Needs and nonsense, truths and twists

A14-year-old boy with prominent ears was failing in school, academically and socially. According to his mother, every day was truly an exercise in survival outside the safety of his home. The repeated taunts and jeers led to reclusive behavior. Would correction be considered a beneficial move for quality of life and increased self-esteem? Or would it be an elective and unnecessary surgery for a teenager? He had ear-correction surgery, and afterward, his grades improved and he became more socially confident. He even joined the school band.

A 15-year-old girl who was a competitive athlete suffered from macromastia. She lived in the South and was called “Dolly Parton” by her classmates. Her overly large breasts caused physical limitations as well as social impositions. Was she too young to consider breast-reduction surgery, and would it be frivolous for her to do so? Prior to surgery, she was evaluated by an endocrinologist, who determined that she was hormonally mature, and by a child psychiatrist, who felt that she was capable of understanding the risks, benefits, and outcomes of surgery.

A 16-year-old boy had feminine-appearing breasts. He did not take his shirt off at the beach or participate in physical education class in school. Did he need to grow to adulthood before he could feel masculine? He had breast-reduction surgery, and afterward he was self-confident enough to join the wrestling team.

A 12-year-old girl was ostracized from her school social group because of her overly large nose, which was significantly disproportionate to her other facial features. She refused to go to school. Did she need to suffer until she was 16? Her parents did not think she should. Everyone involved understood that the fix might be temporary because she had not finished growing. Following rhinoplasty surgery, her personality blossomed and she became part of the “in group.” Indeed, the bump on her nose reappeared to some extent by the time she was 16. However, she was so socially secure by then that she chose to leave it alone.

A 17-year-old high school junior had significant mammary hypoplasia to the point that she felt masculine. She reacted to her “imperfection” by becoming anorexic. She wanted to enjoy a feminine silhouette, and she desired breast implants. I recommended continued psychotherapy and then, with the professionals and parents in agreement, to perform the surgery between high school and college. She is now a college graduate, she no longer has an altered body image, and she is engaged to be married.

A 14-year-old girl had significant mammary asymmetry. One breast was large and ptotic, and the other was small and tubular. No bra would fit her. As she matured socially, she became depressed. She would require a combination of breast-reduction and breast-augmentation surgery. Was she too young for the responsibility of a breast implant? Would she tolerate the scars of a breast reduction? She absolutely did. She is now content with her body, and she is on the tennis team.


Frivolity or Necessity?

Teenagers and plastic surgery! If you believe the media, it seems as though this is a new, explosive, and possibly frivolous phenomenon. The truth is that plastic surgery has been around for a very long time and, with the right patient, it provides an invaluable service for emotional growth and development. It is important for us as plastic surgeons not to confuse self-esteem issues with adolescent whim.

With younger patients, their central focuses  are now and always have been self-esteem, body image, peer pressure, and peer acceptance. Many well-documented studies verify the negative psychological influences that perceived physical flaws can induce.1–3 Many of these studies also center on how adults impart values and judgments on the younger set based on physical appearance. Even in the newborn nursery, the more attractive babies are placed in the front by the window, and in nursery school, teachers afford the “cuter” children more tolerance.4,5

It has also been well-documented that surgery for the right reason on the right patient at the right time will do wonders for self-esteem.6 Plastic surgeons all over the world can attest to the turnaround in their patients’ personalities following otoplasty, rhinoplasty, breast reduction, asymmetric breast correction, or gynecomastia surgeries. These are indelible truths, and they underscore the need for this type of aesthetic intervention.

The current crop of teenagers has been exposed to plastic surgery more than previous generations as a result of their continuous indulgence in the media through the Internet, television shows (“Extreme Make­over,” “I Want a Famous Face,” “Miami Slice,” “Dr. 90210,” and “Nip/Tuck”), and magazines (Teen Elle, Teen People, Cosmo Girl, and Teen Vogue). In fact, many teenagers have parents and grandparents who have undergone plastic surgery, thus making the topic less taboo and more mainstream. Also, the press has shifted away from focusing on the baby boomers and “the greatest generation.”

It is as though plastic surgery has become mainstream, and it is now not  generating news or ratings unless it’s dramatic—“If it bleeds, it reads.” Thus, the value of the right procedure for the right patient at the right time can be twisted by the media and may be exploited by our overindulged youth.

Many procedures are timed so that they are performed at critical social milestones: between high school and college, between middle school and high school, and sometimes even prior to the onset of serious peer socialization. The reason for this is to minimize the social and psychological impacts on the patient and to allow for a smooth emotional transition. The media have often misrepresented this timing to purport that teens are having surgery at younger ages and are even receiving plastic surgeries as graduation presents. This presents a perverse view of attempts to provide sound judgment regarding plastic surgery performed on teenagers.

The truth is that as the world’s population increases, so does the population of teenagers. Therefore, the absolute number of plastic surgery procedures increases likewise. Whether the percentage of teenagers having plastic surgery is increasing remains open to question. Only recently has the American Society of Plastic Surgeons made an earnest attempt to record statistics accurately with its tracking operations and outcomes in plastic surgery (TOPS) program.7 This responsible approach should clarify the rate of growth of our specialty in all age groups, and should take into account new and emerging procedures that can impact the numbers.


Surgeons’ Responsibilities

Responsible Board-certified plastic surgeons will look at the individual patient—whether a child or an adult—and make an informed decision based on the risks, benefits, and outcomes of surgery. The surgery must be appropriate and necessary. It is also necessary to cull out the interlopers into our specialty who view teenage plastic surgery as a new media-generated marketplace. It is easy to use the media—via public relations and advertising campaigns—to create false and undeserved images of excellence and authority, and to prey upon the unsophisticated patient.

Teenagers exist in a precarious age group in which peer pressure is great. If you undertake their care, you must be prepared to deal not only with the teenager, but also with the entire family.8 You also must be aware of the truths behind plastic surgery for teenagers and the perverse twists that marketing professionals and the media can place on their needs and wants.

As Board-certified plastic surgeons, one of our missions is to be the guardians of self-esteem—especially when physical issues have psychological ramifications.9 We need to raise the banner of quality and excellence and be able to justify what we do for our patients’ benefit. We need to be able to see the truths behind what we do and prevent the media from twisting them. We also must be able to determine what is beneficial and what is nonsense—like the teenager who wants a quick fix, or brings in pictures of celebrities and requests their features. Sometimes, we need to say no! n

Frederick N. Lukash, MD, FACS, is in private practice in New York City and Manhasset, NY. He can be reached at (516) 365-1040 or drlukash@aol.com.


References

1. Macgregor FC. Social and psychological considerations in plastic surgery: Past, present and future. Clin Plast Surg. 1982;9:283.

2. Berscheid E, Gangestad S. The social and psychological implications of facial attractiveness. Clin Plast Surg. 1982;9:289.

3. Lukash FN. Adolescent plastic surgery. Child Hosp Q. 1996;8:73.

4. Clifford MM, Walster F. The effect of physical attractiveness on teacher expectations. Soc Educ. 1973;46:248.

5. Dion K, Berscheid E, Walster F. What is beautiful is good. J Pers Soc Psychol. 1972;24:285.

6. Lukash FN. Children’s art as an index of anxiety and self-esteem with plastic surgery. Plast Reconstr Surg. 2002;109:1777.

7. American Society of Plastic Surgeons. Tracking Operations and Outcomes for Plastic Surgeons. National Data Base. Available at: https://secure.dataharbor.com/tops/index.cfm?action=dsp_login&showlogin=1. Restricted site.

8. Lukash FN. Children are not small adults. Plastic Surgery Products. 2003;13(11):47.

9. Lukash FN. Guardians of self-esteem. Plastic Surgery Products. 2004;14(7):58.