Ethical Considerations for Board Certified Plastic Surgeons?

After asking a question on this site I did visit a board certified plastic surgeon and after discussing my wishes, he refused because of "ethical considerations".

Why should a surgeon care how I want my breasts to look if its not dangerous or unnatural? How is a 400CC high profile round textured "gummi bear" implant placed subglandular through a transaxillary procedure unethical?

Doctor Answers 6

Ethics may not be the issue here!

My colleagues' answers here are quite good; you would be wise to read them all. Here's what I have to add.

Sometimes doctors have trouble telling a patient they don't think they can make them happy, for a multitude of reasons. I tell patients who come to see me with tales like yours about other doctors that sometimes what they were told is "doctor-speak" for "I don't know how to do that operation" or "I don't feel comfortable being told how or what to do by a patient who has just done 'research' and isn't interested in my recommendation based on medical school, surgery residency, plastic surgical fellowship, and years of experience" or "You seem unhappy with your life, not your breasts, and giving you bigger breasts will just make you a still-unhappy woman with bigger breasts and a lighter wallet and a new person to blame for your unhappiness." Etc. Some patients are just plain crazy, but we can't tell them that, can we? (And I NEVER say that to someone who I feel is unstable, so don't be offended--I think your question is a very good one and understandably troubling to you or any patient treated this way!) You just have to try to understand why.

Perhaps it is the fact that the "gummy bear" implant is not yet approved by the FDA, and is used by only some plastic surgeons in approved studies (which I believe are now closed). Perhaps it is the fact that textured, form-stable, "gummy bear" implants don't come in round shapes--they are all teardrop-shaped. Perhaps you mean to say 5th generation, cohesive textured silicone gel implants, NOT "gummy bear" implants. Many patients confuse the differing degrees of polydimethylsiloxane cross-linking in present FDA-approved cohesive silicone gel implants with the even-more cross-linked form-stable (you could say "ultra-cohesive") gummy-bear implants, and call all cohesive implants "gummy-bear" implants. That would be incorrect. They are all cohesive, but different kinds of cohesive, and different kinds of implants.

Perhaps it is the fact that placement of textured implants via an axillary incision can be quite difficult if not nearly impossible! The textured surface inhibits sliding, and the axillary incision is small enough (as are periareolar AND normal-size crease (inframammary) incisions) that even the recommended (for textured implants) 5-6cm incision  may  not "be enough" to easily get these "rough-surface" implants in, and into proper position via this incision location. And the bacteria in the armpit are more commonly "dragged-in" by the textured surface.

There are indeed a few ethical considerations, like "I don't participate in the 'gummy bear' implant study, so I can't do that for you" but that would have been pretty easy to say. Not every good surgeon is a "great communicator," and not every silver-tongued surgeon is a great plastic surgeon--the same goes for "bedside manner."

You really need to see several other ABPS-certified (NOT just "board-certified", but American Board of Plastic Surgery-certified) plastic surgeons ("board-certified cosmetic surgeons" can be Dermatologists, ENT, family practice, or doctors of various training backgrounds and board-certifications. The "American Board of Cosmetic Surgery" is NOT an ABMS member board; the American Board of Plastic Surgery is, and is the only ABMS board that certifies plastic surgeons). Perhaps you can hear good advice and proper explanations!

Your goals ARE important, and should be foremost in every plastic surgeon's mind when providing you with his or her best advice. Please don't be offended when all of your personal research and decision making seems to be disregarded by one or more doctors, but you should also understand that unless you too are a fully-trained, board-certified, experienced plastic surgeon, your own research may be based on false assumptions or incomplete information. It is your surgeon's job to educate you so that you CAN make the ideal choices for YOUR body and YOUR goals. That way, we can best achieve (or at least come as close to as possible) your best and safest result in keeping with your wishes. Good luck!

Minneapolis Plastic Surgeon
4.9 out of 5 stars 255 reviews

Ethics in Plastic Surgery

A very important part of being a plastic surgeon is knowing when to say no. Plastic surgeons are not technicians fulfilling an order. Just because the surgeon has the technical ability to perform a procedure does not mean it is right for you. What you are requesting doesn't sound like a good idea for a number of reasons. Gummi bear implants are not available in a round shape in the US. They are tear drop shaped and require the creation of a very precise pocket during placement. This is best done with an inframammary incision, which allows excellent access and control of the pocket. The transaxillary approach does not offer the same advantage. Not only that, but the gummi bear implants also need a longer incision for placement, and for a 400 cc implant it would likely be 4 cm long. That is better camoflouged under the breast rather than a long incision in your axilla. Also, the gummi bear implants are not available for general use at this time, and there are specific inclusion and exclusion criteria for trial use. I think your question "Why should a surgeon care how I want my breasts to look if it is not dangerous or unnatural?" says a lot. Your surgeon should absolutely care, and one that does not is not doing you any favors. I cannot say specifically why your surgeon turned you down, but a few good reasons to not operate include: 1) when the patient does not have a good understanding of a procedure or the consequences 2) when the surgeon does not agree with the goals of a patient 3) when the surgeon does not feel he or she can perform a surgery that will make the patient happy. It's possible the surgeon was simply not a good fit for you, and you can always seek out another opinion. Good luck!

Anita Patel, MD, FACS
Beverly Hills Plastic Surgeon
4.7 out of 5 stars 12 reviews

Ethics in Plastic Surgery

Plastic surgeons who are board certified by the American Board of Plastic Surgery and who are members of the American Society of Plastic Surgeons(ASPS)  abide by a comprehensive Ethics bylaws that ensures a proper code of professional by its members.  It also ensures that your ASPS member surgeon will adhere to strict principles to provide you with honest and responsible care.   This is yet another reason why proper certification matters. 

I am a bit baffled as to what transpired in your dialogue with your surgeon.   But this is why its important to select a board certified plastic surgeon with whom you feel most comfortable.  Proper certification should be a mandatory requirement, but the doctor-patient relationship is also very important.  So please visit with another ASPS member surgeon in your area to learn more about your options. 

C. Bob Basu, MD, FACS
Houston Plastic Surgeon
4.7 out of 5 stars 211 reviews

Gummi Bear Implants

Hi Bethy,

I am sorry that the doctor did not explain himself fully.  One can only guess what he was thinking now.  However, I can tell you what I'm thinking about your request.  True gummi bear implants (form stable) are all contoured and not round, so you wouldn't be able to get that part of what you are asking for regardless of what surgeon you go to.  Transaxillary access to either a sub muscular or subglandular pocket is a great technique for saline or cohesive silicone gel implants, but is absolutely contraindicated for gummi bear implants.  This is because gummi bear implants are fragile and the gel can crack when placed through a small incision.  In fact, gummi bear implants can only be placed via an inframammary incision that is at least 4 cm.

Beyond those absolute issues mentioned, there are more issues to contend with.  We would hope that a surgeon certified by the American Board of Plastic Surgery is ethical, and just as importantly, knowledgable of the best techniques possible base on 'evidence based medicine'.  That is to say, performing the best surgery possible to achieve your desired asthetic goals with the lowert risk for complications and reoperation. If this is the case, one might consider submuscular placement as an important factor in minimizing the risk of capsular contracture and implant palpability, the two most common complications, with capsular contracture being the number one reason for early reoperation.  A 400 cc high profile implant is not an innocuous device, and may cause irreparable changes to your body regardless of reoperation.  Size and profile are very important factors that should be considered by the surgeon, not the patient.

I hope that I have given you some insite as two what  we are thinking.  I understand that individual preference may vary, and that alternatives can be considered, but only after adequate patient education of the risks have been performed and the patient acknowledges those (increased) risks.

I wish you the best of luck!

Gerald Minniti, MD, FACS
Beverly Hills Plastic Surgeon
4.9 out of 5 stars 90 reviews

Ethical Considerations


Hi Bethy,

I am sorry to hear you had such a negative experience from your consultations and it did not meet your expectations.  Don't be dismayed, I would get a second opinion.  It sounds to me like there may be more to this story than you have told.  What are the ethical considerations you refer to?

Todd B. Koch, MD
Buffalo Plastic Surgeon
4.6 out of 5 stars 36 reviews

Ethical decision-making in plastic surgery

Without knowing more details it isn't possible to give a definitive answer, but there are a few general principles that may be helpful. What it comes down to is that plastic surgeons do not feel that it is ethical to proceed with a surgery that they do not believe is the best one for that particular patient. There are certainly many plastic surgeons around the world that put gummy bear implants in through the axillary incision and get good results, but that does not mean that it is always the best choice based on each doctor's judgment and each patient's individual expectations and pre-existing anatomy. Other potential issues are that the gummy bear implants (Mentor CPG, Allergan style 410) are not FDA-approved and you may not meet the criteria required to get them under a study protocol. Assuming the doctor you saw is a clinical investigator for the gummy bear implants, using them on patients who don't qualify would be an ethical violation too. Most patients will do better with the round implants that we have available now anyway in my opinion.

Richard Baxter, MD
Seattle Plastic Surgeon
4.9 out of 5 stars 53 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.