Naked from the waist up, Sharon Eller endured the medical exam by avoiding the eyes of two men staring at her breasts.
Dr. J.P. Riou backed up for a better look. He tipped his head toward Sharon's husband, Maurice, and pointed out that her right breast hung lower than her left. Women's breasts rarely match, the plastic surgeon said. But he could fix that.
Red marking pen in hand, Dr. Riou drew a half circle under Sharon's left breast, to show where it should hang. He added dotted lines down the center of her chest and from nipple to nipple. A map for surgery to come.
"The next question," he said, "is size."
We're obsessed with breasts.
The bigger the better.
Across centuries, their significance has shifted back and forth, from maternal to erotic.
Today in the United States, women who breastfeed in public may be ridiculed, even arrested. But stuff a couple firm, round bosoms in a low-cut top, and you get a different kind of attention.
In America, there's no doubt. Breasts are more than fatty milk factories intended to nurse offspring. They're sex objects.
More than 300,000 U.S. women had breast augmentation in 2004, compared with 100,000 in 1997, according to the American Society for Aesthetic Plastic Surgery. It's the second most popular cosmetic procedure, next to liposuction, and it's becoming more affordable. Nationally, the cost of a new set of breasts costs US$3,000 to US$10,000.
Forget the stereotype.
Like Sharon Eller, a purchasing agent, women seeking breast implants aren't just dancers or actresses or wealthy middle-aged women trying to keep their youth.
Plastic surgeons say most patients are young mothers whose breasts have gone flat as fried eggs after breastfeeding.
They want to fill out a swimsuit.
They want to look sexier in a dress.
"Many people see this as an investment in themselves," said David Sarwer, of the University of Pennsylvania's Center for Human Appearance. "For some people, it's no different than eating a healthy diet or going to the health club."
Flat and unhappy
Sharon Eller wasn't always unhappy with her breasts. By 32, she had nursed two babies. Her breasts seemed flat, "not perky like they used to be."
A 34A bra was too tight, 34B was too big.
Dresses hung like sacks.
She wore blouses, instead of clingier sweaters, to camouflage her flat chest.
Though a size 4 with a tiny waist, Sharon dreaded shopping for bathing suits. They'd fit fine in the hips, but the tops looked like deflated balloons.
She didn't talk about it, not even with her husband, Maurice. But she read stories about celebrities who got implants, and she watched cosmetic surgery shows on the Learning Channel.
She figured it was too expensive for her, a county employee in Wilkesboro, near the North Carolina mountains.
Then, in summer 2002, Sharon talked to a friend who knew someone who got implants from a doctor near Charlotte, North Carolina. They looked real, Sharon's friend said, and they didn't cost as much as you'd think.
Sharon looked up the doctor's Web site and got the prices.
Then she talked to Maurice.
You're kidding, he said.
Maurice didn't want her to get breast implants. He married her when he was 20, and she was 19. He loved her the way she was.
Sharon reminded Maurice that she never stopped him from spending money on things he wanted: shotguns, rifles and the all-terrain vehicle for hunting deer and turkey.
Soon after, Sharon and Maurice took out a US$3,500 home equity loan. It was enough to pay for the operation, which isn't covered by insurance.
Silicone implants gained popularity until the late 1980s. That's when women began claiming they caused serious illnesses, such as lupus and rheumatoid arthritis. Some testified about pain and crippling health problems when silicone leaked into their breasts.
Class-action lawsuits led to huge settlements from manufacturers, and in 1992, the Food and Drug Administration banned silicone implants for general use.
Many predicted that breast implants in the United States were finished. In 1994, doctors performed just about as many implant removals (38,000) as they did enhancements (39,000), according to the American Society of Plastic Surgeons.
But, with saline as a substitute for silicone, demand for bigger breasts returned, more than ever.
Without eye makeup and lipstick, Sharon was pale and tired as she waited for Dr. Riou to finish marking her chest. She and her husband, Maurice, had gotten up early for the hour and a half drive from Wilkesboro to Cornelius. Sharon's blond hair didn't have its usual bounce. Her 5-foot-3 frame looked even smaller with her chest bared in the harsh light.
Riou asked Sharon what size breasts she wanted. "Just enough to fill out a dress," she said - from a small B-cup bra to a full C.
In that way, Riou thought, she was typical of his patients. Finished having children. Conservative. Meticulous about her appearance, but not vain.
The plastic surgeon translated bra size into the volume of saline needed. A 32C uses about 200 cubic centimeters, about the size of an orange. But a C cup varies depending on a woman's chest size.
That used to be about average for patients in Riou's office. But over the past 10 years, he has watched women's ideas of the ideal grow - to C-plus or D-minus.
At first, many implant patients think their enhanced breasts are too big, he said. But when he surveys patients later, about one in 10 say they wish they had gone bigger.
Before the operation, Riou's nurse double-checked with Sharon, just to make sure.
"No D?" the nurse asked.
Sharon scoffed: "Why would you want to be a D?"
What's the ideal breast size?
It depends on the decade.
Very thin, small-breasted flappers were popular in the United States in the 1920s, a period of women's liberation that coincided with winning the right to vote. But the style in breasts ballooned, interrupted briefly by the popularity of Twiggy, a rail-thin British model in the 1960s.
Bust measurements of Miss America contestants reflect the trend toward bigger-is-better.
In the 1920s, the average contestant's bust was 32 inches, according to Carolyn Latteier, author of "Breasts: The Women's Perspective on an American Obsession." That vital statistic rose to 35 inches in the 1940s. And through the two decades following 1950, Latteier wrote, it stayed at a "perfect 36."
Bust measurements of Playboy Playmates followed the same pattern, Latteier said, but always a couple of inches bigger. In Hollywood, women with larger chests, such as Marilyn Monroe, tended to get parts that fit their image as sexual beings. Small-chested women, such as Katharine Hepburn, played characters with careers and upper-class sophistication.
The message was: More bosom, less brain.
Celebrities still set the bar for many women, but even "Baywatch" alumna Pamela Anderson said she got tired of her all-breast-no-brain image. She dropped from about a 34D to 34C when she had her implants removed in 1999, according to People magazine.
In the operating room at Riou's office, green towels covered most of Sharon's anesthetized body, stretched out on a table like a crucifix.
Standing at her side, Riou made the first cut, less than an inch, near Sharon's left armpit.
He stuck his gloved index finger inside as far as it would go.
With a sweeping motion, he cleared a pocket between two layers of muscle. From the inside, the tip of his finger pressed against her skin, like a cartoon mole digging an underground path.
He replaced his finger with a blunt dissecting tool. Sharon's breast danced jerkily as Riou pushed the instrument around inside.
Then, he rolled up an empty implant bag like a cigar and guided it into the tunnel he'd created with his finger. A tube, attached to the implant, remained outside Sharon's body.
A nurse connected the tube to a bag of saline hanging overhead. The clear liquid flowed, and Sharon's left breast rose slowly like a yeast roll.
In the next five minutes, Riou repeated the procedure on Sharon's right breast.
With both implants inflated, a nurse tilted the operating table until Sharon's unconscious body was almost vertical and gravity pulled at her breasts.
Someone brought Sharon's husband, Maurice, to the operating room door, where he looked through a small window.
Riou, delighting in his handiwork, shouted two questions at Maurice.
"Bigger?" he asked, holding his thumb up like a hitchhiker.
"Smaller?" he asked, thumb down.
Maurice smiled nervously. He gave the doctor two thumbs up. Just right.
Source of self-worth
Should breasts have anything to do with self-esteem?
Many women say no. Self-worth should come from inside, they say.
Molly Barker blames much of today's emphasis on breasts and physical beauty on advertising and other media images. She worries about its effect on girls and women.
"I'm frustrated with a culture that is telling women what they need to look like to be beautiful," said Barker, founder of Girls on the Run, a national self-esteem and health program for pre-teens.
"I'd like to see a transformation at the cultural level where we don't correlate self-esteem with breast size. ... I really believe we get confidence through what we do with our lives."
Psychologists say many women who get breast implants aren't necessarily unhappy with their whole bodies or their lives. They are simply more unhappy with their breasts than the average woman.
"They're as psychologically stable as women who don't get (implants)," said Ann Kearney-Cooke, a Cincinnati psychologist and author of "Change Your Mind, Change Your Body."
Research shows that most women who get breast implants report feeling better about their bodies.
As long as women aren't having multiple surgeries with unrealistic expectations, Kearney-Cooke said breast implant surgery can be good for body image.
"Feeling attractive and sexy is a great feeling," she said. "Women shouldn't be ashamed of that."
After her surgery on a Friday, Sharon Eller spent the weekend in her living room recliner. Even with pain medicine, she was barely able to move her arms. She returned to work on the following Tuesday, wearing baggy clothes, so no one would notice the change in her breasts. It took about a month for the swelling and bruising to go down.
About six weeks after the surgery, when she stepped out of the shower one morning, Maurice was watching her. "You know I really didn't want you to have it done," she remembers him saying. "But you do look nice."
People at her county office building complimented her too. But it wasn't only her breasts they noticed.
She laughed and talked more. Her hazel eyes seemed brighter. She bought new clothes - form-fitting knit shirts and sheath dresses instead of blouses and shirtwaists. They aren't low-cut or showy. But they fit better, and she wears them confidently.
In the three years since her surgery, Sharon has exercised more, running in a park and punching the boxing bag in her basement. She's cultivating a shape to match her new self-image.
"She just has a new glow about her," said Neal Hayes, a friend.
Sharon didn't get the implants to attract attention. She just wanted to feel better about herself.
And she does.