Cosmetic Surgery and Teens

Washington Post Health Feature

Growing popular among teenagers, cosmetic surgery such as breast implants and liposuction are now bestowed by parents as graduation or birthday gifts. While cosmetic surgery remains most popular in other cities -- Miami, Dallas, Los Angeles and New York City -- local plastic surgeons who practice in the Washington area say they are seeing more teenagers than ever. In the past few months several doctors' groups have cautioned teenagers and their parents against resorting to major surgery as a quick fix for popularity or self-esteem. Between 2002 and 2003 From 2002 to 2003, according to the American Society of for Aesthetic Plastic Surgery, the number of girls 18 and younger who got breast implants nearly tripled, from 3,872 to 11,326.

Michael Olding, M.D., director of the Cosmetic Surgery & Laser Center at George Washington University Medical, and Diana Zuckerman, president of the National Research Center for Women and Families, was online Tuesday, Oct. 26, at 3:30 p.m. ET to answer your questions about rise in cosmetic surgery among teens.

Editor's Note: Washingtonpost.com moderators retain editorial control over Live Online discussions and choose the most relevant questions for guests and hosts; guests and hosts can decline to answer questions.

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Diana Zuckerman, Ph.D.: I am Diana Zuckerman, Ph.D., president of the National Research Center for Women & Families. I have read all the studies of breast implants, and have concerns about teens undergoing plastic surgery at a time when they are psychologically vulnerable. I was quoted in today's Washington Post article expressing those views.

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Michael Olding, M.D.: I am chief of Plastic Surgery at George Washington University Medical Center and Director of the Cosmetic and Laser Surgery . I am happy to answer questions regarding cosmetic surgery, and in this particular forum, on teenage cosmetic surgery.

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Vienna, Va.: I wonder if indeed plastic surgury is truly more common--or just more noticed--among teenagers. I can recall in the early '80s that a lot of my girlfriends got nose jobs over summer vacation, either after junior or senior years. Another factor--I think a major shift has been the fashionable body--at that time, smaller breasts were more desirable. Indeed, iirc, breast reduction surgury was much more prevalent.

Diana Zuckerman, Ph.D.: The statistics show an increase in all kinds of plastic surgery among children and teens under 18. The increases in surgery on noses and ears aren't dramatic. The increases in breast implants and liposuction are very dramatic. In fact, the number of girls 18 and younger getting implants has tripled in the last few years.

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Centreville, Va.: If there is such a strong opinion that many teens (or even older women) having this or that plastic surgery procedure don't need it, then why don't the doctors just say no? Why doesn't the AMA just say it is unethical? Is the income more important to the doctors than doing the right thing? Or is the risk of having poor doctors (ethically and medically) being the only ones who will do this surgery that the good doctors (ethically and medically) must step in to prevent catastrophes (or so they would argue)?

Michael Olding, M.D.: That is a great question actually. We, as plastic surgeons do not simply say yes to every request for a surgical procedure. That would be unethical and self-serving. It is why we have patients come in for a consultation and discuss the procedure and the potential complications and implications etc. But, each patient must be evaluated individually before making that decision.

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Gaithersburg, Md.: I think the whole idea is ridiculous, but it makes me wonder how much do these surgeries cost? How can the parents afford this? and what have the parents cut back on to give their children these "graduation presents"?

Diana Zuckerman, Ph.D.: These surgeries cost about $4,000-6,000, depending on where a person lives. You are right that for many families, that means they can't afford other things that might seem more important. But the real cost of implants comes after the first surgery. Implants don't last a lifetime, and research shows that most women will have at least one broken implant within 7-12 years. So, removing broken implants, replacing them, and fixing other problems adds a lot to the cost. That should concern all parents, since their daughters may not be able to afford to fix problems that arise.

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Silver Spring, Md.: I found the article disturbing. Plastic surgery entails real risks, though these are often downplayed, including by TV networks that stand to grain from the popularity of shows such as "Extreme Makeover" and "The Swan." Appearances by people whose surgery didn't go well, or at least whose surgery didn't produce magic results, might help the balance. I wonder if even the parents of these teens understand the risks.

Michael Olding, M.D.: You are exactly right.. Any surgery entails significant risks, and it is one of my major complaints about these , what I call "semi-reality" shows. The American Society of Plastic Surgeons has repeatedly cautioned the public about the one-sided nature of these programs. Even the simplest, most straightforward procedures have potential complications. It is the DUTY of the plastic surgeon during the consultation to explain these potential complications to the patient so that he or she can make an informed decision. Anyone under the age of 18 has to have parental approval.

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Potomac, Md.: What do you do if Kloids are formed after plastic surgery?

Michael Olding, M.D.: Keloids can occur not only in African-Americans but in any patient population. Usually, but not always, there is a previous history of them in the patient. If they occur there are various techniques to treat them , but occasionally they do not respond to those treatments. It is very important for you to tell your physician in advance of any surgery if you have had problems with healing and hypertrophic or keloid scars.

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Washington, D.C.: How long do breast implants last?

Diana Zuckerman, Ph.D.: Breast implants are rather unpredictable. Some last a few days or weeks or months, others last for years.

It's obvious when saline breast implants break because they deflate quite quickly. But silicone gel implants can have a slow leak that isn't obvious. That can be a problem because silicone can leak into the lymph nodes and travel throughout the body without the woman knowing it.

Using MRI's, the FDA found that most women with silicone breast implants for 11 years or more have at least one broken breast implant, even if she doesn't know it. Saline implants probably last about the same number of years, but there are no studies. So, after 7-12 years is when implants tend to break. Women sometimes think they are lasting longer, but that might be because they have silicone implants and the break isn't obvious. (But it can still result in a leak).

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Washington D,C,: Hello and thank you for such a wonderful topic....I just wanted to share my teenage cosmetic surgery story. I was a 19 year old african american (1988) who had a rhinoplasty done...mine was done when cosmetic surgery was just starting to grow in acceptance....I was 19 had my own money and didn't ask my mom her advice (because I knew what her answer would be)..so I did everything on my own (appt visit on my own, drove myself to the appt, my cousin accompanied me to the surgery etc.) my mom found out the day I when she walked in my room..and saw me with two black eyes swollen.
My teenage life before the surgery was one of embarrasement and low self esteem because I hated my nose. When looking at my pictures from jr. high and high...you will not see a person smiling...you will see a young girl shying away from the camera or holding her head in a certain way in order for the camera to catch the best angle of her nose. Almost 16 years have passed and I walk into a room with my head held high..I run towards the camera and I smile all the time....it's amazing what the surgery has done for my self esteem and my outlook on life...if asked would I do it again..Yes, but allot sooner!

Diana Zuckerman, Ph.D.: I agree with you that many people are very happy with the results of plastic surgery.

I think it's important to distinguish between surgeries like rhinoplasty (which has a low complication rate) and breast implants (which has a high complication rate). Having something implanted in your body causes more problems as the implant ages.

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Washington, D.C.: Since implants can lead to problems, if I want to get my implants replaced, how much does it cost? What about the cost of the anesthioslogists, nurses, etc?

Michael Olding, M.D.: Sooner or later, ALL implants will leak. I tell all patients that seek augmentation or breast reconstruction with implants, that sooner or later they will require another surgery to replace the broken implants. The cost to replace them in some cases is borne in part by the company that produces them, and in many cases, the implant manufacture give a lifetime replacement policy for the cost of the implants.. That does not include the cost of the procedure or the use of the facility. The procedure is usually done under "twilight" anesthesia, and is a lot simpler than the original procedure, thus cheaper. One might expect however that the procedure would cost several thousand dollars.

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Sinking Spring, Pa.: Don't you think teens who are thinking of getting breast implants the doctor should encourage her to wait until their body growth period is over?

Puberty usually occurs in girls between 9 and 16 years old. The rate at which breasts grow varies greatly and is different for each young woman. An 18 year old could still be in the developmental stage. Do you think a teen going through puberty can make a mature and informed decision that can effect her physical, as well as mental health, the rest of her life?

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Michael Olding, M.D.: Teens who undergo plastic surgery are a very special subcategory of patients who have plastic surgery, not only because of the grwoth physically, but also emotionally. I believe that some teens can make an informed and mature decision because some (but not most) are mature. It is why so few people under the age of 18 have cosmetic surgery and why parents must sign the consent.

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Silver Spring, Md.: I've been told many times that women continue to develop through late teens and even early twenties. So giving implants even to a 19-year-old seems far too young to me.
Can implants in someone this age inhibit the natural maturation process?

Diana Zuckerman, Ph.D.: You are right that maturation does continue past age 19. One of the reasons is that girls tend to gain weight between 18-21, and that usually helps to increase bust size.

Nobody has ever studied the impact of implants on 18 or 19 year olds, so I don't think anyone can answer your very good question about whether implants can interfere with natural maturation.

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Reston, Va.: I had a breast reduction surgery by one of the doctors in your article when I was 19. While I have no regrets whatsoever about having the surgery, I recall trying to initiate a conversation about how small the Dr. would make my breasts during the surgery and he told me that he would make them look good and an appropriate size. He would not engage me in a discussion about size. As a woman in her 30s now, I would NEVER consent to surgery with a surgeon who wouldn't let me have a say in the outcome, but as a teenager, I was much more willing, and too scared to speak out. Besides, finding another doctor would have involved more time from school, more rides from my parents, etc. Ultimately, I think that the surgeon was correct about the size he made me...but I didn't get a say in it.

Diana Zuckerman, Ph.D.: You raise a very important point about how doctors treat their young patients. I have heard from many women who told me that they ended up with breasts that were larger than they asked for, because the doctor assumed they would like th result. I have even heard of patients that asked for saline implants and ended up with silicone instead. That really shouldn't happen to women of any age, but I wish plastic surgeons would be much more willing to talk to their patients about what they really want, and then respond to that.

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Dallas, Tex.: I got saline implants when I was 19 and had horrible problems. I was told they were safe but they weren't safe for me. What do you do to warn teens or other patients about the terrible things that have happened to so many women?

Michael Olding, M.D.: All patients who contemplate brest implants must be informed about the risks and potential complications as well as the alternatives. They are substantial. It takes a one hour consultation and review of a videotape on the risks and complications for me as the potential surgeon to feel comfortable with that decision. I tell everyone that THE most important of those comps. are. 1. they will break in your lifetime 2.you will therefore need a second operation 3. they can get hard.. as hard as a rock 4. they make detection of breast cancer more difficult.

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Arlington, Va.: I was a "late bloomer" and a ballet dancer, so I didn't really develop breasts until late high school, early college. Even when I did develop, my breasts were a small B cup. However, I'm now 26 and I have found that in recent years my breasts have filled out and I even have cleavage, now a full C cup. Other friends have also told me their breasts didn't fill out until their mid 20's as well. My question is, do plastic surgeons take this into consideration when performing a breast augmentation on a teenager under 18? Do they recommend to the young woman that she might not be done growing yet and to wait until she is more physically and emotionally mature?

Michael Olding, M.D.: This is why so few plastic surgeons will perform breast enhancement surgery on teenagers.

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Portland, Ore.: The article about teenage plastic surgery made me want to weep. It's sad enough that mature women are willing to have their faces and bodies ripped apart and risk their lives to be "beautiful," but is tragic that women only a few years out of puberty are doing the same thing. I hope at some point our society values women more for their talents, skills, and what they contribute to the world, than the size of their breasts and how youthful they look. But then plastic surgeons would be out of business, wouldn't they?

Diana Zuckerman, Ph.D.: I share your concern that women and girls are undergoing plastic surgery in record numbers. Since this is a cash business, there is a lot of money involved for the doctors -- more than for many surgeries that are covered by insurance.

As long as programs like The Swan and Extreme Makeover glamorize surgery as the answer to all problems, there will be a lot of women and teens trying that strategy.

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Centreville, Va. (followup, please): You said in response to my question (paraphrasing), "Why don't the doctors just say no?", you replied, "It is why we have patients come in for a consultation and discuss the procedure and the potential complications and implications etc." But the next step after discussion is apparently, okay, we've explained the complications/etc to you; your surgery appt is set for whenever. Why don't you say, we think you'd better wait a few years before you make the decision to have surgery?

Michael Olding, M.D.: We do just say no... but that is based on an individual case by case scenario.. I would never make a blanket statement like "no one under the age of 20 can have breast enhancement." But... I am far more circumspect than in a more mature older woman. Remember, some people are not candidates for breast enhancement at ANY age.

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Lawrence, Kan.: Is there any risk that a teen with implants could have problems later on when she has kids and wants to breastfeed?

Diana Zuckerman, Ph.D.: Women with any kind of breast surgery -- implants or breast reduction -- are less likely to be able to breastfeed than other women. Most can, but a substantial number will not have enough milk. Some will find nursing too painful because their nipples are painfully sensitive after surgery.

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Mesquite, Tex.: I received breast implants at 19 because I thought my breasts were finished developing. I assumed that because they were FDA approved for women 18 and older, it must mean that I was finished growing. Well, I WAS NOT finished growing; in fact, I'm 22 and an entire size larger than I was to begin with. Had I decided to keep my breast implants, I would probably need to have them removed by now. What do surgeons do to guard against this problem? Do they tell women that their body can still grow and develop after 18? My surgeon did not.

Michael Olding, M.D.: Not only can their breast increase in size after or around puberty, they can increase in size later in life... with preganancy, with menopause-related hormones, and in general with weight gain. So yes, we do caution patients about this possibility.. especially very thin patients.

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Washington, D.C.: A friend of mine is thinking of getting breast implants but she has lupus. Are there any risks she should know about?

Diana Zuckerman, Ph.D.: The implant manufacturers have a warning that women with autoimmune diseases such as lupus should not get breast implants. There is concern that the implants could make the condition worse.

Even a family history of autoimmune disease should discourage women from getting implants, but I don't think that it does. After all, rheumatoid arthritis is a very common autoimmune disease, and I think that women with mothers or grandmothers with arthritis are getting breast implants.

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Washington, D.C.: Dr. Olding, I was completely flat-chested until around the time I turned 18, at which point I began to develop. No matter how "mature" someone at age 18 is, you cannot predict what will happen to her body. So how can you in good conscience perform this surgery on anyone so young?

Michael Olding, M.D.: It is rare for women to increase dramatically in size after 18 years of age, but it does happen. It usually is associated with an increase in wt. gain but not always. I cannot as you say "in good conscience" deny someone breast augmentation because they "might" increase their breast size in the future. I can inform them of the possibility. In patients who are under 18, I have only performed one bilateral breast augmentation that I can recall. I have done more unilateral (one sided) breast enlargement because of a congenital mismatch.

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Washington, D.C.: Are there legal age limits for plastic surgery? The article suggests that a candidate for implants would need more maturity than a candidate for a nose job or another low-risk form of corrective surgery. If there are no legal age limits, do you believe that there should be age limits on some types of surgery?

Diana Zuckerman, Ph.D.: There are age limits on surgery, and that's why parents need to give consent. However, many parents are giving consent.

So I'm wondering what we should do to better inform parents of the risks -- or how we can help parents say no when they want to say no to their daughters asking for certain types of plastic surgery. I think some parents wish the law said that implants were absolutely forbidden for girls under 18, but that is not what the law says. It would help parents if more plastic surgeons were stricter about age limitations.

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Washington, D.C.: Dr. Olding has said repeatedly that few doctors will perform breast implant surgery on teens, than why did the number of implants in 2003 triple from 2002?

Michael Olding, M.D.: The increase in total numbers of implants done in teenagers has increased, but, as reflected in a percentage of the total numbers of cosmetic surgery (which increased 32 percent), the numbers have increased only a couple of percentage points. the 2003 stats reflect the fact that 8.7 million people had cosmetic surgery..

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Washington, D.C.: why do some women have implants that break after a few months and some whose don't break for years?

Diana Zuckerman, Ph.D.: Some implants break very quickly. If it is immediate, it probably means that the implant was nicked during surgery. But some implants break after just a few months, and nobody knows why.

Since there are probably irregularities in manufacturing, it may be that some implants are better made than others. There are also individual differences in women, which could result in some implants lasting longer than others. But the bottom line is, the FDA has complained that the studies done on implants don't explain why implants break more easily than expected. It is important for implant makers to do better studies to find out why some implants break so easily, and what the health risks are for women whose implants are broken and leaking. One study by the FDA found an increase in fibromyalgia and other autoimmune diseases among women with leaking silicone implants, compared to women whose implants were not leaking.

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Dallas, Tex.: (Follow up question) So you actually go over a video tape and spend an hour in consultation when someone comes to you wanting breast implants? I had more like 15 minutes and was ushered in and out...and I had a friend working in the office. What about the FDA handbook? Do you go over the 80 page booklet with patients? I never knew about it until 2 years too late.

Michael Olding, M.D.: I cant tell you what everyone uses, but patients have to see the video tape that I spoke of, and they have a consent to sign that I go over line item by line item (put out by the American Society of Plastic Surgeons), and they read a pamphlet entitled saline-filled brest implant surgery, making and informed decision, which tells (by percentage) the potential complications as outlined from the clinical studies. I personally no longer use silicone gel implants, and will not do so until the FDA has approved them.

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Livonia, Mich.: Are there any consequences or problems related to a telflon chin implant? It was put in at the same time as my rhinoplastic surgery?

Diana Zuckerman, Ph.D.: There are well-established problems for teflon jaw implants. Anyone with a teflon pan knows that the teflon can flake off if there is friction. There is a lot of friction in a jaw implant, which is why teflon jaw implants caused such serious problems.

The chin has less friction than the jaw, but when you talk, kiss, eat, etc, there is a lot of muscle movement in your chin area. So, it could flake off, especially as the implant ages. The body can respond to those tiny particles of teflon as "foreign bodies." You might want to find out whether that type of implant has been recalled and whether there is a recommendation that they be removed and replaced with something safer.

Even silicone chin implants can cause problems eventually. They are hard silicone, but they can break as the age. I don't think there is any good epidemiological research on silicone chin implants, and I think more research is needed to help patients decide what to do.

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Dallas, Tex.: What does the long-term data say about connections between autoimmune diseases (Rheuamtoid Arthritis, Fibromyalgia, etc.) and breast implants?

Diana Zuckerman, Ph.D.: There aren't any really good studies of the long-term connection between implants and autoimmune disease.

There are short-term studies that show small increases in autoimmune disease among women with implants, but the differences are not usually statistically significant. A recent study by the National Cancer Institute found that women with implants were twice as likely to have autoimmune diseases, but there were problems with the study (for example, the women reported whether they had a disease but there was no medical exam to confirm it).

Also, there is a study that found women with implants who had rheumatological symptoms tended to get better when the implants were removed, and worse if the implants were not removed.

The bottom line is we need more long-term research, since these diseases take years to develop. You can't have studies on women who had implants for just a few months, if you want to know what the long-term risks are.

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Miami, Fla.: I'm contemplating getting silicone gel implants. How long have they been studied? The plastic surgeon's office that I've contacted assures me that they're safe and almost FDA approved.

Michael Olding, M.D.: The FDA has NOT given their approval for silicone gel implants as yet.. and we dont know (and neither does your plastic surgeon) that they will approve them. They have been "studied" since they were originally used, but it is the charge of the FDA to decide if they have been studied enough and when and if they will approve them

Diana Zuckerman, Ph.D.: There is no such thing as "almost FDA approved." Either they are or they aren't. In this case, they aren't.

Although silicone gel implants have been studied for years, there are no studies of women who have had silicone implants for at least 10 years. The studies that implant makers gave to the FDA only studied women for 2 or 3 years. The FDA felt that was not long enough to answer questions about safety, and especially not long enough to answer questions about the risks of leaking implants (since most implants don't leak during the first 3 years).

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Prince Frederick, Md.: Every case of breast enlargement is based on low self=esteem, or what someone else thinks of the patient. Why doesn't the plastic surgeon require lenghty psychiatric treatment instead of implants? I would think risking mutilation, health problems, and possible death because of appearance borders on mental illness.

Michael Olding, M.D.: It seems that you believe that any cosmetic surgery should require a psychiatric evaluation beforehand, and put simply, I disagree with you. There are potential risks and complications with any procedure... Patients MUST make informed decisions. That said, if I have any concerns about the mental well-being of a patient, which might therefore affect their ability to make an informed decision, I am very direct and will express that concern to the patient. Often that means, "Sorry, you are not a candidate for this procedure." Ethically, there is no other choice. I have referred patients for psychiatric assistance who come in for cosmetic surgery.

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Hobe Sound, Fla.: What can be done to discourage teens from this surgery?

Diana Zuckerman, Ph.D.: You have asked a really important question, and one that is difficult to answer.

The easy answer is that parents can help their children feel self-confident, in their looks and as people. If kids ask parents for plastic surgery and parents say yes, they are implying that they agree that their children need the surgery.

It might help to point out actresses and others who have less than "perfect" noses or bodies but are beautiful anyway. There aren't so many of those actresses since plastic surgery is so common in Hollywood, but there are enough to use as examples.

And of course, its important to point out that who we are is as important as what we look like. It may not seem that way in high school, but it gets better after that.

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Washington, D.C.: If a teen gets implants and then changes her mind and doesn't like how they look, what will her breasts look like after they've been removed? Will she need a special surgery to get rid of skin that has been stretched out and sags?

Michael Olding, M.D.: If a teen (or anyone for that matter) has breast implants that are removed at a later date, additional surgery may be necessary. It depends upon... how long they were in, how big they were, how elastic the patients skin is (the older you get the less elastic it becomes). Its a hard question to answer, but think about it in terms of having children... the belly gets stretched out during preganancy and then afterward "snaps back" in some cases, but not in every case.. same can be said of breast implant removal surgery. But, worst case scenario, skin might have to be removed, and permanent scarring can occur.

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Washington, D.C.: How do implants make mammograms more complicated?

Diana Zuckerman, Ph.D.: Implants interfere with mammograms, making it harder to get an accurate reading. That can mean a delay in diagnosis. Special mammograms are done on women with implants, which cost more, require more radiation, and still aren't as accurate. Dr. Olding and I agree that patients need that warning -- especially if there is a history of breast cancer in a woman's family.

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Livonia, Mich.: I asked about the teflon chin implant because I have had a long, lingering case of fibromyalgia and I wonder about the connection. Please advise.

Diana Zuckerman, Ph.D.: There is no research, but it seems like a possible link. There is a link between fibromyalgia and breast implants in an FDA study. In both cases, a foreign body might possiby cause an autoimmune response.

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Diana Zuckerman, Ph.D.: Thanks so much for all your great questions. For more information, please check our website at www.breastimplantinfo.org. We have a new section on teens and implants in our breast augmentation section of the website, and lots of information about other risks. We also have an online health hotline on the website.

Our goal is to provide free, unbiased, research-based information to women and girls who are thinking about breast implants or already have them.

For information about other health topics, we have another website: www.center4research.org

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Michael Olding, M.D.: The session has unfortunately gone over the allotted time. I would like to leave you with a couple of thoughts if you (as a teen) or your child who is a teen is contemplating cosmetic surgery. First and most importantly, make certain you are seeing a board-certified plastic surgeon. Today, many people (some not even MDs) are masquerading as plastic surgeons. One way to do that is to contact the American Society of Plastic Surgeons at www.plasticsurgery.org to get that list. Secondly, in teenagers, EVERYONE should go cautiously before having cosmetic surgery.

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