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updated 2/26/2010 8:11:00 AM ET 2010-02-26T13:11:00

Every day, almost a thousand women in the United States surgically boost their breast size — making breast augmentation the most popular cosmetic-surgery procedure in the country. The practice is now so mainstream that college seniors get implants as graduation gifts and mothers get them after nursing their children. There are also thousands of breast-cancer survivors each year who choose to undergo reconstruction after a mastectomy. Half of American women say they know someone who has had breast implants, according to a poll by the National Women's Health Resource Center.

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Breast augmentation is surgery, of course, and comes with risks, which can include unnatural-looking results, painful hardening of scar tissue, and reoperation. (Detailed information is at fda.gov and breastimplantsafety.org.) But for many women, the perceived rewards outweigh the possible complications, the price tag, and the eventual need for the implants' replacement. Indeed, studies show that about 95 percent of patients say they're satisfied with the results.

In the face of this robust demand, not to mention potential profit, doctors and manufacturers say they are developing ways of making going bigger better.

One such breakthrough in silicone implants is nicknamed “the gummy bears.” Now in clinical trials that could lead to FDA approval soon, these feature a highly cohesive silicone gel, which is formulated into a semisolid consistency. The thick filling holds the implant's shape consistently and poses minimal risk of migrating outside the shell if it ruptures, says Steven Teitelbaum, a plastic surgeon in Santa Monica.

Plastic surgeons are fine-tuning the augmentation procedure itself, too. A technique pioneered by John Tebbetts, a plastic surgeon in Dallas, takes 30 minutes, versus the standard 45 to 90 minutes, and the majority of his patients say they feel well enough to go out the same evening.

The method involves meticulous preoperative planning of size and delicate handling of tissues to reduce postoperative pain, Tebbetts says.

It is currently in limited use, however, and some doctors worry about its safety; patients who are too active soon after surgery might increase their risk of complications, cautions David Hidalgo, a plastic surgeon in New York City. (“Early activity causing complications depends on how the surgeon plans and executes the surgery,” Tebbetts says.)

Most surprisingly, the field of breast enlargement is not even confined to traditional saline- or silicone-implant surgery. Scientists in Australia recently announced a discovery that could lead to an entirely new approach. Their research suggests that it's possible to grow breast tissue gradually by stimulating fat cells. Human trials in mastectomy patients are scheduled to begin soon, and if the procedure is proven safe, growing breasts purely for cosmetic reasons might be feasible someday, the researchers say.

For better or worse, breast enhancement has become part of our culture. As the practice heads into its twelfth decade of existence, allure looks at the biggest news in breast augmentation.

Breast-injection controversy
The phrase “natural breast augmentation” may seem like an oxymoron. But that's the way some doctors promote a procedure that involves enlarging the breasts without implanting any foreign objects in the body. In the operation—known as fat grafting, fat transfer, or liposculpture—a doctor injects the breasts with a woman's own body fat, taken from her waist or thighs. When the doctor is experienced, the results look natural, with none of the rippling, visible edges, or malposition that sometimes result from implants.

One potential problem is that the size may vary over time if the patient's weight changes. But the procedure is “highly controversial,” says Peter Cordeiro, chief of plastic surgery and reconstruction at Memorial Sloan-Kettering Cancer Center in New York City, who believes it should be done only with close monitoring as part of clinical research. “There are no large studies that definitively report its safety with regard to screening of the breast for cancer, or its potential impact on breast cancer,” he notes.

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That's not to suggest that fat transfers to the breast cause cancer, says Grant Carlson, a plastic surgeon and breast-cancer specialist at Emory University in Atlanta. But estrogens that are present in fat can affect dormant cancer cells, increasing their risk of proliferating. Both the American Society of Plastic Surgeons and the American Society for Aesthetic Plastic Surgery have called for more research, and the latter group states that it does “not recommend fat grafting for breast enhancement at this time.” (An exception is injections of small quantities to correct uneven areas around implants.) Still, Carlson says, “Tissue engineering with fat is very exciting. It's where we're headed.”

Trying implants on for size
Choosing a new pair of breasts may make the quest for perfect-fitting jeans seem like a cinch in comparison. Implant patients' dissatisfaction with size is responsible for about a third of all revision operations. In the majority of these cases, the women wished their breasts appeared larger.

For years, prospective patients trying to figure out their desired size have stuffed bras with rice-filled socks. Now, many doctors offer women actual trial implants to place inside their bras and test under their clothes. Plastic surgeon David Hidalgo likes his patients to wear a gray or white T-shirt over the implant-filled bra because darker colors don't always “show the three-dimensional volume well,” he says. Allergan offers a kit of implants in different sizes for potential customers to try on at home.

The problem with this technique? “Many patients have an unrealistic idea of how big they can go without causing physical complications,” says Bradley Bengtson, a plastic surgeon in Grand Rapids, Michigan. To determine the ideal implant size for each patient, Bengtson and two other plastic surgeons, William P. Adams, Jr., in Dallas, and Steven Teitelbaum, have developed a simplified method, called the Implant Selector.

It involves taking measurements of the breasts' width, the distance from the nipple to the crease under the breast, and the skin's elasticity (the more pliable the skin, the larger the implant can be), Teitelbaum says. Based on this data, the doctor creates a computer simulation of the patient, which shows her at different angles with the implant size and shape the surgeon deems most suitable for her frame. Although the approach hasn't been evaluated in published research, the doctors say it has decreased reoperation requests.

Patients most often say they want a C cup, but implants simply come in ccs—as in cubic centimeters—and the same volume can look smaller or larger on women with different builds. In any case, once a woman decides, for example, that a 350-cc implant looks right and her surgeon determines by whatever system that it's safe, some doctors suggest going slightly larger: Adding at least 25 ccs compensates for the bra's volume and compression of the implant once it's under the tissue, Hidalgo explains.

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