The Last Word: How young is too young?

By Dr Raina Zarb Adami / 01 Dec 2014

How young is too young? Dr Raina Zarb Adami argues for case-by-case evaluation of younger patients

Medical aesthetics is encumbered with its fair share of controversy. There exists a common concern that a significant percentage of young adults and teenagers are choosing to undergo cosmetic procedures. Is this really the case? And is there a real cause for concern? The expanding scale and visibility of the aesthetic industry has led, to a certain degree, to a normalisation and acceptance of the practice and it is a commonly known fact that young women are under increasing pressure to look attractive. This is largely due to media and advertising challenging their self-esteem.1
The president of the British Association of Aesthetic Plastic Surgeons (BAAPS) has reported that in the UK, we are seeing more young people seeking cosmetic procedures.2,3 A recent study showed that half of young women aged 16-21 now say they would consider undergoing cosmetic treatments, while more than one in 10 girls aged 11-16-years-old would consider cosmetic surgery.There is a paucity of data on the number and profiles (including age and gender) of people undergoing surgical and non-surgical cosmetic procedures in the UK. Only indicative data is available, primarily from small-scale surveys conducted by professional bodies, market research companies and cosmetic procedure providers.5 In the US, non-invasive procedures accounted for 71% of all cosmetic procedures in the 13-19-year-old age group. While injectables were very popular, laser hair removal was the most popular procedure in this cohort. Interestingly, the number of both surgical and non-invasive interventions in both age groups fell by 1% from 2012 to 2013.6 This decreasing trend in the US is reassuring. It would be interesting to see whether this is because less patients are seeking treatments or because medical professionals are turning such patients away and refusing to perform requested treatments.
Medical aesthetics can be roughly classified dichotomously into rejuvenation and beautification or enhancement procedures. The latter is seen more in our younger patients, and therefore procedures involving dermal fillers are more common than those involving toxins. The most common procedure in the US is lip enhancement.6 It is pertinent to explore the various factors that motivate younger people who choose to subject themselves to the needle or knife in order to modify or improve their outward appearance. There exists little research on the psychological characterisation of adolescents who seek plastic surgery and, similarly, a relative scarcity of literature surrounding the appropriateness of performing these procedures on individuals whose bodies and body images are still developing.7,8 According to The American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) 69% of children and teens undergoing cosmetic interventions do so as a result of bullying, while 31% do so to prevent being bullied.9 Another worrying rising trend has been observed, where parents gift cosmetic intervention to their children. It is therefore hardly surprising that this pressure to conform to peers, family and society is a significant driving force behind the increasingly youthful face of cosmetic medicine and surgery. All these issues, together with the pressure of the media through its promotion of unattainable perfection in body imagery, fuel this desire in younger patients to seek out aesthetic services.10,11 We, the medical professionals, are to a certain extent responsible for stalling this desire in the young to seek our treatments, and measures to make them less easily accessible should be put in place. The Keogh report, published last year, highlighted flaws in the industry where many cosmetic firms are seen to make aesthetic procedures seem alluring to patients and even going as far as incentivising them through discounts, finance schemes and ‘refer a friend’ type offers.12 39% of AAFPRS members surveyed were under the impression that this increased demand of cosmetic interventions by younger patients presenting for rejuvenation treatments is reflective of a belief that non-surgical cosmetic procedures will delay invasive facial surgery down the line, a concept that has been affectionately coined ‘pre-rejuvenation’.9 To my knowledge, there are no PubMed studies to show evidence for this “nipping it in the bud” approach. While the basis of this hypothesis is plausible, as there is no robust science to support this theory as yet, it is not one that should be used to ‘sell’ or incentivise patients. By definition, youth encompasses inherent factors such as immaturity, vulnerability, impulsiveness and trivialisation of certain issues. Quick-fix measures are found especially attractive in this age group. Young adulthood and teenage years already have to contend with building a sense of identity, dealing with the significant physical changes, associated body image fluctuation and the tumultuous mood changes, along with evolving dynamic peer relationships.13 Teenage years and early twenties are the years during which individuals often seek to engage in risky and impulsive behaviour, often without appreciating the long-term consequences.14 Bringing cosmetic interventions into the mix is creating a potential slippery slope and should be handled with great caution and under professional direction. There exists a gulf between ‘need’ and ‘want’. Maturity tends to lend to an understanding of the difference between the two. A patient may want to undergo a lip enhancement procedure but a practitioner should delve deeper into the patient’s motives behind such a request and try to appreciate the psychological factors contributing to this perceived need, and find alternative ways to help them address the problem.
Wanting to look like a celebrity is not a healthy motivation. Nor is a desire to relieve some deep-rooted psychological problem or as the sole response to bullying. Individuals who pursue aesthetic treatments for reasons purely associated with external appearance may be at an increased risk for poor psychological outcomes.15 Obsessions with body image concerns may be indicative of body dysmorphic disorder (BDD). The sufferers obsess about differences between their actual and their ideal selves. When it occurs alongside depression or anxiety, it can significantly impair a young person. Dysmorphophobia, together with many other mood disorders and psychiatric afflictions most often starts in adolescence.16 As concerns and changing opinions pertaining to self-image are normative during adolescence and into the early twenties, it may be challenging to diagnose BDD during this developmental period.8 As medical professionals operating in the field of aesthetics, the ability to probe and detect patientssuffering from this disorder is a reflection of our clinical acumen. It is indeed often deleterious to the patient’s condition to perform any such cosmetic intervention.17 It is important to assert that the patient’s desire for cosmetic interventions is not a reflection or manifestation of an underlying psychological problem that requires professional counselling.
Non-invasive procedures, such as those involving toxins and dermal fillers, tend to be considered entry level and, taken at face value, appear to be benign enough. Most of us can recall a few patients who started off with a little bit of toxin to that stubborn glabella, who over time requested a sample of everything we had to offer. It is our responsibility to recognise such vulnerabilities and not fuel a burgeoning addiction. Cosmetic interventions should never become the proverbial “crutch” to maintain self-esteem. Equally it certainly isn’t fair to assume that every young patient presenting to our clinics is inappropriate for treatment and must have some underlying psychological morbidity. In situations where the size or shape of a feature really does not conform to the ideals of beauty or is objectively disproportional to the rest of the face, and the patient’s reaction to that feature is rational and has a significant and profound negative impact on the person’s well-being and self-image, I don’t think age (or its lack thereof) is a contra-indication to treatment. There does exist a small number of teenagers and young adults for whom cosmetic procedures would be appropriate and would yield beneficial results. Such examples include deformities of the nose or the ears. In cases where the patient has a large dorsal nasal hump that is disproportionate to their other facial features, and this affects their self-esteem to a degree proportionate to the deformity, they will, in all likelihood, regain their self esteem and benefit from a rhinoplasty procedure. A successful aesthetic procedure can have a positive influence on a mature, well-motivated younger adult or teenager, while the same intervention on a psychologically unstable individual can be damaging.18
I am of the opinion that, if you have no static rhytides, you are too young for any sort of rejuvenation procedure. I am, however, an advocate of aesthetic treatments as long as they are employed in the right circumstances, performed on the right individual who has the right grasp on the situation, and to achieve an appropriate and realistic result. The impetus to go forward must ultimately belong to the patient. As long as I can ascertain myself that this is the case, and not the result of bullying, peer pressure or an unreasonable motive, I am happy to proceed.
In truth, the only reason we continue to debate the issue of “how young is too young?” is because a clear-cut answer does not, nor will ever, exist. The real answer is, “it depends”. As clinicians, regardless of the indication, a patient is a patient, so we need to take a history, perform an examination and devise a management plan accordingly. The need for intervention must be evaluated on a case-by-case basis as teenagers and young adults mature physically and emotionally at varying rates. Cosmetic intervention to correct disfigurement should not be discounted but the idea of using it as a cosmetic social enhancement should not be endorsed. Ethically, medical professionals should be mindful of the principles of beneficence and nonmalfeasance19 and are duty bound to always act in the best interest of the patient. It is also our responsibility to point out to the patient that it is impossible to predict or control how others will respond to their altered appearance.8
No such thing as a ‘cosmetic emergency’ exists. The procedures we perform are elective. This means that time is on our side to adequately assess our patient’s suitability for a procedure and ensure they have all the necessary information, including alternative treatments, to choose to undergo the treatment. It is very likely that in most cases where young people present to our clinics for cosmetic interventions, there are less invasive, more appropriate avenues they should be exploring outside Harley Street and the likes. It is our duty to recognise these cases and steer them well away from our expert hands, with clear instructions on how to avoid us for a fair few years ahead. More often than not, the answer to a young person requiring our expertise is: “A generous dollop of sunscreen and a pair of big sunglasses”.

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