LOS ANGELES — The baseball that hit Darlene in the face changed more than her appearance. It made her the butt of classmates' jokes. More importantly, she had trouble breathing. By 16, she wanted it fixed. Tony was also 16 when he reached the same conclusion about his oversized jaw.
They are part of a small but significant trend: teenagers turning to plastic surgery to solve physical deformities, correct congenital defects, or make them look and thus feel better about themselves.
Becca is one of those teens. She asked for breast augmentation for graduation from a New York City high school. So is William, who worked summer jobs in Indianapolis to help pay for surgery to remove excessive male breast tissue.
Experts say plastic surgery can be necessary for teens in some situations, but they question many of the procedures and worry that plastic surgery won't cure underlying problems.
Trending up or down?
The plastic surgery "trend" for teens depends on who counts and when. Researchers at the American Society for Aesthetic Plastic Surgery call reported increases a media concoction. Their numbers show a slight drop from 10 years ago. But in 2005 the numbers dipped, so now comparisons to that year show an "increase." They count about 209,000 procedures for all kids 18 and under.
The American Society of Plastic Surgeons said nearly 219,000 procedures were done just on teens in 2010. They said the most common were nose reshaping, male breast reduction, fixing protruding ears, breast augmentation and liposuction. Breast augmentation is not supposed to happen for cosmetic reasons under age 18, by FDA recommendations. But it does. Teens also underwent laser skin resurfacing, chemical peels and dermabrasions, counted in some statistics and not others. Botox injections were not usually included. That's on the rise among teens.
Because teens may be too young or immature to see future ramifications, may not have stopped growing, and may have unrealistic expectations of what procedures will do for them, doctors, teens and parents must step carefully as they explore the gray areas to decide whether to proceed, according to experts.
Some cases are black-and-white, said Dr. Anthony Youn, the Tony who had his jaw reduced as a teen and is now a plastic surgeon in Detroit. Most doctors believe what's called "ear-pinning" on minors is reasonable, though "when" is debatable, since a young child may not understand the risks and may be growing.
"Most would say injecting botox into a teenager to prevent wrinkles is morally reprehensible," as is liposuction or breast augmentation for a teen, he said.
What about a teen who wants a nose job to fix a "big bump" that's causing her misery among peers? It's an easy question if it also causes breathing problems. "If it's just cosmetic, you could live a happy life, but could it improve quality of life? Gray areas like that are what people argue about," Youn said. "I wouldn't say it's immoral to do this. As a father, it's not something I would do, but for a surgeon who feels it is a moral decision, I would not argue.
"The problem with kids is they are often not mature enough to make that kind of decision on their own," said Youn, who wrote "In Stitches," a book about experiences on both sides of the knife. "Women can go their entire lives with small breasts and be happy and normal and that's not something that needs to be done. It's not the same as someone in chronic pain because breasts are extremely large."
Talk it out
Determining whether to do a procedure requires good communication between doctor, patient and parent, and plenty of parental support. Impetus to go forward must belong to the teen, warned Dr. Catherine Begovic, a plastic surgeon in Beverly Hills. "The responsibility of the doctor is to be sure the teenager is the one initiating it. I usually meet with them and their parents on multiple occasions before proceeding to get a good understanding of motivations and expectations," she said.
Teens tend to ask for plastic surgery to fit in. Adults seek it more to stand out, Begovic said.
Dr. Jeffrey Spiegel said cosmetic need resulting from trauma or birth defect is likely reasonable. Gray areas appear when a child is a teen and doesn't like the way his ears look or the bump on her nose. "Are they emotionally able to make those decisions?" said Spiegel, chief of the Division of Facial Plastic & Reconstructive Surgery at Boston University Medical Center. "I talk to the patient, talk to the family and then must use my judgment as to whether the deformity is substantial or not."
Some people feel strongly that appearance is not a reason for surgery, especially given risk. On the other hand, Spiegel acknowledged, "a beautiful teen with a very large nose" will have a different high school and college experience than she would if the nose was smaller. Fixing a substantial issue may be life-enhancing. Seeking help for a small deformity may signal emotional immaturity.
"A bad candidate is someone who has what most people would classify as a relatively small issue, but they find earth-shatteringly significant," Spiegel said. They won't go to a dance or be seen because of the hated feature. "These people are not ready for surgery and might need counseling for what is really going on."
He recently reviewed a case in the news of a girl who had surgery because her oversized ears resulted in bullying. "Though there may have been an indication for surgery, there are better ways to end bullying. You are going to have negative feedback for something your whole life," Spiegel said. "I don't consider that to be appropriate."
"It's important to understand the motivation behind the desire to have a cosmetic procedure, as you are often your own worst critic," said Dr. Daniel Bober, psychiatrist and assistant clinical professor at Yale. "The magnitude of the visible cosmetic concern and the expressed emotional distress associated with it can sometimes rise to the level of a mental illness if it affects your daily functioning."
Teens obsessed with body image concerns may suffer from body dysmorphic disorder, a type of mental illness, he said. They obsess about differences between their actual and their ideal selves. Mental, physical or emotional neglect can contribute to development of the disorder. When it occurs alongside depression or anxiety, if can significantly impair a young person.
Begovic cautions against teenagers who expect plastic surgery to fix personal issues, not just physical attributes. "Patients who seek surgery to be more popular, get a boyfriend, or just are not emotionally mature enough to handle the changes that come are not good surgical candidates," and Begovic declines the job. She may ask for assessments by psychiatrists and other specialists to help determine whether a patient should have surgery.
Those concerns are also all expressed by the American Society of Plastic Surgeons on the topic of teens seeking plastic surgery.
"Most of what I'm seeing is not bullying that I would think should result in plastic surgery," said Mary Pritchard, a psychology professor at Boise State University. "The latest hot graduation gift" is breast enlargement surgery. "I'm sorry, but that is not a graduation gift. What I am getting frustrated with are kids who want liposuction or breast augmentation for vanity reasons."
Bober knows of parents who gift plastic surgery for graduation and Christmas, too.
Pritchard said research shows when people get plastic surgery for appearance, improved self-esteem lasts a year or less. "Then they're back to where they were at the beginning — or worse."
She also warns that teens may think they know what they want, but the brain's decision-making functions aren't mature until about age 25. "If you haven't solved why you feel as you do about yourself, there are few things you can do externally to erase internal issues."
Advice for parents from the American Society of Plastic Surgeons includes making sure a teen's growth would not hampered, checking maturity and expectations, checking a doctor's credentials (states permit any licensed physician to claim to be a cosmetic surgeon whether trained as one or not; board certification is good), the facility's accreditation and whether the surgeon has operating privileges in an accredited hospital for that procedure.
"There are so many emotional dangers involved for teens that receive plastic surgery for cosmetic and not health reasons," said Erica Ives, marriage and family therapist and author of "Eating Disorders: Decode the Controlled Chaos." "As if developing an identity, striving for increased autonomy, building a sense of self, dealing with the immense physical changes and the tumultuous mood changes, along with evolving peer relationships, is not enough to deal with being a teenager. Bringing cosmetic plastic surgery in the mix is something that should be done with great caution and professional direction."
Not all plastic surgery is the result of teasing or bullying, "but it's clear more teens are undergoing invasive, sometimes dangerous procedures simply to feel they fit in," said Traci S. Campbell, coach, youth advocate and author of a motivational book and workbook called "The C.H.A.M.P. Within." "A far healthier alternative is to develop the character and confidence necessary to navigate adolescence with respect for yourself — and others.
"How much power are you giving the bullies?" she asked, referring to the girl who had surgery because of bullies. "There are kids at every high school who are not aesthetically popular, but are popular because of how they carry themselves. Just because (she) took the action of plastic surgery does not inoculate her from bullying. ... We don't know the end of that story."
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