MIAMI BEACH – Adolescents who undergo elective plastic surgery tend to "sail through surgery more easily" than adults, according to an expert.
In addition, more male teenagers seek these procedures, meaning the gender disparity is not as striking as it is among adults.
Dr. Mary H. McGrath
"When we do cosmetic surgery in teenagers, it is remarkably conflict free, compared with other medical interventions in teenagers, and compared with other age groups," Dr. Mary H. McGrath said. The reasons are not entirely clear – most research in adolescents addresses rhinoplasty only – but it could be because surgery comes during a time of great overall change for teenagers, she said.
Of the estimated 9.2 million surgical and nonsurgical cosmetic procedures in the United States in 2011, 18% were surgical and accounted for 63% of expenditures, according to data from the American Society for Aesthetic Plastic Surgery. Patients 18 years and younger comprised 1.4% of this total and underwent 97,214 nonsurgical and 34,663 surgical procedures.
Otoplasty was the most common 2011 elective surgical procedure in patients under the age of 18 years in 2011. About one third, 34%, of the estimated 11,000 otoplasties were performed on males. Rhinoplasty came in second on the list, with 20% of the 9,500 procedures performed in males. Breast augmentation, liposuction, and breast reduction (for cosmetic reasons) were the next most common, in order, followed by correction of gynecomastia (not surprisingly, 100% in males).
In contrast, in adult patients, more than 90% of all elective plastic surgeries are performed in women, Dr. McGrath said.
Assessment of physical and mental health is the first step when an adolescent asks about plastic surgery in the primary care setting, Dr. McGrath said at the annual meeting of the North American Society for Pediatric and Adolescent Gynecology.
Ensure the adolescent has the necessary emotional and physical maturity. "Determine that the patient has reached the growth milestone and physical maturity for that surgery. We wouldn’t do breast augmentation on a 16-year-old," for example, said Dr. McGrath, professor of surgery in the division of plastic and reconstructive surgery at the University of California, San Francisco. Also rule out any psychiatric contraindication, such as body dysmorphic disorder, she said.
Speak with the patient alone. Also talk with them with their family present to assess the degree of support. Ask the patient to articulate why they want the surgery. Ensure patient expectations are realistic. After referral, a plastic surgeon ideally will assess the specific deficit, outline what can be accomplished surgically, and describe the potential risks. Efficacy and safety considerations are critical, Dr. McGrath said.
Ask teenagers to explain how they would handle a complication. Dr. McGrath also asks them to repeat back important aspects of the discussion to ensure they understand.
Dr. McGrath shared some tips and insight on the following procedures:
• Otoplasty. The ear achieves 85% of full growth by age 3 years, which is "why kids’ ears look so big." Sometimes, the goal of surgery is to approximate symmetry. A good plastic surgeon will be familiar with the subtle anatomic features of the ear: the top of the ear is generally closer to the head than the middle, while the lobule at the bottom should stick out the most.
Otoplasty is usually an outpatient procedure. Patients can expect a bulky head dressing postoperatively, suture removal after 7-10 days, and to sleep with an elastic band around their head for 2-3 weeks. Hematoma and infection are potential early complications and residual deformity or asymmetry can emerge later. An estimated 8%-10% of patients undergo reoperations, almost always for asymmetry, Dr. McGrath said.
• Rhinoplasty. "Very rarely do we do rhinoplasty in someone younger than 17 or 18 [years old] or they can outgrow the changes in nasal contour," Dr. McGrath said. "Sometimes, I feel bad telling a 14-year-old with an exceptionally large or unattractive nose they have to wait and come back at age 17."
Prepare teenage patients for the postoperative course by showing them photos of typical patients. Tell them to expect splinting for 7 days, ecchymosis for 10-14 days, and residual swelling for 2-3 months. Postoperative changes become quickly obvious after a bony ridge removal. In contrast, a nasal tip rhinoplasty, because it involves soft tissue and more edema, can take months to see the final result.
"This is the hardest surgery we do," Dr. McGrath said. "It is complicated to understand all the pieces of the puzzle and get it right. It requires the greatest amount of art." The most common complication is bleeding in about 4% of patients.