Created on 10th July 2009
It's ultimately the plastic surgeons that decide if a teen is eligible for cosmetic surgery. But does their largely unregulated clinical judgement really ensure the safety of our teenagers' bodies, and just who's looking out for their minds?
When Jenna Franklin declared in 2001 that she intended to get a £3,250 breast augmentation for her sixteenth birthday to take her modest 34As to an adult 34D, supported by her mother, a plastic surgeon, she fired up a fierce ethical debate across the UK.
Adding fuel to the fire in 2008 was BAAPS member plastic surgeon Douglas McGeorge who performed a rhinoplasty on a 14-year-old child to stop her being bullied at school. Whatever the reasons parents, children's charities, psychologists and governing healthcare bodies were all asking should children be having cosmetic surgery, whatever the circumstances? And is it legal?
The latter question is easier to answer, although it is not necessarily the right answer. The Department of Health does not state that cosmetic surgery should not be carried out on the under 18s, and it is not even law, more a matter of good practice, to have parental support between 16 and 18. This astonishingly means that a 16-year-old such as Jenna can legally have a breast augmentation if she could find a willing surgeon.
There are two types of surgeons; those that would operate on a teenager and those that wouldn't. Equally, there are two types of teenagers wanting surgery: those that would simply LIKE bigger breasts or slimmer thighs, for example, and those that actually have a physical abnormality such as breast asymmetry.
Jenna's surgeon eventually decided she was too young for breast surgery, but she is certainly not alone in her desire. In 2007, according to a Times report, statistics gathered from three of UK‘s biggest cosmetic surgery companies reveal that 600 teenagers had breast implants fitted in 2007, but the average age was higher - between 18 and 19 years.
Within private practices the figures are lower with over half (51 per cent) of BAAPS surgeons claiming to have operated on just 0-2 teenage patients in the last year, while one in ten saw 15 or more teenagers for consultations. BAAPS also claim that the surgeries that did take place were to address deformities or conditions such as breast asymmetry, breast reduction or ear pinning.
As children are still developing both physically and emotionally up to the age of 20, it brings into question both the safety issues and ethics of teenage cosmetic surgery. Reputable surgeons will not offer cosmetic surgery that is likely to dangerously accelerate the sexual or emotional maturity of a child - according to their judgment, that is.
There is of course an exception. "I wouldn't offer a breast augmentation to anyone under the age of 18 for purely aesthetic reasons," says past president of BAAPS and consultant plastic surgeon Douglas McGeorge. "But if there is an obvious abnormality like breast asymmetry you don't have to wait until the age of 18 to have implants," he claims. "I see a number of girls who have one underdeveloped breast which you can help in these formative years with surgery, giving them a near normal adolescent and stop them feeling like freaks. So why put up with it? Part of being a good doctor is knowing what will help; by changing the physical we can give a psychological boost which can help to normalise the individual."
Norman Waterhouse, another BAAPS past president and author of Cosmetic Surgery: The Facts, says, "There are some things in life you should wait for and cosmetic surgery is one of them." Yet like fellow BAAPS member Douglas McGeorge, Norman has operated on teenagers. "The only cosmetic surgery really acceptable for an under 18 is a rhinoplasty," says Norman. "I think that noses, because they are right on the centre of the face, can cause enormous problems. Breasts can be hidden, a nose can't. At aged 16 to 17 noses are not going to change or improve. Operating does not disturb growth in any way and can really help a teen who is feeling isolated and lonely; there's no downside."
This means that the big decision to operate or not is largely down to the discretion of the surgeon. That decision is based on a number of unofficial assessments which surgeons themselves are entrusted to investigate thoroughly. Has the teen reached physical maturity? Is there a physical abnormality? Are they suffering from a distorted body image or low self esteem? All young people during their teens are, to varying degrees, on a hormonal rollercoaster and are likely to be dissatisfied with their bodies at some point. For many, these body woes often pass with growing maturity and developing bodies. Surgeons must ask if surgery is really necessary and if therapy could help instead?
In the case of Douglas's 14-year-old rhinoplasty patient, surgery was a last ditch attempt to stop her being bullied about her nose at school. "She had been through counselling and surgery was her last resort. Her nose was out of proportion to the norm. When I saw her a few months later, she'd gone from introverted to extroverted with her hair confidently tied right back to reveal her new profile."
Psychologists, however, believe surgery does not always treat the root of the problem and can add to emotional issues. But it can, in part, depend on the type of surgery undertaken. Research indicates that breast augmentation patients are four times as likely to commit suicide compared to other plastic surgery patients.
"This raises questions about the mental health of the women who choose implants and the psychological benefits of the surgery," says Professor Diana Zuckerman, in a report published in the US Journal of Adolescent Health in October 2008. "Liposuction is also of particular concern because of its association with eating disorders."
For a teen to undergo extensive and risky surgery in the pursuit of physical perfection when there are any one of these psychological imbalances, could be a huge mistake, so surgeons need to be able to detect such emotional issues. "Around 10 per cent of patients who seek surgery suffer from a serious psychiatric problem such as body dysmorphic disorder and it's important they're identified," says UK consultant psychologist Dr Eileen Bradbury, a member of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS).
When there are huge financial gains to be had, it might be the case that some surgeons do not routinely refer patients. In her recent report, Professor Zuckerman brings the motivations of privately practicing surgeons into question. "It is difficult for a physician to neutrally present both the risks and benefits of an elective procedure that he or she is simultaneously selling."
Dr Eileen Bradbury agrees. "Surgeons have a duty of care but they don't always exercise it well. There are some seriously dodgy operators in this field because there are huge financial gains to be made. I have prepared many clinical negligence reports against plastic surgeons operating in the UK. Some have had only minor training and others don't even speak English.
"If cosmetic surgery is the only option, make sure you research the surgeon as part of a thorough safety check. It is much harder to check out the history of a surgeon within a large hospital group as often you are not told which surgeon will perform the operation."
In the States, the issue is far more prominent. Of the 13-18 year old group, 81,885 had cosmetic procedures in 2008 to correct something that made them self-conscious, according to the American Society of Plastic Surgeons (ASPS). While in the UK BAAPS' members say that the number of young people enquiring about surgery may be significant, but those having surgery no longer appears to be on the rise. "Aesthetic procedures carried out on adolescents are quite unusual," claims Douglas McGeorge.
Despite this teenagers are still enquiring about and undergoing cosmetic surgery. "Teenage surgery may be decreasing with individual BAAPS surgeons, but I would suspect from my exposure to it, it is still increasing amongst clinics," explains Dr Eileen Bradbury. "I've been working in this area for the last twenty years and in the mid to late eighties it was rare to see a 15 or 16 year old about surgery, but it is not unusual now."
The silver lining is that at least surgeons are now referring patients to psychologists. With input from the newly formed British Academy of Cosmetic Practice (BACP) of which the Medical Protection Society and Dr Eileen Bradbury sit on the board, safety guidelines for child cosmetic surgery are currently under scrutiny and regulations are due to be overhauled with the government's Care Quality Commission by 2010.
"We have been working tirelessly towards regulation for 20 years," says Eileen. "Now we finally have the BACP and alongside surgeons and physicians we are training and setting up fellowships into specific procedures and introducing clearer guidelines for surgery."
Finally, the future for teens and surgery looks set to become more tightly regulated, closing the gap between a teenager's delicate mind-set and desire for surgery, and what should be legal.
Surgeons, who may no longer be the main decision maker under the new regulations, will undoubtedly breathe a sigh of relief.
The Expert View:
Three industry experts offer their views on teenagers and cosmetic surgery
What the independent surgery consultant says:
Wendy Lewis is a surgery consultant and author of Plastic Makes Perfect
"Teenage cosmetic surgery is tricky business. Though the average 18-year-old thinks of herself as being 25, her body, hormones, and psyche are stuck in teenage hell.
The most common operations for the under-18 set would be rhinoplasty, chin augmentation, otoplasty (ears pinned back), and breast reduction. These procedures can have tremendous impact on teens' self esteem when needed. For example, a girl who is struggling with 38EE breasts and abstains from gym or sports may feel like a different person after a breast reduction and blossom. Reducing a large nasal hump can make a shy teenager flourish into a self confident and social kid.
The procedures that should be thought about carefully are the quick fixes - lipo and breast augmentation and lip enhancement. In my view, these are best left until the early 20s when girls are more mature and can decide whether it is right for them.
Waiting is always an option and it is important not to rush into anything too young or before they are mature enough to understand the long term consequences."
What the psychologist says:
Eileen Bradbury is a consultant health psychologist and a BAPRAS board member
"It's incumbent that parents consider other means before surgery. If a girl is being teased about her breasts, help her build her self esteem, take her for a good bra fitting and encourage her to wait and see. Particularly of concern is any underlying depression which should be treated first.
In the past, surgeons were almost never referring potential patients to psychologists. They would often say to me, who do we refer to and how do we persuade the patient to go? If they refer to a psychiatrist, their analysis may indicate that the patient is not depressed, and they are safe to go ahead with surgery, whereas a psychologist could see the same patient and say they may well not be stable after surgery.
Surgeons need training to recognise the psychological needs of the patient."
What the UK clinic trainer says:
Lisa Littlehales is a nurse and national clinic trainer with the Harley Medical Group
"When it comes to cosmetic surgery, specifically breast augmentation, any younger than 18 and the patient could still be going through puberty and there is no way they should consider surgery.
It is quite rare that we'd see an 18 year old though. More often patients are in their early 20s and have been waiting a couple of years to see whether their breasts would grow bigger naturally.
But we would never discriminate against a patient because they were 18 - it's old enough, providing they have realistic expectations and a sensible attitude. Our unique nurse-led approach means a patient never sees a salesperson but a specially trained nurse and surgeon with the patient's best interests at heart, so they get the advice that's right for them."
CS&AM
