Teens and Elective Cosmetic Surgery

An Expert Commentary on Real-World Scenarios

Sherrell J. Aston, MD; Robert L. Findling, MD, MBA; Laurie Scudder, DNP, PNP


February 23, 2012

Editor's Note:
The topic of plastic surgery in teens has been in the news lately and raises many clinical and ethical questions. Medscape asked experts in psychiatry, cosmetic surgery, and bioethics to help us explore this issue.

Robert L. Findling, MD, MBA, Professor of Psychiatry and Pediatrics at Case Western Reserve University and Director of Child & Adolescent Psychiatry at Rainbow Babies & Children's Hospital, presented the mental health perspective. Sherrell J. Aston, MD, Professor of Surgery in the Department of Plastic Surgery at New York University School of Medicine and Chairman, Department of Plastic Surgery, Manhattan Eye, Ear and Throat Institute of Lenox Hill Hospital provided input from the surgeon's perspective. The participants also discussed some cases that, although hypothetical, represent real-world scenarios.

Medscape: Appearance is important to all of us -- none more so than teens, who are often uncomfortable with their evolving bodies. Perceived flaws do not only diminish a teen's self-image but can affect his or her social interactions, leading to difficulties in school, withdrawal, or aggression. Teens sometimes have valid cosmetic conditions that may benefit from plastic surgery.

Child and adolescent cosmetic surgery is not new, but the topic has come to the forefront as a result of recent media attention. A major factor in consideration is the fact that the patient is still growing, both physically and emotionally. The decision requires input and agreement from both the child and the parent. What are the very first factors that a clinician should consider when approached about cosmetic concerns by either a patient or a family member?

Dr. Findling: It's important to understand the psychological effects of the cosmetic concern. Certainly, there are issues where cosmetic issues could clearly affect a youngster's emotional well-being. However, there are cases where the degree of the effect of a more modest cosmetic concern on the psychological state of the patient may be less clear. Along the same line, there are times when a patient may express negative emotional sequelae about a perceived flaw, and that cosmetic concern is not even readily apparent.

Simply put, discrepancies can exist between the magnitude of the visible cosmetic concern and the expressed emotional distress associated with it. Appreciating this disconnect can be quite important. This is because such disconnects can lead to unrealistic expectations about the degree to which a surgical procedure might improve a youngster's well-being. Certainly, when the discrepancy between the emotional concern and the physical manifestations are apparent, an understanding of such disconnects can be pivotal.

According to current psychiatric nosology, there is a condition known as body dysmorphic disorder. Patients with this condition may be inordinately distressed by or preoccupied with a minor or even nonexistent cosmetic concern. I should point out that body dysmorphic disorder should be differentiated from developmentally expected body image concerns.

Dr. Aston: First, it is important for the plastic surgeon to determine that the teenager, not the parents or boyfriend or girlfriend, is initiating the request for the cosmetic procedure. The surgeon must determine that the patient has reached a level of physical maturity and that further growth is unlikely to occur. The surgeon must also decide whether the patient's anticipated surgical result is appropriate and consistent with their anatomy, and whether the patients anticipated change in their life is realistic. The surgeon needs to determine that the teenager has realistic requests and goals, as well as sufficient emotional maturity to understand the nature of their requested surgical procedure, the potential problems, the recovery process, and the anticipated long-term results.

Medscape: You both referred to the importance of determining whether the teen's desire for a cosmetic change is realistic. Dr. Findling voiced concern that the magnitude of the perceived flaw may be less significant than the teen believes it to be; Dr. Aston noted the importance of determining whether the desired change is achievable. Recognizing that there is a degree of subjectivity to these assessments, what are the metrics that can be used to evaluate both the degree of distress and the desired change on the part of the teen? Are there strategies that should be implemented in the primary care arena -- where many teens and families will begin this process -- that can assist providers in making a determination as to which child and family can and should be referred for follow-up, whether by a cosmetic practitioner or a mental health provider?

Dr. Findling: From the emotional and psychological perspective, several strategies should be considered.

  1. Identify the cosmetic concern and try to gauge the subjective degree to which the cosmetic concern is "atypical." This assessment applies to both the youngster and the guardian. Compare this concern with that of the "typical" child and family -- recognizing, of course, that there is a wide range of "normal" and that a cosmetic issue that may cause great concern for one teen may be acceptable to another. That same range of perspectives applies to parents.

  2. Try to assess the magnitude of distress due to the physical concern.

  3. Try to assess the sequelae associated with the distress due to the cosmetic concern.

  4. Attempt to identify how the youngster's life might change due to the cosmetic surgery. Is the expectation reasonable or rational?

Although there certainly is a subjective quality to this, physicians, particularly those who are familiar with working with teens, can help identify thoughts, beliefs, and ideas that would raise red flags.

Dr. Aston: Dr. Findling and I are saying the same thing, just in different words. It boils down to the individual cases. I've operated on several thousand teenagers and can't remember a case where there was a postoperative psychological problem. In general, teenagers just want to correct their area of concern and get on with life. Teens, or adults, who are emotionally immature or have unrealistic expectations should not have surgery.


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