The Next Breast Thing

Build a better fake boob, and women will beat a path to your door, along with the occasional lawsuit

They are known by many names, some of which are endearing, silly or downright demeaning, none of which adequately describes our cultural obsession with them. We call them boobs (too whimsical), mammaries (too medical), teats (too Shakespearean), honkers (too Man Show), jugs (too Pamela Anderson), melons (too horticultural), ta tas (too aristocratic), bosoms (too PC) and breasts (too KFC).

Not every culture is as enamored of the big bust (too grandmotherly) as we are. For West African men, the thigh is the object of desire; the Japanese fixate on the back of a woman's neck, while Chinese men had an ages-old love affair with feet, the smaller the better. Our particular cultural titillation with large chests (too gender-neutral) traces its roots to the waning days of World War II when fighting men longed for home and hearth. Certainly there was something nurturing and safe at the thought of being cradled in the bosoms of the women who kept the home fires burning--not to mention the sight of Betty Grable in a tight sweater or, later, Marilyn Monroe in just about anything, particularly Playboy, which elevated the breast to celebrity status, bringing it into the modern visual age.

All of which illustrates our cultural conflict with big knockers (too Home Improvement). On the one hand, they offer mother's milk. On the other, they have been totally sexualized by our culture, seen as the first thing that walks into a room, a rack that needs to be checked out, a partially clad Victoria's secret that teases with coyness and arouses with curiosity.

Dallas attorney Marc Stanley has filed a class-action lawsuit against McGhan Medical Corp. alleging the implant manufacturer deceived his clients with its false advertising campaign.
Mark Graham
Dallas attorney Marc Stanley has filed a class-action lawsuit against McGhan Medical Corp. alleging the implant manufacturer deceived his clients with its false advertising campaign.
Hamas' X-ray studies challenged the notion that anatomic implants offer a more natural shape by demonstrating that gravity has its way with both implants once inside the body, rendering the implants virtually identical.
Courtesy of Dr. Robert Hamas
Hamas' X-ray studies challenged the notion that anatomic implants offer a more natural shape by demonstrating that gravity has its way with both implants once inside the body, rendering the implants virtually identical.
That anatomic implants (right) offer a more natural shape seems obvious when juxtaposed with a round implant (left).
www.implantinfo.com
That anatomic implants (right) offer a more natural shape seems obvious when juxtaposed with a round implant (left).
Dallas plastic surgeon Dr. Robert Hamas contends that once inside the body there is no anatomical difference between round and anatomic implants.
Mark Graham
Dallas plastic surgeon Dr. Robert Hamas contends that once inside the body there is no anatomical difference between round and anatomic implants.
Joyce Hesselberth

And for many men, the bigger the better. "So many bottle-fed babies in the '50s and '60s having been denied access to mother's breast as children may make adult men more interested in women's breasts," says Texas A&M anthropology professor Katherine Dettwyler, who co-edited Beauty and the Breast: The Cultural Context of Breastfeeding in the United States.

Of course, it's not just men doing the ogling. Breasts also hold great psychological significance for women. They mark life's passage from childhood to womanhood to motherhood. They are decorative ornaments, sexual attractants, weapons of power and, sadly, a way to get ahead in the workplace--breasts for success. Women judge women on how they look, how big their hair, how close their cleavage. Breasts can take on a physical and emotional life all their own: They are perky and buoyant; they can excite and delight; they sag and disappoint.

If they are a source of smallness or anguish, they can be enhanced surgically--subjected to the cutthroat world of cosmetic surgery (a subspecialty of plastic surgery), which has staged a comeback from the hit it took when the Food and Drug Administration restricted silicone gel-filled implants in 1992. In 2000, board-certified plastic surgeons of the American Society of Plastic Surgeons reported that they performed more than 212,000 breast augmentations, up from 167,000 in 1999. Of course, few towns are more cutthroat than Dallas, a place where the confluence of image, money and climate cause women to flock to self-promoting physicians who tout state-of-the-art boob jobs at competitive prices. Dallas is also the city where two plastic surgeons and one lawsuit are waging a somewhat ironic battle over what constitutes the most natural fake breast.

"Angie Jameson" is a plaintiff in that lawsuit, though she refuses to allow her true name to be used in this story. A divorced business executive, she had never longed to have her breasts augmented. She fashioned herself more the athletic type, a smallish, petite blonde who stayed shapely by staying in shape. Yet after nursing a child for nine months, she had lost some of the "naturalness" in her breasts, and she wanted it back, "plus a little more," she frankly admits. In 1999, as a 40th birthday present to herself, she decided to investigate the possibilities. "I really wanted to fight the aging process," she says. "If I was going to do it, I didn't want that buxom Dallas look."

A close friend who had her breasts augmented by Dr. John Tebbetts said it changed her life. Jameson went to see him and found him confident, countrified and cool. His head was shaven; his ear pierced--not the brainy, lab-coat countenance many doctors tend to reflect. He assuaged her fears about the risks involved, though pointing out the many complications that were still a possibility. Then he told her about his latest invention, a shaped saline-filled implant. Jameson says he claimed that it "was more anatomically correct than the round saline implant, more natural." He held both implants in his hands: his anatomic, with its teardrop shape, and the round, which would come up rounder and higher on the chest--or so he said. "I didn't want a big cleavage," she says. "I knew it was more expensive, but what difference does $500 make when you are paying $6,000?"

Although Tebbetts claims otherwise, Jameson says he clearly pushed the anatomic implant over the round and never mentioned that he might have an economic incentive for doing so. As the co-designer of the anatomic, he had "a financial arrangement" with McGhan Medical Corp., which manufactures the implant. Not that his arrangement would compromise his medical judgment, he says. Its disclosure, however, might have made a difference to Jameson, who chose "the natural one," she says, as did thousands of women who saw McGhan's national advertising blitz for its "perfectly natural" implants in Glamourand Vogue.Others read about the benefits of anatomic implants in Tebbetts' book The Best Breast,which has been criticized by several plastic surgeons as a crass marketing gimmick.

One of them is Dr. Robert Hamas, a local physician who has conducted his own studies, which he contends prove that once they are placed inside the body there is no physical difference between round and anatomic implants. His research has encouraged Dallas attorney Marc Stanley to file a class-action lawsuit against McGhan on behalf of Jameson and several hundred thousand similarly implanted women because of the company's allegedly false advertising. It helped inform the FDA when the agency insisted that McGhan cease its advertising campaign because it could not prove its claims of naturalness. What's more, it has incited a war of recrimination between Tebbetts and Hamas that has become decidedly personal, though neither man is a party to the lawsuit.

"You're dealing with two strong-willed Texans competing in a hotbed of plastic surgery," says respected Arizona plastic surgeon Boyd Burkhardt, who has served as an adviser to the FDA on implant-related issues. "You can't completely divorce their personalities from their science."


John Tebbetts wasn't the first plastic surgeon seeking to build a better breast. Early attempts at enhancement by doctors began around the turn of the century, first with the direct injection of paraffin into the breast, then with fat-tissue transplants and later with the insertion of the plastic sponge. Liquid silicone developed a grassroots following after World War II, injected into the breast by Japanese prostitutes looking for repeat business from American servicemen. The practice caught on with Las Vegas showgirls, strippers and unconventional doctors who were also looking for repeat business and were willing to risk silicone's possible side effects: infection, disfigurement and migration into the internal organs.

If only there were a way to contain silicone within a bag or shell, then the chance of it leaking into the rest of the body would be minimized. In the early '60s, Houston plastic surgeons Thomas Cronin and Frank Gerow worked with the Dow Corning Corp. to develop a rubbery silicone outer shell, which was filled with a gel-like silicone liquid. "Their first implants were actually teardrop-shaped," says Houston plastic surgeon Thomas Biggs, who did his residency under Cronin and later became his partner. "Then a New York surgeon told us that the breast is not teardrop, it's actually round. So we made them round."

In 1968, Dr. Henry Jenny, a California plastic surgeon, designed the first saline implant, which was little more than an inflated water balloon. But doctors and patients found saline too squishy and unnatural, preferring the softer, more breastlike feel of silicone gel. The '70s and '80s saw demand for silicone implants soar, as plastic surgeons, implant manufacturers and the media promoted implants as a quick fix for low self-esteem, a safe way to attain a quality of life women might never realize if they remained forever flat-chested.

"Plastic surgeons co-opted the language of psychology," says Lithe Sebesta, co-author of The Breast Book, which will be released in May. "They have taken words like inferiority complex and applied it to small-breasted women, even calling it a disease--micromastia--which basically means small-breasted women who have a complex about it." In a 1982 petition before the FDA, the American Association of Plastic and Reconstructive Surgeons (now the American Society of Plastic Surgeons, ASPS) maintained that small breasts "are really a disease, which in most patients results in feelings of inadequacy, lack of self-confidence...and a lack of well-being due to a lack of self-perceived femininity." They offered a cure for this disease: "the enlargement of the underdeveloped breast."

It would seem that feminists would rail against the implants, seeing them as an implement of male oppression, much like they did the bra and fashion trends in general. And they did, for a time. But with reconstructive surgery offering to make breast cancer survivors whole again, and the '60s demand for social equality giving way to the '80s demand for personal empowerment, any feminist outrage toward implants seemed muted at best, particularly since more and more women came away from their breast enlargements with an enhanced feeling of self-worth. The ASPS claims that more than 90 percent of the women who undergo breast augmentation are satisfied customers. "There are legitimate connections between physical image and psychological image," says author Sebesta. "Although plastic surgeons have pushed this connection too hard."

"This operation makes happy ladies," Dr. Biggs says. "It's an operation that beautifully fits the average American woman."

Texas women seem particularly charmed by its cosmetic benefits. Not only does this state rank high in the number of cosmetic surgeries performed (along with Florida and California), but its women request larger breasts more frequently than their East Coast counterparts. "For a region to be a cosmetic capital, it has to have money, because it's an elective surgery and you are paying out of pocket," explains California psychologist Barbara Nash, author of What Your Doctor Didn't Tell You About Plastic Surgery. "The culture probably has to have a large investment in image and body appearance, and a warm climate where you can show off that appearance."

It also helps that Dallas has a deep pool of talented plastic surgeons who are adept at performing what amounts to a fairly simple procedure. After the patient receives a general anesthetic, the surgeon makes an incision in one of three places: in the fold of the breast, in the armpit, around the areola. To position the implant, he creates a pocket, either over the muscle separating the breast tissue from the ribs or partially behind the muscle. Either way, the surgeon centers the implant behind the nipple and then inflates the implant with saline. Silicone-gel implants are prefilled.

"You make a space, make certain there is no bleeding, insert the implant and close it up," says Dallas plastic surgeon Edward Melmed. "It's not rocket science."

But it's not without its complications. The most common is known as capsular contracture--the capsule of scar tissue that forms around the implant as the body's natural defense to the foreign object invading it. In serious cases, the scarring hardens and rounds the breast, creating a grapefruit-in-the-sock effect--the fake-looking, never-at-rest Baywatchboob. The scarring can also hurt like hell, lead to shell rupture, gel leakage and more operations. But some plastic surgeons have suggested that it shouldn't even be labeled a complication, minimizing its sting by calling it a side effect, an expected result, a consequence. Other possible consequences of augmentation include rupture from trauma to the body, infection, disfigurement, hemorrhaging and reduction in nipple sensation.

For nearly 30 years, marketing leaped ahead of science, and many plastic surgeons undersold or misunderstood these risks. Not until the late '80s did research indicate that silicone might not be the safe substance it had been promoted to be. Thousands of silicone-implanted women and their lawyers complained about autoimmune, neurological and muscular-skeletal disorders. Ralph Nader's public advocacy group warned that silicone implants might cause cancer. By 1990, Congress heard these complaints and decided to investigate.

The congressional oversight committee that had jurisdiction over the FDA, which had neither regulated nor approved silicone gel implants, learned that implant manufacturers had never tested their products on humans. "It was only assumed implants were safe because the manufacturers had said they were safe," says Dr. Diana Zuckerman, who worked on the committee and now heads the National Center for Policy Research for Women & Families. "We were given internal memos from Dow Corning that showed their own scientists believed implants leaked and had concerns about their safety."

Mounting public pressure was forcing the FDA to take some sort of regulatory action, though the agency seemed conflicted about what course to take. Weighing the risks vs. benefits of plastic surgery was no easy matter, particularly after plastic surgeons encouraged their patients, many of them who had undergone breast reconstruction following mastectomies, to lobby the FDA on their behalf. Doctors also enlisted a public relations firm to design a campaign couched in the language of the pro-choice movement, Zuckerman says. "Women were told they had a right to choose for themselves. But how could they make a choice when there were no studies to inform them?"

Dow Corning contended that any link between its implants and disease was purely coincidental. It held fast to this position throughout its bankruptcy reorganization, which was largely brought on by the 177,000 women who claimed otherwise. Ironically, the company would be vindicated by a 1999 Institute of Medicine study, which reviewed all the research that had come before it and found no causal connection between implants and major disease.

In April 1992, however, the FDA finally placed the burden of safety where it belonged: on implant manufacturers. Because they couldn't meet that burden, the agency banned silicone gel implants for first-time augmentation patients. Women who were undergoing reoperations or breast reconstruction could use silicone gel if the surgery was part of a government-approved clinical trial. Despite their silicone outer shell, saline-filled implants were not restricted, partly because it was believed that any damage caused by salt water migrating upon rupture would be insignificant.

After one FDA hearing, Dr. John Tebbetts, a Dallas plastic surgeon, grabbed the national media spotlight, briefly appearing on ABC's World News Tonight.While contending the FDA should not ban silicone implants because their saline substitutes do not look as natural, he added, "You have committed patients to a breast that is far from normal, compared to a gel-filled implant."

What he didn't say was that he had already begun his quest for an implant that would present a more natural-looking breast: the anatomic.


In Tebbetts' Oak Lawn medical offices, subtle suggestions are at work: the mauve and lavender walls that soothe the anxious and ease the uncertain; the sculptures and paintings of swans that hint at a transformation from ugly duckling; copies of The Best Breast, which intimate that its author is the best person to deliver the best breast.

And then enters Tebbetts, who instantly diffuses this air of subtlety with his blustery, East Texas country-boy demeanor. At 55, he's a likable cuss, a no-nonsense, tough-talking, opinionated man who tends to dominate the conversation. His hunger to be challenged is evident from the array of photos in his inner office that show him dirt-biking and tarpon-fishing. He inspires strong feelings from his colleagues, who describe him with a mix of guarded admiration and disdain. They find him a bright, innovative surgeon who aggressively promotes his own innovations: "He is as skillful on the breast as anyone in the world." "He's the Jesse Ventura of plastic surgery." "John is widely regarded as being very enthusiastic about his own ideas."

And Tebbetts is full of big ideas. In addition to designing new implants, he has developed new surgical tools and breast-augmentation procedures that minimize tissue damage and hasten recovery. Ninety-five percent of his implant patients, he says, are back to normal activity within 24 hours. He is largely credited as the first plastic surgeon to publicly condemn the fashion of bigger-is-better by advising patients and colleagues that the too-large breast will ultimately sag, whether augmented or not. He is a strong advocate for patient education, insisting his patients read his book before they consult with him. His résumé lists more than 150 scientific publications and presentations that have published his work, though he is criticized for being overly verbose and unnecessarily complex in his writings.

He claims it was never his goal to build a more natural-looking breast. "That's a total misconception. I had been making perfectly natural breasts since 1979 [the year he entered private practice]."

When McGhan Medical Corp. approached him about designing a new implant in the early '90s, he had already been working with another implant manufacturer, researching whether implant rupture might be caused by folds and wrinkling in the implant's shell. After that manufacturer went out of business, he continued his work with McGhan. "Every bioengineer at an implant manufacturer told me that shell folding was one of the main reasons for shell failure," he says. "So how do you make the shell not fold? You put in more fill [either saline or silicone gel]." And the more you put in, the firmer it gets, the less chance the upper shell will fold or wrinkle when its fill decreases as the lower shell inevitably stretches and sags over time--or so surmised Tebbetts. With a fuller, firmer implant, there would be less chance of leaks, rupture and reoperation, all problems that the FDA had been concerned about.

He experimented with round saline-filled implants, he says, but the more they were filled "the more globular the breasts looked, like a softball." That's when he hit upon the idea of changing the shell's shape, "tapering the top of the shell so we could still put in enough [fill], but not have that excessive upper bulge," he says. "And that's how we did it." Tebbetts soft-pedals the aesthetics of his implant design, instead choosing to tout its safety features. "It's not an issue of the most natural breast. It's the most natural breast in conjunction with minimal shell folding."

McGhan, however, didn't see it the same way, at least not in its national ad campaign. When it brought the anatomic to market in the mid-'90s, it didn't promote the implant's longer shell life or wrinkle minimization to the readers of Glamouror Vogue. Instead, it introduced the Style 468 saline-filled implants as "Perfectly Natural...an anatomic design that reflects the shape of the natural breast." The manufacturer appeared to be playing off fears of women worried about buying a Baywatch boob, those that looked too round, high and obviously fake. "So, we designed our anatomical implant to be more like a woman's breast, "with a gentle slope and a more voluptuous, natural shape," one print advertisement claimed. Illustrations showing grapefruit vs. teardrop shapes accompanied the copy, which hailed the Style 468 as "revolutionary."

Women weren't the campaign's only targets. Plastic surgeons were invited to participate in McGhan's "Aesthetic Marketing Alliance" and become one of its "preferred surgeons." To attain this status, a doctor was obliged to pay an ongoing fee and implant "eight pair of Style 468" anatomicals. In exchange, the doctor would receive referrals and advertising support generated by McGhan's national ad campaign and Web site. In 1998, more than 1,000 physicians joined the Aesthetic Marketing Alliance, and the campaign generated more than 100,000 plastic surgeon inquiries by prospective patients. It was in every way a success, both for McGhan and Tebbetts, who acknowledges he had a "financial arrangement" with McGhan dating to 1993.

Many plastic surgeons had strong ethical reservations about the marketing alliance. "If it wasn't unethical, it was close to it," says veteran Dallas plastic surgeon Harlan Pollock, a regional spokesman for the ASPS. "Physicians must use their best medical judgment when advising a patient. A financial relationship with a manufacturer that requires you to use its implants might cloud that judgment." Doug Free, the general counsel for the California Society of Plastic Surgeons, expressed similar reservations. "Any form of consideration in exchange for patient referrals is unethical and illegal under California law." The ASPS voiced its own objections, and McGhan modified the program somewhat. But it ultimately died its own death, says one McGhan official, because it was too expensive for surgeons. And most preferred to use round implants, anyway, believing they did a comparable job at a lower price.

In May 2000, the FDA approved the safety of saline implants over the objections of women's advocacy groups that contended the agency reached the wrong result, failing to take fully into account their high complication rates. (More than 40 percent of patients receiving saline-filled implants had at least one complication within the first three years after surgery.) As part of the same approval process, the FDA prohibited implant manufacturers from marketing their shaped implants as "more anatomical," natural or having "better anatomical results."

"The burden of proof falls on the person who wants to make a positive statement that his product is better than another," explains Dr. Boyd Burkhardt, who served as a member of the FDA advisory panel that recommended the ban. "McGhan and Tebbetts had no proof. They couldn't pull it out of thin air."

The FDA had no objections, however, if manufacturers sought to promote their implants as "shaped" or "contoured." The labeling ban dealt another blow to the Style 468 anatomical, though it wouldn't be the last.


When Angie Jameson went to Dr. Tebbetts, she didn't know the difference between an anatomic implant and a round one. "I just didn't want my breasts entering the room before I did," she says. Tebbetts told her he had invented the anatomic, claimed it was state of the art. "He said when you stand up, it falls like a natural breast, " she recalls. "When you stand up with the round, it doesn't teardrop. It stays round."

Tebbetts says he did not recommend any specific type of implant. "Like all our patients, she was offered a choice of any type of implant she desired, by any manufacturer she desired." She was also given information about shell folding issues, he says, "and she personally selected the implant she received."

Not surprisingly, she chose the anatomic, wanting it placed over the muscle rather than under (quicker recovery), wanting it textured rather than smooth (less chance of implant movement). Things went so well with her surgery, Tebbetts asked her to speak with a reticent patient and allay her concerns. She would later be glad she refused.

For the next three weeks, she felt fine, believing what she had been told, that she had a more natural look. Then one morning while in bed, she reached for a glass of water, heard a pop inside her chest and felt a sharp, shooting pain. She phoned Tebbetts' office and learned he was out of town. His staff thought she was hemorrhaging--a risk that had nothing to do with the shape of the implant and one that Tebbetts now says "was an exceedingly unusual occurrence" that might have been caused by "something other than surgery." Immediately her chest swelled and she called an ambulance. At Baylor Hospital, another doctor on call for Tebbetts performed a second surgery and stopped the bleeding.

By the time she saw Tebbetts, she was quite emotional, demanding he pay for the second surgery, which he did. She found him overly hurried and uncomfortable with her complaints. He quickly brought in his "patient educator"--his wife--who calmed her down. But her complications didn't end there. The upper portion of her left breast had grown hard and sore because of capsular contracture, which might have been caused or worsened by the hemorrhaging. But she had no intention of returning to Tebbetts--too unmannerly, she says--and she made an appointment with Dallas plastic surgeon Robert Hamas.

Hamas and Tebbetts had entered private practice in the same year, working as young associates in the same Dallas office. At least one plastic surgeon speculates that their early relationship might be the source of professional jealousy between them, although Hamas denies that's the case. Jameson knew about Hamas from a girlfriend who had come away from his scalpel with remarkably large breasts, which is why she didn't use him in the first place. Hamas recommended that Jameson undergo a second surgery to clear away her scar tissue, but she refused, unwilling to let anyone else cut her. After Hamas learned her implants were anatomic, she agreed to let him X-ray her, both standing up and lying down. Then he compared her X-rays with those of a woman with round implants. "I could see there was no anatomical difference between round and teardrop," she says. "And I wanted my money back."

Hamas told her about the research he had conducted, supposedly debunking the anatomical differences between round and teardrop implants. After X-raying 14 round implant patients and 12 anatomic, he concluded that while an anatomic implant might look different outside the body, there was essentially no difference between the two once placed inside the body. When a woman is standing upright, gravity causes either implant to assume a teardrop shape. And in a recumbent position, Hamas claims, the round implant behaves more anatomically than the anatomic, spreading out more uniformly like a natural breast.

In May 1999, Hamas presented his findings during the American Society for Aesthetic Plastic Surgeons meeting in Dallas and received a standing ovation, an unusual response at a medical forum. Hamas believes he tapped into something that had been bothering many surgeons: the manipulation they felt by McGhan's advertising campaign. "It was extremely well-crafted," he says. "Patients would walk in with the ad in their hands and say, 'I want the natural one.' Well, then, who's going to give them the unnatural one?"

Despite their patients' wishes, some doctors resisted using anatomic implants, convinced they were no more than a pricey marketing ploy. "The body dictates the shape of the implant, not the implant the shape of the body," says Dr. Melmed. "I could probably put a square implant in there and it would be the same."

What seemed disingenuous about the McGhan campaign was that it appeared to lay the problem of bulging augmented breasts squarely on round implants. But the globular Baywatchbreast is just as likely the result of capsular contracture, a natural bodily reaction beyond the surgeon's control. Dr. Tebbetts himself believes there are more than 50 factors that influence the shape of the breast after augmentation; so why all the fuss over just one of them--the shape of an implant?

McGhan, however, didn't take Hamas' presentation lightly. In June 1999, the company sent a letter to all those doctors who attended the Dallas meeting, questioning the scientific soundness of Hamas' conclusions. Undaunted, Hamas conducted a second study partly to defend his first, but that didn't stop Tebbetts from registering his own objections in a respected plastic surgery journal. He accused Hamas of "ignoring and omitting data," of experimenting on humans without proper guidelines or informed consent, of not using a "qualified radiologist" and having "no personal clinical experience" with anatomic saline implants.

The same year Hamas conducted his first study, Tebbetts co-authored and released his book The Best Breast, which handsomely illustrates and extensively details the round vs. anatomic dilemma facing patients. According to its introduction, the book is aimed at "discriminating women" so they might base their augmentation "decisions on facts and knowledge rather than hype and fluff." Although it does provide valuable information--even cautions women that "there is no single type of implant that is best for every patient"--it often reads like a sales pitch for anatomic implants, indoctrinating patients as much as educating them. What is presented as hard scientific fact--if a surgeon fills a round implant to a manufacturer's recommendation, the implant shell will fold and collapse--is based on Tebbetts' clinical opinion.

Tebbetts says he now has more than opinion on his side. In three separate studies he has recently published in the Journal of Plastic and Reconstructive Surgery, Tebbetts followed 1,662 patients for up to seven years who had used the McGhan Style 468 and found there were extremely low complication and shell failure rates--far fewer than comparable studies published by manufacturers on round implants. "The difference is huge," he says.

But Hamas finds Tebbetts' science wanting--too many unaccounted for variables and questionable research that only examines a McGhan product in which Tebbetts has a financial stake. Besides, he believes the research is a distraction from the real issues of misrepresentation and false advertising. The problem remains Tebbetts' book, he says, whose opinions and illustrations about naturalness amount to little more than promotional pandering for the anatomic:

"Do you want a result that looks more natural than excessively round and bulging in the upper breast?" asks the book rhetorically. "Do you want an adequately filled implant with minimal risk of shell folding and risk of shell rupture?" It then tells those who have answered these and three other questions affirmatively: "You'll almost certainly want an anatomic implant," which the book later claims is "ideal for the majority of first-time augmentation patients." Because he requires each of his patients to read the book, it's not surprising that Tebbetts has performed more "augmentations with anatomic breast implants that any other surgeon worldwide," according to Tebbetts' own Web site.

One Dallas plastic surgeon (Hamas denies it was him) filed a complaint against the book with the ethics committee of the American Society of Plastic Surgeons, claiming in essence that The Best Breast made it impossible for women to discriminate between medical fact and opinion. That complaint, however, was resolved in Tebbetts' favor. "Does everyone agree with what's in the book? Obviously not," Tebbetts says. "But it's been reviewed by the ethics committee for the society. It's our opinion; it's our best opinion based on what we know right now."

As their controversy gained momentum, it was hard to tell where science stopped and ego started. In January 2001, Hamas shared the same podium with Tebbetts before about 250 plastic surgeons at a symposium in Atlanta. During his speech, Hamas, who is generally quiet and unassuming, not only took issue with many of the illustrations and "opinions" in The Best Breast, he was downright provocative about it: "Could [the illustrations] deceive or mislead a woman about round implants? Would they make her choose an anatomic implant? McGhan was forced to do the right thing. They withdrew the anatomical implants ads and claims...Now what about The Best Breast?" he asked. Should the book be corrected? Withdrawn? Hamas challenged Tebbetts to do the "right thing."

And Tebbetts challenged Hamas to a fight. "He said this is not the forum for personal assaults," one doctor recalls. "So, we should go out behind the woodshed and just settle it there."

Cooler heads prevailed. Sort of.

On May 22, Tebbetts filed a complaint with the FDA, questioning the ethics and protocol of Hamas' original X-ray study and suggesting it might have violated federal mammography regulations. Tebbetts had raised similar allegations--lack of informed consent procedures, lack of anyone authorizing the study, the lack of a qualified radiologist--in his previous comments to the medical journal. The FDA found no federal violations and forwarded the complaint to the Texas Department of Health, which conducted its own investigation and also issued no violations. During Hamas' interview with the health inspector, he contended that the real motivation behind the Tebbetts complaint was the attacks he had leveled against The Best Breast for being scientifically insupportable. On December 6, the health department forwarded a copy of its investigation to the Texas State Board of Medical Examiners "for possible action" regarding the "unethical behavior of the complaining physician [Tebbetts] with reference to the advertising claims" related to "breast implants used by that physician."

Even if the Texas medical board refuses to examine the ethical dilemma posed by anatomic and round implants, that won't settle the issue. It's more likely to be resolved in California, where a class-action lawsuit alleging that McGhan deceived Angie Jameson and thousands of similarly implanted women is working its way through state court. Dallas attorney Marc Stanley represents the plaintiffs, both current and prospective. "Our issue is a simple one," he says. "The company sold 100,000 to 200,000 sets of its shaped implants based on the false representation that they were more natural, more anatomically correct, and women paid up to $500 more a set. That's deceptive business practice, and they should give the money back."

Not surprisingly, McGhan has no intention of doing so, raising 25 defenses to the lawsuit and alleging, among other things, that the plaintiff-patients relied on the "learned" judgment of their doctors to make medical decisions--not some national ad campaign. "We think the lawsuit is entirely without merit, and we intend to defend ourselves vigorously," says attorney David Bamberger, general counsel for the Inamed Corp. (McGhan is a division of Inamed). "There are hundreds of surgeons who continue to use shaped implants and get excellent results."

Although Tebbetts has not been sued, both he and Hamas can be expected to continue their war if called as expert witnesses in the lawsuit. And while Hamas may have science on his side, Tebbetts has Tebbetts. No one can argue his case more forcefully; no one has more enthusiasm for his cause. Does he believe what he says? Absolutely. Can he prove what he says? His recently published studies support his claims, he says, at least regarding shell failure. So what if the majority of plastic surgeons want to content themselves with three-decades-old technology, harming the market, he says, for anatomic implants just to save a few bucks? His 23 years of clinical experience have taught him the medical benefits of the anatomic. He knows what works and what doesn't.

After listening to his arguments, you will leave his office thoroughly convinced that he is eradicating any lingering blemish on the plastic surgery profession through his medical breakthroughs, supreme surgical skill and ethical treatment of his patients. He will have you believing that his invention not only gets results that look more natural, but also is safer and more effective, minimizing risks, ruptures and reoperations. You will be persuaded that the anatomic implant is the next best thing to real breasts and wonder if you should get the wife a pair while the supply lasts.

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