1. Wilhite, C. Leigh JD, RN, LHRM

Article Content

Despite a crashing economy, high levels of unemployment, record losses of medical and surgical insurance coverage, and current health care costs that continue spiraling out of control, the market for aesthetic surgical procedures remains strong and continues to thrive as a result of consumer demand. According to The American Society for Aesthetic Plastic Surgery, 2009 saw American consumers spend more than $10 billon on cosmetic procedures. Of the almost 10 million cosmetic surgical and nonsurgical procedures performed that year, two categories that included teens (up to the age of 20 years) accounted for 22% of all procedures (American Society for Aesthetic Plastic Surgery [ASAPS], 2010). This is not surprising, given the plethora of teen celebrities, like Heidi Montague, who are watched on weekly television as they transform their young bodies into superficial versions of perfection through frequent and multiple aesthetic procedures.


According to the February 2010 report of a study commissioned by the ASAPS and conducted by the independent research firm Synovate, 48% of respondents with an income of less than $25,000 approve of cosmetic surgery, 52% of respondents with an income between $25,000 and $50,000 approve, 55% of respondents with an income between $50,000 and $75,000 approve, and 62% of respondents with an income more than $75,000 approve. "Even in this difficult economic time, people are willing to invest in the things that improve their quality of life," said Renato Saltz, MD, president of ASAPS. "Feeling good about the way they look is high on the list of priorities for many Americans"("Almost Half," 2010).


Fueling the increasing teenage and budding adult cosmetic surgical market are reality shows such as Bridalplasty, which premiered on E! Network in November 2010. The premise of the show was competition among 12 engaged women in which the winner of the week's challenge received one plastic surgery procedure from her wish list. The winner of the overall competition received multiple plastic surgeries from her wish list and the wedding of her dreams. The winning bride's new look was not revealed to her husband until the day of their wedding. Teenaged consumers increasingly represented in this market give rise to ethical considerations and legal duties of health care providers that extend beyond those owed to cosmetic surgical patients in recent past.



While in the eyes of the law there is a bright line that distinguishes maturity based on the age, whereby those persons aged 18 years and older are adults who may make decisions on their own, the analysis for surgical providers to these individuals is not so simple. Because the benefits of cosmetic surgery are much more difficult to perceive than with other functional operations, ethical concerns abound. When teens and young adults are considering aesthetic surgery, practitioners must particularly consider both the psychological and physical maturity of young patients seeking cosmetic procedures. Particularly, does the individual possess the intellectual maturity to understand and appreciate what is involved in the procedure(s), as well as the risks that are inherent in both the surgery and the anesthesia that is administered? For example, most women have at least one serious complication within the first 3 years of breast augmentation, including infection, hematomas and seromas, capsular contracture, loss of nipple sensation, and hypertrophic scarring. In addition, breast implants interfere with mammography and increase the likelihood of insufficient lactation when a woman tries to breast-feed (Zuckerman, Anisha, & Abraham, 2008). Notwithstanding complications, breast implants typically last 10 years, subjecting the augmented adolescent to repeated surgeries throughout her lifetime (Institute of Medicine, 1999).


Other critical factors in determining when and for whom surgery is appropriate include that the desire for surgery is personal to the patient and does not reflect what the parent, friend, or boyfriend desires. Equally important is determining that the patient's expectations are realistic (U.S. News and World Report, 2008).


Physical maturity is of paramount concern when determining appropriate candidates for aesthetic procedures. The most obvious is the circumstance in which the teenage body is still growing. In addition to the development that may occur in the late teens, growth charts indicate that the average girl gains weight between the ages of 18 and 21 years, and that is likely to change her desire or need for breast augmentation as well as liposuction (Diana, Zuckerman, Anisha, & Abraham, 2008). Although the FDA approved saline breast implants for women aged 18 years and older, and it is legal for physicians to perform breast augmentation for anyone younger than 18 years as an "off-label" use (Food and Drug Administration, 2000), it was not until December 2004 that the American Society of Plastic Surgeons stated an official position against breast augmentation for patients younger than 18 years. The FDA guidelines suggest waiting until 22 years of age before using gel implants ("FDA Approves," 2006).



Cases relevant to aesthetic surgery typically find their way into the courts as claims of malpractice and/or lack of informed consent. There is a continuum of practice from minimal to gold standard excellence, which is considered acceptable, or standard of care. Only a breach of minimal acceptable standards that causes the aesthetic surgery patient injury constitutes malpractice. Many courts recognize that a bad, or even less than desired, result from cosmetic surgery alone does not establish a claim for malpractice (Wischmeyer v. Schanz, 1995).


Where lack of informed consent is a claimed relative to cosmetic surgery, the standard for informed consent is more stringent than for general surgeries. The standard is more stringent for aesthetic surgeries than for nonelective surgeries. Where teens are involved, that standard is most stringent and often involves claims that the teen lacked the capacity to consent for a number of reasons, which may include age of minority or medical or psychiatric conditions such as body dysmorphic disorder. Body dysmorphic disorder is defined as a preoccupation with an imagined or slight defect in appearance that leads to significant impairment in functioning. Average onset is 16 years of age (American Psychiatric Association, 2000). While body dysmorphic disorder is prevalent in approximately 2% of the general population, the prevalence may be as high as 7%-15% in the plastic surgery population (Sarwer et al., 2005).


Informed consent requires the surgeon inform their patients of (1) the nature of their disease, condition, or injury; (2) the nature and purpose of the proposed procedure; (3) the probability of risks and benefits of the procedure; (4) the disadvantages and limitations of the procedure; (5) reasonable alternatives to the procedure; (6) the risks and benefits of not receiving the procedure; and (7) who will be performing the procedure. The patient's understanding of this information must be assessed and the proposed procedure must be accepted by the patient. These same obligations have been extended to other health care providers, including advanced registered nurse practitioners and physician assistants. This duty may be voluntarily assumed by facilities that have nursing staff obtain the patient's informed consent. Voluntary assumption is accomplished through the policies and procedures of the facility or institution and should be considered most carefully by any nurse who has this duty and then placed upon them as a condition of their employment to ensure compliance and fulfillment of the duty the nurse owes her patient. Absent such voluntary assumption by the nurse's employer, the nurse's duty with regard to the informed consent process is limited to verification of the correct procedure, site, and patient with the surgeon immediately before the surgery, and possibly authenticating the patient's signature on the consent form as a witness.



In addition to the duties mentioned earlier, the plastic surgical nurse must be educated, trained, and prepared to screen their patients for psychological aspects that may warrant evaluation and treatment. Two thirds of plastic surgeons primarily utilize the nurses in their practice to screen and manage the psychological aspects of patient care (Borah, Rankin, & Wey, 1999). Consequently, the plastic surgical nurse must be proficient in communicating with the surgeon and coordinating such care. In addition to being supportive of her patient in evaluation and treatment of psychological aspects, where the patient is young, even though 18 years or older, the nurse should encourage the patient to involve his parents or guardians in surgery-related decisions.



As the cosmetic surgery market continues to thrive, there will be greater demand for aesthetic procedures by teens and young adults. Ethical and legal considerations specific to this population will be present in greater proportion in the plastic surgical nurse's practice, as will the obligations and duties imposed by practice standards and law.




Almost half of Americans approve of cosmetic plastic surgery regardless of income. (2010, ). Retrieved February 15, 2012, from[Context Link]


American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Arlington, VA: American Psychiatric Association Press. [Context Link]


American Society for Aesthetic Plastic Surgery (2010, ). Statistic, surveys and trends. Retrieved February 15, 2012, from[Context Link]


Borah G. L., Rankin M., Wey P. D. (1999). Psychological complications in 281 plastic surgery practices. Plastic and Reconstructive Surgery, 104(5), 1241-1246. [Context Link]


FDA approves silicone gel-filled breast implants after in-depth evaluation. Agency Requiring 10 Years of Patient Follow-Up. November 17, 2006.[Context Link]


Food and Drug Administration. (2000). Report on new health care products approved in 2000. Silver Spring, MD. [Context Link]


Institute of Medicine. (1999). Safety of silicone implants. Washington, DC: National Academies Press. [Context Link]


Sarwer D. B., Cash T. F., Magee L., Williams E. F., Thompson J. K., Roehrig M. A., et al. (2005). Female college students and cosmetic surgery: An investigation of experiences, attitudes, and body image. Plastic and Reconstructive Surgery, 115, 931-938. [Context Link]


U.S. News and World Report. (2008, ). Retrieved February 15, 2012, from[Context Link]


Wischmeyer v. Schanz. (1995). 449 Mich 469, 484; 536 NW2d 760. [Context Link]


Zuckerman D., Abraham A. (2008, ). Teenagers and cosmetic surgery: A focus on breast augmentation and liposuction. Journal of Adolescent Health, 43(4), 318-324. [Context Link]