Teens and Plastic Surgery: An Expert Interview With Michael F. McGuire, MD, President-Elect of the American Society of Plastic S
Posted Nov 19 2009 10:02pm
Having cosmetic surgery is a growing practice among teens. There is general debate about the appropriateness of cosmetic surgery in teens and whether they truly understand the risks involved. Medscape’s Pippa Wysong spoke with Michael F. McGuire, MD, President-Elect of the American Society of Plastic Surgeons (ASPS). He was a member of the team that authored the ASPS guidelines on cosmetic surgery in teens. Dr. McGuire is Associate Clinical Professor of Surgery at the David Geffen School of Medicine at University of California at Los Angeles (UCLA), Chief of Plastic Surgery at St. John’s Health Center in Santa Monica, California, and is board certified by the American Board of Plastic Surgery.
Medscape: Today we’re talking about plastic and cosmetic surgery in teens. Could you start by describing the main types of plastic surgery preformed?
Dr. McGuire: There are 2 basic reasons for performing plastic surgery in children and teens. The first, reconstructive surgery, is aimed at repairing defects that impair normal function. The other, cosmetic surgery, has more to do with improving confidence and self-esteem. We also perform reconstructive plastic surgery in newborns — for example, cleft lip and repairs of various severe birth defects.
Medscape: The popularity of cosmetic surgery in teens is increasing. Why is that?
Dr. McGuire: Plastic surgery is becoming more acceptable in the population in general. More teenagers are having it done. Parents are more accepting of it and are more sensitive to the role that appearance plays in self-image and confidence in teens.
Medscape: Which cosmetic procedures are the most popular?
Dr. McGuire: In the younger middle teenage years, the most common surgical procedure in both young women and men is rhinoplasty. Nasal surgery should be performed after the nose is fully grown, which is generally about age 14 in girls and 15 in boys.
Medscape: Which other procedures are common in teens?
Dr. McGuire: Breast reduction is relatively common. Some young girls develop overly large breasts, hypertrophy, at a young age. This procedure is also increasingly common in boys too (gynecomastia), with over 14,000 operations performed on boys aged 13-19 in 2008. On the other hand, some young women want breast enlargement because they want to have normal-sized breasts that are harmonious with their body. Then there are young women whose breasts grow to be noticeably different sizes, and so surgery is done to make the 2 sides equal.
Otoplasty (ear surgery) is a common procedure for kids around 6 years of age who are teased mercilessly by their peers.
Medscape: Surgery is a permanent thing; are teens mature enough to really understand that?
Dr. McGuire: In some cases, yes, and in some cases, no. It’s not only about their chronologic age but also their emotional age. Some teens are very emotionally mature, whereas some 25-year-olds are not. If a teen is emotionally mature and presents himself or herself as understanding what’s involved, why they’re doing this, and has realistic expectations, then it’s appropriate. But if a 12-year-old comes in wanting rhinoplasty and is unusually emotionally mature, it would still be inappropriate to do the surgery because her nose has not grown fully.
Medscape: Do teens really understand the permanence of procedures?
Dr. McGuire: There is the permanence of a procedure plus the risks of the surgery and having realistic expectations. It all has to be discussed carefully. One job of plastic surgeons is to detect unrealistic expectations.
Medscape: Are there guidelines or instruments available to help plastic surgeons with the psychological assessment of patients?
Dr. McGuire: It’s something that you learn during residency while watching your mentors evaluate patients. When you evaluate a patient, it’s not just the physical examination; it’s also an assessment of patients’ emotional and mental health and stability. Plus, the consultation is a 2-way street: The patient assesses the surgeon to determine whether the surgeon is competent, caring, and appropriate for them, and the surgeon assesses the patient for appropriateness for the surgery.
Medscape: If one surgeon decides that a teenager is not appropriate for surgery, can’t that patient just keep shopping around until she finds a surgeon that will do the job?
Dr. McGuire: Absolutely. When you have a patient who isn’t appropriate for surgery you don’t say, “Get out of here, you’re nuts,” or “You’re not appropriate.” Surgeons are obliged to do an educational session with that patient to explain why this is either not the right time or they’re not a good candidate. It’s a matter of educating the patient and cautioning them not to go to unscrupulous, untrained people who call themselves plastic surgeons who would perform the procedure anyway. Patients should look for an ASPS-member surgeon who is board certified in plastic surgery.
Medscape: Are surgeons actually taking the time to talk to young patients?
Dr. McGuire: If they’re not, they shouldn’t be doing surgery. There is much more to surgery than making incisions. You’ll get into all kinds of problems if you don’t properly evaluate the patient ahead of time. Patients should note that the so-called “free” consults with a nurse are not adequate; the surgeon must be involved.
Medscape: Should the number or type of cosmetic procedures that are available to teens be limited?
Dr. McGuire: Some types of procedures simply are not appropriate. For instance, we generally don’t perform breast implants until at least 18 years of age, and silicone implants can’t be done until patients are age 22. It’s unusual to perform breast reduction before age 15. An exception may be made for young patients with dramatically uneven breast development.
There are several procedures that are increasingly performed on teens. For example, liposuction in teenagers is discouraged, but some patients have specific medical conditions that make it appropriate. Obviously, it shouldn’t be done until nonsurgical approaches have been tried.
You should never do surgery — at any age or in any patient — unless the benefits outweigh the risks and the improvement that’s possible is greater than the costs and risks of surgery.
Medscape: This sounds like general guidelines. Are they enforced by any of the Colleges or other agencies?
Dr. McGuire: There are guidelines on the ASPS Website. However, there are no legal restrictions on performing cosmetic surgery on teens. If a plastic surgeon is doing breast implants on 14-year-olds, this should come to the attention of the national society and be subject to investigation, and potentially be considered unethical conduct.
Medscape: Should there be legal limits?
Dr. McGuire: There’s no legal prohibition, and that’s partly because there are often special circumstances. You don’t want a blanket statement. There are cases in which procedures are medically appropriate; you don’t want to be too restrictive.
Medscape: Australia recently passed legislation restricting cosmetic procedures in kids and teens. What do you think of that?
Dr. McGuire: It’s appropriate as long as it’s appropriately worded and unusual circumstances and exceptions are accounted for. That’s tough to do in legislation. Generally, it’s best handled within the specialty.
Medscape: Do teens ever have regrets about their cosmetic surgery in later years? Has anybody studied that?
Dr. McGuire: I’m not aware of any studies. There is always a small percentage of patients, at any age, who have some regrets. That’s why doctors need to try to evaluate “How are you going to feel about this in 2 or 3 years?” and not just “What do you want today?”
Medscape: Do you have any general tips or messages for surgeons on this topic of teens and kids?
Dr. McGuire: Approach teen cases with even greater concern than adults. Consider not only the age and the physical condition but the emotional maturity and mental stability of the teen, more so than in older patients. If it’s clearly an appropriate problem in an appropriate patient with appropriate emotional stability, the results can be more dramatic than in an adult, simply because the whole image issue in teens is much greater than it is in adults.