Here are two articles in medical journals about the psychological and ethical issues for teenagers considering plastic surgery.

Published in Journal of Adolescent Health, October 2008

Teenagers and Cosmetic Surgery:
Focus on Breast Augmentation and Liposuction

By Diana Zuckerman, Ph.D and Anisha Abraham, M.D., M.P.H.

Two of the most popular and controversial cosmetic procedures for adolescents are liposuction and breast implants. It this review article, the procedures are discussed. In addition, the physiological and psychological reasons to delay these procedures, including concerns about body dysmorphic disorder and research findings regarding changes in teenagers’ body image as they mature, are described. The lack of persuasive empirical research on the mental health benefits of plastic surgery for teenagers is highlighted. Finally, the long-term financial and health implications of implanted medical devices with a limited lifespan are presented. Adolescent medicine providers need to be involved in improving informed decision making for these procedures, aware of the absence of data on the health and mental health risks and benefits of these surgeries for teenagers, and understand the limitations on teenagers’ abilities to evaluate risks.

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Commentary published in the online ethics journal of the American Medical Association
Virtual Monitor, March 2005.

Teenagers and Cosmetic Surgery

by Diana Zuckerman, PhD

In 2003, more than 223 000 cosmetic procedures were performed on patients 18 years of age or younger, and almost 39 000 were surgical procedures such as nose reshaping, breast lifts, breast augmentation, liposuction, and tummy tucks [1]. As we consider under what circumstances plastic surgery is appropriate for teens, it is important to recognize that very few studies have been conducted to examine the risks for teens of these increasingly common procedures. Research is especially needed for the more controversial procedures such as breast implants, liposuction, and genital plastic surgery.

There is no question that reconstructive surgeries can benefit children and youth. Surgical procedures to correct cleft lips and palates, for example, are not controversial. Plastic surgery to correct unattractive facial features that can attract ridicule from other children, such as prominent noses and ears, are generally accepted in the United States. Cultural phenomena such as surgical makeovers on numerous television programs, however, make it increasingly difficult to agree on what constitutes a “normal” appearance and when the desire to improve one’s appearance is questionable or even crosses the line to psychopathology [2]. In this commentary, I will focus on elective, cosmetic procedures on an otherwise healthy adolescent with no illness or defect.

Plastic Surgery in a Developing Teen
One of the concerns about plastic surgery on adolescents is that their bodies are still maturing. In addition to development that may occur in the late teens, growth charts indicate that the average girl gains weight between the ages of 18 and 21, and that is likely to change her desire or need for breast augmentation as well as liposuction. There are no epidemiological studies or clinical trials on the safety and long-term risks of these procedures for adolescents. Although the FDA approved saline breast implants for women ages 18 and older [3], it is legal for physicians to perform breast augmentation for anyone under 18 as an “off-label” use, and the number of teens 18 and younger undergoing breast augmentation tripled from 2002 to 2003. It was not until December 2004 that the American Society of Plastic Surgeons stated an official position against breast augmentation for patients under 18.

Understanding the Risks of Surgery
Will adolescents who want to improve their appearance rationally consider the risks? Studies by implant manufacturers report that most women have at least one serious complication within the first 3 years, including infection, hematomas and seromas, capsular contracture (a sometimes painful hardening of the breasts), loss of nipple sensation, and hypertrophic scarring [4]. Since breast implants typically last 10 years, an adolescent will require repeated surgeries throughout her lifetime [4]. Breast implants also interfere with mammography and increase the likelihood of insufficient lactation when a woman tries to breast-feed.

The economic costs of surgery are substantial, since corrective surgery is rarely covered by health insurance. With many plastic surgeons offering breast implants on the installment plan, our Center (National Research Center for Women and Families) is contacted regularly by young women who need to have a broken or painful implant removed but are still paying for the initial augmentation surgery and unable to afford corrective surgery.

Liposuction also carries potentially serious risks. Primary risks include infection, damage to skin, nerves, or vital organs, fat or blood clots (that can migrate to the lungs, leading to death), and excessive fluid loss that can lead to shock or death. In addition, the different techniques are associated with complications such as skin or deep tissue damage, lidocaine toxicity, and fluid accumulation in the lungs [5].

The long-term physical, emotional, and economic sequelae of many popular cosmetic surgeries, including implants and liposuction, are unknown. Despite the documented risks, the general public has an inflated sense of the benefits and a minimized sense of the risks of plastic surgery [6]. Teenagers are often oblivious to the well-documented long-term health consequences of smoking, tanning, and other risky behaviors, and are likely to pay even less attention to the risks of cosmetic surgery, making informed consent difficult.

In addition to the influence of persuasive and pervasive advertising and television makeover programs that stimulate demand, it is difficult for a physician to neutrally present both the risks and benefits of an elective procedure that he or she is simultaneously selling [7]. Requiring parental consent for patients under 18 does not ensure informed consent, since research is lacking on long-term risks for many cosmetic procedures.

Screening
One way to help ensure that teenagers are mature enough to make decisions about plastic surgery is to screen potential patients using psychological testing. In media interviews, plastic surgeons often describe careful interviews aimed at determining why the teen wants plastic surgery. Unrealistic expectations or having the surgery to please a boyfriend is considered inappropriate, but having surgery so that “I will feel better about myself” or “clothes will fit better” are considered reasonable responses. By the same token, teenagers who use drugs, drive while inebriated, and have unprotected sex may also make those decisions to please themselves, and not others, so that response alone is not sufficient evidence of a mature decision. Currently, there is no evidence that effective screening is widespread.

Teen Self-Consciousness and Plastic Surgery
Teens expect that plastic surgery will improve their self-confidence, but does it? There are no empirical studies examining the long-term benefits among adolescents. One study found that body-image satisfaction improved after cosmetic surgery, but so did satisfaction among the control group, suggesting that improved body image may occur with increasing age, regardless of whether the patient undergoes plastic surgery [8]. In fact, a longitudinal study that followed adolescents from age 11 to 18 found body image satisfaction rates were highest at age 18 in both sexes and that the satisfaction of individual participants varied as a function of their age and developmental stage [9]. This indicates that many adolescents who are very dissatisfied with their appearance will feel more satisfied a few years later, whether or not they undergo surgery. The same study also found that the physical features with which participants were most dissatisfied reflected culturally determined stereotypes of idealized attributes emphasized in books, mass media, and advertisements.

Research indicating that breast augmentation patients are 4 times as likely to commit suicide compared to other plastic surgery patients [10] raises questions about the mental health of the women who choose implants and the psychological benefits of the surgery. Liposuction is also of particular concern because of its association with eating disorders. The average onset of body dysmorphic disorder (BDD), defined as “a preoccupation with an imagined or slight defect in appearance that leads to significant impairment in functioning,” is 16 years of age [11]. However, since the goal of cosmetic surgery is to improve and transform appearance, it may be difficult to distinguish between this desire and a pathological preoccupation [12].

Who decides?
Will most plastic surgeons make an accurate and objective judgment about whether a teenage girl is an appropriate candidate for plastic surgery? If plastic surgeons are performing surgeries that many physicians and psychologists would question, should medical societies and ethicists provide more guidance than is currently being provided by plastic surgery associations?

In the ideal world, informed consent would enable teens and their parents to decide carefully what is best for them. However, in the absence of longitudinal research, it is impossible for physicians to warn patients, or their parents, about the risks of performing cosmetic surgery on bodies that have not reached maturation, the operative complications and long-term physical effects of these surgeries and the psychological implications of surgery on developing body image, or the extent to which distorted body image common among adolescence may result in the pursuit of plastic surgery.

References

1. American Society for Aesthetic Plastic Surgery. 2003 national totals for cosmetic procedures. Cosmetic Surgery National Data Bank. Available at: www.surgery.org/download/2003-stats.pdf.:10. Accessed February 24, 2005.

2. Thompson K, Smolak L. Body Image, Eating Disorders, and Obesity in Youth: Assessment, Prevention, and Treatment. Washington, DC: American Psychological Association; 2001:341.

3. Food and Drug Administration. Report on New Health Care Products Approved in 2000. Available at: www.fda.gov/bbs/topics/answers/2001/ANS01066.html. Accessed February 8, 2005.

4. Institute of Medicine. Safety of Silicone Implants. 1999. Washington DC; National Academy Press.

5. Liposuction: Risks. Available at: www.liposuctionfyi.com/liposuction_risks.html. Accessed February 8, 2005.

6. Thompson, 343.

7. Dubler NN, Schissel A. Women, breasts, and the failure of informed consent. J Amer Med Women’s Assoc. 2000;55:5.

8. Simis KJ, Hovius SER, de Beaufort ID, Verhulst FC, Koot HM, and the Adolescent Plastic Surgical Research Group. After plastic surgery: adolescent-reported appearance ratings and appearance-related burdens in patient and general population groups. Plast Reconstr Surg. 2002;109:16.

9. Rauste-von Wright M. Body image satisfaction in adolescent girls and boys: a longitudinal study. J Youth Adolesc. 1989:18:78-81.

10. Brinton LA, Lubin JH, Burich MC, Colton T, Hoover RN. Mortality among augmentation mammoplasty patients. Epidemiology. 2001;12:321-326.

11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Arlington, Va: American Psychiatric Association Press; 2000.

12. Thompson JK, 349.

Diana Zuckerman, PhD, is president of the National Research Center for Women & Families.

FDA, Journal of Rheumatology, May 28, 2001

The FDA has recently completed a study on the health effects of ruptured silicone gel breast
implants. The study was published in the May 2001 Journal of Rheumatology.
FDA conducted this study because of concerns about the frequency and results of rupture.
Rupture is a concern because:
• Rupture of silicone gel-filled implants may allow silicone to migrate through the tissues.
The relationship of free silicone to development or progression of disease is unknown.
• Implant rupture is a device failure – the implant is no longer performing as intended. […]

Results
• Women with MRI diagnosed breast implant rupture were no more likely than women with
intact implants to report that they had either persistent symptoms or doctor-diagnosed
illnesses that were listed.
• Women with MRI-diagnosed extracapsular silicone gel (that is silicone that had migrated
outside the fibrous scar around the implant) were 2.8 times more likely to report that they had
the soft tissue syndrome, fibromyalgia. This association remained statistically significant
after taking into account other factors including whether women thought their implants were
ruptured, implant age, and implant manufacturer. Fibromyalgia is a syndrome characterized
by widespread pain, fatigue, and sleep disturbance.
• Women with MRI-diagnosed extracapsular silicone gel were 2.7 times more likely to report
that they had “other connective tissue disease,” a category that included a diverse group of
illnesses such as dermatomyositis, polymositis, and mixed connective tissue disease. This
association did not remain statistically significant after taking into account other factors
including whether women thought their implants were ruptured, implant age, and implant
manufacturer. […]

Conclusions
The data suggest an association between extracapsular silicone gel and fibromyalgia. If other
studies are consistent with these findings, women should be informed of the potential risk of
developing fibromyalgia if their breast implants rupture and silicone gel escapes the fibrous scar capsule.

Read original article here.

Funding and Authors

• Funding for this study came from: the Office of Women’s Health, FDA; the Office of the
Commissioner; the National Cancer Institute, NIH; the Office of Research on Women’s
Health, NIH; and the U.S. Department of Health and Human Services.

• Authors were S. Lori Brown, PhD, MPH, Gene Pennello PhD, Wendie A. Berg, MD,
PhD, Mary Scott Soo, MD, Michael S. Middleton, PhD, MD

S. Lori Brown et al., American Journal of Roentgenology. 2000.

ABSTRACT :

OBJECTIVE. Silicone gel breast implants have been reported to rupture, but the prevalence of implant rupture in an unreferred population of women is not known. The objective of this study was to assess the prevalence of implant rupture and the presence of extracapsular silicone gel in an unreferred population of women without regard to the absence or presence of any local or systemic symptoms.

SUBJECTS AND METHODS. Women identified as part of a National Cancer Institute cohort study on breast implants, living in the Birmingham, AL, area were invited to undergo MR imaging of their current silicone gel breast implants at the Kirklin Clinic at the University of Alabama at Birmingham. Three radiologists independently examined and rated all MR images for signs of implant rupture and extracapsular silicone.

RESULTS. A total of 344 women with silicone gel breast implants underwent MR imaging. Breast implant rupture was reported by at least two of three radiologists for 378 (55.0%) of the 687 implants in this study. Another 50 implants (7.2%) were rated as indeterminate (suspicious) for rupture. A majority of women in this study, 265 (77.0%) of 344, had at least one breast implant that was rated as ruptured or indeterminate. Radiologists also agreed that silicone gel could be seen outside the fibrous capsule that forms around the implant in 85 (12.4%) of the 687 implants affecting 73 women (21.2%). Factors that affected implant rupture were implant age and location (submuscular or subglandular). The median implant age at rupture was estimated to be 10.8 years with a 95% confidence interval of 8.4-13.9 years.

CONCLUSION. The prevalence of silent or occult silicone gel breast implant rupture is higher than was previously suspected. Most women in this study had MR imaging evidence of at least one ruptured silicone gel breast implant.

Read full article here.

FDA, Sixth World Biomaterials Conference. May 18, 2000.

FDA has recently completed a study on how often women who had breast implants had to go back to their surgeons for additional surgery on their breast(s). The study was presented at the Sixth World Biomaterials Congress on May 18, 2000.

The study, performed in Birmingham, Alabama, involved women who had their first breast implant before 1988. The majority of women in this study had silicone gel-filled breast implants. Women responded to a telephone questionnaire in which they described past surgeries and whether or not their implants were found to be ruptured after the surgeries. Women also responded to questions about the reason they had the surgery.

The Institute of Medicine recently released its report on the safety of silicone breast implants. It concluded that the primary problems with silicone implants were local complications, including implant removal, ruptures, deflations, capsular contracture, infection, and pain.

FDA conducted this study because of concerns about the frequency and results of rupture. Rupture is a concern because:

• Rupture of silicone gel-filled implants may allow silicone to migrate through the tissues. The relationship of free silicone to development or progression of disease is unknown.

• Rupture is a device failure – the implant is no longer performing as intended.

Read the full study here.

FDA, Sixth World Biomaterials Congress. May 18, 2000.

An FDA study on rupture of silicone gel-filled breast implants was presented at the Sixth World Biomaterials Congress on May 18, 2000.

The study, performed in Birmingham, Alabama, involved women who had their first breast implant before 1988. The majority of the 907 women in this study had silicone gel-filled breast implants. Some women who had silicone gel-filled breast implants were invited to undergo a magnetic resonance imaging (MRI) examination of their breasts to determine whether their implants had ruptured. MRI allows the radiologist to see the breast implant while it is still inside the breast.

FDA conducted this study because of concerns about the frequency and results of rupture. Rupture is a concern because:

– Rupture of silicone gel-filled implants may allow silicone to migrate through the tissues. The relationship of free silicone to development or progression of disease is unknown.

– Rupture is a device failure – the implant is no longer performing as intended.

Protocol
– Women in this study were identified because they had been in a National Cancer Institute study on women with breast implants. Women who responded to a questionnaire in the NCI study were eligible for this study. This cohort included only women who were patients at two plastic surgery practices. The 907 women in this study were a subset of 1247 women in the Birmingham, Ala., area who were part of an NCI study on breast implants.
– The rupture study had two parts. In the first part, 907 women were interviewed about surgeries in which implant(s) were surgically removed (interview component of the study).
– One third of the 907 women in the first part of the study reported that they had at least one surgery in which their implant was removed and replaced. Women were also asked the main reason they had their implants removed, and if an implant rupture was suspected prior to the surgery.

– If women reported that their implant surgery was for a suspected implant rupture, they were asked about symptoms that they may have had and about whether they knew of a possible cause of the rupture.
– In the second part of the study, 344 women with silicone gel breast implants received MRI examinations to detect possible implant rupture. The women, selected randomly from the first part of the study, were invited to have MRI exams when they were called to be in the study until all the MRI appointments planned for the studyhad been filled. The study had funding for up to 400 MRI exams to be accomplished at a particular MRI facility under contract for a certain period of time. Of the 445 women invited to have an MRI, 80% (359) accepted and had the examination. Women were invited for the MRI exam without regard to whether they had symptoms of breast implant rupture. Those who accepted the appointments and came were no more likely to think their breast implant was ruptured than women who declined the examination or did not come to their appointments.
– The 344 women who received MRI examinations had a total of 687 implants. The average age of the women in the MRI cohort was 51 ± 8 years. Most women in this cohort had a single lumen gel breast implant (82%) and the remainder had a double-lumen gel breast implant (silicone and saline). For the 677 implants for which this information was available, the average implant age was 17 ± 3 years.
– Three independent radiologists reviewed the results of all of the women’s MRIs and for each implant, determined whether it was intact, indeterminate (suspicious for rupture), or ruptured. The agreement between the radiologists was very high.

Results
– At least two of the three study radiologists agreed that 378 of the 687 implants were ruptured (55%). This means that 69% of the 344 women had at least one ruptured breast implant.
– Radiologists observed that silicone gel had leaked outside the fibrous scar capsule that forms around the implant in 85 of the 687 implants (12%). Of the 344 women, 73 (21%) had silicone gel outside the capsule in one or both breasts.
– Factors that were associated with rupture: the age of the implant, the implant manufacturer, and whether the device was implanted above or beneath the chest muscles.

Limitations of the Study
– This cohort included only women who were at two plastic surgery practices. It is unknown whether the results of the study might have been different if patients from other parts of the U.S. had been included.
– Only 80% of those invited to have an MRI examination agreed.
– Many types of silicone gel-filled breast implants were included in this study.
– While MR imaging is considered the best method for imaging breast implants for rupture, it is not perfect.

Conclusion
– MRI examination in this cohort of patients demonstrated that the majority of women had at least one ruptured implant.

Funding and Authors
– Funding for this study came from: the Office of Women’s Health, FDA; the Office of the Commissioner; the National Cancer Institute, NIH; the Office of Research on Women’s Health, NIH; and the U.S. Department of Health and Human Services.
– Authors were S. Lori Brown, PhD, MPH , Michael S. Middleton, PhD, MD ² , Wendie A. Berg, MD, PhD ³ , Mary Scott Soo, MD ⁴, and Gene Pennello, PhD ¹.

Read full study here.