plastic surgery and the teenage patient - bashour.com · plastic surgery and the teenage patient...

J Pediatr Adolesc Gynecol (2000) 13:105–118

Plastic Surgery and the Teenage Patient

Mary H. McGrath, MD, MPH, and Sanjay Mukerji, MDDivision of Plastic and Reconstructive Surgery, The George Washington University Medical Center, Washington, DC

Abstract. Over the past year, the media have reported an mammoplasty, surgery for asymmetric breasts, excision ofincrease in the number of teenagers undergoing plastic gynecomastia, augmentation mammoplasty, chin augmen-surgery, and with a tone of faint alarm have suggested that tation, and suction assisted lipoplasty. Each of these isthis merits some cultural self-scrutiny. This paper presents reviewed with regard to techniques, expectations, risks,the statistics on the number and types of plastic surgery and logistics. Guidelines for timing the referral of teenageoperations done in teenagers over the last eight years and patients for plastic surgery evaluation are given.discusses these in the context of cultural influences andsocietal concepts of beauty.

The reason to have plastic surgery is psychological andKey Words. Plastic surgery—Body image—Facialinvolves body image, which is defined as the subjectivesurgery—Breast surgery—Psychiatry, adolescent—perception of the body as it is seen through the mind’s eye.Psychiatry, and surgeryTo explain why changing the external appearance affects

personality and behavior, the complex psychological reac-tions that occur after an operation that alters the size or

Attitudes about plastic surgery have changed overshape of a body part are reviewed. Body image develop-the last ten years, and the demand for it has increased.ment occurs in stages, and puberty stands out as a particu-

larly sensitive time as the teenager undergoes major There are several reasons for this. First, the surgerychanges in his or her physical appearance and does this at is safe; there are very few significant complications.a time of heightened vulnerability to the opinion of others. Second, our society places a high premium on physi-Plastic surgery to correct a truly unattractive feature is cal attractiveness and rewards those who are slender,enormously successful and remarkably free of conflict in youthful, and handsome. Third, we live in a culturethis population. Teenagers undergo a rapid reorganization

that emphasizes competition and legitimatizes self-of their self-image after plastic surgery with subsequentimprovement as a way to gain a competitive edge.positive changes in behavior and interpersonal interactions.And lastly, plastic surgery lives up to expectations.The key to achieving success with plastic surgery is pa-The overwhelming majority of the one million pa-tient selection. The core value of the surgery lies not in

the objective beauty of the visible result, but in the patient’s tients who had cosmetic surgery last year are satisfiedopinion of and response to the change. Good patient man- and say the surgery helped them.agement includes selecting candidates with clear and realis- My intention today is to look at teenagers as atic expectations who are free of psychopathology. There subsegment of the plastic surgery population and dis-must be true informed consent and attention to psychologi- cuss issues peculiar to them from the standpoint ofcal issues must continue into the postoperative period. It

patient motivation, patient selection, and the judg-is the responsibility of the patient’s physician and plasticment and guidance required of their physicians andsurgeon to recognize a need for psychiatric evaluation andplastic surgeons. To manage the care of these pa-to help the patient get this as needed.tients, and all plastic surgery patients, requires anThe eight operations most commonly done in the teen-

age population are rhinoplasty, ear surgery, reduction appreciation of the psychologic as well as the physio-logic dimensions of the surgical intervention. In thefinal analysis, the purpose of plastic surgery is toThis Keynote Speech was presented at the North American Society

for Pediatric and Adolescent Gynecology Sir John Dewhurst Lec- change the patient’s psyche in a positive way. Bytureship, April 15, 2000; Atlanta, Georgia. making what the patient sees as an improvement inAddress reprint requests to: M.H. McGrath, MD, MPH, Professor appearance, his or her self-perception of the body isof Surgery and Chief, Division of Plastic and Reconstructive Sur-

changed, and this has an impact on well-being andgery, Loyola University Medical Center, 2160 South First Avenue,Maywood, IL 60153. the conduct of his or her life.

2000 North American Society for Pediatric and Adolescent Gynecology 1083-3188/00/$20.00Published by Elsevier Science Inc. PII S1083-3188(00)00042-5

106 McGrath and Mukerji: Plastic Surgery and the Teenage Patient

Table 3. Most Common Operations Performed on Patients AgeTable 1. No. Cosmetic Operations Performed on Patients Age18 or Less 18 or Less (1998)

Procedure TotalYear Total

1992 13,314 Rhinoplasty 8,074Ear surgery 4,7211998 24,623Acne scarring 2,322

Statistics courtesy of The American Society of Plastic Surgeons. Retin-A 2,224Male breast reduction 1,862Breast augmentation 1,840

Procedural Statistics Liposuction 1,645

Statistics Courtesy of The American Society of Plastic Surgeons.The media has made much of the increase in thenumber of patients having plastic surgery, and indeedstatistics gathered by the American Society of Plastic ogy such as the laser, which is easier, safer, and moreSurgeons (ASPS) confirm this.1 During the year 1992, effective for facial resurfacing than were previousabout 400,000 patients had surgery done by plastic operative procedures. Similarly, the increased num-surgeons certified by the American Board of Plastic bers for suction assisted lipectomy reflect refinementsSurgery. By 1998, this had risen to over one million in the technique and parallel what is seen in the adultpatients, a 153% increase. The media also reports population, where it is the most commonly performedmovement toward a younger population of plastic cosmetic surgery procedure. The increase in the num-surgery patients, but this is not strictly accurate.2 The ber of breast augmentations may be explained by thenumber of patients aged 18 or less having plastic extremely low numbers of these operations done insurgery did rise from 13,314 in 1992 to 24,623 in 1998 1992 after silicone breast implants were withdrawn(Table 1). However, as a percentage of all patients from the market in 1991 amid much sensational presshaving cosmetic surgery, the age-18-and-less popula- coverage. As studies of saline-filled silicone implantstion dropped from 4% to 2% during the same time completed over the last eight years have shown fewperiod (Table 2). associated systemic problems, the number of aug-

Looking at the seven most common operations in mentation mammoplasties done in the United Statesthe 18 and younger age group shows that rhinoplasty has more than quadrupled. This increase is most mod-and otoplasty (ear surgery) are the most frequently est in the teenage group.performed, in about 8000 and 5000 patients respec-tively during one year (Table 3). The next most com-

Cultural Influencesmon interventions are for the treatment of acne andacne scarring with the use of topical retinoid and laser

The public is assaulted continually with a barrage ofresurfacing of the facial skin. Male breast reduction isarticles in newspapers, fashion magazines, and self-next, done in 1862 young men with gynecomastia.improvement books about plastic surgery and theAbout 1800 breast augmentations are done in the“miracles” that can be achieved by the physical re-under-19 female population; a large proportion ofworking of one’s body. Health columnists in commu-these are unilateral to treat asymmetric development.nity and national newspapers publicize any new pro-Suction assisted lipectomy to reduce fatty depositscedure possible on faces, hips, and breasts—noon the trunck or under the chin was done in 1645matter how incremental or untested. Advertisementspatients.for colored contact lenses, permanent eyeliner, colla-Comparing the statistics for these seven most com-

monly done operations with statistics from 1992shows that the greatest growth is in the number of Table 4. Most Common Operations Performed in 1992 andinterventions treating acne and acne scarring (Table 19984). This reflects the progress made with new technol-

Procedure 1992 1998

Rhinoplasty 5,519 8,074Table 2. Percentage of National Cosmetic Surgery CasesEar surgery 3,024 4,721Involving Patients Age 18 or LessAcne scarring* 1,211 2,322Retin-A* 235 2,224Year %Male breast reduction 1,549 1,862Breast augmentation 978 1,8401992 4

1998 2 Liposuction* 472 1,645

Statistics Courtesy of the American Society of Plastic Surgeons. Statistics Courtesy of The American Society of Plastic Surgeons.

McGrath and Mukerji: Plastic Surgery and the Teenage Patient 107

gen injections, leg veins, and liposuction fill the back effects of what a person looks like. In 1935, Schilder,the first major student of body image, described it aspages of Sunday newspaper magazine sections. While

one may shake his or her head ruefully and dismiss a tridimensional scheme of one’s own body involvinginterpersonal, environmental, and temporal factors.all of this as postmodern folly, we cannot ignore the

antiquity and ubiquitous nature of invasive proce- He talked about the influences that contribute tobody image development. These include what ourdures done for personal beautification.

The art of body enhancement by making physical bodies look like. They also include what people sayabout how we look, our reactions to these inputs,change is described in most primitive groups and

essentially all of the higher cultures. Tribesmen in where and how we grew up, and when certain keyevents happened. As an example, consider a youngBrazil wear disks and plugs as jewelry in perforated

and progressively stretched lips and earlobes. Scari- woman with a large, prominent nose. If she is a Jewishor Armenian girl from a close-knit, positive thinking,fication of the skin as a method of beautification or

a mark of distinction is commonplace in African ethnically proud family, her feelings about her nosemay be quite different from those of a Swedish girltribes. In ancient Athens, women bound their chests

tightly to produce atrophy of the breasts since the of the same age who is the only female in her familynot to have an attractive, refined, feminine nose. Orsmall, firm breast was associated with poise and grace.

In Chaucer’s day, the voluptuous breast was found consider that within a certain family, certain charac-teristics may be valued or despised. Being told thatonly on peasants, and women of the upper class re-

sorted to continuous chest binding to produce breast you look just like your grandmother is an imagebooster if your grandmother was a legendary favoritewasting. From this small sampling of hundreds of

instances of manipulation of the appearance, it be- known for her warmth and charm. Your feelingsmight be quite different if she was a wretched, ill-comes clear that not only are people prepared to

embark on physical interventions but also this is not tempered woman disliked and avoided by her chil-dren. People’s reactions to having familial, ethnicallydone to meet an objective standard of beauty. Beauty

is in the eye of the beholder, and man’s concept of normative, or even a celebrity’s features are coloredin this way by feelings about the individual in ques-ideal beauty seems to be relative and heavily influ-

enced by his cultural environment. tion. Because of this, body image is, by definition,subjective. We cannot know how someone else feelsIn addition to varying from culture to culture, and

from society to society, concepts of beauty are dy- about his or her body based on an evaluation of hisor her objective appearance. Similarly, changes innamic and change over time. In America, the ideal-

ized female face has changed form the soft, round, appearance are “improvements” only if a patientevaluates them as such.baby-doll features of the 1930’s to the more angular

and strong face we see in today’s attractive woman.The idealized male face has gone from the chiseled-looking, pencil-mustached matinee-idol regularity of Body Image DevelopmentTyrone Power or Clark Gable to the far-from-classicunkempt looks of Brad Pitt or Johnny Depp. And Perceptions of body image affect emotional life andeven as society at large changes its perceptions of ultimately change behavior. Let us look at how thisits “ideal” or most attractive members, so do the happens. When we look or think about ourselves, weindividual members adjust the context in which they have a personal body image. When someone elsesee themselves. looks at us, that person forms a body image of us in

his own mind. So, for every encounter there are twobody images for each person. It is from the interactionof these two images that behavior develops.4Defining Body Image

As a person appraises his abilities based on hisimage of his own physical and mental abilities andFor each of us, our own appearance becomes part

of a complex psychological abstraction called body their success in the environment, a psychological ef-fect is produced with varying amounts of confidenceimage. To explain why changing the external appear-

ance affects personality and behavior, we need to or anxiety. These feelings of self-confidence or inade-quacy will then influence one’s ability to perform.define body image and review the complex psycho-

logical reactions that occur after an operation that Thus, when dealing with challenges, one’s individualbody image affects the amount of success that canalters the size or shape of a body part.3

Body image has been defined as the mind-body be achieved. By repeating this process over and over,one learns what can be accomplished and uses thisrelationship; the subjective perception of the body

as seen through the mind’s eye; or the psychological information to develop patterns of goal oriented be-


havior. One learns to avoid situations that bring fail- diminish the authority of the physically older person,and a tired and worn out appearance tends to inten-ure. This behavior then informs others about your

strengths and weaknesses and further determines the sify this type of peer behavior. Although an olderperson may still be bright and competent, he maybehavior of others towards us.

This process of developing body images begins in start to show weakening of body image in the faceof group pressure.the child in his earliest years. Parental approval and

attention, or parental criticism or neglect, will tellthe infant how to think about himself. In a loving Studies of Body Imageand secure environment he will learn that he is attrac- The presence of the feedback loop between personaltive and has value to others, and this feeling of self- appearance and external response as a key elementworth will become the basis of a positive body image. in the development of body image is well docu-

The second step in body image development oc- mented. A number of studies have explored what iscurs when the child encounters others outside the called a “strong physical attractiveness stereotype.”family—usually when entering school—and is tested This means that observers endow attractive peoplein a competitive environment. The child who is attrac- with a wide variety of favorable attributes, assumingtive to others and able to project strong or desired them to be a kinder, more genuine, sincere, warm,qualities will be accepted by his peers. Their positive poised, sociable, sensitive, interesting, strong, and offeedback will lead the child to invest further in the better character. With all of these presumed qualities,attributes that increase popularity and the child’s pat- it follows that attractive people are assumed to leadtern of thinking about himself will be further estab- happier lives. Thus, subjects who see a man with alished. beautiful woman view him as more intelligent, excit-

At puberty, the third step in the acquisition of ing, and successful than a man with an unattractivebody image takes place. For the first time in the partner. Other studies have shown that comparedchild’s memory his physical appearance changes, and with unattractive individuals, attractive people arethis happens at a time when the person is particularly better liked and are more persuasive. A good lookingsensitive to his need to find his own place in the world job applicant is seen as a better candidate and workand vulnerable to the opinion of others. The physical done by attractive pupils is viewed more favorablychanges may be shocking. A previously compact body than that produced by ordinary or unattractive stu-may become bulky or fat, an attractive shapely nose dents.may suddenly be large and dramatically prominent, There are differences between the features thatsmooth facial skin become broken out, and huge our society ascribes to the ideal male and the idealdroopy breasts can appear. The adolescent’s body female. For males, proportioned largeness of size,image will change in response to this and, again, the strength, and intelligence are desirable attributes,

presumably because they increase the chances ofchange will be mediated through the steps of cogni-dominance and success. In contrast, beauty and itstion, emotion, and behavior. He or she will start withability to attract people are prized in the female. It isan opinion about the changes, such as “My nose isinteresting that it is not for its own sake that aestheticreally ugly” or “My new breasts seem to be verybeauty is valued, but for the reaction it stimulatesattractive.” This thinking will include a picture thein others, namely, the ability to attract people andteenager has of self-appearance in his own mind, andinfluence their behavior.this will be multiply tested for validation against the

opinions of his peers. A negative thinking pattern,or alternatively a positive and adaptive one, can pro-voke strong emotions in this age group. From an How Plastic Surgery Changes Body Imageimage of oneself as ugly or disgusting may come feel-ings of depression, anger, anxiety, or hopelessness. The ultimate role of plastic surgery is to alter the

patient’s body image, and thus to improve the pa-If the emotional response is persistent, maladaptivebehavior follows. Someone who thinks he is ugly and tient’s quality of life. It is relevant that plastic surgery

tends to be done at the time of one of the four stagesis depressed by feelings of shame will likely developnegative behavior such as social withdrawal. Social of body image development.5–7 First, plastic surgery is

done in the child with a congenital defect or physicalinteraction can be affected by negative patterns ofbody image cognition and emotions on many levels deformity that might cause early rejection, even if

this is only of trivial proportions. The second periodranging from nonverbal behavior during everydaycommunication to frank antisocial activity. when a child enters school is the usual time for correc-

tion of protruding ears, webbed fingers, and otherThe final adjustment to body image occurs whenthe person begins to age. Competitors use age to problems that will catch the attention and draw the


criticism of the child’s peers. The teenager years are image. Obviously, a rhinoplasty cannot change basiclife conflicts nor can it offer solutions for them. How-a time for correction of newly developed unattractiveever, changes within a patient resulting from the rhi-features, and the aging person seeks plastic surgerynoplasty may change the way in which he or she dealsto correct the drooping and wrinkling that producewith conflicts.a worn, tired appearance.

A case history may help to illustrate these observa-Focusing on the adolescent puts us squarely at thetions. A slender 16-year-old boy felt that his beakperiod of development when there is the greatestnose made him ugly and he articulated that he feltconcern about becoming attractive, competent, andit made others think he was unathletic, mean, andacceptable to other people. For this reason, perhapshumorless. His family tried to discourage him, tellingit is not at all surprising that invasive procedures tohim that he looked fine, but he continued to complainimprove appearance, when condoned by parents, areand felt that he was not attractive to the girls in hisremarkably free of emotional turmoil and sequelae.class. He had some social contacts but was a typicalWhether it is surgery to prepare for orthodontia,insecure adolescent who was not scape-goated butwhich is almost a rite of passage for middle-classalso was not part of a warm circle of friends. Afterpreteens, or surgery to correct a nasal hump, theremuch discussion, his pediatrician found him a plasticis little or none of the anxiety and emotional conflictsurgeon and a rhinoplasty was done. The surgeonthat accompany intra-abdominal surgery, sinus oper-told him and his family that there would not be aations, or repair of facial injuries in adolescents.drastic change in his appearance, and indeed thereSeveral studies have been done to investigate thewas not. However, the patient and his family wereapparent lack of conflict about teenage rhinoplasty.very happy with the result. He went off to college atIt has been suggested that this event may stand outage 18 and felt he had an advantage; he felt he lookedas an area of tacit agreement between parent andattractive and enjoyed his social life in college andchild at a time when almost every other issue hasgraduate school. After finishing school he married.become a focus of intense struggle. The parent andTen years later he was studied with in-depth psychiat-child seem to agree almost without discussion thatric interviews and expressed delight that he had takenthe operation is desirable. It is unclear how much ofthe surgical step and given himself an “edge.” Hethis is the parents’ wish to fulfill their own aspirationssaw the surgery as a positive and useful experienceor relieve feelings of guilt by making their child morethat freed him from over-awareness of his appear-perfect. For the youngster, rhinoplasty is seen as aance and let him devote more energy to construc-gift; and it is an unearned gift, requiring none of thetively working out other adjustments in life.effort required for good grades, popularity, making

For this patient, as for the vast majority of adoles-the sports team, after-school lessons, or watching dietcent plastic surgery patients, the surgery was success-and weight. There also are undertones of magicalful—not because the plastic surgeon did a nice job

transformation, as when the ugly duckling becomeson the nose, but because the surgery was done on a

a swan, or the frog a prince—metamorphoses that patient who then felt more positive about himselfalso were effortless. and his life. The surgery treated a body image discom-

Teenage patients seem to undergo very rapid reor- fort that lay at the heart of the young man’s senseganization of their self-image after rhinoplasty. Many of identity.state that within several weeks they cannot rememberwhat they used to look like, express surprise whenshown their preoperative photographs, and harbor Skills for Patient Selectionvery little sense of invasion. In most cases, a preoper-ative preoccupation with the nose disappears, and Since the psychologic concerns of patients are thethe patients in general are more pleased and satisfied motivation for plastic surgery, it is essential to under-than are older patients having the same surgery. Feel- stand them if the surgery is going to work.8 Under-ings of inferiority may be replaced with self-confi- standing them also is necessary to avoid problemsdence, and anxiety and awkwardness in social situa- with patient dissatisfaction or psychopathology.tions tend to diminish. Preoperative assessment starts with inquiring

Now, how does a rhinoplasty actually produce about patients’ expectations about the physicalthese beneficial effects? There is little doubt that the change to be made, what they think their own emo-nose first has to be made objectively more attractive. tional response to the change will be, and their esti-The changes in the nose are real (Fig. 1). The patient mate of how others will respond to it. Good surgicalcan see them in a mirror, and just as importantly, candidates will have clear and realistic expectations,other people can see them and give the verbal and be able to articulate what they are seeking, and de-

scribe why they are motivated to have the surgery.nonverbal feedback that changes the patient’s self-


Fig. 1. (a) Girl, 15 years old, with a large nose with a prominent dorsal hump. The appearance of the nose had been stablefor 18 months prior to this photograph. (b) Postoperative appearance following rhinoplasty to reduce the bony andcartilaginous dorsum and nasal tip.

Most plastic surgery patients do not evidence psy- The problem with doing surgery in these patients ischopathology, but this reflects a selection process that that operations address only the symptom, not thehas eliminated those with psychologic disorders that grave underlying problem of significant body imagewill not be helped with surgery. Patients with psychi- distortion. These patients generally are pleased withatric disorders who present to plastic surgeons re- the surgical outcome, but reducing the size of theirquesting surgery include, among others, those with body part does not alleviate their fundamental dissat-body dysmorphic disorder, personality disorders, and isfaction with their bodies. When a plastic surgeoneating disorders. detects an eating disorder in a young patient, direct

Body dysmorphic disorder is well recognized by attention should be given to the underlying disorder.most plastic surgeons. These patients have an exces-sively strong negative response to some aspect oftheir appearance despite the fact that there is little Informed Consentor no objective deformity. They often exhibit theclassic contraindications to plastic surgery, which are We have said that the primary reason to do plasticminimal deformity, multiple consultations with plas- surgery is the psychological benefit of the operation.tic surgeons, obsessive focus on appearance, and Once it is determined that the patient has realisticemotional volatility. These patients require psychiat-

expectations and is psychologically healthy, the nextric evaluation and treatment. Doing surgery on them

step is helping the patient make a good decision aboutis problematic since they may not be competent tothe risk-benefit ratio of the surgery. Deciding whatmake medical decisions and give informed consent.level of risk is acceptable for elective cosmetic sur-Personality disorders commonly seen in plasticgery is very subjective judgment. Even as the patientsurgery practice include those with narcissistic, de-must have realistic expectations about the plannedpendent, and borderline features. Most plastic sur-improvement, so must he or she know, understand,geons learn to recognize these traits and decide howand weigh the potential risks. Without informed con-comfortable they are caring for these patients.sent, a patient for whom any setback is a catastrophePatients with an eating disorder are somewhat dif-of immense proportions will proceed with surgery heferent. As many as 8% of the female adolescent popu-or she would not have undertaken if he or she hadlation in the United States have some symptoms ofreally considered the likelihood of small complica-anorexia nervosa and/or bulimia nervosa. Thesetions. When the patient is a teenager, the informedyoung women have body image distortions and ex-consent process must include the patient and the par-treme dissatisfaction with their appearance. In addi-ents; and the surgeon must be convinced that alltion to excessive dieting and other measures for appe-parties are prepared to accept the pertinent degreetite and weight control, some pursue plastic surgery,

usually for liposuction and breast related operations. of risk. In adolescents this means recognizing their


psychological vulnerability, tendency to wishful medical specialist for a cardiac murmur. Dependingon the particular situation, the surgeon explains tothinking, and lack of maturity and experience.the patient that he wants him or her to have a higherlevel of psychologic support, or treatment for thesymptoms of emotional distress, or help with adapt-The Dissatisfied Patienting to a physical feature that is a particular problemfor the patient. Ideally, a plastic surgeon can find aThe attention devoted to psychological issues extends

into the postoperative period. There are a certain pyschiatrist with a particular interest in body imageor adolescent surgery with whom a collaborative rela-percentage of plastic surgery patients who are dissati-

sfied with an operation that did not turn out well. tionship can be established.With regard to dissatisfied patients, the watchwordThere are also patients who are dissatisfied with oper-

ations that turned out perfectly.9 is prevention rather than treatment. This means thatthe criteria for patient selection must be followedFor the former, the suboptimal result should be

addressed openly and frankly, a plan should be articu- carefully and sensitively. It is well recognized that acompetent plastic surgeon turns away a significantlated, and with the patient’s support, a revision or

correction is done. For the patient who is dissatisfied number of the patients who present themselves forcosmetic surgery consultations.with the results of surgery that is highly successful

by objective standards, retrospective analysis oftenreveals one of the factors discussed earlier. Perhapsthere was a violation of the patient’s expectations, Operations Performed for Teenage Patientsor a facet of psychopathology was missed. These canbe very difficult problems and it is customary for Rhinoplasty

Patients who are candidates for rhinoplasty (Fig. 2)plastic surgeons to spend a great deal of time withthese patients discussing the problem and providing are those with noses with humps, bumps, or hooks;

too big or too high; or with a poor angle betweenencouragement. Sometimes the patient will respondwith increasing acceptance of the result; in other the nose and upper lip. A black or Asian person who

wants a “Caucasian” nose is not a good candidate,cases, the patient may become seriously depressedand discouraged, and it is critical for the plastic sur- nor are those with minor imperfections, because they

have unrealistic expectations. In order to allow thegeon to watch for this and enlist the aid of the pa-tient’s other physicians and a psychiatry consultant nose to be fully grown, the patient should be older

than 14 to 15 for a girl and 15 for a boy.10 Contraindi-as needed.Referring a patient for psychiatric consultation is cations to surgery are a bleeding disorder and allergic

rhinitis, which may be aggravated by the procedure.not uncommon in plastic surgery—more often as apreoperative rather than a postoperative evaluation. As part of the preoperative workup, the surgery

is individualized for each patient, depending uponFor most plastic surgeons, this type of referral is asmatter-of-fact and straightforward as referral to a their deformity and their goals. Preoperative plan-

Fig. 2. (a) Girl, 17 years old, with a high, long nose and a short upper lip. (b) Postoperative appearance following rhinoplastyto lower the dorsum, shorten the length, and elevate the tip of the nose. Note the improved angle of the nose with theupper lip producing a more balanced profile.


ning can involve using a mirror, photographs, draw- more prominent ear. Following correction, the otherear is corrected to match before skin closure of eitherings, and computer images. An external and internal

nasal examination is performed. is undertaken.For children, general anesthesia may be preferred;For patients with nasal deformities due to congeni-

tal defects, e.g., nasal deformities associated with a for an adult, local anesthesia is almost always used.The surgery consists of an incision placed behind thecleft lip or palate, or posttraumatic nasal deformity,

insurance companies may provide reimbursement. ear, where it is inconspicuous. The lateral surface ofthe ear cartilage is scored or partially incised to allowPatients without defects or injury seeking rhinoplasty

to improve their appearance are undergoing cosmetic it to bend, and sutures are used to hold the ear in afolded-back position.12 Dressings consist of a protec-surgery, and this is not covered by health insurance.

Rhinoplasty may be done under local or general tive bandage and are removed on the third to fifthpostoperative day, and the patient is given a head-anesthesia, and some surgeons prefer a hospital set-

ting to perform the procedure. band to be worn continuously for 3 weeks, and atnight, for a minimum of one month.Rhinoplasty may involve bone, cartilage, or both,

and may be accompanied by work on the septum and Infection is rare. An occasional complication isrecurrence of protrusion, occurring most commonlysometimes the turbinates. It may be done via either

an open or a closed route, leaving inconspicuous or within 2 to 6 months after surgery, usually due toinadequate suturing or inadequate weakening of theno external scars. Cartilage grafts may be harvested

from the septum, or occasionally from the posterior cartilage of the antihelix.13

In terms of long-term results, few changes occuraspect of the ear, which would require an additionalincision. in the long term, other than infrequent problems

related to sutures, such as exposure of nonabsorbableAfter rhinoplasty, the surgeon packs the nose, andthe patient wears a support for 5 to 10 days. Bone sutures or bow-stringing, which requires removal of

the sutures.reshaping causes bruising around the eyes. The pa-tient can resume most activities within 3 to 4 days,though strenuous activities should be deferred for 3 Reduction Mammoplastyto 4 weeks. Bruising usually is visible for 2 weeks, For a young women with extremely large breasts,and signs of surgery may linger for 6 to 9 months. reduction mammoplasty (Fig. 3) can improve bothThe patient is followed up at gradually increasing her appearance and her functional status.14,15 Womenintervals until the postoperative swelling has resolved seek reduction mammoplasty for alleviation of symp-and the final contour of the nose has been obtained. toms, which may include upper back and neck pain,

Bleeding is the most common early postoperative shoulder groove pain, and rashes between and belowcomplication in 2%–3% of patients. If bleeding oc- the breasts.16 Plastic surgery surveys always havecurs in the septum, with a hematoma formation, sec- shown a very high degree of patient satisfaction withondary infection may result in septal perforation or this procedure, with over 94%–95% of patients stat-saddle deformity. Patient dissatisfaction is another ing that they would have their surgery again. It ispossible complication and may require corrections.11 usually done in the hospital, and usually requires a

postoperative overnight stay. General anesthesia isused. Some patients choose autologous donation ofEar Surgery

The candidate for otoplasty has protruding ears with their blood before surgery, but blood transfusion isoften unnecessary.a gap of at least 2 cm between the helix (rim) of the

ear and the head. Usually both ears are affected, but Depending on the weight of breast tissue removed,in association with the woman’s build, and associatedoften the degree is asymmetric. The surgery is usually

done after 6 to 8 years of age, when the child is more problems with very large breasts, reduction mam-moplasty is often covered by health insurance.aware because of teasing from his peers.

Since the purpose of the surgery is the improve- Informed consent includes discussion of the scar-ring associated with the surgery, a 20% chance ofment of appearance, as a rule insurance companies

consider otoplasty to be cosmetic and will not pay nipple numbness after surgery, and the probabilitythat the young woman will be unable to breastfeed.for this procedure. Other congenital deformities of the

ear, such as microtia, may be covered by insurance. Incisions used are circumareolar, and vertical andhorizontal incisions to define the skin envelope thatThe goals of surgery are natural appearing sym-

metrical ears, with a smooth and regular rim. The will shape the recontoured breast.17 Excess skin andtissue are removed from the lower part of the breast.postauricular sulcus should be maintained, and in

the anterior view, the helix should be visible beyond The nipple and areola, usually still attached to theunderlying tissue, are then repositioned upward tothe antihelix. Initially, attention is focused on the


postoperative infection is 2%. A small number of pa-tients experience fat necrosis, which may result inasymmetry. Visible scars in the form of an inverted Tare unavoidable. They are located below the nippleand will not be seen with low-cut clothing, but in somepatients, the scars are so noticeable that they may needsurgical revision. In some cases, the scars may widen,or the suture material and stitches may appear throughthe skin 2 to 3 months postoperatively. Loss of nippleor skin tissue is a rarer complication.

While all patients experience a change in nipplesensation, it generally improves with time. However,if the nipple needs to be grafted, loss of sensibilitymay be more profound, and these patients also willbe unable to breastfeed.

Surgery for Asymmetric BreastsPatients with marked breast asymmetry (more thanone cup size) (Fig. 4) may require either unilateralbreast augmentation, unilateral breast reduction, ora combination of both. Occasionally, recontouring orsculpturing of any underlying abnormal costal carti-lages can be done to correct or improve an underlyingchest-wall deformity and thus enhance the final aes-thetic result.19 Insurance companies occasionally willreimburse for a severe asymmetry, treating it as adeformity rather than cosmetic surgery.

In a series of 49 female patients with severe devel-opmental breast asymmetry, Poland’s syndrome andisolated unilateral hypoplasia were the most frequentetiological factor (69%).20 If the asymmetry is due toPoland’s syndrome, additional deformities may bepresent including absence of the sternal head of thepectoralis major muscle and hand deformities.

Surgery is postponed until the late teenage years,Fig. 3. (a) Girl, 18 years of age, with bilateral breast hyper-to allow full development of the contralateral, unaf-trophy. She is 596″ tall, weighs 145 lbs, and wears a 36fected breast. When augmentation of a hypoplasticDD bra. She complains of back and shoulder discomfort,

difficulty maintaining her posture, moisture of the skin breast is required, prosthetic augmentation alone,under her breasts, and difficulty playing sports and exercis- transfer of the latissimus dorsi muscle, or an expandering. (b) Postoperative appearance after resection of 700 prosthesis are potential choices depending on thegrams of tissue from each breast. case. In order to achieve symmetry, the opposite

drooping/hypertrophic breast can be corrected insome patients.21,22

correct drooping. With particularly large breasts, theThe setting for the surgery is determined by thesurgeon may have to detach the nipple and areola

extent of surgery planned. If augmentation with anand graft them to their new location.18

implant is selected, it can be done as an outpatientTemporary discomfort following breast reductionprocedure, under local anesthesia and sedation. How-rarely lasts more than a few weeks. There is swellingever, the more extensive procedures will require gen-and discoloration, but minimal pain. The patient wearseral anesthesia, possible blood transfusion, and ata surgical bra or dressing for 2 to 3 weeks, and thenleast an overnight hospital stay.a regular bra for the next month. She can return to

The complications of the procedures will be similarfull activities in 3 to 4 weeks. Minor wound drainageto those for breast augmentation, or breast reduction,or scabbing is common and treated with local care.as applicable. In addition, any thoracic wall surgeryPossible complications include those related to an-

esthesia, bleeding, and hematoma. The incidence of will carry its own morbidity.


Fig. 4. (a) Girl, 16 years of age, with Poland’s syndrome with hypoplasia of the right breast and nipple and absence of thepectoralis major muscle on the right side. (b) Postoperative appearance after placement of a custom-made silicone breastimplant on the right side to add volume to the right breast and fill the hollow above the breast where the pectoral muscleis absent.

Excision of Gynecomastia and will be wrinkled or droopy. In these cases, excessskin is removed to allow the remaining skin to adjustGynecomastia (Fig. 5) is a medical term that comes

from the Greek words for “women-like breasts.” smoothly and firmly to the smaller breast contour.24

Sometimes, a small drain is inserted through aGynecomastia is quite common, affecting an esti-mated 40 to 50 percent of young men. It may affect separate incision to draw off excess fluids. Once

closed, the incisions are covered with a dressing andonly one breast or both. Though certain drugs andmedical problems have been linked with male breast the chest is wrapped circumferentially to keep the

skin firmly in place.overdevelopment, there is no known cause in the vastmajority of cases.23 For most adolescent males, the There may be some discomfort for a few days after

surgery and, in addition, some swelling and bruisingprocess resolves spontaneously, and for this reasonsurgery is not done until the gynecomastia has been for a few weeks. To help reduce swelling and prevent

fluid collections, patients are instructed to wear anpersistent for at least two years.Surgical removal of excess breast tissue remains elastic pressure garment continuously for several

weeks. It may be three months or more before thethe primary method for correcting gynecomastia, andit is usually performed as an outpatient procedure final results of the surgery are apparent.

The most common complications are seroma orunder general anesthesia, or in some cases, underlocal anesthesia plus sedation. hematoma collections under the skin flaps. Less fre-

quent complications include infection, skin injury,Treatment of gynecomastia may be covered bymedical insurance, but policies vary greatly. noticeable scars, permanent pigment changes in the

breast area, or slightly mismatched breasts or nipples.Excess breast tissue is removed by surgical exci-sion or by suction assisted lipectomy. An incision is If asymmetry is significant, a second procedure may

be performed to remove additional tissue. The tem-made in an inconspicuous location—either on theedge of the areola or in the axilla. The surgeon re- porary effects of breast reduction include loss of

breast sensation or numbness, and it may take severalmoves the excess glandular tissue and fat fromaround the areola and from the sides and bottom of months for this to return.the breast. If suction assisted lipectomy is used toremove the tissue, the suction cannula is inserted Augmentation Mammaplasty

Bilateral breast augmentation is not usually done inthrough the same incision. If large amounts of fat orglandular tissue will have to be removed, the skin women under 18 to 20 years of age, as breast develop-

ment may not be complete in a teenager. In addition,may not adjust well to the new smaller breast contour


Fig. 5. (a) Boy, 16 years old, with mild to moderate gynecomastia of 3 years’ duration. (b) Postoperative appearancefollowing excision of gynecomastia through a superior periareolar incision with excision of a crescent of skin and superioradvancement of the nipple.

the patient may not be mature enough to make this comes so thick and tight that the breast becomes hardand painful, and surgery may be required to breakimportant decision. However, unilateral breast aug-

mentation for asymmetry is done in younger women, up or remove the capsule. Some surgeons tell theirpatients to massage the breasts during the first 3 toagain provided breast growth has stabilized.

Prior to 1991, silicone-filled breast implants were 6 months to help prevent this problem. Folds in theimplant may be evident in the thin-skinned patient.used for breast augmentation. However, with ques-

tions about their safety, they were withdrawn from In about 1% of patients, infection develops aroundthe implant. Postoperative bleeding, hematoma for-the market. Now saline-filled silicone implants are

the only ones available.25–27 mation, and anesthetic complications also are postop-erative complications. Although many patients expe-Breast augmentation can be done under local or

general anesthesia, often on an outpatient basis. rience some change in nipple sensation, it is usuallytemporary unless a nipple incision was used. Disloca-The incision is made in the inframammary fold, on

the lower border of the areola, or less frequently, in tion of the implant is rare.Breast augmentation does not affect the ability tothe axilla. A pocket is then created under either the

breast tissue or the pectoralis major muscle. The im- breastfeed. The implants do not impede the interpre-tation of chest X-rays, but they do create a hazyplant is placed in the pocket and the soft tissues and

skin are closed around it. Postoperative discomfort opacity on mammograms and special techniques arerequired when mammograms are done to displacelasts about 2 to 3 days. Sutures are removed within

a week. The patient wears a surgical bra or supportive the implant to better view the breast tissue. There isno evidence that breast implants increase the inci-dressing for about 2 weeks and for 4 to 6 weeks she

must avoid strenuous activities, especially those that dence of breast cancer, and no evidence that thestage at which breast cancers are detected is higheruse the arm or chest muscles. After about six months,

the scar can be detected only on careful examination. in women with implants.28,29 If a needle biopsy is everrequired, care must be taken to avoid puncturing theThe major negative sequelae of this procedure are

related to the use of a prosthetic device. These in- prosthesis.clude implant rupture, or leaking, and capsular con-tracture, which is the tightening or firmness of the Chin Augmentation

The three important facial promontories are the nose,fibrous capsule the body naturally forms around thesynthetic implant. In some patients, this capsule be- the cheekbones, and the chin. Altering any one of


these changes the relative prominence of the others. cannula is passed through the fat layer, breaking upthe fat cells and suctioning them out. The suctionHence patients who have rhinoplasties may wish chinaction is provided by a vacuum pump or a large sy-augmentation or vice versa, to establish facial bal-ringe, depending on the surgeon’s preference. Fluidance. Chin augmentation can be done either by ais lost along with the fat, and it is crucial that thissliding genioplasty, which involves making osteotom-fluid be replaced during the procedure to maintainies in the mandible and advancing a segment of thehemodynamic stability. For this reason, patients needbone, or using a synthetic chin implant, placed under-to be carefully monitored and receive intravenousneath the soft tissues over the most prominent partfluids during and immediately after surgery.33of the chin.30 Synthetic implant materials include solid

After the incisions are closed, the tunnels left bysilicone or porous blocks of polymer. There is nothe removal of fat collapse and contract. The result isscientific evidence of systemic problems related toa reduction in contour and this change is permanent,the use of these substances.31,32

because the removed fat cells never regenerate. IfThe operation is usually done in an outpatientthe patient gains weight, remaining fat cells will en-facility. Sometimes, the surgeon may require that thelarge so it is likely to be evenly distributed over thepatient stay overnight. Facial implant surgery mayentire body, rather than localized to one area.require only local anesthesia combined with a seda-

Discomfort following suction assisted lipectomytive; general anesthesia may be recommended.consists primarily of itching, bruising, and swelling.A small incision is made inside the mouth (alongThe patient wears a compression garment for aboutthe lower lip) or in the skin just under the chin area.one month to help prevent hematoma or seroma for-The implant is placed in the pocket and secured bymation and aid the skin retraction process. Ecchymo-closing the soft tissues around it. Usually, the chin issis clears in 4 to 6 weeks.taped after surgery to minimize swelling and discom-

Complications include fluid accumulations such asfort. Sutures in the skin will be removed in 5 to 7hematoma or seroma, infection, and those related todays. If an intra-oral incision is used, the sutures willthe anesthetic. The incidence of infection is highestdissolve.in patients who have liposuction of the inner thighsComplications include asymmetry, malposition,combined with skin removal because of proximityhematoma, seroma, infection, and removal. Thereto the perineum. With ultrasound assisted lipectomycan be injury to the sensory nerves, causing numb-(UAL) technique, the heat from the ultrasound de-ness, and to the motor nerves, causing lip asymmetry.vice used to liquefy the fat cells may cause injury toUsually this nerve dysfunction is temporary.the skin or deeper tissues.34 In the tumescent tech-nique, anesthetic fluid with epinephrine is injectedSuction-assisted Lipoplastyto cause vasoconstriction and control postoperativeThe best candidate for suction assisted lipectomy ispain. This could cause lidocaine toxicity if the solu-

a person of normal or near-normal weight with goodtion’s lidocaine content is too high, or pulmonary

skin tone, who has unsightly deposits of fat despite edema if too much fluid is administered.35 The scarsdiet and exercise. Because the technique depends on from liposuction are small and placed so they areretraction, or tightening of the skin after the subcuta- hidden from view.neous fat is removed, it is most successful in younger Imperfections in the final appearance are not un-patients with elastic skin. It is not suitable for the common after lipectomy. The skin surface may beobese patient because large areas cannot be sucti- irregular, asymmetric, or even “baggy,” but this isoned. Suction assisted lipectomy may be used in sev- rare in the younger patient. Numbness and pigmenta-eral body areas, including the abdomen, buttocks, tion changes may occur. Sometimes, additional sur-thighs, hips, knees, calves, ankles, and arms as well gery may be recommended for contour defects.as the neck and chin.

When a small area is to be suctioned, it is doneunder local anesthesia on an outpatient basis. For Conclusionsareas that are more extensive, general anesthesia andovernight stays are necessary. Teenagers who seek plastic surgery are similar to

Liposuction is a procedure in which localized de- adults in their motivations and goals. An unattractiveposits of fat are removed to recontour one or more feature and an individual’s subjective perception ofareas of the body. Through a tiny incision, a narrow his appearance reinforced by the response of otherstube or cannula is inserted and used to vacuum the produces body image discomfort. Plastic surgery canfat layer that lies deep beneath the skin. If ultrasound change the feature. If the patient perceives theis being used, the ultrasonic cannula is inserted change as positive, his or her body image and patterns

of thinking, emotion, and behavior will change.through this incision and used to liquefy the fat. The


VA Sadock. Philadelphia, Lippincott Williams andNot every teenager who seeks surgery is wellWilkins, 2000, pp. 2550–2557suited for an operation. Emotional maturity is re-

5. Clifford E: Psychologic considerations: Patients withquired to understand the limitations of plastic surgeryClefts and Craniofacial Malformations. In: Pediatricand the complications that can occur. In addition,Plastic Surgery. Edited by D Serafin, NG Georgiade.the teenager needs to have reached certain growthSt. Louis, The CV Mosby Co., 1984, pp. 259–267

milestones or physical maturity depending on the 6. Stal S, Peterson R, Spira M: Aesthetic considerationssurgical procedure. and the pediatric population. Clinics Plast Surg 1998;

The American Society of Plastic Surgeons has de- 25:631veloped a position statement about surgery in teenag- 7. Belfer ML, Harrison AM, Pillemer FC, Murray JE:ers and this cites three important characteristics of Appearance and the influence of reconstructive surgerythe teenage patient.36 First, the adolescent must initi- on body image. Clinics Plast Surg 1982; 9:307

8. Pruzinsky T, Edgerton MT: Psychologic Understand-ate and reiterate his or her own desire for the plasticing and Management of the Plastic Surgery Patient.surgical improvement. Second, there must be realisticIn: Georgiade Plastic, Maxillofacial and Reconstructivegoals and appreciation of the benefits and risks.Surgery (3rd ed.). Edited by GS Georgiade, R Riefkohl,Third, there must be sufficient maturity to tolerateLS Levin. Baltimore, Williams and Wilkins, 1997, pp.the discomfort and temporary disfigurement of a sur-1189–1197

gical procedure. The position statement cautions 9. Gifford S: Cosmetic Surgery and Personality Change:against plastic surgery in teens who are prone to A Review and Some Clinical Observations. In: Themood swings or erratic behavior, who are abusing Unfavorable Result in Plastic Surgery. Edited by RMdrugs or alcohol, or who are being treated for clinical Goldwyn. Boston, Little, Brown and Co., 1972, pp.depression or other mental disease. 11–33

From the American Society for Aesthetic Plastic 10. Sheen JH. Rhinoplasty and Mentoplasty. In: M BB,ed. Patient care in plastic surgery. St. Louis: Mosby-Surgery come guidelines about teens and the cautionYear Book, Inc., 1996; 244–256that the teenage patient must be appropriately se-

11. Dziewulski P, Dujon D, Spyriounis P, Griffiths RW,lected.37 They recommend that the referring physicianet al: A retrospective analysis of the results of 218assess the physical maturity of the youngster sinceconsecutive rhinoplasties. Br J Plast Surg 1995; 48:451operating on a feature that is not yet fully developed

12. Caouette-Laberge L, Guay N, Bortoluzzi P, et al:could interfere with growth or undo over time theotoplasty: anterior scoring technique and results in 500

benefits of surgery. Second, the physician must ex- cases. Plast Reconstr Surg 2000; 105:504plore the emotional maturity and expectations of the 13. Foda HM: Otoplasty: A graduated approach. Aestheticpatient. Third, the credentials of the surgeon and Plast Surg 1999; 23:407the facility must be checked. The surgeon should be 14. Samuelov R, Siplovich L: Juvenile gigantomastia. Jboard certified and the facility should be accredited. Pediatr Surg 1988; 23:1014

15. Brown DM, Young VL: Reduction mammoplasty forAdditionally, the surgeon should have operating priv-macromastia. Aesthetic Plast Surg 1993; 17:211ileges in an accredited hospital for the same proce-

16. Serletti JM, Reading G, Caldwell E, et al: Long-termdure being considered. Lastly, the teen and the par-patient satisfaction following reduction mammoplasty.ents should be given some idea of the risks,Ann Plast Surg 1992; 28:363postoperative restrictions, and typical recovery time.

17. Savaci N: Reduction mammoplasty by the central pedi-With these precautions, the patient will be richlycle, avoiding a vertical scar. Aesthetic Plast Surg 1996;

rewarded with a change in psyche in a positive way— 20:171the ultimate goal of plastic surgery. 18. Romano JJ, Francel TJ, Hoopes JE: Free nipple graft

reduction mammoplasty. Ann Plast Surg 1992; 28:27119. Spear SL, Romm S, Hakki A, et al: Costal cartilage

References sculpturing as an adjunct to augmentation mamma-plasty. Plast Reconstr Surg 1987; 79:921

20. Rintala AE, Nordstrom RE: Treatment of severe de-1. National Clearinghouse of Plastic Surgery Statistics,velopmental asymmetry of the female breast. Scand J1999 Report. American Society of Plastic Surgeons.Plast Reconstr Surg Hand Surg 1989; 23:231Email: [email protected]

21. Urschel HC, Jr., Byrd HS, Sethi SM, et al: Poland’sURL: www.plasticsurgery.com2. Our Quest to be Perfect. Newsweek 1999, Aug 9, pp. syndrome: improved surgical management. Ann

Thorac Surg 1984; 37:20452–59. www.newsweek.com3. Fisher GT, Fisher JB, Stark RB: The Body Image. In: 22. Baker JL, Jr., Mara JE: Simultaneous correction of

the chest wall deformity and prosthetic augmentationAesthetic Plastic Surgery. Edited by RB Stark. Boston,Little, Brown and Co., 1980, pp. 1–32 mammaplasty in a case of Poland’s syndrome. Br J

Plast Surg 1976; 29:3474. Cotton NS: Normal Adolescence. In: ComprehensiveTextbook of Psychiatry (7th ed.). Edited by BJ Sadock, 23. McGrath M: Gynecomastia. In: Plastic Surgery Princi-


ples and Practice. Vol. 2. Edited by MJ Jurkiewicz. St. Augmentation—the allures and the alerts. Plast Re-constr Surg 1999; 104:1843: discussion 1861Louis, C V Mosby, 1990, pp. 1119–1136

24. Brenner P, Berger A, Schneider W, et al: Male reduc- 32. Karras SC, Wolford LM: Augmentation genioplastywith hard tissue replacement implants. J Oral Maxillo-tion mammoplasty in serious gynecomastias. Aesthetic

Plast Surg 1992; 16:325 fac Surg 1998; 56:54933. Gilliland MD, Common GW, Halperin B: Safety issues25. Rohrich RJ: Safety of silicone breast implants: scientific

validation/vindication at last. Plast Reconstr Surg 1999; in ultrasound-assisted large-volume lipoplasty. ClinPlast Surg 1999; 26:317104:1786

26. Hulka BS, Kerkvliet NL, Tugwell P: Experience of a 34. Young VL, Schorr MW: Report from the conferenceon ultrasound-assisted liposuction safety and effects.scientific panel formed to advise the federal judiciary

on silicone breast implants. N Engl J Med 2000; 342:812 Clin Plast Surg 1999; 26:48135. Matarasso A: Lidocaine in ultrasound-assisted lipo-27. Janowsky EC, Kupper LL, Hulka BS: Meta-analyses

of the relation between silicone breast implants and plasty. Clin Plast Surg 1999; 26:43136. Plastic Surgery for Teenagers. Plastic Surgery Briefingthe risk of connective-tissue diseases. N Engl J Med

2000; 342:781 Paper, 2000. American Society of Plastic Surgeons, De-partment of Communications 444 East Algonquin Rd.,28. Azavedo E, Bone B: Imaging breasts with silicone im-

plants. Eur Radiol 1999; 9:349 Arlington Heights, IL 60005 (847) 228-9900 ext. 349www.plasticsurgery.org29. Reynolds HE: Evaluation of the augmented breast.

Radiol Clin North Am 1995; 33:1131 37. What Everyone Needs to Know About Teenagers andCosmetic Plastic Surgery. 2000, Jan 3. American Soci-30. Rosen HM: Surgical correction of the vertically defi-

cient chin. Plast Reconstr Surg 1988; 82:247 ety for Aesthetic Plastic Surgery, Communications Of-fice, New York, NY31. Zide BM, Pfeifer TM, Longaker MT: Chin surgery: I.

plastic surgery and the teenage patient - bashour.com · plastic surgery and the teenage patient...

Documents