Cosmetic surgery in teenagers: to do or not to do.

The media makes it out to be a big story that teens are getting cosmetic surgery in larger numbers than ever. However, this is far from the truth. Yearly data, is increasingly showing a reduction in the percentage, as well as absolute numbers of these surgeries. Only, very essential surgery should be done for teenagers. The consult should be done in the presence of a parent, and even if the teen is above legal consenting age, parental supervision is still needed. A cooling off period, informed consent under parental supervision, and a time to rethink is essential. If a problem is severe enough to cause psychological problems, a psychologist can help in arriving at a decision.

“They think like adults but behave like children”[1]

Cosmetic surgery, which was once exclusive to older women, is a newer trendy option for teenagers with an adolescent hang-up. Headlines were made world over when a 15 year old British girl decided to get breast implants for her sixteenth birthday. Her parents supported her, but the doctors refused and told them that she would have to wait till she was 18.[1]

Should cosmetic surgery in teenagers be banned? According to Dr Gabrielle Caswell, president of The Cosmetic Physicians Society of Australasia, ‘Children should not receive cosmetic or surgical procedures of any kind unless there are compelling medical or psychological reasons to do so,’’. In Queensland, physicians who operate on children without good reason can face two years’ imprisonment.[2]

Medical Council of New South Wales guidelines require minors considering cosmetic surgery to have a 3-month cooling-off period, followed by another consultation.[2]

However, owner of the Medispa, a Sydney cosmetic medicine centre, was reported last as saying it was “extremely common” for high school girls to have their lips plumped up as a reward for graduating.

“Between the ages of 13 and 19, there's a lot of emphasis on peers and what others think of you. It's also a time when things such as not being part of the popular crowd, changes in financial situation and divorce can negatively affect a teenager's self esteem.” Therefore, it is important to determine whether or not these patients are requesting surgery to satisfy their own interest or to meet the expectations of someone else, for example a parent or boyfriend.

It is important to distinguish between teenagers below 18 years, and those above 18 years, as the older ones are legally of consenting age. But the problems before the teenagers have nothing to do with this division. They have two types of issues: To conform to their peer group, and obvious cosmetic problems, for example, asymmetry of breasts or gigantomastia causing severe medical problems.

American Society of Plastic Surgeons published data showing that number of cosmetic surgery done for the teens has actually come down progressively over the years, in contrast to the media reports suggesting otherwise. ASPS reported’: There were 220,077 procedures in 2002 representing 3.2% of the total; there were 178,041 procedures in 2006 representing 1.6% of the total; there were 131,877 procedures in 2011 representing 1.4% of the total; there were 130,502 procedures in 2012 representing 1.3% of the total.[4]

ASAPS statistics show that the number of lipoplasty procedures has decreased from 2,504 in 1997 to 2,253 in 2012, whereas there were 3,576 breast augmentation procedures performed on women 18 and under, 1.1% percent of the total number of breast augmentation procedures. The reasons for surgery were: 52% Cosmetic Bilateral Breast Augmentation; 15% Severe Asymmetry; 12% Poland's Syndrome (congenital absent breast); 10% Tubular Breast Deformity; 9% Congenital Micromastia (severe underdevelopment); 2% Other.[3]

The following are among the most common surgical procedures performed on those 18 years of age and younger, according to ASAPS statistics: Otoplasty, Rhinoplasty, Breast reduction, Correction of breast asymmetry and Gynecomastia. FDA (2006) approved use of silicone implants only in women above 22 years, whereas above 18 years of age saline-filled implants can be used.[4]

There are psychological studies which have reported a reduced psychological burden in teens undergoing cosmetic surgery, most significantly in the breast surgery group, suggesting that burden related to appearance-related issues particularly breasts, was significantly decreased after surgery. Authors concluded that surgery in this group may actually improve physical, psychological and emotional burden and improve condition of teenagers and attain bodily satisfaction, both for aesthetic and reconstructive issues.[5]

The Food and Drug Administration considers aesthetic breast augmentation for patients less than 18 years of age to be an off-label use. The FDA has not approved breast augmentation in patients younger than 18 for the following reasons:

Teens and their parents may not realise the risks associated with breast implants.

The teen's body may not have finished developing.

The teen needs to be psychologically ready to handle the outcome of surgery.[6]

Recently, there has been considerable focus on teenagers who seek breast augmentation. Breast augmentation may be performed for either reconstructive purposes related to congenital defects or for aesthetic reasons. Reconstructive breast augmentation is generally performed to correct asymmetry caused by congenital errors, trauma or disease, Poland's Syndrome and tuberous breast deformity.

Poland's Syndrome includes unilateral congenital abnormalities of the chest wall that may or may not involve the arm. The defining defect is the absence of the pectoralis major muscle. Additional findings may include underdevelopment or absence of one nipple. In females, one breast may also be underdeveloped or absent.

Tuberous breast deformities result from incomplete development of part or all of the lower portion of the breast. It can include skin deficiency and breast constriction. Also, breast deformities include supernumerary breasts or nipples. Injury or trauma to the chest may result in breast deformity requiring surgery for its correction.

Besides the conditions already mentioned, breast augmentation is often performed on teenagers to treat simple, unilateral asymmetric breast development. According to studies, patients undergoing corrective breast surgery are the most satisfied of all patients and have the most improved body appraisal.[5]

Teenagers who seek breast augmentation for purely aesthetic reasons often make the request around the time of high school graduation. Generally, they do not have underlying psycho-social issues but are concerned about appearance.[7]

Many times, teenagers requesting aesthetic breast augmentation surgery are younger than the legal age for medical consent and need parental permission for the procedure.

Informed consent

It is important that the adolescent patient completely understand the procedure, possible complications and likelihood for additional surgery at some future date.

As with all surgical procedures, appropriate informed consent will be required.

The education process associated with an informed consent should help the patient and the parent/guardian understand the risks, benefits and potential complications associated with the procedure.[8]

While breast implants have proven to be very safe, possible risks include bleeding, infection or poor healing of the incision and changes in nipple or breast sensation. Capsular contracture, implant leakage or rupture or wrinkling of the skin over the implant is also a possible risk and may require secondary procedures. All surgery also carries risks associated with aneasthesia.[8]

In India, the legal age for consent is 18 years. In our experience, gynecomastia is the most common surgery performed in boys, presenting as early as 13 years of age with moderate to severe enlargement of breasts, causing these children to abstain from outdoor sports, swimming, changing their dress to very loose-fitting clothes to hide their embarrassment, being teased and bullied in school as a result of their physical appearance, and in some cases leading to severe psychological issues. In a study by Nuzzi et al.[9] they recommended that “Health care providers and patients should be aware of the psychosocial impairments associated with gynecomastia and consider early treatment for adolescents suffering from this condition, regardless of severity. Otoplasty comes next and is common in both boys and girls.

PolyCystic Ovarian Syndrome is getting very common in Indian adolescent girls, and the hirsutism component frequently requires laser-assisted depilation, along with antiandrogen treatment and other measures like weight control, supported by a study by Salmi et al.[10]

Acne treatments are sought after quite often as severe acne in teens can be quite disfiguring as well as lead to scarring on face.

Striae treatments are also sought in teenage girls and boys, who have had childhood obesity and have lost considerable weight with striae developing around the shoulders and hips, chest and abdomen. Often lasers and other energy-based devices are used to minimise the appearance of these striae.

Also, we have observed that even in late teens, above legal age of consent, particularly rhinoplasty patients, are more likely to have emotional problems, difficulty in adapting to their new appearance and impatience in the recovery period. Therefore, it is wise to defer cosmetic surgery, where not absolutely necessary for reasons stated above, till they are 20 or above, and may still require parental guidance in their decision making.