Decades of research suggest that breast augmentation is safe when performed and maintained as recommended. But the tens of thousands of women who attribute their health problems to their breast implants still suggest that significant problems can occur with how the procedure is recommended, performed, and maintained. No matter how the FDA moves forward, at least part of the problem faced by patients is the glib culture that can downplay the procedure’s seriousness.

Breast augmentation is the most popular cosmetic surgical procedure in America. In 2018, it was performed more than 300,000 times, according to a recent report from the American Society of Plastic Surgeons. That’s a 4 percent jump over the previous year, and part of a larger trend in plastic surgery in the United States. As minimally invasive facial injectables like Botox and Juvéderm gain popularity, consumers are starting to move away from facial surgeries, which have traditionally been most popular, and toward body modifications like liposuction, butt lifts, and tummy tucks, in addition to breast augmentation.

But as Alan Matarasso, the president of the American Society of Plastic Surgeons, points out, there’s a fundamental difference between breast augmentation and other popular procedures. “Many of the most popular surgical procedures involve taking something out—a bump in the nose or some fat,” he says. “[Breast augmentation] has the same issues of having an operation, but with the limitations of a device.”

Augmentations are frequently performed on very young women, and those patients are likely to need additional procedures to maintain their health. “I tell young implant patients who are coming in for augmentation, this will not be the last surgery they have on their breasts,” says Jason Spector, a professor and plastic surgeon at Weill Cornell Medical Center, in New York City. Modern implants can require replacement less than 10 years after a patient’s initial surgery. The FDA recommends that patients have follow-ups with their doctors and MRI surveillance throughout the life of the implant, something that Spector says not all doctors insist on and not all patients adhere to.

Read: Rebuilding the breast

Given how casually breast augmentation is often talked about and advertised, it can seem like skipping the lifetime of follow-up is no big deal. But patients can suffer from the less-than-serious cultural attitude toward cosmetic modifications—and unscrupulous doctors can benefit. “Not everybody putting breast implants in across the country is a board-certified plastic surgeon,” Spector says. “You have variation in state laws, and if you’re doing things in your own office, all you need is a medical license.” Untrained surgeons performing cosmetic procedures in high-volume, low-cost settings can have deadly results. In February, USA Today published an investigation into a group of Miami clinics where eight women had died from surgical complications. (The owner of the clinics has denied any wrongdoing.)