All in the Family
Cosmetic Interventions for the Very Young, Teens, and the Very Old
CHILDREN
Cosmetic interventions as defined in this book—alterations of normal features—are rarely if ever appropriate for young children. However, children do undergo a variety of procedures to correct deformities related to imperfect development, injuries, or other causes. In many cases these deformities are corrected for the purpose of improving the child’s appearance and social integration rather than for any functional need. In this chapter I will not discuss surgery for cleft lip and related defects, microtia (severe underdevelopment of the ear), large moles, or treatment of large blood vessel abnormalities like hemangiomas because these deformities often have functional impact and do not properly belong in a book about purely cosmetic procedures.
Body image develops in childhood and evolves throughout adolescence. For the most part a child’s body image will adjust fairly easily to physical changes, although certain longer- lasting physical conditions may have more profound effects (for example, obese children may grow up to be adults who, despite normal body weight, see themselves as fat). For this reason surgeons try to complete reconstructions of congenital deformities during early childhood whenever possible.
Procedures for children that may have improvement of appearance as the primary goal include ear surgery (otoplasty) for prominent ears, excision or laser treatment of small blood vessel tumors (telangiectasias, spider angiomas, small hemangiomas), ear tags (branchial cleft remnants), treatment of port wine stains, and correction of problems related to ear piercing.
Fortunately, it is sometimes possible to obtain insurance coverage for these kinds of surgery in children, even when the same policy would not cover treatment of an adult with the same condition. In some cases, surgery can be performed with local anesthesia, although younger children and some older children do better with sedation or general anesthesia, especially for more extensive procedures such as bilateral otoplasties and laser treatment of large port wine stains.
Children should undergo procedures requiring anything more than local anesthesia only in a hospital or accredited ambulatory surgery facility that is properly staffed and equipped to take care of children. Fortunately, children usually do well after surgery. The two main categories of risks for children are those associated with general anesthesia, especially for the very young infant or any child with a respiratory illness, and those related to healing problems in a child too young to cooperate with postoperative wound care, thereby leading to poor scarring or the need for further surgery.
TEENS
Statistics
Of the roughly 333,000 cosmetic procedures performed on patients under the age of eighteen in 2005, the vast majority were performed on teens. Most of these were of the minimally invasive variety, often to treat acne-related conditions or for hair removal. Of the less than 80,000 reported invasive surgeries on minors, nearly two-thirds were rhinoplasties.
Psychological Considerations
Adolescents tend to fixate on visible body parts that fall anywhere outside the “average.” Typically, noses for boys and breasts and noses for girls receive the most self-scrutiny. Many teenagers, like adults, find the idea of a cosmetic intervention appealing and have a body feature that they feel could benefit from a little tweaking (even though most do not pursue surgery).
As a society we must be concerned about the effects of mediaperpetuated cultural “norms” on children. For those teens who do undergo cosmetic interventions, however, the psychological risks seem to be lower than they are for adults. Teenagers actually incorporate physical changes into their body image more readily than do adults.
One potentially psychologically risky practice that many cosmetic surgeons discourage is the “family combo.” Most commonly this scenario involves a mother and daughter undergoing the same operation (often rhinoplasty or breast augmentation) by the same surgeon on the same day. In the daughter’s case the procedure may be a birthday or graduation present. The emotional traps are numerous for the patients and the surgeon, especially if one patient gets a better result or has problems. Just as important, the mother who might otherwise be the designated caregiver becomes herself a patient, in competition with her daughter for attention during the recovery period.
Eating Disorders
Many parents are concerned about body image disturbances leading to unhealthy behaviors, including eating disorders, in their adolescent girls. Our culture is permeated with images of young girls that, for many parents, are too sexualized, too thin, or both. Cultural historian Joan Jacobs Brumberg (in Fasting Girls: A History of Anorexia Nervosa) and others have written at length about how our society has so successfully harnessed female sexuality to the interests of capitalist marketing.
An eating disorder is generally defined as a pattern of dangerous weight-control behavior usually associated with body image disturbance. The most well-known eating disorders are anorexia nervosa and bulimia nervosa. Although these potentially lethal medical problems can develop in members of almost any demographic group, they are disproportionately seen in young women and girls and may affect up to 20 percent of female college students. Eating disorders require aggressive psychiatric evaluation and treatment, and as a general rule cosmetic interventions are not appropriate for these patients. Having said that, there is some evidence that, in carefully selected patients, certain procedures such as breast reduction surgery may be helpful in the treatment of girls and women whose eating disorders stem from a specific body issue like overly large breasts.
Marketing to Teens
Since the dawn of the modern advertising age, the beauty industry has found teenagers, a population group already obsessed with appearances, to be an eager audience for its sales pitches. Teenagers report getting almost all of their information about cosmetic medical care from television and teen magazines. Undoubtedly, future surveys will add the Internet to this short list of information sources that exercise substantial influence over teens. There has been considerable controversy in recent years over the effects of advertising on teens, especially girls, and whether it predisposes them to eating and other body image disorders, self-esteem problems, and diffi culty handling pressures to be sexually active, among other concerns. The barrage of images of thin bodies, all irregularities airbrushed away, jar against the reality of increasing childhood and adolescent obesity in America. On top of the predatory media attention, teens watch as the adults around them seek cosmetic changes. A survey of readers of a magazine aimed at preadolescent girls asked for reader input on the topic of makeovers and managed to capture the confusion that many kids feel. One twelve-year-old wrote, “Aren’t adults always saying that ‘All that counts is on the inside’?”
Periodically, there is a mea culpa maneuver by the beauty industry to expand its imagery; for example, a decade or so ago magazines started to use more ethnic models. In mid-2005, magazines such as Seventeen, Teen People, CosmoGirl! and Teen Vogue claimed that they would be including more typically shaped girls in their pages.2 It remains to be seen how extensive this trend will be or how long it will last.
Specific Cosmetic Procedures for Children and Teens
Breast Surgery
For both girls and boys breast development during adolescence can be the source of considerable trauma. Girls are self-conscious about their budding breasts at any age, but a girl whose breasts do not develop in a way that she thinks is desirable may develop a variety of undesirable responses, including social withdrawal, posture problems, and even eating disorders. Certain breast confi gurations are the result of congenital deformities, such as Poland syndrome in which one breast, and sometimes the pectoral muscle and upper extremity on the same side, does not develop normally. Other potentially stressful breast configurations include lesser asymmetries, macromastia (a typical example of which is a twelve- or thirteenyear- old wearing a DD bra cup), hypomastia (minimal breast development), and in boys any degree of breast enlargement. These conditions are almost always within the range of what is considered normal, yet they can create great embarrassment for a teenager. Whereas timing is an important consideration for every teen who wants breast surgery, few cosmetic surgeons would debate the appropriateness of surgery for the problems just mentioned. In some cases the procedures may even be covered by health insurance. However, before agreeing to purely aesthetic requests—that is, for surgery on breasts that are developmentally within the normal or typical range and therefore should not be causing undo psychological distress—most surgeons feel that the patient should possess an additional level of maturity. The ASPS does not recommend purely aesthetic breast augmentation for girls under the age of eighteen. Hormone-induced pubertal gynecomastia in boys often subsides as the young men mature, but in some cases the breast tissue remains enlarged and will turn an outgoing, sports-minded boy into a hunch-shouldered adolescent who won’t take his shirt off in public. Breast surgery for gynecomastia in boys is sometimes, but not predictably, covered by insurance plans.
Several general rules apply to adolescents who wish to have breast surgery: (1) Pubertal growth should be complete and stable for at least one and preferably two years before surgery is performed. (2) Persis tent breast enlargement in boys and massive breast enlargement in girls warrant a hormone evaluation, usually by an endocrinologist, although most of the time the results of these evaluations will be normal. (3) Massive enlargement or severe psychological distress may warrant earlier surgical intervention, but patients and their families need to understand that early surgery includes the increased risk that a second operation may be required for the same problem in the future.
Ear Surgery
Surgery for prominent ears (otoplasty, ear pinning) can be performed with local or general anesthesia. After surgery the patient will have a head dressing for a few days and will likely have to wear ear protection twenty-four hours a day for several weeks and at night for months. Bruising and swelling are common, and final ear shape takes months to appear. Normally patients can resume full activities within a few weeks as long as the ears can be protected against injury. Boys are discouraged from future wrestling because even with headgear, ear injuries are very common in that sport. Scars are usually well hidden although occasionally will be problematic. Major complications are uncommon; irregularities, asymmetries, recurrent prominence, and need for additional surgery are quite common. Liposuction
Liposuction should not be offered to teens as an alternative to good eating and exercise habits, nor should it be used as a treatment for the residual and generally temporary fat distribution patterns of childhood.
Rhinoplasty
The shape of one’s nose changes dramatically during adolescence and can be the cause of considerable dismay for some. Rhinoplasty for adolescents is fairly common, and the results are usually quite successfully incorporated into both male and female teenagers’ evolving body images. This is a particularly important point for boys, who as teenagers tend to adjust much better to rhinoplasty than do their adult counterparts. All teenagers should defer nose reshaping surgery until facial bone growth is complete. This usually means delaying surgery until at least age fourteen or fifteen for girls and sixteen for boys. Decision Making for the Parents of Teens Making the decision to allow your teen to undergo a cosmetic intervention can be difficult, and in most cases it should be. Wanting to do it because “everybody else has done it” is not the decision of a mature individual and is not sufficient grounds to proceed. The ASPS has no formal policy on plastic surgery for teenagers but stresses that a patient should be physically and emotionally mature before undergoing a cosmetic procedure. The society reports that the most rewarding outcomes are likely to occur under the following circumstances:
• The teenager initiates the request.
• The teenager has realistic goals.
• The teenager has sufficient emotional maturity. In partic ular the teen must be able to handle temporary pain and disfigurement. Surgery is not recommended for teens prone to mood swings or erratic behavior, drug or alcohol use, depression, or other mental illness.
ELDERLY—OVER SEVENTY-FIVE
Elderly people—those over seventy- five years of age, say—do undergo cosmetic procedures, although as the available statistics do not stratify groups over age sixty- five, the numbers may not be large. Unfortunately, even the elderly cannot escape the buzzwords and images designed to convince them to buy cosmetic products and services. (My personal favorite absurdity: skin creams with calcium in them.) Several points regarding cosmetic procedures on elderly patients are worth mentioning:
• Elderly patients, properly selected, can undergo conservative cosmetic procedures safely, but one must always take into consideration their reduced physiologic reserve compared with younger patients.
• Older skin has less elasticity and less fat. Dramatic changes should not be expected, and overcorrection can lead to a very unappealing result.
• Bruising can be quite pronounced and prolonged.
• Long operations should be avoided to minimize risks of hypothermia, blood clots, excessive anesthesia, and joint stiffness leading to pain and immobility after surgery.
• A healthy person age seventy-five may have no higher risk than a person age sixty with multiple medical conditions.
• Cardiovascular disease is common in the older population and significantly adds to the risk of surgery for any patient.
• Drugs, including painkillers, anesthetics, and sedatives, must be used carefully and in lower doses in older patients.
• Nutrition should be emphasized before and after surgery and supplemented if necessary.
• Procedures should be performed in a fully equipped, accredited ambulatory facility or a hospital rather than in an offi ce setting so that sufficient resources are available in case of emergency
. Any high-risk patient should have surgery only in a hospital.
• Extra attention should be paid to ensure that an elderly patient will have adequate care and means of transportation for as long as necessary after discharge from the medical facility.
Tags: blood clots, Cardiovascular disease, conservative cosmetic procedures, excessive anesthesia, joint stiffness, rhinoplasty, risks of hypothermia