Dr. Zuckerman on CNN & JAMA article on Plastic Surgery

[Guest guest]

(Message from Ilena: If any of you are not on Dr. Zuckerman's mail

list and would like to receive her important messages ... please

write and request to:

Return-Path: dz@... )

I just wanted to let you know I will be on CNN on Thursday May 3 at

2:15, talking about new polls showing a decreased confidence in the

FDA as well as strong support for strengthening the agency. The

polls were done for a coalition of consumer and patient

organizations, including ours.

In addition, we continue to speak out against privatization

proposals on Social Security, all of which would undermine the

safety net aspects of the program. Today I was interviewed on

FoxNews radio on the topic. It was a " debate " and the pro-

privatization person on with me was Newt Gingrich's communications

director. I think I held my own, especially when I reminded him

that President Reagan made a pledge to the American people to keep

Social Security secure when he signed legislation changing the

Social Security system, and that it is important to keep that pledge.

Sen. Lieberman was recently quoted as working with Republicans on a

compromise for Social Security. In response, our Advisory Board

member Pat Hendel (former head of the Commission for Women in

Connecticut as well as the National Association of Commissions for

Women) and I are meeting with Sen. Lieberman's key staffer on this

topic on Thursday.

And, here's the article I just published in the Journal of the

American Medical Association's ethics journal on teens and cosmetic

surgery:

http://www.ama-assn.org/ama/pub/category/14695.html. It is also

copied below.

Yes, we're busy! I'm leaving town to give a speech at Rutgers

Thursday night right after my CNN gig.

Zuckerman

JAMA Op-Ed

Teenagers and Cosmetic Surgery

by 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 State s. 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: http://www.surgery.org/download/2003-stats.pdf.:10.

Accessed February 24, 2005.

2. 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:

http://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. , 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 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. JK, 349.

Zuckerman, PhD, is president of the National Research Center

for Women & Families.

The viewpoints expressed on this site are those of the authors and

do not necessarily reflect the views and policies of the AMA.