Cosmetic Surgery for children

Major influences on children’s development of self-concept include communication from others about the self, comparisons they make with others in their immediate environment and the role assigned to them by the community1. The face is a key component of many adults’ self-identity and to the developing child, the face provides an early and continuing source of information about a persons’ personal identity2. If the face is so important, should we let children have cosmetic surgery?

The Nuffield Council on Bioethics defines cosmetic surgery as surgery which will alter a person’s appearance, and which has a primarily aesthetic rather than functional aim. Their 2017 report identified specific ethical concerns for teenagers in particular as sensitive to peer pressures, and at a vulnerable stage of development with respect to their sense of their own identity.

A survey by the American Academy of Facial Plastic and Reconstructive Surgeons found 55% of surgeons said patients now seek cosmetic procedures expressly for improved selfies and pictures on social media platforms. Concerns have been raised that some software developers are still deliberately targeting children with facial surgical apps, and Instagram has recently decided to remove filters that promote cosmetic surgery.

Two of the most common cosmetic surgical procedures on the face include the nose (Rhinoplasty) and ears (Otoplasty), and both procedures are performed for children.

Let’s start with the nose. Post-traumatic 'correction' rhinoplasty (making your nose look more like it did before an accident in which the nose is broken) or treatment of congenital nose deformity that causes breathing issues are available and NHS-funded in the UK, but a 'purely cosmetic' rhinoplasty is no longer offered on the NHS. In the US, a plastic surgeon spoke on CBS news in support of rhinoplasty “to improve self-esteem amongst kids”. But in the UK if the clinician spots a child without a “perfect“ nose, they are not obliged to offer them a rhinoplasty.

However, the pervasive medical culture is different for ears. Otoplasty is available in some regions on the NHS, on the presumption that cosmetic alteration of the ears can decrease the perceived bullying or disadvantage suffered from a child's peers who may have 'more normal' ears. According to data from the British Association of Plastic and Reconstructive surgeons, approximately 2% of the population feel that their ears stick out too far.

Otoplasty before and after
Most surgeons would advise that surgery for prominent ears is not undertaken until the child becomes old enough to understand what the surgery involves. Although no objective measure of psychological distress needs to be satisfied here, collective concern for our children and fears about exclusion and emotional trauma during their development suffices.

“Quality adjusted life year” scales and other metrics struggle to calculate the value or cost effectiveness of these interventions. It is challenging to truly quantify the "value" of a lifetime of 'bully-free' work and play.

But do more complex parameters govern some of these interventions? It is not clear why otoplasty is only offered to those aged less than 18 years unless a calculation incorporating 'number of years predicted bullying avoided' or an assumed bully-free or resilient adulthood is considered. Perversely, once a child becomes an adult at 19, and has ethical and legal autonomy and competence, the pervasive medical lens suddenly removes them of their right to express this autonomy by seeking Otoplasty on the NHS. Otoplasty is not offered for adults on the NHS. This means we are effectively endorsing a societal view that prominent or non-morophologically “normal” ears are a horrendous burden on children but of absolutely no consequence for adults?

When we consider cosmetic intervention for the face perhaps we should follow the lead of our international colleagues and aim to reframe perceptions of cosmetic by demonstrating the functional significance of appearance.

A Korean study has demonstrated that 97% of patients felt surgery to improve facial nerve injury was functional rather than cosmetic. Furthermore, 67% of respondents agreed that surgery to normalise the appearance of facial scars resulting from accidents was also functional3. Patients in an American study felt normal appearance was more significant than their sense of smell or expression as a primary function of the face4.

There are several childhood syndromes which cause characteristic, non-average facial appearance that may easily surpass prominent ears as a cause of social exclusion and bullying from children's peers. A natural extension of this question is whether surgeons should consider performing cosmetic surgery to all those who find fault with their appearance with an aim to deliver complete social well-being?

The first logical step would be to offer cosmetic surgery to those most outside normal variation. Under those auspices, some may consider offering cosmetic surgery to children with complex syndromes to give them a more conventional appearance.

In the past surgeons offered eye surgery to patients living with Down’s Syndrome as it was felt that they might somehow live better, conforming to society with a more conventional or averaged facial appearance. This controversial surgery was occurring in the 1980s but is now largely no longer performed. Both otoplasty and the surgery for eyelids were performed because the parents believed that their child would be unable to function in his or her society without it. At the time there was even a growing scientific evidence base supporting the beneficial effects of cosmetic surgery for Down’s syndrome5

Though these are both non-emergency procedures, delivered with societal acceptance in mind, there would be strong differences in cultural precedent and acceptance amongst the public now, but what has actually changed? When we decide what we think is acceptable, should we look at what is acceptable as a median public position of what is desired in the here and now, or should we strive for more universal and timeless thresholds for what interventions are necessary?
                                                                     
Starting to advocate again for cosmetic facial surgery for Down's syndrome would be a majorly divisive moral and social intervention but it becomes increasingly difficult to differentiate this from similar interventions (Otoplasty and Rhinoplasty). All are virtually equivalent in terms of societal rather than pathological or functional therapeutic necessity.

In the aforementioned Korean study 89% reported that surgery to normalise the appearance of a congenital facial disfigurement would be functional. The statement "A normal appearance is related to normal social activity in Korea," was accepted by 83% of the participants.

Normal appearance is deemed important to be a normal functioning member of American society too. The Americans felt that restoration of "dysfunctional facial appearance" was more important than restoring the function of their upper and lower limbs or even reconstructing their breasts. Change the cultural norms and context and here in the UK, choosing breast reconstruction after mastectomy is commonplace and readily encouraged free on the NHS, reinforced by NICE guidelines, even though some argue this is another type of cosmetic procedure and the operations (such as autologous DIEP) can cost in the region of £7,000 per breast. 

Otoplasty and Rhinoplasty surgeons do not universally agree with their patients that their ears and noses look bad and “need” surgery. These surgeons merely respond to patients exerting their right to seek out an intervention for a perceived problem and feeling. Perhaps we should start a wider debate involving the opinions of parents, surgeons and the children themselves, on what, if any, cosmetic surgery for children should be performed.

Tom Hampton is a trainee in Ear, Nose & Throat and Head & Neck surgery. He is interested in the ethics of aesthetics and identity and how changes to the concept of medical necessity can impact on patient care. 

References
1: McRoy, R.G. et al. (1982) Self esteem and racial identity in transracial and inracial adoptees. Social Work, 26, 522-526. doi: 10.1093/sw/27.6.522
2: Cunningham, J.G., & Odom, R.D. (1986) Differential Salience of Facial Features in Children's Perception of Affective Expression. Child Development, 57, 136-142. doi: 10.2307/1130645.
3: Kim, Y.J., Park, J.W., Kim, J.M., et al. (2013) The Functionality of Facial Appearance and Its Importance to a Korean Population. Archives of Plastic Surgery, 40, 715-720. doi:10.5999/aps.2013.40.6.715.
4: Borah, G.L., & Rankin, M.K. (2010) Appearance is a function of the face. Plastic and Reconstructive Surgery, 125, 873-878. doi: 10.1097/PRS.0b013e3181cb613d
5: Goeke, J. (2003). Parents Speak Out: Facial Plastic Surgery for Children with Down Syndrome. Education and Training in Developmental Disabilities, 38, 323-333. Retrieved from http://www.jstor.org/stable/23879833
6: Paget, J.T., Young, K.C., & Wilson, S.M. (2013) Accurately costing unilateral delayed DIEP flap breast reconstruction. Journal of Plastic Reconstructive and Aesthetic Surgery, 66, 926-930. doi: 10.1016/j.bjps.2013.03.032.



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