Buying and Selling Breasts: Cosmetic Surgery,Beauty Treatments and Risk

Introduction

The market for cosmetic surgery has grown considerably in the last ten years. In the UK, the British Association of Aesthetic Plastic Surgeons (BAAPS) estimate it to be worth about £900 million per year, and the number of surgical procedures in 2010 showed a slow but steady rise of 5 per cent from 2009 to a total of 38, 274 (BAAPS, 2011). Within this, breast augmentation, commonly known as the ‘boob job’, is one of the biggest sectors in the industry (estimated to make up a quarter of the invasive cosmetic procedures, Mintel, 2010). As cosmetic surgery has become more affordable, individuals are financing surgery by taking out small personal loans or saving for a relatively short period of time. Once the province of the rich and famous, access to elective cosmetic surgery has been increasingly ‘democratized’ (Edmonds, 2007). Parallel to this has been a process of ‘normalization’, with TV programmes and magazine articles increasingly presenting aesthetic surgery as an everyday phenomenon and a route to happiness (Heyes, 2007; Tait, 2007). Recent market research suggests that the proportion of young people who would consider having cosmetic surgery has risen sharply, reporting that young people are now less accepting of bodily ‘faults’ and that 35% of women would have breast implants if they could afford to do so (Mintel, 2010).

Women's demand for cosmetic surgery has attracted a certain amount of attention from feminist researchers and theorists over the past twenty years, and questions about women's agency as consumers in this market, and whether or not those who pay for surgery are mere victims of a patriarchal beauty myth, have been fiercely debated (eg, Bordo, 1997; Davis, 1995; Fraser, 2003; Haiken, 1997; Morgan, 1991). More recently, there have been calls for more nuanced analyses of cosmetic surgery, and the relationships between body modification, social identity and the cultural meanings of cosmetic interventions have become a focus of attention (Gimlin, 2005; Doyle and Roen, 2008; Jones, 2008).

Women's participation in and experience of breast reconstruction surgery has also been examined (Rowsella et al., 2000) and Naugler (2009) has explored distinctions between the medical discourse surrounding elective cosmetic and reconstructive breast surgery, arguing that this difference is embedded in perceptions of the procedures as either performed on ‘normal’ bodies for aesthetic reasons, or on ‘abnormal’ bodies for health reasons. Such work also highlights the ways in which factors such as class, ethnicity and age shape concepts of health, and in particular, how gender is embedded in medical discourses and understandings of health which reflect cultural ideas about the masculine or feminine body (Moore, 2010; Lupton, 2003).

There is also growing interest in cosmetic surgery as a market (Holliday and Cairnie, 2007; Edmonds, 2007), and here theoretical analysis is complicated by the fact that cosmetic surgery industry straddles two areas of social activity (that of medicine, and that of beauty and fashion) that are not only socially imagined in very different ways, but that have also historically constituted largely separate fields of sociological enquiry. Though both may be sites of consumption, the moral and ethical responsibilities of service-providers, and indeed of consumers, are not typically regarded in the same way. And yet as Warde (1994) observes, making consumption choices can be risky, and this is especially significant for medical consumers, who, because constructed as ‘consumers’, become responsible for managing risk and their own well being (Petersen and Wilkinson, 2008). This was well illustrated by the recent Poly Implant Prothèse (PIP) implant scandal, which highlighted not only some of the risks associated with having breast implants (Horton, 2012), but also the hard moral boundaries drawn between the irresponsible and so stigmatized consumer who bought new breasts to satisfy mere vanity, and the true victim who had accepted breast implants on the basis of medical advice.

Cosmetic surgeons have long proclaimed themselves to be both medical practitioners and practitioners of the art of beauty (Haiken, 1997). The expansion of the cosmetic surgery industry might appear to reflect a form of ‘medicalization’ (Riessman, 2003) in which medical professionals use their power to define certain bodies as medical problems. Haiken (1997: 299) argues that plastic surgeons ‘have not created the process of medicalisation, but they have contributed to it by inventing new names for a growing number of deformities’ including ‘bat wing deformity’, ‘spare tire deformity’, and so on. Yet it could also be argued that the expansion of the cosmetic surgery industry reflects and contributes to the ‘radical extension of the scope and authority of the market’ that has taken place over the past three decades (Soron and Laxer, 2006: 28).

Indeed, such surgery has now become so profoundly and explicitly com-modified that the ex-president of BAAPS, Nigel Mercer, compared the growth of the industry to a modern gold-rush founded on human vanity and the search for eternal youth, noting that ‘today's prospectors are surgeons, not miners, and the lives they risk are not their own but those of their mostly female clients, lured with impossible promises of anatomical perfection’ (2009). He observed that ‘We have reached a stage where public expectation, driven by media hype and, dare one say, professional greed, has brought us to a “perfect storm” in the cosmetic surgical market’ (2009).

The aim of this paper is to examine how this perfect storm looks from the vantage point of potential consumers of cosmetic surgery. Drawing on research with a group of young women in the UK, and in line with Woodward's (2006: 236) more general call to explore how consumption anxieties ‘are manifested and managed – or performed – by individuals within specific social and consumption settings’, it looks at how they make sense of the tension between cosmetic surgery as a medical procedure and cosmetic surgery as a beauty treatment. These narratives are then compared with the ways in which breast augmentation surgery is sold to them by the companies and medical professionals involved.

The research

The research draws on ethnographic data and qualitative interviews with a single friendship group of young, white, heterosexual, working-class women aged between 20 and 28 in a town in the Midlands. It has involved multiple unstructured interviews with four key informants from the friendship group (two of whom have not had surgery); semi-structured one-off interviews with 9 out of the 18 young women who have had cosmetic surgery; three interviews with young women who have not yet had surgery but want to; three with young women who do not want to have surgery; and two interviews with parents of young women in the group who have had surgery. All interviews were recorded and transcribed. I have also accompanied one member of the group (Tanya) to her pre-surgery consultation (these consultations are part of the marketing package for breast augmentation surgery), and have attended open days promoting cosmetic surgery at local clinics. I have also gathered background data from questionnaires filled in by the members of the group. Finally, I have gathered and analysed advertisements and other marketing materials produced by cosmetic surgery clinics in the UK and Belgium where the young women in my study had surgery.

The research started in 2009 and is ongoing. I am tracking the developments within the group over time. This year, for example, one participant who wanted surgery has had it, one has developed capsular contraction and one has just announced her pregnancy. I am interested in how these changes over time impact on their desire for breast implants, or their feelings about having had surgery.

All the women in this friendship network have known each other for eight years or more. They are either related (sisters and cousins), old school friends, or they met socially as teenagers and have remained friends. Three have young children and are co-habiting with partners, most have boyfriends, but none are married or express a desire to be married – yet. None of these young women self identify as working class, indeed, they are suspicious of or reject the idea of class as a category of social identity. However, if social and cultural practices are ways of identifying social class categories (see Bottero, 2004), then all those who had cosmetic surgery could be described as coming from working-class backgrounds. For example, only one of the group has completed any form of post-16 education. All bar two are in employment, in beauty, administration or sales, though one is trying to establish a career in acting and another is a health professional. Most have never been to the theatre or read any broadsheet newspaper, preferring Hello or Heat magazine. Only one who belongs to the friendship network but who did not have surgery could be categorized as coming from a middle-class family and has a more diverse range of social networks and leisure activities. All the women who had breast augmentation surgery were aged between 18 and 25 at the time of their operation.

Shopping for breasts not undergoing surgery

Over the last five years, 18 young women in the close friendship network entered the market for cosmetic surgery and paid for breast augmentation surgery. Six had surgery abroad and eleven had surgery in the UK. Those who went abroad went to the same clinic because it offered the procedure more cheaply. As the quote from Lucy above illustrates, they talk about the surgery in much the same way as they might talk about buying shoes or clothing or going for a beauty treatment, forms of consumption that they regularly and enthusiastically participate in. On average, my interviewees spend £100–200 on clothes and £50–150 on beauty treatments each month. The latter include regular weekly or twice-weekly trips to the hairdressers to straighten their hair, manicures and fake nails, waxing, teeth whitening and occasional facials. Fake tanning is also an important part of their beauty regimes – as teenagers their motto was ‘better orange than white’. Though their demand for these kinds of beauty products is not the focus of this article, it is worth noting that it speaks closely to the work of feminist scholars such as Skeggs (1997), Gill and Scharff (2011), and Black (2004), who have explored the expression of embodied femininities that are socially produced and mediated through very specific class cultures.

Though their level of commitment to grooming varied, beauty regimes and processes are an important part of their everyday life and often linked to respectability and agency. Grooming is seen as vitally important in terms of how women present themselves to the outside world. These young women all believe it is important to look good, be attractive and fashionable, and they take pride in being able to do all this well. Their consumption of clothing and beauty treatments is used as a means to display and construct a particular gendered identity, and as Croghan et al. (2006) found in their research on adolescent style and consumption patterns, it is also a marker of belonging to the friendship network. The group have a shared view of aesthetic ideals for women, and adhering as closely as possible to these ideals in terms of style of dress and grooming gives the women status and honour in their immediate social circle.

In this group, the visible artificiality of breast implants, fake tans, nails, hair extensions and so on is not disparaged but regarded as a display of their owner's success and economic power (see Coy and Garner, 2010). They admire celebrities like Victoria Beckham and Jordan, seeing them as fashionable business women who look after their families and are successful in their own right, rather than regarding them as ‘Others’ who have had ‘extreme’ or ‘excessive’ surgery (Gimlin, 2010). The young women wanted big breasts and spoke of their new ‘boobs’ as if they were fashion items or accessories. In addition, the artificiality of their breasts signified success, a ‘go-getting’ attitude and agency (Holliday and Sanchez Taylor, 2006). This was part of a more general tendency to discuss people's bodies as though comprised of a series of separable parts that can be individually evaluated as ‘good’ or ‘bad’, and modified or enhanced through consumption practices. Indeed, ‘boob jobs’ were framed by my interviewees so much in terms of beauty and fashion that they found it difficult to say whether they could actually be described as surgery:

They point to the speed at which operations are performed, the lack of pain and discomfort they had suffered after surgery and the popularity of breast implants to support the idea that it is not really like surgery. Though propagated amongst the friendship network, this is not a discourse that these young women have invented for themselves, however. Instead, it closely mirrors the discourse about breast augmentation procedures generated by the industry that sells them their new breasts.

‘Confidence starts with money off the new you’: marketing big breasts

Advertisements in magazines, on billboards and as web pop-ups advertise cosmetic surgery clinics and direct potential consumers to clinic websites. Such advertisements typically feature images of slim and smiling young women with large, pert, breasts, and make an association between big breasts and beauty, happiness and success. Clinic websites also feature such images, and the accompanying text strongly emphasizes the benefits that will come from possession of new, bigger breasts. It suggests that breast enlargement surgery will improve a woman's quality of life, ‘self confidence’, femininity and therefore her psychological health. These ideas rest on the assumption that there are ‘bad’ or ‘ugly’ breasts, and that women cursed with small or ugly breasts suffer psychologically.

Thus, marketing materials regularly refer to certain types of breasts in negative ways, using terms such as ‘drooping breasts’, ‘sagging breasts’, and ‘misshapen breasts’, and often medicalize them as ‘problems’ linked to factors such as childbirth or breastfeeding, dramatic weight loss or weight gain, hormonal fluctuations, or the ageing process whereby the skin loses elasticity. This language reflects and reinforces the idea that there are ‘good’ breasts and ‘bad’ breasts, and suggests that the latter can only be corrected by surgery. As one clinic announces on its website: ‘breast uplifts are ideal for sagging and misshapen breasts’ (Harley Medical, 2011). The same discourse can be found at ‘open evenings’ at private hospitals that offer cosmetic surgery. At one such open evening that I attended at a private clinic in the Midlands, surgeons tapped into popular understandings of ‘bad’ breasts in their discussion of breast enlargement surgery. For example, ‘before and after’ photos were shown, with the ‘before’ photos introduced by statements such as: ‘This lady has sagging breasts’, and ‘This lady has always been very flat-chested’, and ‘Sometimes breasts have no volume and can be below the feet’, and:

As ‘sagging’ breasts do not actually pose a threat to health, there is no medical terminology to describe them and surgeons are forced to turn slang and euphemism to convey images of ‘bad’ breasts. In marketing materials produced by the cosmetic surgery industry, small breasts are also in the ‘bad’ category, because women with small breasts are held to lack confidence in their own femininity, and suffer from low self-esteem, in addition to being unable to enjoy the latest fashions. In other words, large breasts are presented as desirable commodities, but a therapeutic medical discourse is drawn upon to rationalize the desire for them. At the same time, however, the risks associated with the invasive surgery required to attain these desirable objects is trivialized.

The risks associated with breast enlargement surgery are in fact similar to those of any other invasive surgical procedure requiring a general anaesthetic. They include: bleeding; infection; reaction to anaesthesia; implants rupture, leak or become displaced; unexpected scarring; decreased sensation in the breasts; and capsular contracture where the breast muscle around the implant hardens and causes pain and discomfort. In other words, there is a possibility of suffering anything from mild discomfort through to death as a result of the surgery.

The clinics that advertise in the UK often refer customers abroad for the actual surgery (an estimated 20, 000 people travel outside the UK for cosmetic surgery; BAPRAS, 2011), often to countries where the industry is subject to even less regulation than in the UK. Even in the UK itself, the industry has been criticized as poorly regulated and sometimes featuring ‘have a go’ surgeons based in small practices (Goodwin et al., 2010). The number of botched jobs in the UK is rising significantly and often linked to problem cases associated with surgery undertaken abroad. The British Association of Plastic Reconstructive and Aesthetic Surgeons (BAPRAS, 2011) states that ‘No procedure is free from risk and complications after cosmetic surgery can occur whether your surgery is carried out in the UK or abroad’. To dissuade potential patients from going abroad, it then argues that risk can be minimized if surgery is performed by a reputable surgeon or clinic in the UK.

Certainly the risks that attend on the operation are minimized in marketing materials on websites advertising breast enlargement surgery, and this is done partly by emphasizing the expertise and experience of the medical team who will perform it, and partly by stressing how quickly and easily it is performed. Potential consumers are told that the operation ‘only takes an hour or so’ and few details are provided on possible complications or their consequences. For example, this page from a UK clinic explains the entire procedure in the following few words:

Another clinic website sells breast enlargement as a commodity that will increase femininity and self-esteem, allow the potential consumer to ‘buy clothes and underwear that previously were not suitable’, lead to ‘improved shape as well as size correction to achieve more symmetrical breasts’, provide breasts that are ‘more in proportion to the body’. It promises not just ‘renewed confidence’ but also ‘money off the new you’. So far as the actual surgery is concerned, it states that ‘the procedure commonly known as the “boob job” is ‘safe and simple and only takes an hour’ (MYA, 2011).

Clinic websites often feature videos or podcasts featuring ‘satisfied customers’. These too stress the benefits that surgery will mean for women who feel they are not real women because they lack big breasts. Women who previously had small breasts are shown explaining how having surgery has increased their ‘confidence’ and changed their lives for the better. They feature no discussion of the risks associated with surgery, and this is in marked contrast to the content of podcasts on breast reconstruction surgery on sites discussing post-mastectomy implants and cosmetic surgery (see NHS, n.d.), highlighting the distinction made between reconstructive surgery and cosmetic surgery (Naugler, 2009). The materials and techniques used to market breast augmentation and other forms of elective cosmetic surgery are not modelled on those used by the NHS to provide public health and medical information, but rather on those used to sell other luxury consumer goods. For example, a number of lifestyle discount websites that offer time limited discount vouchers on hotels, hairdressing, beauty treatments and other luxury goods also offer discount vouchers for breast implants. One such offer promised to reduce the cost of surgery from £5, 950 to £2, 995 if the consumer took up the offer within a specified time limit. Multiple vouchers could also be purchased as gifts. This particular website did state that buyers should think carefully about having surgery. And yet at the same time, the frivolous and familiar tone of the sales pitch suggested that the subject of this careful thought was not really a matter of great significance:

Discount voucher companies such as Groupon in the UK (which sold 78 breast implants for £1, 999 in 2011, see Groupon, 2011), and others in the US have been criticized for using online marketing and offering discount breast procedures in which a lower price is charged to a customer who can encourage another person to undergo the same procedure (Nassab et al., 2011). Although the link between marketing pressure and the decision to have surgery may be weak, they do underscore the way that these invasive treatments are sold like any other luxury consumer product, such as cars, where offers of free finance and arranged credit are used to make sales and capture the consumer from rivals in competitive industry. It is not usual to try to sell medical procedures by providing economic incentives to buy, and this development worries many medical ethicists (Smith, 2005).

As a result of these sales techniques, many women have been sold breast enlargement surgery before ever having spoken to a medical professional. This demonstrates that some surgeons are willing to go along with the treatment of breast enlargement surgery as a consumer product that can be selected and prepaid without a medical consultation to determine whether or not the treatment is actually appropriate. However, as will be shown below, contact with medical professionals who are involved in the private provision of cosmetic surgery does not necessarily mean that potential consumers are encouraged to think in medical terms about the procedure they are considering paying for.

Selling surgery as beauty treatment: the consultation

When a woman decides she is interested in having breast enlargement surgery, the first thing she needs to do is to choose a clinic and arrange an appointment for a consultation. Nine of my interviewees chose a clinic on the recommendation of a friend or relative who had already had surgery arranged through this clinic; two were attracted by offers advertised by the clinic. In their narratives of the process of having breast augmentation surgery, the pre-surgery consultation visit was exciting. It meant they were taking a definite first step towards acquiring the bigger breasts that they desired. They had all been accompanied by a friend to the consultation, and when one of my key informants – a 23-year-old who wanted to have surgery – decided that she could afford to have her breasts enlarged and arranged a consultation, she invited me to accompany her. Below is a description of that consultation visit.

Tanya and I went to Manchester for her consultation visit. We walked into the office and sat in the reception area where Tanya was given a one-page long medical history form to complete. After ten minutes, the consultant came into the waiting room, introduced herself, and took a quick look at the medical history document. She then showed us into the consulting room where she briefly asked Tanya what surgery she wanted, and then almost immediately took us to the adjacent small white box room, in which was a mirror and a table on which sat a selection of bras and implants to try on. Tanya was invited to try on a selection of bras with different cup sizes and test them out with various types of implants. Implants could be high profile, low profile, textured, tear drop or round and each came in a range of sizes.

Tanya was also given a tight white T-shirt to put on over the bra and implant so that, as the doctor explained, she would be able to see which cup size and type of implant corresponded to the ‘look’ she wanted. As Tanya tried the different bras and implants, the doctor commented on the pros and cons of each implant and ‘look’. This was a major part of the consultation and took about 15 minutes. The discussion was light-hearted and friendly. It was as though we were in a changing room in a clothes shop, chatting with a sales assistant. The doctor did not employ any medical terminology, and described different breast shapes and sizes as ‘teabag breasts’, ‘vulgar breasts’, ‘fried eggs’ and ‘fake breasts’.

Tanya is a slim young woman whose breasts are large enough to mean that she wears a bra size 34C. She told the doctor that she felt they were too small however. Rather than challenge this perception, the doctor agreed that her breasts were ‘on the smaller side’ and could be described as ‘slightly lacking in fullness’, although she observed that they had good tissue which would be an advantage for the operation. After the 15 minutes of trying on bras and implants was over, we were invited to the consultation room where the doctor gave a quick and basic description of the procedure that would be involved in the actual operation. Tanya, who had only engaged in minimal Internet research and reading on what the operation entails and what types of implants were on offer before attending the consultation, asked very few questions about the product, the procedures and the implications of the surgery. She was clear on the size and ‘look’ she wanted but that was all. She told me afterwards that she felt that she had obtained all the information she needed from friends who had already had the operation, and so had nothing in particular to ask the doctor. The doctor did not volunteer any details about the risks and complications associated with the operation unless asked specific questions.

Other participants in my research all reported having been provided only the most basic information about the operation at their consultation visit. Risks and the consequences of possible complications were not explained unless the prospective consumer asked questions about them. One of my interviewees said that although she had read up about the operation on the Internet and had gone to the consultation meaning to ask about complications, she forgot all her questions when she got to her consultation. Others who had asked vague and general questions about complications reported that the doctor at their consultation suggested that further surgery could correct any major problems that arose. NHS advice on breast implants states that about 30 per cent of those who have breast enlargement surgery have to have the implants removed within 10 years (NHS, 2010), yet half of all my participants were told in consultations that their implants would last a lifetime, and other common problems as well as post-operative discomfort were also downplayed at their consultations.

The accounts of the consultation visit provided by the other young women in my study who had had surgery, like the consultation that I observed, suggest that when a woman makes an appointment and arrives at the clinic for a consultation, it is assumed that they are there because they want surgery and are not simply browsing or seeking medical advice about whether the operation is necessary, appropriate or safe for them as an individual. The clinic consultation is therefore geared towards translating that desire into a sale, which is achieved by focusing on aesthetic rather than health issues. The discussion in the consultation room is about improving the look of a body by consuming a particular product, and how this will lead to increased self esteem, and the women are treated as clients or consumers with choices to make, rather than as patients in need of medical advice.

The procedure was not referred to as major surgery, indeed, reassurances were given that served to distance breast enlargement surgery from major surgery. For example, several of my interviewees had been told that a ‘twilight’ local anaesthetic would be used instead of a general anaesthetic and that this makes the operation less risky. As in the website promotional materials, it was emphasized that the procedure only takes an hour or so, that no over-night stay in hospital is required, and in the case of the clinic that sent clients to Belgium for surgery, they were reassured they would be back to sleep the night in their own hotel room following the operation. Interviewees who had used this particular clinic were not told very much about the surgeon who would be performing the operation, and did not ask for any information about her or his record.

The young women in my study went along to consultations focusing on the end product or ‘look’ they were purchasing rather than on questions of medical risk or complications, and the consultation visit did nothing to challenge their framing of breast enlargement surgery as a beauty treatment rather than major surgery. None of those who had surgery had ‘shopped around’ or attended open days at other clinics. With the exception of Charlene (whose story is discussed below), the consultation visit was their first and only contact with a medical professional prior to embarking on the actual surgery, and the rapidity with which surgery was arranged following the consultation was remarkable. Twenty-year-old Karen had her ‘boob job’ just one week after her first and only consultation visit at a clinic in Birmingham where she had stated that her priority was the speed at which they could do the operation; 21-one-year-old Sienna had her consultation visit on a Thursday and was in the operating theatre the following Tuesday. Despite recommendations from BAAPS for a ‘cooling off period’ of at least six weeks between the consultation and the surgery, it seems there are clinics willing to ignore such guidelines if the customer makes it plain she wants them to act fast.

Some research on women's consumption of cosmetic surgery has found women going to these kinds of consultations having researched the issues extensively, and who therefore arrive armed with an understanding of the realities and potential risks of surgery (Gimlin, 2010; Jones, 2008; Rowsella et al., 2000; Davis, 1995). Gimlin (2005: 104), who interviewed a sample of women in the UK and the US of mixed ages who had had a range of cosmetic procedures in the 1990s and early 2000s, states that the women prided themselves on being knowledgeable about the process and its attendant risks, and had surgery only after ‘careful consideration’. They also tried to identify and select surgeons who were judged to be professional medical practitioners rather than ‘seedy’ doctors motivated by profit. The moral character of the doctor was thus considered to be as important as their ability to perform the operations, and Gimlin describes the process of deciding on surgery as a joint venture between the doctor and the patient (albeit one in which both parties appear to have been concerned to limit the ‘excesses’ of cosmetic surgery and construct a morally legitimate demand for cosmetic surgery within well-defined notions of ‘natural’ beauty).

There is certainly a great deal of information about the medical aspects of cosmetic surgery available from independent online sites and books, and as evidenced by the above mentioned research, some consumers carefully and systematically research and evaluate this information. However, the eleven women in my study who had breast enlargement surgery had it when they were aged between 18 and 23, and did not undertake rigorous independent research or ask doctors complex questions or spend time weighing up risks or considering the credentials of who would perform operations on them. They relied on scant information gleaned from clinic websites, word of mouth recommendations and the subjective experience of members of their friendship network to inform their decisions. They preferred to place their trust in the medical expertise of the doctors and surgeons employed by clinics that friends had previously used, and they arrived at consultations expecting to be told about the procedure, not to ask questions, as the following quotes show:

Those who had surgery in Brussels did not all feel complete confidence in the clinic after the consultation, but still went ahead with this company because it offered cheaper surgery than alternative options. There were no further opportunities for discussion or clarification until they actually arrived in Brussels, and even then, such opportunities were highly restricted. For example, Kia met the surgeon who was to operate on her for the first time ten minutes before the operation, and had to demand a consultation with him as she had changed her mind about the size and type of implant she had chosen at her initial consultation in the UK. As she explained:

None of the women I interviewed had their desire or motives for seeking surgery questioned or challenged during a consultation. This is despite the fact that all are fairly slight of frame (most wear UK dress size 8 or 10), with firm breasts that were in keeping with such body-types, that is, the cup size of their bra was AA in one case, and A or B in the others. Only one had given birth to a child and stated that she wanted to correct ‘sagging’ breasts. No medical interrogation of, or advice on the ‘problem’ was offered by doctors at consultation visits, no alternative to surgery was suggested. The ‘consultation’ was not to diagnose the problem and advise on the pros and cons of different forms of treatment. The women's own diagnosis of the problem sufficed (smaller than fashionable breasts), and the point of the consultation was to ensure that, like a consumer in a shop, they selected new breasts of the size and shape that they ideally wanted.

To have breast implants requires a major medical procedure, but they are sold as a fashion accessory and the procedure is framed as a beauty treatment rather than an operation by those who sell it. This framing was reproduced in my research participants' discourse about their decision to buy new breasts. And yet, as they narrated the story of their experience, it became clear that whilst they constructed surgery as a beauty treatment at one level, on another level they were aware that it was nothing like having a manicure or a leg-wax.

Taking the plunge

All my interviewees retrospectively say that their surgery was ‘nothing’. They speak of how little pain they experienced and the speed of recovery to emphasize the nothingness of the medical procedure they underwent. Lucy, for example, told me and also other friends considering having surgery that she was able to drive herself home from the airport the day after the operation, even though the surgeon had told her it was inadvisable to drive for two weeks after breast surgery. Yet, as Lucy tells her friends, she drove the next day and ‘it was fine!’ Hannah likewise explained that she always tells people, ‘I had it done on the Friday and went back to work on the Monday’. The pain experienced directly after surgery was described by these young women as ‘bearable’, and even the one young woman who suffered post-operative infection minimized the pain. Several of my interviewees explained the nothingness of the operation by contrasting their physical sensations afterwards against pain and discomfort experienced during miscarriage and, in Charlene's case, giving birth. The ‘nothing’ narratives are central to how risk is perceived and talked about by the group and is used to distance themselves from being constructed as vulnerable or ‘at risk’ and allow them to cope with the surgery by trivializing it. These trouble-free narratives between before and after also hide the ‘labour of cosmetic surgery’ and keep the real risks involved a ‘secret’ (Jones, 2008: 17–8).

As noted above, these young women do not approach breast enlargement surgery as major surgery, but rather as a ‘must have’ beauty treatment. When selecting a service provider, they researched prices and the waiting time between the consultation visit and the surgery, not the medical risks associated with breast implants. When I asked whether they had considered the risks as they made plans to have surgery, they were mostly quite dismissive:

Nonetheless, there were also tensions in the story of acquiring their new breasts, for most described moments of real and intense fear before actually going for surgery. Fear of death was a common theme. When it came to the point of no return, and they were actually awaiting the operation, they suddenly feared they would not wake up from the anaesthetic and felt they were taking a huge risk with their lives, one not really worth taking:

In their narratives, the fear experienced immediately before going for surgery is represented as something real and yet something that had to be conquered in order to achieve their ambition to acquire new breasts. They describe themselves mastering the fear, going on to have the operation, and afterwards realizing how unfounded and irrational their pre-operative fear had been. It is against this intense fear of death that the nothingness of the surgery is so vigorously asserted. Afterwards, they realized that it really was not like surgery. It was nothing. And because risk was only imagined in relation to the absolutely disastrous outcome of death, more common complications that arise from having breast implants such as capsular contraction do not feature in the discourse about surgery and risk that is promulgated within the friendship network. The fact that their friends have had the operation and survived becomes proof of its safety.

However, the medical professionals involved also play an important role in encouraging women to overcome their fears, as Charlene's story illustrates. Charlene was given the gift of breast surgery by her parents after the birth of her first child as a ‘push present’ (a present for giving birth), because she said she was unhappy with the shape of her breasts after childbirth. However, Charlene, who is the youngest in the friendship network at 21, describes herself as an anxious person, and she was more fearful about having the operation than others in the group. Indeed, it was because she was fearful that she had not had the operation at a younger age, despite wanting to emulate others in the group who had already undergone surgery. When her parents offered to pay for new breasts, Charlene initially attended a consultation with the clinic that had arranged for others in the friendship group to have surgery in Brussels, but she then decided she was too scared to go abroad. As her parents were paying, she decided to pursue the more expensive option of having surgery in the UK.

On the recommendation of other friends who had had surgery in the UK, she arranged to see a consultant at a local private hospital. (Marketing materials from surgeons at this hospital stress that it is less risky to have breast enlargement surgery in the UK.) The fact that friends and relatives had already had their ‘boob job’ done by him also reassured her:

Charlene said that she had really, really, wanted the surgery and so fixed a date for the operation. And yet despite the consultant's reassurances about the likelihood of surviving surgery, she worried so much about ‘not waking up’ that when the day arrived:

She then set another date for the operation, but cancelled it a second time. And yet she continued to want new breasts. She went on holiday and:

When she got home, she wrote to her surgeon explaining that she was an anxious person and needed help to overcome her fear of death. He obliged. He called her and asked what exactly it was she feared, and on discovering that she was slightly claustrophobic and also became very anxious when kept waiting, he promised to make sure that she did not have to enter a lift and to arrange for her to be first into theatre on the day of her operation so that she would not have to wait. He gave her his mobile phone number and told her she could call him whenever she wanted for advice or if she began to worry about anything new before the day of the operation. Charlene also paid the doctor in advance for the operation, telling him she wanted him to keep the money if she did not go through with her third attempt at the operation, and described this arrangement as an ‘incentive to herself’. On her third attempt, she said she managed the stay calm by ‘only thinking of myself’. She was happy with the outcome of the surgery. However, just over two years after the surgery, Charlene has capsular contraction in one breast and is now worried about this. She can feel the tissue hardening, and says it is uncomfortable, but ‘I just keep massaging it’.

Conclusion

When the young women in my study thought about how much they wanted new breasts, cosmetic surgery was imagined as a beauty treatment. When they contemplated the actual operation, the fear they experienced suggests they also recognized it as a medical procedure. When they recognized it as such, they reassured themselves by focusing on the fact it would be undertaken by surgeons who are medical experts. This article has shown that the tension between the idea of the cosmetic (derived from the Greek word kosmein meaning to arrange or adorn, and originally used as a noun to denote the art of beautifying the body), and that of surgery (defined as ‘the treatment of injuries or disorders of the body by incision or manipulation’ (Oxford Dictionary, 2011), is important to the way in which these young women think about the risks and benefits of consuming breast augmentation surgery. However, it is also managed and manipulated by those who market and sell such procedures, such that at one moment breast enlargement appears as a beauty treatment or fashion accessory that can be chosen by the sovereign consumer, the next moment as a medical intervention to solve a psychological or physical problem that will be conducted by highly skilled, experienced and trustworthy medical professionals who can be relied upon to act in their patients' best interests.

It seems that in the context of a neoliberal shift towards privatization and de-regulation of areas of collective provisioning – such as health – previously shielded from the market (Soron and Laxer, 2006), culturally constructed demand for ‘cosmetic’ change can be almost entirely detached from medical concerns and restraints. The bodies of young women like those in my study are opened up for profit, albeit with their consent.