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When it is more extensive, general anesthesia and overnight stays are necessary. The acute adverse reactions following suctionassisted lipectomy consists of itching, bruising, and swelling. The patient must wear a compression garment for approximately 1 month to prevent hematoma formation, and bruising may last for 4 – 6 weeks. In addition to surgical risks, primary risks of liposuction include infection; damage to skin, nerves, or vital organs; fat or blood emboli; and excessive fluid loss [15]. The different techniques (tumescent, superwet, and ultrasound-assisted liposuction) are associated with additional complications such as skin or deep tissue damage. The American Society of Plastic Surgeons’ advisory states that the likelihood of serious medical complications, such as lidocaine toxicity and fluid accumulation in the lungs, increase with “the number of sites treated and the volume of fat aspirated” [16]. D. Zuckerman and A. Abraham / Journal of Adolescent Health 43 (2008) 318 –324 319 Pubertal Development and Body Image Physiological and psychological changes occur during puberty, which are important to consider when discussing cosmetic surgery in adolescents. Breast development can continue after age 18. In fact, when the FDA approved silicone gel breast implants only for women ages 22 and older, they pointed out that breast development can continue into the late teens and early 20s [17]. Breast size may also increase with weight gain, and growth charts indicate that the average female gains weight between the ages of 18 and 21. Normal weight gain may reduce dissatisfaction with breast size and the desire for breast augmentation. In addition, that same weight gain may also increase fat deposits in the areas most likely to be considered for liposuction. Therefore, the likelihood of weight gain in the late teens and early 20s raises important questions about whether decisions about either breast augmentation or liposuction for adolescents should be delayed. For augmentation, the desire for surgery could be reduced as a result of likely weight gain, whereas for liposuction, the benefits of surgery could be short-lived as a result of likely weight gain. The process of body image development begins at an early age. Parental approval and attention, or parental criticism and neglect, influence how children think about themselves. and mental health risks and benefits of these surgeries for teenagers, and understand the limitations on teenagers’ abilities to evaluate risks. © 2008 Society for Adolescent Medicine. All rights reserved. Keywords: Cosmetic surgery; Liposuction; Breast augmentation; Informed consent The number of adolescents requesting and undergoing cosmetic procedures has increased dramatically over the last decade. The American Society of Plastic Surgeons (ASPS) estimates that more than 333,000 cosmetic procedures were performed on patients 18 years of age or younger in the United States in 2005, compared to approximately 14,000 in 1996 [1]. In 2005, one in four of these were surgical procedures such as nose reshaping, ear surgery, breast augmentation, liposuction, chin augmentation, and abdominoplasty (tummy tucks). ASPS does not report demographic information specifically for adolescent patients. However, among all patients, including adults, children, and teenagers, approximately 90% are female, 20% are racial and ethnic minorities, and there is a considerable income range. Reconstructive surgery is defined as a procedure to correct a clear abnormality. Reconstructive procedures such as correction of cleft lip or palate, can provide enormous benefit to children and teenagers. In contrast, cosmetic surgery is defined as surgery to improve a “normal” appearance, such as reshaping a nose or augmenting breasts. As cosmetic procedures have become much more pervasive, advertised in the mass media and the subject of numerous prime time television programs, it has become increasingly difficult for health professionals to agree on when it is appropriate or necessary [2,3]. This literature review focuses on data-based articles regarding the risks and benefits, as well as the need for improved standards for screening and informed consent. We reviewed data from all articles on these topics listed in the PubMed and PsycINFO databases from 1985 through June 2007, in addition to books, book chapters, and materials on the Food and Drug Administration (FDA) and plastic surgery medical association Web sites. This literature review focuses on two of the most popular cosmetic surgical procedures performed on teens: breast augmentation and liposuction. Although less popular for children under 18 than ear pinning or nose reshaping, they are more controversial because of higher complication rates, longterm financial and health risks, and concerns about “body *Address correspondence to: Anisha Abraham, M.D., Department of Pediatrics, 2nd Floor PHC, Georgetown University Medical Center, 3800 Reservoir Road, Washington, DC 20007. E-mail address: axay@gunet.georgetown.edu Journal of Adolescent Health 43 (2008) 318 –324 1054-139X/08/$ – see front matter © 2008 Society for Adolescent Medicine. All rights reserved. doi:10.1016/j.jadohealth.2008.04.018 sculpting” on bodies that are still developing. Despite the rising popularity of cosmetic surgery for teenagers, there are no empirical studies on the cultural and economic factors that are causing the increase. Breast Augmentation Although the FDA approved saline breast implants only for women ages 18 and older [4], and silicone gel breast implants for women ages 22 and older [5,6], it is legal for doctors to perform breast augmentation using either type of implant for teens under 18, as an “off-label” (i.e., not approved) use with parental consent [7]. It is FDA policy to approve medical products for specific uses for which they are proven safe and effective, and to allow physicians to determine if they want to use those products for other medical purposes. It is not possible to determine exactly how many procedures are performed each year on teens, although estimates are available. The ASPS and the American Society for Aesthetic Plastic Surgery (ASAPS) each provide estimates of the number of plastic surgeries performed by their members on children ages 18 and younger. The estimates are based on surveys of their members, vary considerably because of differences in membership criteria, and do not include the many plastic surgeries performed by other physicians. The ASAPS, which includes dermatologists and other disciplines that perform cosmetic surgery and procedures, estimated more than 11,300 breast augmentations for teens 18 and under in 2003 [8]. In contrast, ASPS, which only includes plastic surgeons, reported approximately 4000 procedures for teens ages 18 and younger in the same year. Through 2005, both medical societies reported approximately 3000 – 4000 breast augmentations for teens 18 and younger [1,9]. Of note, in 2006, ASPS calculated procedures for ages 19 and under. Adding age 19 resulted in more than a doubling in the number of procedures to more than 9100 [1]. Breast augmentation is performed under intravenous or general anesthesia, usually on an outpatient basis. A pocket is created under the breast tissue or in the pectoralis major muscle. The breast implant, a silicone envelope filled with silicone gel or saline, is placed in the pocket and then the soft tissue is closed. According to the literature, postoperative discomfort may last several days. The patient must wear a surgical bra for about 2 weeks and avoid strenuous exercise for 4 – 6 weeks [10]. Most complications of this procedure are related to the prosthetic
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