Adolescence is the transition period between puberty and adulthood and is being increasingly recognized as an important subgroup in those demanding cosmetic or esthetic procedures to improve physical appearance. Although the World Health Organization defines an adolescent as a person between 10 and 19 years of age, it is commonly the teenage period, between 13 and 19 years. The explosive use of social networking sites such as Facebook, Twitter, and Instagram and the easy availability of smartphones and the Internet are the game changers in an adolescent's life. They are among the most common activities of today's children and adolescents, which serve as a portal for communication and entertainment. Their activities and lifestyle have become an open book, with physical appearance playing a major role in their interactions with their peers. Selfies are shared, and instant negative feedback and comments are making more and more teenagers seek cosmetic procedures to have a perfect look.
Cosmetic procedures are techniques, invasive or noninvasive, to change the appearance and achieve what patients perceive to be more desirable. Teenagers post photographs of themselves, see the photographs of others, and compare one's body image. Adolescents of today's generation are more vulnerable to being bullied and teased about their appearance than the previous generation. This leads to poor self-esteem and psychological stress. In addition, there are a lot of apps and games based on appearance and cosmetic surgery, which are luring children as young as 8 years into the world of cosmetic surgery [Figure 1]. The motivation for cosmetic procedures in teenagers is often different from adults. They want to fit in with their peers. Parents and physicians alike face a dilemma when adolescents seek cosmetic procedures to improve their self-confidence. Hence, the cosmetic surgeon should be well versed with the nuances of procedures in teenagers and be able to distinguish between what is safe and what can wait. This review addresses the various aspects of cosmetic surgery in adolescents.
The Rise in Teenage Cosmetic Surgery
There has been an exponential rise worldwide in teenagers as young as 15 years seeking consultations for cosmetic procedures. This is fueled by their obsession with physical appearance and the rising incidence of body shaming by their peers. According to the American Society of Plastic surgeons, 14,000 cosmetic procedures were carried out on adolescent patients in 1996. The numbers increased to 229,000 cosmetic procedures on patients aged 13–19 years in 2017, but 2018 has shown a slight decrease at 226,984. Of these, 162,000 were minimally invasive and 64,994 were surgical procedures. India ranks among the top five countries in the number of cosmetic surgeries being performed overall, with 895,896 being the total number of procedures in India, of which 390,793 were surgical and 505,103 were nonsurgical in 2018. In India, a 30% increase in cosmetic surgery for children under 18, including boys and girls, has been reported over the past decade. One of the factors attributed to this rise is bullying by peers, leading to poor body image. This spurt in demand and consultations occurs mostly before they start college or their careers.
Reconstructive versus Cosmetic Surgery
It is important to differentiate reconstructive surgery from cosmetic surgery. Reconstructive surgery is performed to restore proper function to any area of the body that is deranged due to congenital development such as a cleft lip or palate or has been disfigured or damaged due to trauma. On the other hand, cosmetic surgery is a procedure performed solely for the purpose of improving appearance for non-medical reasons.
Important Aspects to Keep in Mind When Considering Cosmetic Surgery for Adolescents
It is critical that parents as well as physicians fully understand the various aspects before undertaking such procedures.
It should be remembered that children's bodies continue to develop well into their mid-20’s. The dissatisfaction issues of a particular body part such as the breast, nose, or lips the child has as a 13 year old may naturally correct or diminish through the natural development process by the time the child is 18 years. The procedure may not be required then.
Adolescents are emotionally vulnerable to peer pressure to look a certain way and more so because their bodies are rapidly changing with puberty. They have a strong desire to “fit in” with their peers and can easily be cowed down by body shaming and cyberbullying. Parents and doctors need to take a sympathetic stance when dealing with them and handle the emotional aspects delicately, rather than disparagingly.
Adolescence is a key time in body image development that can motivate many self-improvement behaviors, such as dieting and exercise. They are mentally immature and tend to think that societal conformity is normal, which may lead to risky behavior and procedures. They may not be capable to understand that they can be different and yet normal.
Beneficence, nonmaleficence, and autonomy are the key ethical aspects of medical practice. Nonmaleficence is the physician's duty to reduce risk, and beneficence is the duty to maximize benefit. It is the duty of the physician to not only avoid harm to the patient, but also weigh the risks of the surgery versus the needs of the patient. Ethical aspects imply whether catering to the adolescent's desire for cosmetic change is in the patient's best interests or not. It is the duty of the physician to inform the patient and the caregivers of the risks associated with the procedures.
In addition to the ethical aspects, there are several legal aspects which must be considered. Informed consent of adolescents is a complex issue. The legal age of giving consent is 18 years. In any cosmetic surgery on teenagers, it is safer to have informed consent of the parents, even though they are “mature minors” and capable of understanding. Informed consent is a decision-making process based on the full disclosure of the procedure and the risks involved through the interaction between surgeon himself/herself and patient/parents over time and not just a signature on a consent form. Patients must be given enough time to assess the risks of the procedure, make decisions, and ask all the questions they wish to ask.
In the past, cosmetic surgery was performed with the purpose of restoring a disfigurement or a serious wound, or scars caused by an accident, illness, or birth defect. Today, the majority of cosmetic surgeries are performed for esthetic purposes to improve normal appearances. Adolescents have an idea of beauty which mirrors the current trends, and most of it is synthetic or unreal seen from social media and magazines with photoshopped photographs. They get obsessed with their body image and can go into isolation, depression, and even suicidal tendencies if this is not achieved. Most cases of body dysmorphic disorders (BDDs) develop during adolescence. Though the incidence varies, it is usually reported at 5%–15% of patients who present for cosmetic disorders, which may meet the diagnostic criteria for BDD. The surgeon should be able to recognize early symptoms and refer to a psychologist who is well versed in dealing with adolescents.
Assessment and Counseling
Assessment and counseling is the most important part of the entire procedure and consultation. Listen and counsel, assess the reasons why, and give a 3-month cooling period, if it is decided to do the procedure. It is recommended that after the cooling period, another consultation should be done, and the adolescent should be assessed again. The first consultation should be by the operating medical practitioner and not with an agent or patient adviser. There must be an assessment of the person's motivation for seeking treatment. There is a need to ensure that the person has realistic expectations. If the requested surgery/procedure has no medical justification, there must be a “cooling-off” period of 3 months, followed by a further consultation. The patient can be prescribed topical therapy in the interim and the doctor should convey that their concerns are being taken seriously [Table 1]. The requested surgery/procedure should not be scheduled at the initial consultation. The person should be encouraged to discuss their desire for the surgery/procedure and any concerns. Surgical outcomes, including risks, poor results, and side effects as well as social issues, should be compared with not having the surgery. There should be a requirement for the person to be assessed by an appropriately qualified health professional (e.g., psychiatrist, psychologist, or specialist child counselor), if need be.
Body Dysmorphic Disorder
BDD is a psychological disorder where patients repeatedly seek cosmetic surgeries for correction of real or imagined defects. It usually begins in adolescence and has been shown that childhood neglect; emotional, physical, or sexual abuse; and bullying lead to a higher incidence of BDD in adolescents and young adults, which leads them to seek cosmetic surgery. It may not be apparent initially in the first consultation, and clues to a possible diagnosis include frequent mirror checking, excessive grooming, skin picking, acne excoree, frequently changing clothes, always comparing with others, and believing that others are constantly observing their defects. A study observed that 94.3% of adolescents reported moderate, severe, or extreme distress due to BDD; 80.6% had a history of suicidal ideation; and 44.4% had attempted suicide. A majority of patients with BDD are dissatisfied with their results and consultations and repeatedly seek treatments to find solutions for their defects. However, whether cosmetic surgery really has a positive impact on the quality of life is controversial. A study showed that cosmetic surgery may lead to significant improvements in depression and anxiety in some patients. However, some studies show that repeated surgeries do not improve BDD. Thus, there should be facilities for screening for BDD in teenagers who are obsessed with their body image.
Indications for Cosmetic Procedures in Children and Adolescence – What Teens Want
Teenagers commonly seek procedures for improvement of body parts such as the nose, ears, eyelids, chin, lips, and breasts, which they perceive are not conforming to what is called beautiful. Improvement of scars following trauma, burns, varicella, acne or surgery, nevi, and pigmentation is another area of concern [Table 2]. According to statistics, the top five nonsurgical procedures performed in teens are laser hair removal, laser skin resurfacing, botulinum toxin, laser treatment of leg veins, and chemical peels. The top five surgical procedures include rhinoplasty, breast augmentation, breast reduction of male gynecomastia, otoplasty, and liposuction.
Safety and Recommendations of Cosmetic Procedures in Adolescence
There are very few studies and hardly any guidelines regarding the safety of various cosmetic procedures in the teenage subgroup [Tables 3 and 4].
Scars not only cause cosmetic and functional disability, but can also cause severe psychosocial stress in adolescence. They can be atrophic, commonly following acne and striae or hypertrophic, commonly following burns [Figure 2]. Contractures over joints or around the lips or eyes also cause functional impairment. The necessity to actively treat scars in children and adolescents depends on many factors [Table 5]. Scars located over high-tension areas such as chest, shoulders, and ankle should be approached cautiously as they are prone to developing keloids. If there are fresh scars, they should first be treated with appropriate topical therapy as most scars will improve over time [Figure 3]. Old disfiguring scars on cosmetically important areas such as the face should be treated if they are disturbing and affecting the quality of life. Ear lobe keloids are particularly problematic in teenagers who go in for multiple ear piercings [Figure 4]. In a prospective study of 15 young patients with earlobe keloids, excision combined with intralesional steroids was effective, with recurrence in one patient at 18 months. However, pain is an important factor, and teenagers must be motivated enough to tolerate the procedures. Laser-assisted drug delivery, using a fractional CO2 laser followed by topical steroid, is another method that has been used in adults but can also be used in adolescents. The adverse effects of steroids is another concern in adolescent patients. Resurfacing procedures such as nonablative lasers (Erbium glass laser 1550 nm), pulsed dye laser (585 nm), or ablative lasers (CO2 laser 10,600 nm, fractional mode, erbium yttrium-aluminum-garnet [YAG] laser 2940 nm) can improve the scars. However, the risks of postinflammatory hyperpigmentation (PIH) and limitations of the procedure should be explained. For extensive scars or atrophic scars not responding to lasers, scar revision techniques such as scar excision may be employed. Contracted scars benefit from scar-lengthening procedures such as Z-plasty. However, these may be delayed for a year or more to allow for spontaneous scar maturation. Complex scars require a multidisciplinary approach for optimal treatment.
Laser hair reduction
Laser hair reduction (LHR) for hirsutism is a common cosmetic procedure sought by teenagers. The etiology should first be established and any hormonal disorder, particularly polycystic ovarian syndrome, should be treated before attempting laser hair removal. They should be motivated to make lifestyle changes such as dietary restrictions on unhealthy junk food, weight loss, and exercise. Ideally, one should wait and let the hormones stabilize. The minimum age of LHR is 2 years post menarche or 15 years of age. However, the procedure may be done earlier if hirsutism is severe inviting ridicule and affecting the quality of life or there is no response to medical therapy [Figure 5]. However, medical management must continue. They may also require maintenance laser therapy 2–3 times a year as hormonal levels fluctuate. Adolescents must be explained that fine hair is difficult to treat. Besides LHR of the face, many teenage girls also opt for underarms, arms, and legs or a full-body LHR. This freedom from fortnightly waxing regimens has really promoted LHR trends in teenagers who do not want hassles of hair growth on the body.
Boys are also catching up on this trend with beard shaping and LHR of the chest, back, and arms. The expectation in boys is normally to reduce the density of coarse hair on the body and a well-defined beard line for the metro sexual look. Outdoor activities, sports, swimming, and visiting gyms have led to this surge in boys seeking LHR. In the recent decade, the acceptance of LHR in patients and their parents has really gone up as elder siblings or friends have undergone the procedure. The procedure is safe provided it is done by trained qualified hands, using the right laser parameters.
Pigmented lesions such as nevus of Ota, freckles, and lentigines, which occur on the face, are common cosmetic disorders for which children and adolescents seek treatment. Pigmentary lasers (Q-switched neodymium-doped YAG [Nd:YAG] laser 1064 nm) may be used judiciously after discussion of the likely improvement and prognosis because the chances of recurrence are high. It is recommended that treatment should begin early in childhood to prevent darkening and worsening.
Tattoos and tattoo removal
Teenagers are most susceptible to peer pressure and follow their role models such as actors and sportspersons. They do not understand the risks involved in tattoos and body piercing and think it is very glamorous and “in” thing to sport tattoos. Since 1969, it has been illegal to tattoo individuals <18 years in the United Kingdom, however it is very prevalent world over. In an Indian study, the mean age of doing tattoos was 15.8 ± 3 years. It was reported that the most common reason for doing a tattoo was for fashion in 87.7%, fun in 6.6%, and peer pressure in 4.7%. These teenagers had poor risk perceptions about the various infections and complications of tattooing. Tattoo removal is another common indication for pigmentary lasers in teenagers. They get tattoos done without being aware of the permanent consequences and subsequently have regrets, seeking tattoo removal. The most common reason for tattoo removal in a study was eligibility for jobs (49.5%); regret (21.7%); social reasons, such as elder or school pressure (14.2%); personal (12.7%); and unsightly appearance and complications such as hypertrophic scarring in tattoo (1.9%). Tattoo removal is done by the Q-switched Nd:YAG laser, picoseconds laser, or combination techniques. Despite advances in laser therapy, tattoo removal is still difficult, is expensive, is painful, requires several treatments, and is rarely complete, without scarring. In their study on tattoo removal in adolescents, Cegolon et al. reported that male adolescents were less likely to be aware of the several issued regarding tattoo removal and they should be the target of health education.
Vascular lasers have been safely used in children for portwine stains and thus can be used in adolescence. Pulsed dye laser (585 nm) is the most effective. They are used mainly for the treatment of portwine stains, telangiectasia, and other vascular lesions. They are also helpful in the treatment of striae distensae in the early stages, angiofibromas and erythematous scars, and keloids.
Chemical peels are common cosmetic procedures demanded by teenagers after reading the net. They believe that they can magically improve acne and pigmentation and get an even skin tone and glow. Chemical peels should not be encouraged as first-line therapy and be done only if there is an inadequate response to standard treatment and it affects the quality of life. The risks, especially PIH, should be clearly explained. Salicylic acid, mandelic acid, and glycolic acid are common peels used for acne and dyspigmentation. Lactic acid peels are useful for acne and skin glow. However, when dealing with teenagers, it is important to discuss the peeling outcomes and risks involved. The risk of PIH is more common in dark-skinned individuals and in those with a recent tan. They should be motivated enough to follow proper home care regimens and be regular with their treatment.
Acne and acne scar surgery
Adolescents with acne suffer from more depressive symptoms, lower self-esteem, and lower quality of life when compared to adolescents without acne. This does not correlate with the severity of acne and unfortunately, how acne affects an adolescent's well-being is underappreciated. Procedures in active acne such as comedone extraction, cyst surgery, and chemical peels may be done if the response to standard therapy is delayed or is not tolerated. Procedures for acne scars may be done as indicated and if scarring is severe.
Mole and Nevus Surgery
There may be a spurt in the size and number of melanocytic nevi during adolescence, and adolescents may desire removal. Radiofrequency ablation, excision, or ablative lasers are the procedures of choice and may be undertaken if desired.
Stable vitiligo lesions unresponsive to medical treatment may be taken up for surgery, especially if they are on cosmetically sensitive areas such as the face and cause distress. Vitiligo surgery may be done in stable segmental vitiligo. In nonsegmental vitiligo, results are unpredictable in children and adolescents, and camouflage should be offered as an option till the child grows and vitiligo becomes stable. If stable lesions are present on cosmetically important sites, and are resistant to medical treatment, surgery can be an option [Figure 6]. Immobilization of the recipient area is an important step for success, and this should be emphasized to the adolescent. The possible outcomes, possibility of incomplete pigmentation, unpredictability of results over large areas, and likely complications should be discussed. Suction blister epidermal grafting has been found to be most convenient and effective for children and adolescents. Gupta and Kumar reported more than 75% repigmentation with suction blister grafting in 80% of children and adolescents with vitiligo. This success rate was better in children as compared to adults. However, suction blister technique requires prolonged immobility for generation of blisters, more so in children because of their strong dermoepidermal adherence. It may be difficult to keep them in restricted posture till the required duration. Hence, they require a high level of motivation to cooperate. Surgical procedures combined with medical therapy have also been tried in childhood vitiligo. In a randomized, placebo-controlled trial using microdermabrasion and pimecrolimus cream (1%) in childhood nonsegmental vitiligo, more than 50% repigmentation was observed after 3 months in 60.4% of patches treated with this combination as compared to pimecrolimus alone (32.1%) and placebo (1.7%). Noncultured autologous epidermal cell transplantation has also been used successfully in children and adolescents with stable vitiligo. Sahni et al. used this technique in 13 children and adolescents with stable vitiligo and achieved 75%–90% repigmentation at the end of 1 year. They reported that being a day-care procedure that could be performed under topical anesthesia made it a procedure of choice in children and adolescence.
Botulinum toxin therapy is a minimally invasive technique which has been used for facial reshaping such as for masseter hypertrophy, eyelid roll, bunny lines, gummy smile, and chin reshaping. However, in adolescents, it should be strongly discouraged, unless it causes severe psychosocial distress. The temporary effect of this procedure should be repeatedly emphasized. It is better to counsel them and their parents and wait for them to outgrow their insecurities. Psychotherapy may be of help in overcoming their distress. It has also been used for facial, axillary, and primary focal hyperhidrosis with great benefit in children and adolescents. It greatly improves the quality of life, social skills, and day-to-day activities.
Similarly, hyaluronic acid fillers have been used as minimally invasive procedures for nose or chin reshaping, facial reshaping and asymmetry, and also for under-eye dark circles. These should be strongly discouraged, till they are 18 years. Risks and complications of fillers should be emphasized, and their temporary effect should be discussed. Parents and teenagers should be advised to wait, and full psychological support should be provided to help them tide over their stress.
Though they are performed by plastic surgeons, dermatologists must be aware of the merits and demerits of these procedures in order to counsel their patients. Rhinoplasty is one of the most common cosmetic procedures requested by teens, more commonly by girls. The nose should reach its adult size before surgery can be considered. This should be performed only when the growth of the nose is complete and has reached adult size (15–16 years in girls, and age 16–17 in boys). They must be counseled that the surgery is permanent and cannot be reversed, hence there should be high motivation and understanding by the adolescent before the procedure. Complications of the procedure should be explained. A recent trend is to reshape the nose using fillers, which is a minimally invasive procedure. Patients could be offered this procedure, if they insist on it, as it is temporary and reversible. Correction of ear deformities, such as prominent ears (otoplasty), is another common procedure. The ears reach adult size by 5–7 years and otoplasty can be considered at an early age in adolescents if it causes stress. Liposuction and body contouring should not be encouraged and teenagers must be advised lifestyle modifications to lose weight. However, morbidly obese adolescents who have undergone bariatric surgery have excess of loose skin. Many of them develop depression and negative body image following surgery. They express their desire to remove excess skin and can be considered for body-contouring surgery. Breast augmentation must also be avoided till the teenager is at least 18 years, as hormonal changes stabilize. Plastic surgeons should carefully assess each adolescent requesting surgery and judge their motivations and expectations, as well as psychological stability prior to surgery.
There are hardly any studies which focus on complications in this age group. A majority of studies report a no-complication rate of 33% in nonsurgical procedures such as lasers and chemical peels. In one study, erythema was the most common complication (26.4%) and discoloration (5.7%) in patients undergoing laser therapy, while no complications were reported with chemical peels and microdermabrasion, except burning. The most common complication for rhinoplasty was poor esthetic results (9.5%), pain in otoplasty (7.8%), and scarring with reduction mammoplasty (2%). Yeslev et al. compared the complication rates of cosmetic procedures between adolescents and older adults and observed a lower incidence of major complications in adolescents (0.71% in adolescents vs. 1.99% in adults, P < 0.01). However, the likely complications, major or minor, as well as the risk of poor outcomes, must be discussed as teenagers may not be aware of the risks of procedures [Table 6].
What Doctors Need to Do
It is rightly said that “Just because you can doesn’t mean you should.” The physician should assess, counsel, and ideally involve the parents in the decision-making process [Table 7]. A cooling period gives time to the teenager and the parents to rethink. In the cooling period, the doctor can prescribe topical and systemic therapy to condition the skin. It also helps in judging how motivated the patient is in following instructions and detecting intolerances to medication. A wise doctor should try and convince the parents and the teenager that their strengths and skills should be appreciated and encouraged, and looks should be the last thing to worry about.
Adolescents seek cosmetic procedures to correct real or perceived physical defects. Exposure to social media, peer pressure, body shaming, cyberbullying, higher disposable incomes, reduced stigma, and easy availability of cosmetic procedures have contributed to this rise. Teenagers are also pushing the limits of human endeavor to change their appearance, far beyond the limitations of their age, looking beyond using make-up, grooming, camouflage, and body art.
Adolescents are very vulnerable to psychosocial stress, and their demands must be viewed sympathetically. What appears cosmetic to the parent, or even the doctor, may be essential to the adolescent! If demands seem unreasonable, subtle clues to the underlying BDD must be looked into. The field of esthetic dermatology and surgery is evolving quickly, with limited studies of safety and efficacy in the pediatric and adolescent age groups. In the absence of long-term research, it is difficult for physicians to impart accurate information on the risks of performing cosmetic surgery on bodies that have not reached maturation. The operative complications and long-term physical and psychological effects of these surgeries on distorted body image, that is common among adolescence, are unknown. As doctors, we must try and understand the needs of adolescents. We must customize solutions and act judiciously. Though children may benefit from thoughtful application of these technologies and procedures, we must be cautious in our approach.
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