1. Nelson, Roxanne BSN, RN


Questioning cosmetic procedures in adolescents.


Article Content

The appropriateness of performing cosmetic procedures in children and adolescents under the age of 18 recently came under scrutiny when a high school senior died while undergoing breast augmentation. According to an online report by ABC News on March 25, Stephanie Kuleba was "captain of her varsity cheerleading team at West Boca High School, and she had been accepted to the University of Florida where she hoped to study medicine." But shortly after surgery began, Kuleba suffered complications and later died at Delray Medical Center in Delray Beach, Florida.


"The media has picked up the story, so this issue is getting more exposure," says Alan Gold, MD, president of the American Society for Aesthetic Plastic Surgery (ASAPS). Gold points out, however, that although this case is tragic, it wasn't the procedure that killed Kuleba. It's believed that the cause of death was malignant hyperthermia, a relatively rare metabolic condition that can be triggered by anesthetic agents.


"The same thing would have happened during any other type of surgery," he says. "The argument here is that she wasn't undergoing a necessary surgical procedure."


Kuleba's procedure was being done to correct asymmetric breasts.


According to statistics released by the ASAPS, there were "nearly 11.7 million cosmetic surgical and nonsurgical procedures performed in the United States in 2007." Since 1997 there has been a 457% increase in the total number of cosmetic procedures performed in this country, with the greatest increase seen in nonsurgical procedures, which includes botulinum toxin (Botox) injections, chemical peels, laser hair removal, and skin resurfacing.


In 2007 the top five procedures performed in people 18 years of age and younger were laser hair removal, microdermabrasion, chemical peel, otoplasty, and rhinoplasty. This age group accounted for 2.4% of all surgical procedures, with a total of 49,330 operations; there were 155,790 nonsurgical procedures.


Among the surgical procedures performed in this age group were 7,882 breast augmentations. But some reconstructive procedures are included in those statistics, according to Malcolm Z. Roth, MD, FACS, director of the Division of Plastic Surgery at Maimonides Medical Center in Brooklyn, New York. "I would consider correcting asymmetric breasts to be reconstructive surgery," he says. "The patient may need an implant on one side or a lift on the other. It can be emotionally distressing to have asymmetric breasts, especially during adolescence, which is an important psychological stage. Having surgery can have an enormous impact on patients' lives."


Otoplasty accounted for the largest proportion of surgical cosmetic procedures in teens in 2007: more than 12,400 procedures were performed. Rhinoplasty accounted for 10,709 procedures. Nonsurgical aesthetic treatments were far more popular, though, with laser hair removal topping the list at 75,457 procedures, followed by microdermabrasion, which 41,009 teens underwent.

Figure. Stephanie Ku... - Click to enlarge in new windowFigure. Stephanie Kuleba, center, with friends from her high school cheerleading squad in Boca Raton, Florida. The 18-year-old died, probably from malignant hyperthermia, after undergoing elective breast surgery.

Plastic surgery in teenagers is controversial, and some critics ask whether it's appropriate for a teenager to undergo a procedure that isn't medically necessary and carries some risk, including the risks posed by altering a body that's still growing.


Michael Peterson, EdD, associate professor and coordinator of the graduate health promotion program at the University of Delaware, points out that teenagers, especially girls, are often dissatisfied with their bodies. Television, movies, magazines, and advertising all idealize the human body.


"There is a lot of pressure on young girls to have perfect bodies and even more pressure to be sexy," says Peterson.


Gold believes that, in general, the personal motivations behind teens' desire for cosmetic procedures are similar to those of adults. "While adults are often seeking to have age-related changes made, the motivation for having a nose job at 16 is the same as it would be at 36," he says. "The evaluation of the patient is very similar, and age alone doesn't determine emotional maturity. I might see someone who at age 16 is more mature than an adult."



No studies on the effects of cosmetic procedures on natural growth have been conducted, and the decision to perform a procedure is left largely to the physician. Children's ears, for example, are often fully developed by age four, and the majority of patients who undergo otoplasty are between four and 14 years old.


"Otoplasty is most frequently done at age five or six and is considered a cosmetic procedure," says Roth. "However, protruding ears can be devastating for young children because they're often ridiculed at school."


Rhinoplasty is usually not performed until the nose reaches its adult size, which occurs between ages 15 and 16 in girls, and by age 17 in boys. The Food and Drug Administration (FDA) hasn't approved cosmetic breast augmentation in patients younger than 18 and considers such procedures to be off label. While the recommendation is not binding, most plastic surgeons will follow those guidelines, says Gold.


In its policy statement on breast augmentation in teenagers, the American Society of Plastic Surgeons (ASPS) follows the FDA guidelines and recommends that girls be at least 18 years old before having breast augmentation that is purely cosmetic. While the ASPS doesn't have a formal position on plastic surgery in teenagers, it states that to achieve a positive outcome, the desire for plastic surgery must begin with the patient.


"We want to make sure that the patient-rather than her mother, say-wants the procedure," says Leo McCafferty, MD, a spokesperson for the ASPS. "I typically meet with patients more than once, to make sure this is what they want and to find out if there are any underlying issues."


Conversely, there could be a situation where a teen is pushing for a cosmetic procedure and the parent doesn't want the teen to have it. "In those situations, it may be better to counsel the patient to wait until she or he is older," says McCafferty.


The ASPS also specifies that the teen should have realistic goals about the procedure and realize both the benefits and limitations of plastic surgery. Finally, teenagers must be mature enough to tolerate the discomfort and temporary disfigurement that is part of having any type of surgery.



Perhaps even more controversial than teenagers seeking cosmetic procedures is a movement in Australia to ban purely cosmetic plastic surgery in teens younger than 18. According to an April 21 article in the Australian, the government of Queensland is set to ban all cosmetic plastic surgery in anyone under the age of 18, and the government of New South Wales will introduce legislation in July that forces "teenagers seeking cosmetic surgery to observe a three-month cooling-off period-a move it says is aimed at curtailing unnecessary surgery."


In a statement reported on April 17 on the Web site Medical Search-Australia and New Zealand, Queensland's premier, Anna Bligh, insisted that the ban in Queensland wouldn't affect "procedures to correct deformities" or those addressing particular physical features that affect an individual's "medical, psychological, or social well-being." Roth, however, disagrees with having a government mandate.


"It shouldn't be up to the government to decide who is or is not a suitable candidate," he says. "And what is considered reconstructive and what is considered aesthetic can be a gray area."


"Part of a plastic surgeon's training is to learn how to screen patients," Roth adds, "to determine if their motivation is appropriate and if they are mature enough to understand the risks and benefits. An outright ban could be devastating for many teens."


Roxanne Nelson, BSN, RN