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If you’ve commuted in an American city in the past decade, you’ve probably seen some kind of cheeky ad for affordable, accessible breast implants. A young woman comparing tangerines with grapefruits has greeted subway riders in New York City for the past several years. A giant close-up of cleavage promising “a gift you can both enjoy” loomed over the streets of one Utah town in 2007. Almost a decade later, a California billboard reminded women that size matters.

Boob jobs have been ubiquitous in American popular culture since the 1980s, when laws changed to allow plastic surgeons to advertise and credit cards became widely available. But safety concerns have dogged the procedure since the first silicone breast enhancements were successfully implanted by Texas surgeons in 1962. In that time, the Food and Drug Administration has banned the use of silicone implants and then reinstated them on the condition that the industry closely monitor their impact on patients.

Now both silicone implants and the more popular, saline-filled alternatives have found themselves under the agency’s lens again, this time over their potential links to a rare cancer and claims from patients that they cause pain, chronic fatigue, and autoimmune problems. On Tuesday, an FDA advisory committee completed two days of hearings on breast implants’ links to long-term complications, a forum that women’s advocacy groups have been demanding for years. The meetings concluded with the panel recommending that the FDA require manufacturers to provide simpler and clearer health warnings to all patients, but stopped short of encouraging a ban on any particular type of implants.

Decades of research suggest that breast augmentation is safe when performed and maintained as recommended. But the tens of thousands of women who attribute their health problems to their breast implants still suggest that significant problems can occur with how the procedure is recommended, performed, and maintained. No matter how the FDA moves forward, at least part of the problem faced by patients is the glib culture that can downplay the procedure’s seriousness.

Breast augmentation is the most popular cosmetic surgical procedure in America. In 2018, it was performed more than 300,000 times, according to a recent report from the American Society of Plastic Surgeons. That’s a 4 percent jump over the previous year, and part of a larger trend in plastic surgery in the United States. As minimally invasive facial injectables like Botox and Juvéderm gain popularity, consumers are starting to move away from facial surgeries, which have traditionally been most popular, and toward body modifications like liposuction, butt lifts, and tummy tucks, in addition to breast augmentation.

But as Alan Matarasso, the president of the American Society of Plastic Surgeons, points out, there’s a fundamental difference between breast augmentation and other popular procedures. “Many of the most popular surgical procedures involve taking something out—a bump in the nose or some fat,” he says. “[Breast augmentation] has the same issues of having an operation, but with the limitations of a device.”

Augmentations are frequently performed on very young women, and those patients are likely to need additional procedures to maintain their health. “I tell young implant patients who are coming in for augmentation, this will not be the last surgery they have on their breasts,” says Jason Spector, a professor and plastic surgeon at Weill Cornell Medical Center, in New York City. Modern implants can require replacement less than 10 years after a patient’s initial surgery. The FDA recommends that patients have follow-ups with their doctors and MRI surveillance throughout the life of the implant, something that Spector says not all doctors insist on and not all patients adhere to.

Given how casually breast augmentation is often talked about and advertised, it can seem like skipping the lifetime of follow-up is no big deal. But patients can suffer from the less-than-serious cultural attitude toward cosmetic modifications—and unscrupulous doctors can benefit. “Not everybody putting breast implants in across the country is a board-certified plastic surgeon,” Spector says. “You have variation in state laws, and if you’re doing things in your own office, all you need is a medical license.” Untrained surgeons performing cosmetic procedures in high-volume, low-cost settings can have deadly results. In February, USA Today published an investigation into a group of Miami clinics where eight women had died from surgical complications. (The owner of the clinics has denied any wrongdoing.)

Although the surgeons I spoke with said that many patients’ breast-augmentation complications are likely the result of errors in their treatment, they were also clear that even a flawlessly performed augmentation carries risks. In some people, an implant can become encapsulated in scar tissue, causing pain and deformity. Recent evidence suggests that the rare cancer anaplastic large cell lymphoma, or ALCL, is more common in patients who have had textured-surface breast implants. In a controversial 2018 study, researchers also found a link between several cancers and autoimmune diseases and silicone implants, but the study did not go so far as to demonstrate that the implants were the cause of those health concerns.

In spite of the risks carried by the implantation of any kind of medical device, the benefits can win out, even for a procedure that is often dismissed as frivolous. According to Matarasso, about a quarter of all breast-implant surgeries are done in patients who have had mastectomies, which have become a popular preventive measure against breast cancer in recent years for those in high-risk populations. Breast implants can also be an important element of gender confirmation for trans women.

Even when women choose breast implants for purely aesthetic reasons, it’s expensive and invasive. There’s little reason to trivialize it, and yet there’s a constant cultural encouragement to see it as no big deal. This dismissiveness gives license to some practitioners to characterize a medical device as a fun, sexy purchase your hubby will love instead of a serious lifetime commitment to an invasive procedure that will permanently alter your body. A lot of different women get implants for a lot of different reasons, and none of them are served particularly well by a babe on a billboard.

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