Breast enlargement and reduction surgeries are classified under the general category of mammoplasty within the field of cosmetic surgery. Breast enlargement surgery (more commonly referred to as breast augmentation) involves the insertion of an implant between the breast tissue and the chest muscles, or underneath the chest muscles, for the purposes of increasing the size of the breast. Breast reduction surgery (less commonly referred to as reduction mammoplasty) involves the removal of breast tissue and skin for the purposes of decreasing the size of the breast. Breast enlargement and reduction surgeries raise two significant issues within the field of cosmetic surgery concerning informed consent and the often arbitrary distinction between “cosmetic” surgeries and “reconstructive” surgeries. While breast enlargement and reduction surgeries are performed worldwide, statistical information about the prevalence of both is lacking about areas outside of North America (and the United States more specifically). This is primarily because surgeons who perform breast surgeries might not be plastic or cosmetic surgeons, and thus may not belong to a national cosmetic surgery association (or, alternatively, there may be no national cosmetic surgery association).
Breast enlargement surgeries are very popular in North America, and in the United States, breast augmentation is currently the most commonly performed cosmetic surgery. Although the number of breast augmentations performed in the United States declined by 12 percent between 2007 and 2008 (due to an economic recession), the overall increase in breast augmentation procedures between 2000 and 2008 was 45 percent. Women choose to undergo breast enlargement surgeries for a variety of reasons, including dissatisfaction with breast shape and size, occupational purposes, loss of one or both breasts due to mastectomy, and sex reassignment surgery. Because there are no laws in North America that limit who can claim the title of plastic surgeon, and thus any person holding a medical degree can operate a plastic surgery practice, there are a range of economic options for women seeking breast augmentation depending on the individual surgeon's qualifications, prestige, and geographical location.
In the late 19th and early 20th centuries, Western doctors unsuccessfully experimented with fat and liquid paraffin injections to augment body parts, including women's breasts, although this was not a commercially viable project at that historical moment. Countless other substances have been unsuccessfully implanted in the breast to make it larger during the early to mid-20th century, from wool to ivory to glass and also several synthetic substances (most popularly Silastic rubber implants and liquid silicone). It was not until the 1950s and 1960s that surgeons began to experiment with saline and silicone implants, and that breast augmentation gained a wider public acknowledgment, although not acceptance.
The implants that women receive today are most commonly silicone envelopes filled with either saline or silicone gel, and can be circular, teardrop-shaped, or shaped to fill in areas hollowed out by a lumpectomy. A recent breakthrough in silicone implant technology is the cohesive gel implant, or “gummy bear implant,” which is a solid but malleable piece of silicone that will not rupture.
Surgeons make an incision most commonly in the fold underneath the breast, but sometimes in the armpit or around the nipple, and very rarely in the navel (this is a new technique that is not commonly performed), and insert the implant into a pocket created by the surgeon either above or underneath the chest wall. Silicone implants are manufactured pre-filled, and so they require a larger incision than saline implants, which are filled with sterile saline after they are inserted into the body. Potential risks and side effects of breast augmentation include severe reactions to general anesthesia and pain medication, excessive bleeding, loss of sensation in the breasts and nipples, formation of hard painful scar tissue around the implant that must be manually broken down (encapsulation), the rupture or migration of the implant, and excessive scarring.
Silicone implants are particularly controversial due to their perceived effect on women's body image in breast-obsessed American culture and their potential risks. Silicone implants are considered to look and feel more natural than saline implants, and are thus desired by many women considering breast implants. In 1992, the Food and Drug Administration and Health Canada severely restricted the use of silicone implants due to a lack of information about their potential long-term risks and rising anecdotal accounts of systemic illness. Many of these women launched lawsuits against surgeons and manufacturers of silicone implants alleging that they were misled about the risks of silicone implants and did not give their full informed consent as a result. However, after conducting clinical trials that could not establish a link between silicone implants and systemic illness, in 2006 Allergan and Mentor were granted licenses in Canada and the United States to market their silicone implants.
Breast reduction surgeries are less popular than breast enlargement surgeries in North America, although the number of breast reduction procedures has increased by 5 percent in the United States between 2000 and 2008, and breast reduction surgery is the third most common reconstructive plastic surgery according to the American Society for Plastic Surgeons. Women undergo breast reduction surgery due to dissatisfaction with the size and appearance of their breasts, and pain in the neck, shoulders, and back. Because breast reduction surgery is commonly classified as a “reconstructive,” and thus medically necessary surgery, women are often able to receive some medical insurance coverage for this surgery. This means that in countries with public health insurance especially, breast reduction surgeries can be popular. Men obtain breast reduction surgery as well for gynecomastia as well as sex reassignment surgery, although men are more likely to receive medical insurance coverage for the former and self-finance the latter.
Breast reduction surgeries were performed as early as the 16th century in Europe, but they were not a common part of surgical practice until the late 19th century. Techniques for breast reduction surgery have been relatively consistent in the 20th century. While surgeons occasionally perform liposuction to reduce breast size, most commonly they create a vertical or keyhole-shaped incision from the fold underneath the breast to the nipple. Surgeons remove the nipple to reposition it in a higher location on the breast, and also remove breast tissue and a small amount of skin from the lower breast, creating a lifting effect in addition to the reduction. Risks and side effects of breast reduction surgery include severe reactions from general anesthesia and pain medication, excessive bleeding and scarring, severe pain, and loss of sensation and ability to breastfeed. Furthermore, as women's breast development can continue into their mid-20s, when younger women undergo breast reduction surgeries their breasts often return to their original size several years after their operation.
Breast reduction surgeries are considered more socially acceptable than breast augmentation, as they are understood to be medically necessary and reconstructive, rather than cosmetic. However, there is evidence to suggest that many women strategically emphasize neck, back, and shoulder pain in their surgical consultations to obtain insurance coverage for the procedure. Interestingly, one of the most frequent comments women make about their breast reduction surgeries is that they are excited about purchasing clothing and lingerie that fits properly. While it is likely that there are some women who experience pain because of large breasts, the pain explanation supports the argument that breast reduction is reconstructive and thus entitled to insurance coverage.
Beauty Standards, Cross-Cultural, Body Image, Cosmetic Surgery, “Femininity,” Social Construction of, Pornography, Portrayal of Women in.
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