While Donna's right breast was a B cup, her left breast never developed. The casual observer would never have known, as she was a master at camouflaging her flattened chest with special bras. But after awhile, she wanted to have similar-sized breasts, like other women. Her insurance company deemed the operation medically unnecessary, so with the cost coming from her own pocket, she wanted to find a surgeon who would do the job well. Donna turned to Dr. Mark Granick, then practicing in the Philadelphia area. "I felt very comfortable with him. He put me at ease," she says. "Every question and concern I had, he addressed."

The same-day surgery went well for Donna, but she admits that the recovery period was rougher than she anticipated. It would have been much worse, she says, without friends and family to care for her, an ample supply of videos, and lots of ice.

Today, several months after the January 2001 operation, Donna is pleased with the results. She is now an even-sided 36 C cup and happy that "I didn't do it for anyone else but myself."

Julie also had breast augmentation surgery. When she was an A cup, she always wished she were fuller breasted, like her sisters. How her wish came true was partly happenstance. The 39-year-old personal trainer worked at a rehabilitation facility/fitness center and met Dr. Granick there when he made an educational presentation on facelifts. She mentioned that she was interested in learning more about breast implants and shortly after, she had a consultation appointment to talk about what the surgery entailed.

"I told Dr. Granick I wanted to have cleavage, but not look garish," says Julie. "Other than that, I trusted him to select the type of implant and suggest a size that would go well with my body build and height. He has a great, easy going manner."

Julie, too, experienced discomfort following her June 2000 surgery, but she was back to work in one week. And today, she says she would do it all over again. "I've told hundreds of people about how great implants are and have even suggested breast lifts for my sisters," says the personal trainer.

As these women's stories show, the most defining feature of the female body-her breasts-are for some women the most disappointing or embarrassing. From the AAA cup to the overly endowed, many women try to change their appearance by using different styles of bras or taking supplements that claim to alter breast size.

These temporary, often ineffective, and possibly unsafe efforts do little to induce lasting change. Plastic surgery, when performed by an experienced, board-certified surgeon, can provide a woman with the breasts she wants in a safe, supportive, and supervised setting.

And it's not all about vanity. Women with extremely large breasts often have back and neck pain. From a practical standpoint, it's difficult for adult women at both ends of the breast-size spectrum to buy clothes that fit. Even men with unusually large breasts can suffer emotionally.

Where to Start

Before a woman steps into a plastic surgeon's office, she should have realistic expectations about what surgery can do for her. It cannot mend a broken relationship or pave the way to Hollywood stardom. The patient should consider all aspects of the surgery, not just the final result.

"It's a decision that requires maturity and thought," says Dr. Granick, who recently became professor of surgery at the New Jersey Medical School and chief of plastic surgery at University Hospital. "She should understand the consequences of the surgery, know what she is doing, and why. For example, like all mechanical devices, implants wear out over time. A woman who undergoes breast augmentation in her early 20s needs to realize that by the time she is in her 40s, she will need another set of implants."

There are many choices when it comes to plastic surgery of the breast, but none are as important as the selection of the plastic surgeon. The most significant criterion is the surgeon's certification. While there are many self-designated boards, only the American Board of Plastic Surgery is accredited by the American Board of Medical Specialties for plastic surgery of the breast. It's also desirable for the surgeon to be a member of the American Society of Plastic Surgeons, which has standards for physician behavior and ethics, as well as continuing medical education.

Patients need to do their homework and ask a lot of questions. "There are many subspecialties in plastic surgery, so the patient needs to find a surgeon who is experienced in the specific procedure she or he is interested in," says Dr. Granick. "Ask friends and acquaintances who have had cosmetic work what they liked and didn't like about their surgeon. Primary care physicians and nurses often know who has a good reputation, both in terms of surgical skill and dealing with patients."

"Another big question to ask is, 'Can I easily talk to this surgeon?,'" he continues. "Communication is key. If the surgeon is not courteous or tries to pressure you into additional procedures, the best thing to do is get up and walk away."

Breast Implants: Safe or Risky?

Perhaps no other plastic surgery procedure has come under more scrutiny than breast augmentation--specifically, with regard to the safety of breast implants. About 40 years ago, when silicone prostheses for mastectomy patients were developed, manufacturers also used the material for cosmetic breast implants. Problems emerged when some silicone implants hardened, but the biggest blow came during the 1990s: Concerns were raised that women with silicone implants had higher rates of breast cancer and that they caused systemic illnesses such as rheumatoid arthritis. A moratorium was placed by the Food and Drug Administration on silicone implants, except for research.

"Large studies have shown that there is no link between silicone implants and systemic illness or breast cancer," says Dr. Granick. "In fact, there's evidence that women with silicone breast implants had lower rates of breast cancer." Still, routine screening mammography is recommended for women with implants. The technician needs to know if a woman has implants so that different techniques can be used to take X-rays of the breast.

Saline implants have been used for breast augmentation since the 1970s, but in their original design, tended to leak or deflate. Today's variety are greatly improved. Leakage problems are rare, says Dr. Granick, and most manufacturers offer a five-year warranty on saline implants and keep detailed records about them.

Once the safety issue was resolved, the number of breast augmentation surgeries skyrocketed. In 1992, 32,600 procedures were performed. In 1999, the number had risen to 167,000-a 413 percent increase.

Reshaping the Breast

Breast augmentation, breast reduction, and breast lift (mastopexy), while elective procedures, are not taken lightly by the surgical team. Not all women who want them are considered good candidates. It may not be advisable for women with certain breast configurations, poor emotional stability, or a strong family history of breast cancer to have breast augmentation, for example. Women planning to breastfeed should consider postponing breast reduction surgery, which involves moving the areolae and nipples, or breast lifts--as breastfeeding can stretch the breast downward--until after weaning. And pregnancy-whether or not a woman plans to breastfeed-affects the breasts' shape.

Breast augmentation

If there's one significant advantage to saline implants over silicone, it's a small, 1-inch incision. "An incision is generally made either underneath the breast or through the armpit," says Dr. Granick. "The implant is inserted deflated, and then once in place, the saline is added." Most surgeons prefer to place the implant below the breast muscle, rather than breast tissue, for a more natural look.

The surgery, done as a same-day procedure under general anesthesia, is usually routine. However, as with any surgical procedure, there are risks to the operation. Afterward, there may be a loss of nipple sensation or the development of capsular contracture, which is caused by scarring around the implant. Many patients find they are tired and sore for a few days after the surgery, as muscle and tissue heal and the breasts adjust to the implant. Most women resume work and regular activities within a week. About a month after the surgery, the implants have rounded out and the breasts look more natural.

Breast Lift

Some women are happy with the size of the breasts, but not the sagging brought on by aging, significant weight loss, or breastfeeding. A breast lift involves removing extra skin on the lower part of the breast and repositioning the nipples and the areolae; implants can be also be inserted. There are different techniques that can be used, but all are usually done with the patient under general anesthesia. After surgery, the breasts may be slightly sore for a couple of weeks, but most women resume their regular activities-excluding rigorous exercise-within a week.

Breast Reduction

Large, heavy breasts can cause back and neck pain, as well as embarrassment. Bra straps can dig into a woman's shoulders, and she often finds it difficult to find well-fitting clothes. In 1998, about 70,000 women had breast reduction surgery. Sometimes insurance companies will cover this procedure if it is considered medically necessary.

A surgeon can reduce the size of breasts by removing excess fat and tissue and then repositioning the areolae and nipples. This is a same-day surgery, during which the patient is given general anesthesia, and it may take about two weeks until the patient can resume work and other activities.

It's not only women who can be overly developed. Gynecomastia, a benign enlargement of the male breast tissue, is estimated to affect between 40 to 60 percent of men. Usually there is no medical reason for men to have large breasts, although some drugs can allow breasts to overdevelop. In 1999, 9,000 men had surgery to reduce the size of the breasts. A combination of liposuction and directly removing breast tissue is commonly done during this same-day procedure.

The Cost of Beauty

While some insurance companies will cover medically necessary breast reduction surgery, most consider plastic surgery of the breast to be an elective procedure. That leaves the patient to determine how to pay for the surgeon's fee and the hospital bill. The overall cost of breast augmentation is between $5,000-$7,000 and is usually payable in advance.

Donna received a loan from her credit union to pay for her surgery, and there are companies that specialize in lending to plastic surgery patients. The ASPS has a financing affiliate that charges interest based on the risk of the surgery. A low-risk operation would carry a lower interest rate than a high-risk procedure.

For Dr. Granick, the reward of performing plastic surgery of the breast comes from his patients' satisfaction. "Their breasts look more beautiful, their clothes fit better, and their self esteem often improves," he says.

Just ask Donna. "As I was being prepped for surgery and they were drawing lines on my breasts, I began to cry," she says. "I said, 'It's the last time I will have to be embarrassed by looking at my breasts."

For more information about breast augmentation or reduction, please visit the Cosmetic Surgery Center Web site at: www.TheUniversityHospital.com/plastics/ or call (973) 972-8071.