CPD: Children and Aesthetic Treatment

Children and Aesthetic Treatment

Dr Nestor Demosthenous explores the motivations and appropriateness of aesthetic treatment in patients under 18

There is a rising concern about reports of cosmetic interventions on children 1 and the appropriateness of children undergoing cosmetic interventions (surgical and non-surgical) is controversial. There are few studies looking at the psychological factors of minors who seek cosmetic treatments, or studies that look at the appropriateness of performing these procedures. Considering the increased rates of aesthetic intervention worldwide, this article will discuss the professional and legal obligations that practitioners have when children, and their parents, present to clinic seeking cosmetic interventions. In Scotland, those between 16-18 can be considered adults. 2 However, in most of the UK a child is regarded as anyone under the age of 18, so for the purpose of this article, those under the age of 18 years are considered a child.

Why do children seek treatments? The desire for cosmetic interventions is prevalent in both males and females of varying socio-economic backgrounds and ages. 3 The International Society of Aesthetic Plastic Surgery found a total of 31.6 million plastic surgery operations performed in 2016, with more than 63,000 surgical procedures performed in children (13-18 years) in 2013. 4 According to more recent stats from The American Society of Plastic Surgeons, 227,000 cosmetic surgical and nonsurgical procedures were performed on patients aged 13 to 19 in 2018, although it should be noted that this was only 1% of the total procedures. 5 As medical aesthetic practitioners, it is our professional responsibility to understand the motives of young people seeking treatments, to protect them from harm, support them in accepting themselves, and explaining the importance of prevention, helping them to live healthier lives. In today’s society, there is an emphasis on physical appearance, idealising beauty which is often unattainable. 3 Media, the internet and social media play a key role in supporting the idea that our appearance is related to our success, burdening us, especially children, with psychological pressures to improve our looks. 6 The greatest physical and psychological changes occur during the developmental years of adolescence. French plastic surgeon Duquennoy-Martinot identified reasons children present for cosmetic surgery, which included wanting to be ‘normal’, to feel better about themselves, be more beautiful, or emulate celebrities. 7 Glamourised celebrity lifestyles portrayed in the media are recognised to drive children to seek treatments. 8 A survey of 2,265 adolescents between the ages of 13 and 18 found that around 75% seek treatment to emulate celebrities, while it also suggests that girls compared to boys show greater dissatisfaction of their bodies (78%), with 31.3% wanting cosmetic surgery. 9 The most common procedures were breast augmentation followed by rhinoplasties, then breast reduction and otoplasty. 4 Appropriateness of aesthetic interventions Aesthetic treatments may be considered unnecessary, as cosmetic interventions, surgical and non-surgical, do not address disease or ill health. However, the World Health Organisation describes good health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’. 10 This validates the idea that cosmetic procedures that are carried out can improve a patient’s psychological and social wellbeing. For example, cleft lip procedures that are not life threatening are often sought for this reason. Similarly, acne treatments are highly sought-after treatments by adolescents and it can have a profound psychological effect on children’s self-confidence. 11 Acne itself is a skin ailment requiring medical treatment. The residual scarring it can leave, however, may be seen by some as purely cosmetic, yet addressing these scars can improve an adolescent’s psychological wellbeing. 11 Treatment is therefore reasonable. However, where psychiatric illness is at the core of seeking interventions, treatments are not appropriate. Body dysmorphic disorder (BDD) is most common in teenagers and young adults – see BDD section. 12,13 Appropriate treatment for such psychological issues involve referral to a psychiatrist/psychologist. Treatments that would alter a child’s development, for example breast or nose surgery, should be refused. Many individuals seek otoplasty procedures to correct protruding ears. As a child’s ears have fully grown to 90-95% of their full size by the age of eight years, 14 surgery is not altering their development and therefore the intervention is appropriate. Surgical correction may help avoid psychological stress in early and/or later years. It should be noted that practitioners must understand who exactly is seeking the procedure – child or parent/ guardian. The parent may be seeking treatments for their child for their own reasons/prejudice (for example protruding ears), however this anomaly may not bother the child at all. Ultimately, it is the responsibility of the practitioner to decline treatments deemed inappropriate, such as a sixteen-year-old patient seeking botulinum toxin for ageing concerns when facial lines are not present. Girls do not attain adult lip dimensions until the age of 17/18 and boys 18/19 years of age. Treating them with lip fillers before this should therefore be considered inappropriate. 15 All surgical and non-surgical interventions carry the risk of complications/harm. One of the four pillars of Good Medical Practice is ‘do no harm’ so to perform a treatment such as botulinum toxin for cosmetic reasons on a child as an elective procedure, where the risks outweigh the benefits, would be wrong. 16 This moral compass should be present in every decision a practitioner makes. A child may lack the maturity to appreciate that the requested treatment may cause harm. For example, Ellart et al. found that 14% of sixteen-year-old girls wanted a breast augmentation procedure, often to a size that could cause complications such as postural or respiratory problems. 17

Body dysmorphic disorder Most often, BDD develops in teens and adolescents. 12,13 A recent survey published in 2018 by NHS Digital consisting of 9,117 children aged 2-19 suggested that BDD is prevalent in 1% of 5 to 19-year-olds. The research also found that it affects 1.8% of girls and 0.3% of boys. Rates were highest in girls aged 17-19, with 5.6% experiencing BDD at the time of the interview. 13,28 Statistics are slightly different in the US. According to the Anxiety and Depression Association of America, it is thought that 1.7-2.4% of the population suffer from BDD 12 and it affects men and women almost equally – 2.5% of males and in 2.2 % of females. 12 BDD is characterised by a preoccupation with an imagined defect in one’s appearance, or in the case of a slight physical anomaly, the person’s concern is markedly excessive. BDD is characterised by time consuming behaviours such as mirror gazing, comparing particular features to those of others, excessive camouflaging tactics to hide the defect, skin picking and reassurance seeking. 12,13 National Institute for Health and Care Excellence (NICE) guidelines state that for people known to be at a higher risk of BDD (such as individuals with symptoms of depression, social phobia, alcohol or substance misuse, OCD or an eating disorder), or for people with mild disfigurements or blemishes who are seeking a cosmetic procedure, healthcare professionals should routinely consider and explore the possibility of BDD. 29 If BDD is suspected, NICE suggests that the patient should be referred to their GP to then be referred onto a specialist BDD multidisciplinary team offering age-appropriate care. Depending on the severity of the BDD, the patient may be treated with cognitive behavioural therapy, involving family or carers, with the possible addition of selective serotonin reuptake inhibitors (SSRI) antidepressants. 29

According to NICE, the assessment of people at higher risk of BDD should be asked the following questions: 29 1. Do you worry a lot about the way you look and wish you could think about it less? 2. What specific concerns do you have about your appearance? 3. On a typical day, how many hours a day is your appearance on your mind? 4. What effect does it have on your life? 5. Does it make it hard to do your work or be with friends?

Practitioners can use the Derriford Appearance Scale 30 – a validated and arguably one of the more reliable psychometric scales – to measure the expectations of how one’s looks could be improved and to what extent their quality of life would be improved following surgery. This can help to identify BDD. It measures the extent that psycho-social distress is linked to physical appearance. A reasonable argument for treatment would be if a child’s psychological distress caused by BDD results in difficulties to function within society, resulting from social isolation and withdrawal. 31

It is also important for the practitioner to know which conditions children will outgrow. Greydanus et al. found that although breast asymmetry in young girls and the presence of breast tissue in young boys cause depression and low self-esteem in children, it often resolves in adulthood. 18 With regards to potential non-surgical rhinoplasty treatments, the female nose develops around the age of 17, the male nose approximately 18. Treatment before these ages would be inappropriate. 19 Therefore, practitioners should advise patients accordingly, and not comply with treatment request, but help support their mental wellbeing during this time by referring them to an appropriate psychologist or their GP. As well as this, concerns and desires (and trends) are likely to change through adolescence. One study by Wright found that adolescents’ ideas of body image improved between the ages of 11 and 18 without interventions. 20 It is the practitioner’s obligation to initiate these kinds of discussions to help the patient realise insight. A practitioner must seek to understand the patient’s (or parents’) motivation for treatments, assess how long they have wanted treatment and what they hope treatment will achieve. They should even go as far as to point out how concerns, wants and trends change over the years and that the patient should consider waiting a couple of years.

Guidance on treating children These professional and legal responsibilities for treating children are outlined in the General Medical Council’s (GMC) ‘Guidance for doctor’s who offer cosmetic interventions’. 21 For patients of all ages, the guidance advises withholding treatment if the desired outcome will not be achieved or if there would be no benefit; and to consider a patient’s vulnerabilities and psychological reflection. 21 They do not clarify what constitutes a ‘cooling-off period’ for non-surgical procedures, however two weeks is considered appropriate for surgical procedures. Specifically relating to children, the GMC recommends to carry out treatments in a child-friendly environment and to only perform procedures that are in the child’s best interest. 21 Parents know the patient best, are an important mediator between practitioner and patient, and can provide useful insight into why a child is requesting a procedure, as well as help explain the risks involved and why a procedure may be refused. Therefore, the GMC states that a parent can consent to an intervention for a child ‘that lacks the maturity’ to make the decision; however, doctors can decline treatment if they believe the child does not want it. 21 Children should be appropriately involved in decision making, respecting their autonomy. The GMC also says that practitioners must seek to help the child/parent become aware of their own subjectivity of severity and realise the risk perhaps outweighs the benefit of what they are asking. 21 They should also recommend alternative, lessinvasive measures, such as diet and exercise vs. liposuction. There is no specific guidance for nurses who offer cosmetic interventions by the Nursing and Midwifery Council; however, the British Association of Cosmetic Nurses state in its 2015

needs. 21 It also advises a cooling-off period allowing time for Competency Framework that, ‘It is generally accepted that the patient should be over 18 years of age to access aesthetic medical services in order to provide full consent for elective, non-emergency procedures.’ 22 The same goes for dentists, however they must adhere to the General Dental Council’s general ‘Guidance on child protection and vulnerable adults’, which is nonspecific to cosmetic interventions like dermal fillers. 23

Consent and capacity As with all treatments, practitioners must obtain informed consent prior to intervention. As part of informed consent, treatment options must be offered, intended outcomes of proposed treatment with associated risk must be discussed as well as the likelihood of these risks. Fundamentals of informed consent include receiving appropriate information, capacity and voluntariness. The GMC’s guidance for doctors on treating 0-18 years is clear on assessing the capacity of the patient. 23 Before obtaining consent, a doctor must decide if a child is able to understand the nature, purpose and possible consequences of treatments, or not having treatment. 24 With regards to capacity, of importance is a child’s ability to understand and weigh options, rather than age. Maturity and understanding must be assessed on an individual basis. If a child under the age of 16 is deemed to have ‘enough intelligence, competence and understanding to fully appreciate what’s involved in their treatment’, they are deemed to be Gillick competent. 25,26 In children who lack capacity, a parent’s consent is acceptable. It is paramount that the parent’s motivations are explored when cosmetic interventions are sought. Parents may seek such treatments out of an effort to realise ‘the ideal child’ or in the case of congenital deformities, out of guilt. 7 A practitioner must understand the motivations of the parent/guardian in the case of an incompetent child. For example, in a child with Down’s syndrome, parents may seek corrective surgery to alter facial features. Surgery purely at the request of the parents is not acceptable. Surgery will not affect the child’s interaction with society and quality of life. 1 The legal framework for the treatment of 16 and 17-year-olds lacking capacity to consent differs across the UK. In England, Wales and Northern Ireland parents can consent to treatments in a child’s best interest. 27 In England and Wales, treatment may be provided in a child’s best interest without parental consent. 27 In Scotland, patients aged 16 and 17 are treated as adults who lack capacity. 27 Treatment may be given to safeguard or promote their health.

Conclusion Cosmetic procedures can have positive psycho-social benefits such as improved self-esteem and quality of life. 32 Cosmetic treatments may be offered to children, however with caution. When a child, or parent of the child, seeks non-surgical or surgical cosmetic interventions, the practitioner must act in the patient’s best interest, do no harm and observe the law. Manufacturers of products and devices used in a cosmetic medicine often carry guidelines for age-appropriate use. This is usually in the form of ‘Contra-indications: children’, however they do not qualify how they define a child. The consultation should be well structured to enable practitioners to understand the child’s/ parent’s motivation and these reasons should be explored before making a decision to treat or not. Capacity must be determined and consent gained. Any suspicion of BDD must be referred appropriately. Young patients are more often vulnerable and must be supported and respected. Ample information must be given and a cooling-off period applied if proceeding to treatment. Practitioners retain the right to refuse treatment if deemed inappropriate.

Dr Nestor Demosthenous is one of Scotland’s most experienced cosmetic doctors. He is an international speaker and published author in the specialty. Dr Nestor has been an advisory board member for Allergan’s complications group 2015, and Healthcare Improvement Scotland Phase I (2016-7) & II (2017-8). He has previously been a key opinion leader for Sinclair Pharma and is currently a member of Allergan’s Medical Institute Mentorship Program.

REFERENCES

1. Bowyer L1, et al., A critical review of cosmetic treatment outcomes in body dysmorphic disorder Body

Image. 2016 Dec;19:1-8 2. Citizens Advice for Scotland, Young people and the law. <https://www.citizensadvice.org.uk/scotland/ law-and-courts/legal-system-s/taking-legal-action-s/young-people-and-the-law-s/> 3. Vergallo GM, Marinelli E, Napoletano S, Di Luca NM, Zaami S. Ethics and/ or Aesthetics? Reflections on Cosmetic Surgery for Adolescents. Cuad Bioet. 2018 May-Aug; 29(96):177-189. 4. International Society of aesthetic plastic surgery. 2019. ISAPS. <https:// www.isaps.org/medicalprofessionals/isaps-global-statistics/> 5. American Society of Aesthetic Plastic Surgeons, ASPS National Clearinghouse of Plastic Surgery

Procedural Statistics, 2018. <https://www.plasticsurgery.org/documents/News/Statistics/2018/plasticsurgery-statistics-full-report-2018.pdf> 6. Rufai, S.R.; Davis, C.R. “Aesthetic surgery and Google: ubiquitous, unregulated and enticing websites for patients considering cosmetic surgery”. Journal of Plastic, Reconstructive and Aesthetic Surgery. 2014; 67(5): 640-643. 7. Duquennoy-Martinot V, et al., Is cosmetic surgery proposal to children and adolescents wellfounded?]Ann Chir Plast Esthet. 2016 Oct;61(5):622-628. Epub 2016 Jun 8. 8. Gunn, E.G.; Loh, C.Y.; Athanassopoulos, T. “Cosmetic web- sites Scotland: legal or lurid”. Journal of

Plastic, Reconstructive and Aesthetic Surgery. 2014;67(8):1144-7. 9. Portale Della Medicina Estetica. 2019. Portale Della Medicina Estetica. <https://www. lamedicinaestetica.it/index.php/pubblicazioni-scientifiche/> 10. World Health Organisation. 2019. About WHO. <https://www.who.int/about/who-we-are/constitution> 11. Al-Talib, H.; Al-Khateeb, et al., “Efficacy and safety of superficial chemical peeling in treat- ment of active acne vulgaris”. Anais Brasileiros de Dermatologia. 2017;92(2):212-216. 12. ADAA, Body Dysmorphic Disorder (BDD) <https://adaa.org/understanding-anxiety/related-illnesses/ other-related-conditions/body-dysmorphic-disorder-bdd> 13. Franziska Marcheselli, England’s first estimates of body dysmorphic disorder prevalence in children and young people, NatCen, 2018. < http://natcen.ac.uk/blog/englands-first-estimates-of-bodydysmorphic-disorder-prevalence-in-children-and-young-people> 14. Farkas LG1, Posnick JC, Hreczko TM. Anthropometric growth study of the ear. Cleft Palate Craniofac

J. 1992 Jul;29(4):324-9. 15. Ferrario VF1, et al., Normal growth and development of the lips: a 3-dimensional study from 6 years to adulthood using a geometric model.J Anat. 2000 Apr;196 ( Pt 3):415-23. 16. Medical protection society. 2000. Essential learning: Law and ethics. <https://www.medicalprotection. org/uk/articles/essential-learning-law-and-ethics> 17. Ellart, J, et al., “Breast asymmetry of the teenager and the young adult. Stability of the result in time.

About 144 patients”. 2016:61 (5) 665-679. 18. Greydanus, D.E.; Matytsina, L.; Gains, M. “Breast disorders in children and adolescents”. Primary Care. 2006;33(2):455-502. 19. Carel D. A. Verwoerd & Henriette L. Verwoerd-Verhoef, Rhinosurgery in children: developmental and surgical aspects of the growing nose GMS Curr Top Otorhinolaryngol Head Neck Surg. 2010; 9 20. M.R. Wright. Body image satisfaction in adolescent girls and boys: a longitudinal study. J Youth

Adolesc, 18 (1988), pp. 7183 M.R. Wright. Body image satisfaction in adolescent girls and boys: a longitudinal study. J Youth Adolesc, 18 (1988), pp. 7183 21. GMC. 2019. 0-18 years: Guidance for all doctors. <https://www.gmcuk.org/ethical-guidance/ethicalguidance-for-doctors/0-18-years> 22. BACN, 2015 Competency Framework, 2015. <http://www.bacn.org.uk/ content/56e95e6b8a8781.43460561.pdf> 23. GDC, Guidance on child protection and vulnerable adults < https://www.gdc-uk.org/docs/ default-source/guidance-documents/guidance-on-child-protection-and-vulnerable-adults. pdf?sfvrsn=eebbd01b_2> 24. GMC. 2019. Cosmetic Interventions Content. <https://www.gmc-uk.org/ethical-guidance/ethicalguidance-for-doctors/cosmetic-interventions/key-points> 25. NHS. 2019. Children and Young people, consent to treatment. <https://www.nhs.uk/conditions/ consent-to-treatment/children/> 26. C Harrison, N P Kenny, M Sidarous, and M Rowell Bioethics for clinicians: 9. Involving children in medical decisions CMAJ. 1997 Mar 15; 156(6): 825–828. 27. Mddu. 2000. Consent and young patients. <https://www.theddu.com/guidance-and-advice/guides/ consent-and-young-patients> 28. NHS Digital, Mental Health of Children and Young People in England, 2017, November 2018. <https:// digital.nhs.uk/data-and-information/publications/statistical/mental-health-of-children-and-youngpeople-in-england/2017/2017> 29. National Institute for Health and Care Excellence, June 2019 ‘Obsessive-compulsive disorder and body dysmorphic disorder overview’. <https://pathways.nice.org.uk/pathways/obsessive-compulsivedisorder-and-body-dysmorphic-disorder/obsessive-compulsive-disorder-and-body-dysmorphicdisorder-overview.pdf> 30. Derriford. 2010. Derriford Appearance Scale, 7 January 2019, <http://www.derriford.info> 31. Singh. K. “Cosmetic Surgery in Teenagers: To Do or Not to Do”. . 2015; 8(1): 57–59 32. RJ Honigman , KA Phillips , Castle DJ A review of psychosocial outcomes for patients seeking cosmetic surgery Plast Reconstr Surg , 113 ( 2004 ), pp. 1229 1237.

Visit our website to test your knowledge and complete our Multiple Choice Questions based on this article. You will then receive a certificate confirmation of your CPD point.