he once saw a patient who had been shot. She was a showgirl, and her implants were so hard that the bullet bounced off and saved her life. “They were like doorbells,” he said of her breasts.
Doctors speculated the contracture was a response to contamination and infection. Early dissections of the affected tissue revealed that pieces of paper, wood, cotton, talc—essentially pieces of the operating room—had routinely lodged on the implants. The operation itself, initially performed with fairly crude implements like scissors, resulted in a lot of blood and hematomas—gnarly bruises—around the implant. Eventually, surgeons would develop a cleaner, “no-touch” technique with fewer side effects.
Implant makers also attempted to address the problems. Dow Corning created a thinner, seamless bag. That solved the ridge problem, but the bag was so thin the gel freely oozed out of it (this was known as “gel bleed”), and the bags ruptured more easily. Company salesmen were told to wash the leaking implants with soap and water before presenting them to surgeons.
“We had the silicone catastrophe because the implants were made with a not totally impermeable barrier,” Biggs, now a retired plastic surgeon in Houston, told me. “It was a bad product.”
Beginning in 1982, manufacturers introduced a new, polyure-thane-foam-covered implant, called Meme, in hopes it would keep breasts from becoming bulletproof. Patients with these implants did experience lower rates of capsular contracture, and by 1991 this was the most widely used device. But the reason for the success was that the foam was evidently breaking down in the breast, causing a prolonged inflammatory response and “microencapsulations,” in which “multidirectional contractile forces cancel one another.”
In fact, as the implants got better, they were actually getting worse. Despite some sporadic earlier testing, it wasn’t until 1991 that the FDA released a report that the foam was releasing 2,4-toluenediamine, a known carcinogen. Within days, Bristol-Myers Squibb withdrew Meme from the market. But by then, at least 110,000 women had received those implants. Amazingly, the polyurethane foam being used in the breasts of women was the same stuff headed for carpet pads and carburetors. It was never reformulated for medical use, and the manufacturer of the foam was apparently surprised to learn where it was ending up. Many surgeons remember these implants fondly, and foam-covered implants continue to be used in Europe and South America.
(Lest you think the Europeans are making better products, however, a glimpse into the 2011 French implant scandal will set you straight. Jean-Claude Mas, the seventy-two-year-old founder of Poly Implant Prothèse [PIP], is currently facing criminal charges in France for fraud and injury. For nine years, PIP sold implants secretly made with cheap industrial silicone including fuel additives and other chemicals never studied or approved for medical use. The adulterated implants, now installed in a quarter million woman throughout Europe and South America, are believed to be rupturing at higher than expected rates and causing inflammation.)
By the time of the foam revelations in the United States in 1991, another, bigger wave was crashing. Patients whose silicone implants had ruptured were reporting various idiopathic illnesses, everything ranging from fatigue to joint pain to lupus. The stories were all over the media, in the hearing rooms of Congress, and in the mailroom of the FDA. Several multimillion-dollar judgments were awarded to individual patients in juried courtrooms. The agency’s commissioner at the time, David Kessler, stated that “we know more about the life span of automobile tires than we do about the longevity of breast implants.”
In 1992, the FDA issued a moratorium on silicone implants except in women following breast cancer surgery who agreed to participate in clinical studies. (Saline implants were still available.) By 1995, half a million women were suing the makers of implants and their surgeons. Faced with 20,000 lawsuits and 410,000 impending claims, Dow Corning declared bankruptcy. The company eventually entered into a $3.2 billion settlement with 170,000 women. It was the largest-ever class-action settlement at the time.
A recent college graduate, I clicked into the implant controversy around the time of the moratorium. I’d studied pesticide contamination of farm workers, chemical-plant explosions in Bhopal, and radiation poisoning in Chernobyl. Then an Exxon tanker cracked open in Valdez, Alaska, leaving birds slickened and imperiled. When I saw numerous news reports that plastic implants were rupturing inside women, who then came down with mysterious immunesystem ailments, it seemed to make perfect sense as another example of corporate malfeasance and crimes against nature.
But now, after twenty years of study, science has not backed up most of these claims. Research to date has found that women with silicone implants, even the older versions, do not have more immune-system diseases than their au naturel peers. Some research suggests that they have slightly higher rates of immune-related symptoms such as fatigue and arthritis, but other studies contradict that. In 2011, the FDA reported that implant patients have higher rates of a very rare cancer called anaplastic large-cell lymphoma. This cancer grows in the cells of the scar tissue surrounding the implant, but it is distinct from breast cancer. Implant patients do not have statistically higher rates of breast cancer, but they do have higher rates of lung and brain cancer. This is possibly because of migrating silicone, but more likely due to associated lifestyle factors such as smoking.
To be sure, many things are still distressing about the implant story. Doctors and manufacturers profited by introducing a poorly understood substance into women’s bodies. Implants were not engineered well at the beginning, they were inadequately tested, and patients were not always informed of the many real risks of the surgery, or of the high failure rates of the devices. Ultimately, the immune-system scare became a distraction from these other issues. As the legal scholar Julie Spanbauer put it in 1997, “The message that never reaches the public is that the majority of women with breast implants, those who received their implants before approximately 1992, have become nonconsenting, de facto participants in these and, unfortunately, in future safety studies.” But the crazy thing about the implant story is that no one comes out looking clean. Everyone was out to exploit everyone else, the media included. The implant patients themselves proved able opportunists; if the medical studies are correct, many more women jumped on the classaction gravy train than had claim to do so.
After 1992, the numbers of women receiving implants in the United States briefly plummeted from a high of 150,000 to about 30,000 annually during the conditional moratorium. But by 2007, a year after the FDA approved the next generation of silicone implants—still based on the original Cronin-Gerow concept of gel in a baggie—that figure had increased nearly 1,000 percent. Despite the recession, the worldwide market for breast implants is roughly $820 million a year and growing at 8 percent a year. Between five and ten million women are walking around with implants.
After a fourteen-year silicone hiatus, the fake-boob industrial complex was fully back in business.
BEFORE I LEFT HOUSTON, I WAS INVITED TO OBSERVE DR. CIARavino in action. I was curious to know who his patients were and, I suppose, to bear witness to this visceral alteration of the natural breast. I steeled myself for the operating room by watching stills and YouTube videos of implant operations. One set of photos showed how the nipples were cut open and tubes placed in them to fill saline sacs. It gave the term breast-feeding a whole new visual. This is nurture turned on its head, a gut-churning reversal of lactation.
Fortunately, I would be spared that. Ciaravino prefers to work through a small, neat incision under the breast in what’s called the inframammary fold. He has a kind and compassionate staff, and he uses an experienced anesthesiologist. If you want implants, this seems to be a good place to come. Ciaravino is known for what he calls a “no-bleed” surgery. He cleaves the chest muscle from the rib cage using a pen-sized cauterizing tool that seals the tissue as it goes. He doesn’t want blood because a dry seal around the implant reduces risk of encapsulation and because iron is a primo nutrient for bacteria.
Katye had assured me that implants “are the most studied medical device in history,” and that they are now “100 percent safe.” But are they? The truth is that ongoing studies continue to raise basic health questions, and the FDA and even implant makers acknowledge as much. When the agency approved the new silicone implants in 2006, it was under the condition that manufacturers carry out ten-year follow-up studies. In its fifty-two-page product insert data sheet for MemoryGel implants, the Mentor corporation summarizes the results of the first three years of this study. In addition to finding an eye-raising three-year complication rate of 36 to 50 percent for implant patients (including trickier cancer reconstruction patients), the insert states, “Compared to before having the implants, significant increases were found [in patients] for fatigue, exhaustion, joint swelling, joint pain, numbness of hands, frequent muscle cramps, and the combined categories of fatigue, pain, and fibromyalgia-like symptoms… These increases were not found to be related to simply getting older over time.”
The Mentor study has found that the three-year reoperation rate for patients (depending on whether they received augmentation or reconstruction procedures) is between 15 and 29 percent. Some reoperations are done because of cosmetic failure. The door-knob effect isn’t the only visual problem. A perusal of “bad boob jobs” on the Internet yields a grim parade of Uniboob (also called “bread-loafing”) in which the implants migrate toward each other; Double Bubble or “bottoming out,” in which the implant drops below the breast fold, creating what looks like a double-decker breast as well as serious asymmetry; Highballing, in which the implant sits too high; and various degrees of wrinkling and dimpling. A woman buying implants today may still be buying into recurrent surgeries, costly, regular MRI screenings (to detect “silent” ruptures), and a reduced ability to detect early breast cancer (the implants can block effective mammography).
Even more troubling, though, is that some women continue to report problems with nipple sensation and breast-feeding because nerves can be damaged during surgery. While Ciaravino says these effects in his practice are rare, a major review of the literature from the Institute of Medicine in 2000 stated that women with either silicone gel–filled or saline-filled breast implants showed lactation insufficiency (not enough milk) at rates ranging from 28 to 64 percent. The FDA’s Breast Implant Consumer Handbook further states, “It is not known if a small amount of silicone may pass from the silicone shell of an implant into breast milk. If this occurs, it is not known what effect it may have on the nursing infant.”
Perhaps few women with implants are interested in nursing, but one would expect (and hope) that a great number are interested in sexual sensation. Let’s be clear about what these under-sung side effects mean: in a world where breasts are considered purely sexy, we jeopardize the central natural functioning of breasts (lactation and dynamite neural sensation) so that they can be even more sexy, to the point where the improvement actually eliminates the sexual feeling in this allegedly sexy organ. Now we can have hard, lifeless replicas of something sexy. Plastic surgeons understand this: in 1976, a pair of them observed in a trade journal, “Fortunately, patients undergoing plastic surgery of the breast are concerned more with getting rid of a deformity and achieving a desired body image than with maintaining or improving mammary sensation.”
They appear to be correct. When I learned about the continuing problems attributed to implants, what I was most astonished by is that so many women still want them, especially in Texas. Even with their contractures and ruptures and door-knob breasts and lifeless nipples, most women say they are happy with their implants. At least over the short term, many implantees report increases in self-esteem and sexual self-confidence, if not actual sensation. As the brain is the body’s largest sex organ, this makes some kind of sense. Mentor’s study to date shows that of 456 new augmentation patients within three years of surgery, 98 percent would have the procedure again. Other studies show that even seasoned patients do it all over again after their old implants have crumpled and died.
Do big breasts really have that much more fun? Or are we, as critics like Naomi Wolf suggest, hopelessly brainwashed by a beauty myth designed to keep our minds distracted by frivolity? That women should feel good about themselves is their right; but that they should feel so bad about themselves in the first place shows that the modern boob job represents a great failure of the imagination.
How do we convince our daughters not to join the legion of women who feel they have such limited avenues to happiness? Unfortunately, that challenge seems to be only growing. Double-D breasts on skinny women are not all that common in nature. (Barbie’s proportions are naturally found in one out of one hundred thousand women, according to researchers from the University of South Australia; Ken’s bod, by contrast, is found in one in fifty men.) Big, fake breasts have so thoroughly saturated mainstream entertainment and media that they’ve created a new standard by which boys judge girls and girls judge themselves.
Thanks to the alliance of two kinds of silica-based technologies—breasts and computer chips—most young people learn about bodies and sex from the Internet; they have seen many more factorymade breasts than real ones. In this crowd anyway, natural breasts just keep losing traction.
THE PATIENTS IN DR. C’S SURGICAL SUITE KNEW AS MUCH. THE first patient I met was a twenty-nine-year-old named Gloria who weighs ninety-nine pounds. A recent college graduate, she has a two-year-old. When Dr. C came in for a pre-op review, she took off her robe to reveal breasts that are quite fantastic: firm and nicely rounded, probably a B cup. A delicate butterfly tattoo lay between them, and her back sported a geisha surrounded by cascading pink blossoms. She would be getting 275-cubic-centimeter implants, for “a full C.” I asked her what made her decide to do this. “I just want to put back what I had before my son was born,” she said.
Gloria was, explained Ciaravino later, ideal for surgery. “You want the little skinny ones,” he said, reflecting a truism among all surgeons. “The ideal patient, she’s had a couple of kids, she’s good looking to start out with. If you have funky breasts to begin with, they’re going to be funky after. It’s not going to be picture perfect. It’s all a relative improvement.”
As Gloria went off to meet the anesthesiologist, Dr. C strode to OR1 to place saline implants in a forty-one-year-old Filipina nurse. I watched as he rolled up the silicone shell like a pirouette cookie and then pushed it through the incision. After he flattened it out with his fingers inside her breast, he connected some tubing to its valve. He talked as he went. “With silicone, you have to push it in. You can get a little wear and tear. And you can see her filling up here before your eyes. She’s blowing up like we’re filling up a balloon here.” A machine was pumping in 340 cubic centimeters of saline fluid through the tube and into her breast. When she was fully inflated, Ciaravino stuffed some escaping yellow breast tissue and fat back into the incision, and then he and a nurse took turns sewing her up. She moaned and thrashed a bit. The anesthesiologist by her head adjusted her dose.
Next we went to have a pre-op with Courtney. As always, Ciaravino had a half-dozen patients rolling through the surgical suite in a conveyor belt of calm efficiency. Courtney was sitting with her husband, who wore a T-shirt and baseball cap. They were both in their mid-twenties, from a small town not far away. Courtney, a former cheerleader, now owns a tanning salon. She has dark shoulder-length hair and strenuously plucked brows. A mother of two small kids, she was eager for a better body. In a Texas accent, she explained what brought her here. “I’m a very small B or A, probably A. When I was in high school, I probably had a small C. My sister, she didn’t have big boobs, but after her daughter was born, hers stayed big. But mine, they got smaller every time. My sister-in-law used him,” she said of Dr. C. “Some of my good friends and customers have implants. I just want a full C. I don’t have to look good for anybody else, just for myself, I guess to help me feel better about myself.”
When I next saw Courtney, she was lying asleep on the surgery table. Her uncovered breasts had been marked with a blue pen. The ink made dotted lines along the contours of her flesh like rivers on a topographical map. Her torso had an orange-tinted tan, and her breasts were indeed small. She’d be getting 350-cubic-centimeter Mentor MemoryGel implants, bigger than the old-fashioned Burlesque. Dr. C explained that Courtney was a bit of a challenging case. “The issues here,” he said, “are that she doesn’t really have a defined fold at all so we’re going to have to sort of create that. It puts her at a little bit of a risk for the implant moving down. So when I close it I’m going to have to tack it in place.” He went to work on her, cutting and singeing below her pectoral muscle. He pulled the space open with an instrument resembling a shoehorn. It’s called a Biggs Retractor, named after the Houston surgeon who trained with Cronin. Ciaravino motioned me over to catch a glimpse of Courtney’s heart beating between her ribs. The wound smelled of burning flesh.
When I’d seen enough, I stepped out to chat with the next patient in line, an insurance agent named Katie. She was thirty, a brown-haired mother of two, from Orange, Texas. She said she’s never been under anesthesia before, and she’s nervous. She wanted to go from a size A to just a small C because “we’re conservative people,” Katie explained. “It’s not like all my life, I said, ‘Oh my God, I want boobs, I want fake boobs.’ I just want my clothes to fit better without having to buy an extra padded bra.” Not having implants, she said, “I’m like the minority, I think, in our circle of friends.” She laughs, patting down her hospital gown. “It’s peer pressure.”
DDT on Jones Beach, 1948