There was a time during the Food and Drug Administration's nearly 15-year ban on the use of silicone gel implants for cosmetic breast surgery that Dr. Michael White and some of his colleagues questioned whether they wanted to do any augmentation surgeries at all.

"It was the litigation, surgeons being sued for implant complications," Dr. White said of his soul-searching. "I wasn't, [but] it made it difficult to keep going with it."

A plastic surgeon at Allegheny General Hospital and a partner in a private practice called Plastic Surgery of Pittsburgh with offices at AGH and in McCandless, Dr. White instead asked his patients to write him letters explaining why they wanted the elective surgery, which was limited during the ban, except under special circumstances, to saline implants. (Silicone gel implants were never banned for reconstructive surgery.)

While saline implants work very well in many patients, particularly those with more tissue to cover them, the silicone gel would have been a better fit for others, especially those with thin overlying tissues. Saline implants can wrinkle or ripple and those imperfections might be obvious under thin tissue.

"These letters were so moving," Dr. White said. "I remember one letter where the woman described how hard it was to shop for clothing and finding a bra to fit and her leaving a store in tears.

"There were a lot of stories like that. ... Most patients are looking for subtle improvement that will make them feel good about themselves."

Fran Mammarelli of Monroeville, Amie Marx of Ross, and a 42-year-old Westmoreland County woman who asked to remain anonymous, can relate to those feelings.

Boosted confidence

A year after her breast enhancement, the third woman still hasn't told members of her husband's family about the surgery, which was done by Dr. Kenneth C. Shestak, director, UPMC Center for Cosmetic Surgery.

It's not due to any feeling of shame -- on the contrary, she says the enlargement of her breasts from a size AA cup to a C with silicone gel implants has been a huge confidence booster. It's just that some of the in-laws might not approve.

"I would do it again," she said. "I was toying with it for years. I was never well-endowed. My two best friends were. I was always standing next to them" and feeling inadequate.

"With my first child, I lost some [size]. Then with my second child, they almost completely went away. I had breast-fed both children. That was the main reason [for the implants]: There was nothing left.

"It was not only for appearance," she added. "I did it for my self-esteem. I had low self-esteem because of it. I did it mainly for that reason but also for the physical appearance. I was embarrassed in bathing suits, tank tops, that kind of thing."

Her change in bra size was relatively conservative. "I didn't want to go like, 'Wow, here she comes.' I just wanted to fill out a shirt. I think I picked the right size. I can hide, like in a sweatshirt, or wear something tighter if I want to."

Wanted to restore size

Ms. Mammarelli had the first of two augmentation surgeries 10 years ago in Palm Beach County, Fla., for similar reasons. A 34 B before her two pregnancies, she said she was reduced to a 32 AAA after breast-feeding both babies. Because the ban on silicone gel implants was in effect at the time, she had saline implants inserted to restore her size to a 34 B.

Then she moved back to Pittsburgh and became a personal trainer and nutritionist while working out herself. As she got fitter and more muscular, her entire physique, including her breasts, changed.

"My implants shifted to my underarms," she said. "No one could see it, but I could see it."

She started collecting names of good plastic surgeons she heard about while working at The Fitness Factory in Shadyside.

She did consultations with three doctors and decided she felt most comfortable with Dr. Leo McCafferty, a clinical professor of plastic surgery at the University of Pittsburgh School of Medicine with a private Shadyside practice.

"When he saw me three years ago, he said, 'I see what you're talking about. You don't look bad, but you want them closer together,' " Ms. Mammarelli said.

"I said, 'Can we just go up [in size] a teeny bit more?' He said, 'You're too tiny to have a D cup but you could be a C cup.' "

Despite the ban, Ms. Mammarelli was eligible for silicone gel because her saline implants had wrinkled, which the FDA classified as "saline implant failure," Dr. McCafferty said. She also could have gotten them by agreeing to be part of a scientific study.

But in the end, she and the surgeon decided to stick with saline.

"Both of us decided that since I did so well with saline, we should continue what had worked for me," Ms. Mammarelli said. "I was afraid to try silicone because I knew saline worked in my body. ... [but] if Dr. McCafferty had said it's silicone only, I'd have said OK."

Three years later, everything is fine.

"I love my breasts," Ms. Mammarelli said. "They're nothing but an accent piece to my physique and personality."

Bad first experience

Ms. Marx, a massage therapist and physical trainer at Allegheny Athletic Club in Warrendale, got her first pair of implants during the silicone gel ban in 1999, "and because they turned out so badly I won't name the doctor."

Within a year or two, one of the saline implants shifted. "I had a very abnormal shaped breast, one up by my collarbone," she said, "and one normally placed."

Ironically, Ms. Marx had gotten the original implants to correct a similar appearance problem. She has scoliosis, or a lateral curvature of the spine, which rotates her rib cage. "I had one that was an A [cup] and the other was a droopy B. They were very asymmetrical.

"After I started working out and losing weight, the difference between the two became more apparent."

She said she "dealt with it as long as I could." Then, acting on the recommendations of clients, she also ended up with Dr. McCafferty. After hearing the pros and cons of both, Ms. Marx chose silicone gel implants, for which, Dr. McCafferty said, she also qualified because the saline had provided "less than optimal results."

The surgeon removed the old implants and placed the new ones.

"They're amazing now," Ms. Marx said of her breasts. "He completely fixed me. I'm a 34 C-D, a large C, a low D. It definitely fits my frame a lot better. ... It improved my self-esteem and the way my clothes fit and everything."