1. Introduction

Before delving into the ethical-moral aspects relative to cosmetic surgery performed on adolescents, it is worth conducting a swift analysis of the motives behind the spreading of cosmetic surgery use, not only in western countries, but in eastern and far-eastern countries as well (China, Iran, Korea, Japan, Lebanon), which have become a popular destination of so-called “cosmetic tourism”.^[2]

Among the reasons for such a robust growth, there is an overall improvement of economic, social and cultural conditions, the simplification and accessibility of payment methods (financing, payment by installments etc...), which enables most people to afford the costs of almost all cosmetic surgical procedures. Cosmetic surgery was first conceived to help those who had been severely traumatized and disfigured in the aftermath of major road accidents, fires or diseases, but it may serve a purpose in presence of unsightly traits, which may give rise to psychological distress or disorders.

Modern societies have become increasingly consumerist, and physical appearance outweighs personal values, which leads to the creation of an idealization of beauty in and of itself, and often unattainable.

For that reason, the Italian National Bioethics Committee^[3] has seen fit to raise awareness in aesthetic surgery providers as to the risks inherent in messages that lionize the notion of ideal, perfect beauty that may pressure people, and adolescents in particular, into rejecting their body images.^[4]

The Bioethics Committee also calls for the enactment of new legislation meant to ban from television programs in specific time slots, messages which may foster social marginalization on physical appearance grounds³.

Psychological pressure is undoubtedly intense: to have an attractive body has become to many an absolute priority, since there seems to be an increasingly widespread belief that success in life is somehow intertwined with physical attributes. Mainstream media and the internet play a pivotal role in perpetuating this state of affairs, at times glamorizing cosmetic surgery procedures and even going as far as showcasing live mastoplasty or rhinoplasty procedures^[5].

A growing number of people from every walk of life and social class have been turning to plastic surgeons in order to improve their looks or slow down the ageing process. According to the latest data from (International Society of Aesthetic Plastic Surgery), in 2016 one million more plastic surgical operations were performed worldwide compared to 2015, totaling 31.610 million, with Italy ranking ninth globally for the amount of such procedures.

In addition to all that, over the past years there has been a net increase in the number of men requesting and undergoing cosmetic surgery. In 2015, men accounted for 15.3%, as opposed to 13.7% in 2014 (Source ISAPS). That can be explained away via anthropology. In the past, social standing was paramount for men to get a woman on grounds of his financial stability and well-being. The emancipation of women has changed that scenario. More and more women, having become financially independent, are now in the position to choose their partners on the basis of their physical appeal too.

2. Adolescents and cosmetic surgery

Multiple studies have evaluated the psychological profiles of those adults who decide to undergo cosmetic surgical procedures. On the contrary, there are relatively few pieces of research looking into the psychological traits of those adolescents who make such a choice, and equally few studies take into account the appropriateness of performing similar operations on adolescents, whose bodies are still developing.

Statistical data reflect the upward trend in the number of youngsters turning to surgery, lamenting esthetic flaws that are often non-existent. This paper aims to try and figure out the root causes and motives of such young individuals in order to attempt to protect them from improper surgical procedures and above all, help them to accept themselves, emphasizing their positive physiognomic traits and convey the importance of prevention, stressing the importance of sound eating and behavioral rules.

In order to tackle such alarming trends, many European countries have devised more stringent rules meant to safeguard those youths who decide to undergo cosmetic surgery.

The Austrian government^[6] passed restrictive regulations, designed to ban teens under the age of 16 from undergoing cosmetic surgery, and so did the German government^[7] in 2014.

Prospective patients between the ages of 16 and 18 are required not to gain their parents’ consent, but to go through mandatory psychological assessment as well; besides, two weeks must elapse between the preliminary meeting with physicians and the signing of consent forms.

In 2012, the Italian government has enacted a specific piece of legislation, as will be expounded on further in this paper.

The main reason a good deal of youngsters are attracted to cosmetic surgery or medicine is to be found in the worlds of show-business and fashion industry, which often set forth unrealistic standards of beauty and provided a warped image of cosmetic surgery itself^[8]. In 2015, the Italian Society of Aesthetic Medicine conducted research along with the University “Magna Grecia” of Catanzaro, involving 2265 youngsters, out of whom 880 boys (or 38.9%) and 1385 girls (61.1%) between the ages of 13 and 18^[9], Southern Italian regions had greater representation in the survey compared to Northern ones (69.3% versus 12.7% respectively), whereas the male-to-female ratio was homogeneous in each region surveyed. What conclusions have been drawn? Girls have generally tended to show greater dissatisfaction with their bodies and physical attributes compared to boys, who have exhibited greater self-esteem, on average. Overall, a significant share of said youths have voiced their dissatisfaction with their body images, namely 78% of girls and 54% of boys. 49,2% of those surveyed have stated their willingness to resort to cosmetic surgery. Those willing to undergo surgery to improve their looks accounted for 31.3%, the vast majority of whom were female interviewees. Every scale used in the survey (EDI3, BUT e BIDA) has shown girls to have higher levels of discontent with their bodies, compared to boys. 15.8% of girls as opposed to 3.3% of boys have already undergone esthetic medicine procedures (such as acne treatments, the removal of unwanted body hair or stretch marks), or even plastic surgery aimed at correcting nose ears or breasts perceived imperfections), but incredible as it may seem, more boys turned to cosmetic surgery than girls (5.3% and 1.9% respectively).

It is noteworthy that 3 adolescents out of 4 seek cosmetic surgery for the purpose of looking like a show business celebrity, who in modern society seems more achievable and realistic a model, someone who might even be run into on the street or contacted via social networks. In Italian society, resorting to cosmetic surgery has become so “commonplace” that 73% of female adolescents surveyed have admitted to having undergone “some form of operation”, acne treatments, the removal of unwanted body hair or stretch marks, tackle cellulitis, change nose inclination, improve protruding ears or achieve the desired breast size, 10% of whom declare to be “proud” of their choice. A lower percentage of those who prefer to conceal such experiences, on privacy grounds (17%)^[10]. Often times, parents themselves are not opposed to such extreme measures. On the contrary, 14,6% of adolescents admits to being aware that some of their family members have already undergone any given esthetic medical procedure; according to the survey, 12.6% of the boys surveyed had chosen to consult with a cosmetic surgeon on advice from their parents, and as many girls undergo breast augmentation spurred by their mothers, who sometimes “present” them with the operation for the girls’ eighteenth birthdays^[11].

3. Cosmetic surgery in teens: whim or real need?

It is well-known just how cosmetic surgery distorts the traditional relationship between doctors and diseased patients into one between doctor and a healthy individual who deliberately chooses to undergo clinically unwarranted surgery. With regards to such “unnecessary” procedures though, it is worth noting that the World Health Organization (WHO) has characterized the concept of good health not merely as the absence of disease in itself, but also as the overall state of physical, mental and social well-being. Worded in such terms, cosmetic surgery may well be deemed as falling within the right to enjoy good health, provided that they may be instrumental in improving the ability to have rewarding interrelationships of those who feel distressed or uneasy over their body images.

That being said, it is necessary to differentiate reconstructive plastic surgery, in the aftermath of major traumas, accidents and illnesses, and reparative surgery (e.g. a procedure aimed at treating cleft lips or cleft palates and similar congenital malformations) from those operations that are unrelated to any pathology or major disfigurement, but rather performed for solely aesthetic purposes. Doctors should question the reasons why an adolescent feels compelled to undergo cosmetic surgery in order to figure out what external pressure factors, such as media-conveyed notions of ideal beauty, may play a role in his or her making that decision.

In fact, in adolescence, there is no solid psycho-physical balance needed to make such relevant choices. Thus, if dissatisfaction with one’s looks stems from the particular age, it can be overcome as the individual grows older, thus making any cosmetic surgery unnecessary.

On the contrary, over time minors may regret having undergone cosmetic procedures.

If, on the other hand, the request for surgery arises from psychiatric disorders, for instance dismorphophobia, resorting to surgery would not solve any issue. In fact, body dismorphic disorder is originated with one’s body image on the mental level, not the real one, therefore surgery cannot alter such a flawed perception and cure or abate the adolescent patient’s distress. In several cases, those who experience such a disorder present minor physical flaws, which they tend to magnify. In other instances, instead, physical traits are altogether normal, yet the individuals feel as if they were constantly stared at, and experience a strong sense of awkwardness when meeting new people^[12].

For those reasons, individuals suffering from body dysmorphic disorder tend to avoid all situations that entail direct social contacts (school, workplace, interrelationships)^[13].

Sufferers may also resort o new surgery, thus creating a “snowball effect”, though no amount of surgery is ever satisfactory, since the issue is emotional and psychological, rather than physical, and is associated with body dysmorphic disorder. Patients do not need surgery, but psychotherapy instead. It is therefore inescapable to adequately make sure that no mental conditions are at the root of the adolescent patient’s intention to pursue cosmetic surgical operations with virtually no chance of success. In order to gauge and evaluate psycho-social disorders, expectations and motives borne by adolescents who seek cosmetic surgery, scientifically validated psychometric scales should be applied. These assessment tools are devised to measure: (1) the expectations of how one’s looks could be improved and to what extent the patient’s quality of life would consequently be raised as a result of cosmetic surgical procedures; and (2) the magnitude of psycho-social distress linked to physical appearance. Among such tools, the DAS-59^[14] is noteworthy: The Derriford Appearance Scaleis validated and acknowledged for clinical use (for plastic surgery, oncology, psychology) and is regarded as highly reliable. By applying DAS-59 standards, specialists can promptly diagnose possible mental health conditions, to avoid going through with the surgery if the patient’s prospects are deemed too unfavorable. Through such precautions, doctors may prevent possible damages and liability claims.

A young person’s psychological distress caused by dysmorphia and the related difficulties to function within society constitute solid enough a reason to legitimize cosmetic surgical operations on otherwise healthy youths^[15]. Let’s consider otoplasty: many parents make their children undergo such procedure meant to correct protruding ears, so as to avoid uneasiness over their looks. Otoplasty techniques can be performed at early an age as 8, when the child’s ears have grown to 90-95% of their final size. In such instances, an early correction is achievable, which may be instrumental in staving off psychological repercussions in the children involved possibly arising from comparisons with their peers. As a matter of fact, more and more adolescents seek plastic surgery in attempt to avoid being bullied.

Similarly, less severe cases of cleft lip are no life threatening conditions, yet parents often decide to have their child’s defect surgically corrected, in order to stave off possible psychological repercussions and related difficulties fitting into society that such “diversity” may cause^[16].

Acne treatment, among the most widespread in adolescents, is advisable. Acne is a condition which may, in severe cases, leave the face permanently scarred. Plus, young people are psychologically affected by this condition, which often gives rise to suffering and awkwardness^[17].

4. Inadvisable procedures

Often times, young people make shallow, vacuous requests, which doctors should turn down. Following growing popularity in the United States^[18], in Italy the use of botox meant to ward off facial wrinkles on the forehead and elsewhere. Such treatment is not ethically advisable, but is inappropriate, since no adolescent has wrinkles to smoothen. Instead, it may create an addiction, compelling the adolescents to have botulinum toxin injected their whole life. Same goes for fillers^[19]. Many teenage girls undergo injections of such products aimed at getting rid of minor fine lines and facial wrinkles. They are considered to be “minor” procedures, but may turn out pointless, and even harmful. Filler injections have many unwanted side effects, such as herpes labialis, autoimmune diseases, ongoing therapies with retinoids which make the skin sensitive. Besides, doctors need to take into account whether the teenage patient has undergone previous operations, since there may be incompatibility between cosmetic synthesis products which cannot be used in the same location.

Patients often ignore exactly what kind of substance they have been injected with. Therefore, it is necessary to make withdrawals and have the substances analyzed in a laboratory in order to figure out exactly what substances have been used and how to intervene. The Umberto I polyclinic of Rome has activated an emergency room for filler injection-related complications.

Foot cushioning by collagen injection or other dermal fillers (requested by some women in order to be able to wear extremely high heels) or interventions meant to alter one’s ethnic traits are also unacceptable, and should be advised against.

In Italy, adolescents of Asian background, (of Chinese, Koreans or Philippine origins) commonly request blepharoplasty, or eyelid surgery, aimed at “broadening” the eyes and making them look “westernized”. Such practices are inadvisable too, since they may give rise to harmful “identity crises” in the aftermath of the physical alteration. The young patient may in fact look in the mirror and fail to recognize his or her own face, thus feeling estranged from his or her image and ultimately reject it. Moreover, such procedures are irreversible.

Another surgical procedure has been in increasingly high demand: hymenorrhaphy, or hymen reconstruction for the purpose of restoring virginity^[20]. Performing such a procedure poses ethical and moral issues, due to the consequences it may entail especially in cultural backgrounds where “virginity” is considered to be a value, in addition to an absolute requirement in order to get married. In Islamic culture, virginity of the prospective bride is necessary not only to avoid rejection from the husband, but also the definitive disowning on the part of the woman’s family. Obviously, in cases of hymen reconstruction, the marriage would be based on falsehood^[21]. Moreover, there are no statistic-epidemiologic data as to possible complications, side-effects, duration, etc20. Therefore, further issues arise as to the risk-benefit ratio: a key clinical requirement in establishing the appropriateness of any given procedure. Many moral implications pressure parents into requesting corrective surgery for their children born with Down Syndrome, for the purpose of altering the facial features typically associated with trisomy 21. Such surgical operations are unacceptable, because they are solely based on the will of the parents, is physically demanding in terms of pain, and there is no guarantee to achieved the desired outcome^[22].

In fact, altering facial features does not avoid or reduce the risk of marginalization for disabled individuals, since the issues that Down Syndrome children face will not go away thanks to the facial alterations.

5. Augmentation and reduction mammaplasty plastic surgery

A survey conducted in Italy by SWG has shown that 14% of sixteen-year-olds would like to increase the size of their breasts, sometimes to a disproportionate, unwarranted degree which may give rise to overall complications such as postural or respiratory alterations^[23],[24]. It is documented how pubescent girls (aged 12-17) mammary glands may be asymmetrical, whether large or small. That may cause uneasiness in the girl who requests breast surgery. It is certainly possible o intervene in cases of gigantomastia to perform reduction mammaplasty plastic surgery, but only for those cases where functional implications exist. In fact, frequently gigantomastia causes cervical joint disease, neck and back pain, headaches, poor posture and, in severe cases, scoliosis^[25]. Boys may also experience the enlargement of mammary glands, caused by an increase in localized fat deposits and the relaxation of pectoral muscles. Such an anomaly usually reverses itself within a few years, thanks to tissue atrophy^[26]. Two American studies have shown these physical flaws may cause anxiety, depression, low self-esteem and social exclusion and may reverberate negatively from the psychological and emotional standpoints, possibly compromising mental health^[27].

In severe cases, surgery might be necessary to correct these flaws, but scrupulous and clear-thinking surgeons should try to convince the parents to postpone any operation until the adolescent’s

development is complete^[28]. In order to safeguard the health of adolescents, Italian lawmakers have put in place a ban on mammaplasty plastic surgery for underage girls, through Law 87, 5th June 2012^[29]. Said law limits breast surgery to those cases in which there is a documented medical condition or in cases of congenital malformations. The presence of such malformations must be certified by a doctor within the national health care system or in a public hospital^[30]. The priority is to avoid surgery being performed on girls whose development is still incomplete. In fact, at that juncture, breasts may change naturally, thus making the girl perceive her body image differently and change her psychological approach towards the choice of undergoing surgery at all.

6. Information in cosmetic treatments for adolescents

It is well known that exhaustive, thorough information must be provided by doctors prior to any surgical operation; the information must include every aspect associated with the procedure: risks, benefits, possible complications^[31]. That holds valid and is especially true with regards to cosmetic surgery. In fact, in most cases, the adolescent patients who request cosmetic surgical treatment are healthy individuals who choose to undergo surgery, without any urgency, only meant to correct a physical flaw. For that reason, “doctors are required to estimate the statistical likelihood of any intervention bringing about real physical improvement, since that is the only way in which a patient can make a truly informed decision whether to agree to undergo the cosmetic procedure or not^[32]”. We firmly believe that the provision of information is the most critical stage in term of laying the groundwork for a good relationship with patients. The contents of all information provided is key in order to get through to the minor patient the very nature of the procedure about to be carried out, the difficulties involved, any complications that might possibly arise from the use of materials and prosthetics (as in the egregious Poly Implant Prothèse scandal, involving illegally manufactured breast implants), unforeseeable developments as well as the amount of pain that may stem from the procedure^[33]. Since cosmetic surgery is not meant to preserve the patients’ health in itself, it is not enough to inform them of the possible, ordinary risks, but it is essential to discuss any extra-ordinary hazard possibly resulting from the surgery, so that patients can make up their minds as to the pros and cons^[34].

Patients undoubtedly expect physical improvement from cosmetic surgery operations, thus doctors should adequately disclose all relevant information pertaining to the actual likelihood to achieve the outcome hoped for by their patients.^[35]. Cosmetic surgeons need to elaborate on all eventualities, however unlikely and remote, and on the possibility that the ultimate outcome may not live up to expectations. Furthermore, physicians ought to verify whether, and to what extent, their patients have grasped the information provided to them^[36].

Informed consent ought to be signed following two distinct stages of talks devised to lay out all relevant information: firstly a standardized one, irrespective of any particular intervention and regulated at a national level by scientific societies; secondly, a personalized, patient-centered approach designed to meet individual needs and issues arising from any given procedure. Plastic surgeons may well resort to technology in order to gain a more thoroughly informed consent, using for instance the wide array of affordable and easy-to-use photo-editing software available, in order to simulate the desirable outcomes and possible unwanted side-effects, even of the esthetic kind (scars and whatnot), which may stem from any procedure starting from unedited pictures of their patients^[37].

For the purpose of gaining consent, doctors must outline a full picture as to the possible complications; for mastoplastic surgery as well, where it is necessary to clearly describe surgical techniques that will be applied and the extension of the scars which will probably be left.

The survey conducted by the Italian Society of Aesthetic Surgery along with the University “Magna Grecia” of Catanzaro has shown that 58% of the girls interviewed consider the information provided to them about the cosmetic surgical procedures to be lacking. According to 4% of those surveyed, such information is completely insufficient, whereas just a small minority of them considers it exhaustive (7%) or at least sufficient (19%) to enable them to make an informed decision. 16 and 17-year-olds declare to be in favor of a law meant to regulate cosmetic surgery procedures, thus guaranteeing patients a thorough set of information as to the risks involved (85%) or mandating that patients sign a written statement certifying their awareness of the risks inherent in the surgical procedures. (84%). Furthermore, 79% of the girls interviewed would agree with a piece of legislation to enforce a ban on cosmetic surgery for adolescents under 18 years of age.

An adolescent’s personality is not as steady as a fully mature adult’s.

It is the likely that his or her choice will not be entirely free from external pressure, conditioning and fully aware^[38]. Plus, priorities, convictions and tastes, even aesthetic ones, held as adolescents are likely to change and evolve over the years. But reversing the effects of a cosmetic surgical procedure is often impossible and anyway risky. That makes it all the more pressing to assess the benefits which may arise from surgery not only in relation to the time being, but over the long term as well. Dialogue and doctor-patient counseling is imperative

“Conversation is a way to clarify misconceptions and misunderstandings and helps patients to act with an awareness of the influences on their thinking. In other words, conversation helps not only with assessing autonomy in the first instance, but also in promoting autonomy, e.g. by getting patients to engage in self-reflection and reflection with others.”^[39]

Besides, dialogue helps, on the one hand, to shed light on the motives behind the choice to undergo cosmetic surgery; on the other hand, it also highlights the opportunities for further methods and measures - i.e. alternative to surgery - in order to deal with and overcome the distress and unease experienced by the individual. In addition to the clinical aspect, surgeons need to take into account the emotional one, that is the psychological maturity and the decision-making capacity of the patient, in order to determine how much weight his or her will should carry.

The fact that a treatment is required not for functional reasons, but merely aesthetic ones, makes it necessary to have more time pass between the preliminary visit, the information procedure and the ultimate consent to treatment. In such a way, patients have more time to decide whether to expose their health to possible risks for merely aesthetic purposes. That also enables adolescents to estimate whether the wish to resort to cosmetic surgery still persists.

7. The doctor-adolescent-parents relationship

Italian law does not allow adolescent to decide for themselves: informed consent must be given by the legal guardians: the parents or other legally appointed guardian. They must always decide in the best interest of the adolescent involved^[40],[41]. Yet the adolescent still plays an important role in the decision-making process. Adolescents don’t have a fully formed personality, need protection, but they are at the same time entitled to exercise their rights. Especially when dealing with medical-surgical treatments, a distinction between child and adolescent is needed, particularly meant to highlight the position of those adolescents who have already attained autonomous capacity and self-determination in the growth process.

As for the right to enjoy good health and to be free to decide for one’s body, the relation between parental authority and minors’ freedom is a dynamic one in that parental authority is gradually diminished as the child grows older^[42]. In that regard, the Convention on the Rights of the Child^[43], the European Convention on the Exercise of Children’s Rights^[44], the Oviedo Convention^[45], and the Charter of Children’s Rights in Hospital state that a child patient’s opinion is a determining factor in relation to their age and level of maturity. The Italian Medical Code of Ethics (2014) asserts that “doctors must ensure that minors have all the elements of information needed to understand their situations, health conditions and the planned diagnostic-therapeutic procedures in order to get them involved in the decision-making process” (art. 33) and “must take into account the opinions voiced by minor patients in every decision-making process that directly impacts them (art. 34)^[46].

In Italy, there are no specific age-related references in order to acquire the capacity to express an opinion about one’s health^[47]. According to the National Bioethics Committee, “it is hard to imagine valid informed consent or dissent before the age of 7. From the age of 12, in the phase of adolescence, a gradually aware consent or dissent can be believed in”^[48].

If a teenager patient’s will, in real cases, turns out to be sensible and mature, it is still necessary to acquire parental consent, though the adolescent must consistently express the wish to undergo surgery, having been made fully aware of the benefits and of the limits of such practices and of what to reasonably expect from the procedure^[49]. Any possible discrepancy between the adolescent’s will and the parents’ or legal guardian’s compels the doctor to at least try to solve their differences, by means of psychological counseling. At a later stage, once the impossibility to find common ground has been established, doctors should bring the case to the attention of the courts, unless the surgical procedure requested by the parents may present a smaller potential aesthetic benefit compared to the risks involved. In such cases, doctors must not agree to the parents’ request. Doctors, for instance, should refuse to carry out procedures that they deem inadequate for the patient’s age. In fact, it is improper to surgically intervene on a patient in the age of development, because that would alter something that nature is still molding.

Medicine, in fact, despite its giant strides, must still abide by the laws of biology. If a teenager requests filler injections, doctors should turn down that request: the only treatment option is prevention, a thorough dermatological check-up to determine skin type and prescribe the appropriate cosmetics meant to slow down skin aging. Similarly, if a teenager needs to cut body fat, doctors should advise against liposuction procedures and recommend a healthier lifestyle instead. Certainly, patients should never be left alone with their physical or aesthetic discomfort, but rather need to be included in a prevention path that can lead them to harmonic development, preserving them from any inappropriate intervention. Along those same lines, the National Bioethics Committee deems proper only those cosmetic surgical procedures carried out in the best interest of the teenage patient form the health and psychological balance standpoints. Conversely, surgery is unacceptable when it is disproportionate, overly invasive or pointlessly risky or inappropriate with respect to the possible benefits expected by the patient. Fundamentally, the principle of proportionality needs to be reasserted, that is the evaluation of appropriateness of a given operation based on weighing possible risks and benefits, in relation to the psycho-physical conditions of the adolescent involved, the functionality of the organs interested by it, the expected outcomes and those reasonably achievable.

The above considerations should not in any way lead to a discounting of the role of parents. They have the fundamental role to protect the freedom of self-determination and their child’s health. On account of their greater maturity, they may be closer to the doctor’s vantage point. They are also those who best know the patient, their child. Hence, theirs is a fundamental role of connection, of mediators between doctor and patient. They can, for instance, provide doctors with useful elements in order to figure out the adolescent’s degree of maturity; but also help their child cope with the fact that surgery cannot be carried out because the motivations are born out of unrealistic expectations, defined by ideal, unattainable standards of beauty.

8. Conclusions

Cosmetic surgery on adolescents is a very current issue. Adolescence is the stage of life in which the greatest physical changes occur, which a teenager may not necessarily accept; hence the urge to resort to cosmetic surgery. Nonetheless, cosmetic surgery in adolescents must be administered with greatest caution and proportionality, because often such a choice is underpinned by psychological issues; it is therefore necessary to consult with a psychotherapist, who could help the child deal with his or her physical appearance and boost his or her self-esteem, thus achieving psycho-physical well-being. Particularly when dealing with adolescent patients, doctors need to act as “ethical surgeons”, in addition to “cosmetic surgeons”: they should be able to effectively provide advise or dissuade, in light of the patient’s young age and their still undeveloped personality. Furthermore, it is necessary to strongly advise against surgery if alternative, less invasive options are available. Lastly, the importance of prevention needs to be highlighted and prioritized. In that regard, families and media outlets play a pivotal role. Mothers for instance should explain their daughters that between disliking one’s body image and cosmetic surgery there is an easier, just as effective middle-ground option: cosmetic medicine.

Therefore, doctors should not agree to any of the patient’s requests, but must intervene only in cases where an objective physical flaw (e.g. macrotia or protruding ears) serious and conspicuous enough to constitute a hindrance to a fulfilling social life, possibly to the extent of becoming an existential issue, though not harmful to one’s health. Within the scope of cosmetic surgery, the principle of autonomy needs to be reconciled with the principles of beneficialness and proportionality; it is then essential to weigh possible risks against possible benefits.

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Notes