March 27, 2000 (Chantilly, Va.) -- Six months after the birth of her second daughter, Julia was trying on a swimsuit when she looked out the window. "I remember [seeing] all the young women on the beach, and thinking, 'I used to look like that,' " she recalled. "I decided right then and there that I was going to get implants."
It's a decision she now regrets.
The Dulles, Va., woman, who asked that her last name not be used, is contemplating a lawsuit against her surgeon and the company that made her implants: In the five years since her breast augmentation surgery, she has had to have her implants replaced twice.
Last month, she had them removed for good.
The breast tissue surrounding Julia's implants had become so sensitive that she could hardly touch her breasts. "The pain had gotten to be almost unbearable at times," she said. "I had gotten them to boost my self-esteem, but by the time I had them out I decided there was nothing sexy about me."
Women like Julia are watching Washington, D.C., these days following the Food and Drug Administration's (FDA) first formal review of saline implants.
Earlier this month, an FDA advisory panel recommended that two leading brands -- manufactured by McGhan Medical Corp. and Mentor Corp., both of Santa Clara, Calif. -- remain on the market as long as women are fully informed of the risks, including the possibility that their implants may rupture, leak, or cause an infection.
Among the panel's recommendations: that the FDA review the consent forms that women sign prior to surgery, and that implant makers provide more complete information about postsurgical complications such as reoperations to replace leaky or ruptured implants.
The FDA is expected to issue a final decision in mid-May. Most observers expect it to endorse the panel's recommendations.
A Legacy of Worry
Saline implants have been the only option for many women since 1992, when the FDA banned silicone implants based on concerns that they might be causing autoimmune disorders, such as lupus, arthritis, and body aches.
An Institute of Medicine report last year found no link between silicone implants and autoimmune problems; so did a study reported in the New England Journal of Medicine earlier this month. Yet the controversy over silicone has put pressure on the FDA to take a harder look at saline.
At the recent panel hearings, saline implant maker McGhan Medical acknowledged there were at least minor problems among 60% of patients within four years of implantation and among 84% of breast reconstruction patients. Meanwhile, Mentor said its study of 1,680 saline implant recipients found that up to 27% of the implants were removed within three years, mostly due to infections, pain, or leaking.
In a published report, panel member Stephen Li, M.D., of New York's Hospital for Special Surgery, called Mentor's failure rates "alarmingly high" and said, "it's amazing to me it seems to be tolerated as just something you have to live with."
Nevertheless, implant makers and others will likely take the FDA panel's final decision "as a blessing," says Michael Williams, an attorney who has represented women in lawsuits over silicone implants.
"The medical industry likes to use the FDA as a shield. " They believe that if the FDA has OK'd it, then that should be the end of it."
Increasing Attention on Informed Consent
That's not likely.
Legal experts say women will still have grounds to sue if their doctor fails to inform them adequately of the risks involved or if they experience problem that are worse or different than the ones described in a company's product literature.
And depending on the FDA's final decision, doctors and implant makers may well have to provide additional information on specific risks (see Details of the FDA Panel's Hearings).
Since the early 1990s, many plastic surgeons have required women contemplating implant surgery to sign a special consent form; the content can vary from state to state although the American Society for Aesthetic Plastic Surgery (ASAPS) has published guidelines (see A Guideline to Risks).
Many doctors make it a point to emphasize the downside: "All I do is talk about complications," says Sherwood Baxt, a New Jersey plastic surgeon.
But Diana Zuckerman, Executive Director of the Washington-based National Center for Policy Research for Women and Families, says some doctors aren't so clear. "Many women will tell you that their doctors told them their implants were perfectly safe and nobody told them about the failure rate or that implants could break," she said, adding that consent forms often read like a "mortgage application."
"Everybody knows that there is a huge gap between what a written document says and what the doctor tells a patient," says Zuckerman. "If the doctor says, 'Don't worry, my patients are all very happy,' few women will get up and leave."
Calls for Change and Caution
Mark Jewell, a California plastic surgeon who represented ASAPS at the hearings, called for a single consent form to be used nationwide. "We need something that is a plain English explanation for whatever the problems are that could occur," he said.
Ultimately, however, it's up to a woman to ask questions. Julia, for example, signed a consent form but now wishes she had read it more closely.
"My advice to other women considering implants is to learn everything about it," she says, "or don't do it."
Michael D. Towle is based in Chantilly, Va., and writes regularly on health and legal issues for WebMD.