As the saying goes, "Just because you can doesn't mean you should," reflects the current dilemma presented to plastic surgeons. The demand for plastic surgery in adolescents has increased dramatically, despite the controversy over performing plastic surgery procedures in this population. In contrast to previous generations, this adolescent generation is particularly more exposed to social media influence and peer-related feedback.[5,50] They instantly receive external feedback regarding their body image from friends, peers, and unknown social media users, and they also follow celebrities on a daily basis.
This paradigm change in adolescent behaviors is evident in the rise of plastic surgery procedures performed in this group. According to the American Society of Plastic Surgeons, teenagers now constitute 4 percent of surgical patients and 1 percent of nonsurgical patients in the United States. Given the demand and popularity, the question of whether plastic surgery procedures in this group are indicated, safe, and ethical needs to be answered.
As discussed earlier, there are few indicated plastic surgery procedures for adolescents: rhinoplasty for cleft lip patients, breast reduction for symptomatic macromastia, otoplasty for prominent ears, and breast augmentation for congenital breast absence or severe asymmetry.[16,29,30,32] These procedures are extensively studied in the literature, and the benefits of performing them during teenage years are evident. However, there is a limited number of studies evaluating other indications for teenage plastic surgery.
Our study shows that the plastic surgical procedures in teenagers are safe, but there is a very limited number of studies on nonsurgical procedures. Our systematic review revealed that there were only eight studies evaluating laser, chemical peel, and microdermabrasion use in adolescents. Moreover, there were no outcomes studies on injectable use despite its increased popularity. For the surgical procedures, our study shows that the majority of complications were minor, such as poor aesthetic outcomes, recurrence of the deformity, and scarring. The most common complication for rhinoplasty, otoplasty, and reduction mammaplasty was poor aesthetic results (9.5 percent), pain (7.8 percent), and scarring (2 percent), respectively. Furthermore, there were no major complications such as death or venous thromboembolism. Our finding is in agreement with the complication and outcome study of adolescent plastic surgery using the CosmetAssure database. They reviewed surgeon-reported major complications in the database such as hematoma, venous thromboembolism, cardiac/pulmonary complications, and wound problems. In their review of 3519 adolescent patients, they had lower overall complications rates, and the most common complication was hematoma (0.34 percent), followed by infection (0.28 percent).
Collectively, our review of the literature suggests a lack of guidelines, outcome studies, and consensus on teenage plastic surgery despite its widespread popularity. Currently, the American Society of Plastic Surgeons recommends parental consent for all plastic surgery procedures performed on teens younger than 18 years and advises parents to evaluate the teenager's physical and emotional maturity. After review of our findings, we recommend the following when considering plastic surgery procedures in adolescents (Table 3). First, we recommend age 5 to 7 years for otoplasty. For cosmetic rhinoplasty, we recommend age 16 to 18 years for male patients and age 15 to 17 years for female patients if there is significant peer ridicule. We recommend age older than 18 years for cosmetic breast augmentation, breast reduction, and liposuction if the patient is unresponsive to diet and exercise. Similarly, we recommend age older than 18 years for chemical peels and cosmetic laser and injectables (botulinum toxin type A and fillers) unless the patient has early tear troughs, small lips, weak cheeks, and premature frown lines. Lastly, we recommend age 5 to 6 years to start sunscreen, age 16 to 18 years to start skin care, and age 16 to 18 years for Retin A (Ortho Pharmaceutical Corp., Raritan, N.J.).
In addition, we advise plastic surgeons to carefully evaluate the emotional and physical maturity of adolescents preoperatively. We recommend following recommendations for the American Society of Plastic Surgeons statement when evaluating adolescents: (1) the teenager initiates the request; (2) the teenager has realistic goals; and (3) the teenager has sufficient maturity. Plastic surgeons must discuss realistic goals and expectations with both the patient and his or her parents. As discussed earlier, teenagers may be misinformed on the effects of certain injectables, have ulterior motives for seeking plastic surgery such as celebrity worship, are being victimized by peers, or just want to "fit in."[6,14,50,51] Moreover, studies show that the decision-making competence of adolescents (sixth, eighth, tenth, and twelfth graders) lags behind that of adults in consideration of options, risks, benefits, and long-term consequences of their actions.[59,60] Therefore, an extensive preoperative visit is required to discuss the desire, goals, risks, expected postoperative course, limitations, and complications of the procedure. If teenagers are not mature enough to understand or accept both the risks and benefits of the procedure, we encourage applying "wait and see" to allow for additional maturity.
The limit of our study is the number of studies. To determine the safety of performing plastic surgery in adolescent patients, we specifically did not include studies with a mixture of adults and adolescents because of the infeasibility of separating patient outcomes. Many studies have presented their experience and patient outcomes in both adult and adolescent patients, but it was impossible to separate the two populations. In addition, most studies evaluated a mixture of children and adolescent patients, not a specifically dedicated group of adolescents.
Plast Reconstr Surg. 2018;142(3):293e-302e. © 2018 Lippincott Williams & Wilkins