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painful implant removed will be still paying for the initial augmentation surgery and may be unable to afford corrective surgery [38]. Financial costs are higher for silicone gel breast implants compared to saline breast implants. Silicone gel breast implants cost at least $1000 more per pair. In addition, the FDA urges that women with silicone gel breast implants undergo regular screening with breast coil magnetic resonance imaging (MRI) to determine if the breast implant is broken or leaking. The FDA points out that only 30% of silicone gel implant ruptures are accurately diagnosed by clinical exams, which is why the FDA required implant makers to distribute patient booklets warning women that “you should have your first MRI 3 years after your initial implant surgery and then every 2 years, thereafter” and have implants removed quickly if they are found to be ruptured or leaking. The FDA specified greater financial costs, as well as greater risks, as their reason for limiting approval of silicone gel implants to women age 22 and over, rather than age 18 [39]. Liposuction has fewer long-term complications than breast implants, but like augmentation, may require additional future surgeries to maintain the results. However, unlike the replacement of a deflated or leaking breast implant, repeat liposuction surgeries are not required to avoid an abnormal appearance or potential health problems. Informed Consent Research indicates that the general public has an inflated sense of the benefits, and minimized sense of the risks of plastic surgery [40]. This optimistic view may be even greater for adolescents, who are oblivious to the wellestablished long-term health risks of smoking and other risk behaviors, and tend to focus on the short-term benefits instead. Recent studies of brain development indicate that the region of the brain that inhibits risky behavior is not fully developed until age 25 [41]. A study of high school juniors found considerable interest in cosmetic surgery, based primarily on information from television and teen magazines [42]. These findings suggest that informed consent for adolescents considering cosmetic surgery is especially problematic. Informed consent forms and the consent process are intended to support the right of self-determination and patient choice [43]. Bioethicists point out that in cosmetic surgery, where both supply and demand for procedures are determined in the marketplace and can be stimulated by manufacturers’ and physicians’ self-interest, the ability of informed consent to meet this purpose may be compromised [43]. In addition to the influence of persuasive and pervasive advertising designed to stimulate demand, it is difficult for a physician to neutrally present both the risks and benefits of an elective procedure that has no medical benefits, which he or she is simultaneously selling. It has been suggested that, like pharmaceutical companies, the manufacturers of cosmetic medical devices should be legally mandated to disclose all information regarding side effects, complications, and any other adverse outcomes along with the promises of beauty in advertisements [43]. The FDA requires that each implant manufacturer provide patient booklets that clearly describe the risks. However, these informed consent publications are lengthy and are more complex than health educators would recommend for either adults or adolescents. Although the booklets are not required by regulatory agencies in other countries, the European Parliament’s Public Health Committee has urged European Union Member States to ban direct advertising to the public for breast implants, require risk information on the labeling, and promote alternatives to breast implants [44]. For adolescents, informed consent for cosmetic surgery follows the legal guidelines of any other medical treatment. If the adolescent is under age 18, parental consent is required. Unfortunately, no specific informed consent procedures exist for adolescents undergoing plastic surgery. As children and adolescents are thought to be even less likely than adults to have read or been informed regarding the issues related to surgery, it has been suggested that true informed consent for pediatric cosmetic surgery should include not only a discussion of risks and benefits, but body image concerns and expectations of surgery [2]. Conclusions and Recommendations This review paper describes research-based literature on liposuction and breast augmentation among teenagers, and highlights issues regarding the appropriateness of performing cosmetic surgery on patients whose bodies have not reached maturity, the long-term physical effects of these surgeries, and postoperative complications that may arise. This paper also raises concerns about the broader issues of the psychological implications of cosmetic surgery on developing body image, the extent to which distorted body image common among adolescents may result in the pursuit of cosmetic surgery, and the comparative effectiveness of therapy or other treatments to reduce negative body image. Finally, this paper presents concerns about the appropriateness of current standards for obtaining informed consent. 322 D. Zuckerman and A. Abraham / Journal of Adolescent Health 43 (2008) 318 –324 Important areas for future research are the potential effects of surgery on a teen’s developing body, the extent to which
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