Families should consider risks of teen cosmetic surgery

How young is too young to have plastic surgery?

In the aftermath of a $20 million-plus court award in Pennsylvania to a family whose 18-year-old daughter died from what was likely a pulmonary embolism after liposuction, some parents may be wondering whether cosmetic treatments in teens are safe. U.S. News and World Report asked Richard D'Amico, president of the American Society of Plastic Surgeons, what families should consider when deciding whether to take the plunge.

Q. How do doctors determine if surgery in teens is appropriate?

A. I think it's important to draw a distinction between teenagers who are younger than 18 and those who are older. At 18, these individuals are adults in the eyes of the law and are allowed to make the decision on their own. For those under 18, it becomes a family and parental matter.

We also have to distinguish between procedures that are purely cosmetic and those that are reconstructive.

Several factors are important in deciding when and for whom surgery is appropriate: an ability to understand the procedure; that the desire for surgery does not reflect what a parent, friend, or boyfriend desires; and that expectations are realistic.

If your expectations aren't realistic and you have low self-esteem or no friends, cosmetic surgery is not the right answer. Rather, I would recommend counseling. But if a young person has good self-esteem and good family support, can understand what's going on, and has realistic expectations, then surgery may be appropriate. The need to know all these things is what makes the consultation so critical.

It can be entirely appropriate for teenagers under 18 to undergo reconstructive procedures. This is most often for maldevelopment of the breast in girls (which can include deformities and severe underdevelopment of the breast and nipple) and overdevelopment of the breast in young teenage boys - a condition known as gynecomastia. When girls' breasts are too big for their bodies, a breast reduction is also considered a reconstructive procedure.

Q. What about cosmetic or aesthetic procedures?

A. On the cosmetic side for those under 18, we're really talking about rhinoplasty, where the primary endeavor is to improve the appearance of the nose, whether or not there is a problem with the septum. Both the U.S. Food and Drug Administration and the American Society of Plastic Surgeons feel that young women under 18 should not get breast implants for purely cosmetic reasons.

Once a teenager reaches 18, we can perform cosmetic enhancements or enlargement of the breast using saline implants. FDA guidelines suggest waiting until 22 years of age before using gel implants.

Q. Is it considered OK for teens who are concerned with their weight to get liposuction?

A. It's generally discouraged in teens younger than 18 with weight problems. It's recommended that weight loss is addressed and controlled with diet and exercise. The body contouring technique is not a weight loss tool, and that is true at any age. In fact, if someone is grossly overweight, he or she has to get to a better weight before liposuction is considered.

There are a lot of teenagers with psychological issues related to their weight. And while as plastic surgeons we usually don't get involved in counseling, if someone who is 15 or 16 is obsessed with their weight, counseling can be very helpful.

Q. And for teens 18 and older?

A. It's a very reasonable and useful tool, but we like to have people with the maturity to be able to manage their weight with diet and exercise. Then contouring improvements can be made.

Q. Are teenagers more susceptible to certain complications than adults are?

A. No. But people need to know that cosmetic surgery is still surgery and, though extremely rare, there are risks. Before we even go ahead with surgery, the family and the teenager need to understand the potential risks from both surgery and anesthesia.

However, there are instances where the teenage body is still growing and we don't operate on structures if they need time for further growth. With rhinoplasties, the issue is usually that the nose is already too big, so further growth will not be beneficial.

Q. Can you describe what happens at a typical consultation?

A. When a teenager who is younger than 18 comes in for the consultation, he or she must be accompanied by a parent or guardian. We first sit down and discuss the patient's request--in this case it would almost always be rhinoplasty--and we make sure it's something the teenager actually wants.

You can tell when people want something or if they're simply there because mom has expectations of the teenager's appearance. Those things come out in the discussion. We find out if the teenager's expectations are realistic and ask them point-blank why they want the surgery. They have to be able to talk and communicate their desires and not just parrot what someone else told them.

If their reason is just that their boyfriend wants it or because some friends tease them, then that's inappropriate and I wouldn't offer that family the surgery. In that case, I would postpone the discussion until they're really ready. What you want to hear is that the teenager wants the surgery for themselves. And as we talk to them, we determine what their self-esteem is.

Q. What then?

A. If I don't think they're ready, I'll tell the parents that yes, there may be an issue with the teen's nose, but I don't think this young person is ready yet. Let's talk again next year. If the teenager believes that if only she got her nose done, she would no longer be ostracized, then I'd refer her for counseling. I also look at the level of parental support.

You really have to look at personal maturity and make sure that the expectations are realistic. Certainly parents can seek a second opinion, but they must treat what the surgeon says very seriously.

Q. What are the main considerations a parent and teenager should take into account when deciding on plastic surgery?

A. No matter what someone's age is, patients should always choose a plastic surgeon certified by the American Board of Plastic Surgery. The second critical element is to make sure the surgery is carried out in a licensed hospital or accredited facility because complications can happen to people of all ages.

Make sure you sit down with the plastic surgeon and have a thorough consultation that goes beyond just the area of concern, particularly with teenagers. This includes a thorough physical exam and all preoperative testing. The doctor should get to know the teenager and make sure he or she is emotionally ready and will be able to deal with complications if they come up. I see all of my patients twice before I do surgery, and I think it's a good idea to have the patient come back after the first discussion. It shows perseverance and drives home the point that this is a serious decision.

And if the patient is 18 and older, but still young, I encourage parents or guardians to be involved in the decision making, even though it is the patient's legal choice.