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Cultural shifts and rifts: cosmetic surgery, breast augmentation comes of age

Michelle Tackla

Few procedures have a history as fascinating or as divisive as that of the breast enhancement. As early as 1890, paraffin was attempted; since then, ivory, glass balls, ground rubber, ox cartilage, sponges, sacs, rubber, goat's milk, Teflon, silicone, and soybean and peanut oil have all been used to try to improve breast size or shape. The development of various enhancement techniques was characterized, at each turn, by high optimism, searing criticism and various mis-steps, as well as victories--defined as procedures performed safely with satisfying results.

While the Japanese fixate upon the nape of the neck and the Chinese cast their eyes on tiny feet, one could argue that breasts, in our culture, are simply more than breasts. Within these spheres, so much of a woman's identity seems to originate, perhaps explaining the popularity of breast augmentation procedures--the second most commonly performed cosmetic surgery procedure in the United States, numbering 249,641 in 2002, according to the American Society for Aesthetic Plastic Surgery.

Author Carolyn Latteier explains her personal interpretation of her breasts: "My discomfort with small breasts was more than cosmetic. I felt the lack as a poverty of being, as if my very nature were somehow stark and bony." Breasts have represented all that is sexually potent, maternal, and powerful about women--and about society. They have served as political symbols, such as the bare-breasted images of Liberty and Equality popular in the new French republic of the late eighteenth century. They have even taken on literary and artistic representations, according to author Marilyn Yalom, that begin as early as the biblical Eve. "Associated by Christians and Jews with the apple of the fall, [Eve is] often is depicted with apple-like breasts, a connection made visible by innumerable works of art."

In recent decades, breasts have been increasingly objectified and commercialized. Hardly could this be made more apparent than by the words of Cynthia Hess, an exotic dancer who explained why she sought--successfully--to have her size 56FF breast implants declared a tax-deductible business expense. "It was obvious that the size of your chest was in direct proportion to the size of your salary," she said in a Newsweek article published in 1994.

What is the ideal breast, sought after through surgery? Though much of it is individual, it also depends upon the decade, according to Latteier. "Today, media imagery communicates quite clearly that the best breast--the breast as it should be--is the adolescent breast. It is a firm, milky white globe. The nipple is smooth, not the lumpy, bumpy nipple of women who have nursed a baby or outlived their youth," she says.

In western culture, and even in recent history, the idea breast was not always adolescent, she says. "From the nearly flat-chested look of the 1920s, the style in breasts slowly ballooned in the mammoth mammaries of the 1950s and 1960s, reaching its zenith in the late 1960s," she says, adding, "In the 1920s, the bust measurements of Miss America contestants averaged 32 inches. These vital stats rose to 35 inches in the 1940s and through the two decades following 1950, stayed at what was considered a 'perfect 36.'"

Certainly, the meaning of a woman's breast has changed over the centuries, long before surgical alteration was attempted. In particular, a shift in thinking of the breast--from maternal to erotic--became apparent through a change in artistic expressions. "The nursing Madonna of fourteenth century Italy [did] battle with a new, predominantly sexual image of the breast," according to Yalom. "In countless paintings and poems that proliferated in Italy, France, England, and Northern Europe in the fifteenth through the seventeenth centuries, the breast's erotic potential came to overshadow its maternal, sacred meanings."

However, the lactating woman, rife with symbolism, would not be so easily dethroned. In the seventeenth century Dutch republic, she became a visage of civic responsibility, seen as a contributor to the health of her household and to the community. A century later, some French subjects believed that a general social reform would result if mothers nursed their own babies, rather than sending them out to wet nurses.

It took Sigmund Freud to connect the nursing mother to the sexuality of her breasts when he contended that suckling was not only a child's first activity, but also the starting point of one's sexual life.

Augmentation techniques develop

While Dr. Robert Gersuny of Vienna attempted paraffin for breast augmentation in the 1890s, resulting in infection, breast hardening, and lump formations, most surgeons did not address the problem of small breasts until after World War II.

Autologous fat transplants in the 1920s utilized fat from the abdomen and buttock area for the breasts, but the body would reabsorb the fat and breasts would become lumpy and asymmetrical. The resulting lumps also made it difficult to detect cancer.

In the 1940s, various liquid substances were injected into breasts, including paraffin and petroleum jellies. At this time, various reports say that silicone, in all likelihood, was used first in Japan, where prostitutes had industrial silicone liquid injected into their breasts, supposedly to increase their clientele among American servicemen during World War II, after goat's milk and paraffin were found to be unsatisfactory.

According to some reports, silicone injections were being developed simultaneously in the United States. Over several decades, thousands had this procedure done, including actresses and topless dancers in the San Francisco area and in Las Vegas, where estimates range between 12,000 and 40,000 women, who reportedly had undergone the procedure before it was banned in the United States in 1976. These breast injections could cause pain, discoloration, ulceration or infection--or more seriously--disfigurement or death.

Transplants that included most of the dermis were attempted at this time to help ensure that the skin grafts would not die, but these too, did not have satisfactory results. By 1944, external prosthesis of sponge rubber for women suffering from atrophy or absence of the breast was recommended to surgeons in the Archives of Surgery.

"Surgeons started the postwar years with a distinct lack of sympathy for the problems of small-breasted women, but this attitude changed quickly as women--encouraged by fashion magazines and inspired by movie stars such as lane Russell an Marilyn Monroe to fill out Dior's 'new look,' clamored for solutions," Haiken says. 'Hypomastia,' said to cause 'psychological rather than physical distress' took its place with hypermastia and gigantomastia as problems deserving of a surgeon's attention. At this time, H.O. Bames, M.D., wrote that the correction of hypomastia since "'our cult of the body beautiful' has revealed its existence in rather large numbers."

In the 1950s, Ivalon polyvinyl sponges began to be implanted and were later joined by Polistan (discovered in 1959), Etheron (introduced in the 1960s, and Hydron (introduced in 1961). At this time, the considerable psychological implications of breast surgery began to become clear to surgeons.

Psychology and Breast Implants

In 1958, Milton T. Edgerton, M.D. and psychiatrist A.R. McClary published an article exploring the psychological aspects of breast augmentation based on a study of 53 women who had had Ivalon sponge implants since 1950 and supplemented by random observations drawn from 19 additional cases. "Literally thousands of women in this country alone are seriously disturbed by feelings of inadequacy in regard to concepts of the body image." They wrote of "an almost paralyzing self-consciousness focused on the feeling [of women studied] that [they] do not have the correct bosom size."

The authors wondered what procedure would ultimately be "safe, simple, and satisfactory" and asked if such a procedure could be found, would solve patients' emotional problems? While the study found that most women who had received sponge implants were satisfied post-operatively, the sponges caused some complications. They tended to harden over time and breast tissue did not simply contract around the sponges, but actually filled the pores. This made removal difficult or impossible without a great deal of scarring and deformity.

Silicone on the Scene

In the 1960s, silicone was a new substance that had just began to come into the hands of plastic surgeons. Initially, it was used to treat skin imperfections, then Thomas Cronin, M.D., used a breast implant device, consisting of a silicone envelope filled with silicone gel on a thirty-six-year-old mother of six at Texas Charity Hospital in 1962.

Through the 1960s, breast implants remained relatively rare because the implants often felt hard and unnatural due to scar tissue formation around hardened implants. Reports of complications began to surface from those who had received silicone in the form of shots, including chronic inflammation, infections leading to necessary mastectomy, organ damage due to silicone migration, and tumor-like lumps. By 1971, the FDA determined that at least four women had died from silicone embolisms that had formed after injection. In 1965, Dr. H.G. Arion introduced the Simaplast inflatable prosthesis, which a surgeon would fill with saline after implantation. However, it could deflate spontaneously.

A more natural silicone implant was developed in the 1970s. While it represented an improvement in design, it also tended to break more easily. Once broken, total removal of the implant was difficult and sometimes impossible. Other changes included polyurethane foam covering for implants to prevent capsular contracture. However, the foam began to disintegrate in the body almost immediately, making it difficult to remove and causing complications. At this time, reconstructive patients, estimated at 20 percent of total implant recipients, became more vocal as the women's movement brought breast reconstruction issues into the public consciousness.

In 1976, the Food and Drug Administration gained authority to regulate implants, classifying them as medical devices. In the 1980s, women with implants reported illnesses thought to have a possible link to ruptured implants, but nothing could be proven. Capsular contracture was a problem remedied by covering the implants with polyurethane foam in 1982.

In 1992, as complaints about silicone gel-filled implants mounted, the FDA requested that manufacturers provide evidence of their safety mid effectiveness. Dow Corning made a valiant effort, presenting a report of more than thirty thousand pages, but the data it presented were deemed insufficient. As a result, the FDA classified silicone gel filled breast implants as experimental and disallowed their use with some exceptions. The committee found no direct evidence that many of the reported illnesses were a direct result of the implants and the silicone gel-filled implants were not restricted from patients with breast cancer or those who received the implants through specially monitored research studies.

Enter Saline

Saline as an implant replaced silicone gel after 1992, offering less favorable results, but appearing to suffer less capsular contracture than silicone. In 1995, Europe launched a trilucent breast implant filled with Fat from soybean oil. However, it was found that the filler could become toxic in the body as it broke down. In 1999, the Institute of Medicine declared in a 400-page report that there was not evidence linking breast implants to serious illnesses, but that rupturing, pain, and other local complications frequently occurred. The same year, Dow Corning Corp. was required to pay a $3.2 billion settlement to compensate 170,000 women who had sued based on claims that silicone gel implants had been harmful to them. Currently, Inamed Corp. has requested that the FDA approve its silicone-gel implants, which were recently reviewed in FDA hearings.

Plastic surgery advances

1930s "Legitimate plastic surgery was considered reconstructive, largely limited to patients suffering from trauma and congenital defects."--Hait P. Schnur

1937-1944 American Society of Plastic and Reconstructive Surgery presidents are certified by the American Board of Otolaryngology

1941-1945 World War II "The world war has not alone brought cosmetic rhinoplasty into its own.... The time seems auspicious ... for all cosmetic surgery to be elevated to its proper dignity, to be popularized and made available ... to those in civil life."--Seymour Oppenheimer

1945 "American surgeons numbered sixty, more than ten times as many as Britain and almost twice as many as the rest of the world combined,"--Elizabeth Haiken.

1950s Plastic surgery discoveries came in rapid succession, derived in pall from rear-area hospitals in Korea. Prominent among developments were internal wiring for facial fractures and rotation flaps for skin deformities.

1960s Negotiations began between Fomon's American Otolaryngologic Society of Plastic Surgery, Goldman's Society of Facial Plastic Surgery, and Cottle's American Rhinologic Society.

1961 The first silicone breast implant was developed.

1963 Richard C. Webster, M.D. met with members of the three nasal societies and described his experience: "For the first time in my life, I met man after man who honestly, without any shame at all, evinced a paramount interest in what I considered my field, cosmetic surgery."

1964 October 18, the American Otolaryngologic Society of Plastic surgery and the Society of Facial Plastic Surgery united to form the American Academy of Facial Plastic and Reconstructive Surgery


* Dolsky, Richard. Cosmetic Surgery in the United States: Its Past and Present. Derm Surg 1998).

* Haiken, Elizabeth. "Venus Envy, A History of Cosmetic Surgery" (The Johns Hopkins University Press, 1997).

* Hait P. Schnur. PL. History of the American Society of Plastic Reconstructive Surgeons, Inc., 1931-1994. Hast Recon Surg 1994; 94: 5A-19A.

* Latteier, Carolyn. "Breasts, The Women's Perspective on an American Obsession" Haworth Press, 1998).

* Yalom, Marilyn. "A History of the Breast," Knopf, 1997.

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