Plastic surgery comprises interventions of either reconstructive or cosmetic purposes. In adolescents, surgical correction of cleft lips and cleft palates are among the most common reconstructive procedures, while otoplasty, breast augmentation or reduction, abdominoplasty and rhinoplasty represent most of cosmetic interventions [1,2]. Between 20142015, 15, 9 million surgical and minimal invasive procedures were performed in the United States; 226,000 of those procedures were performed in 13-19 years old . Rates of cosmetic surgery are similarly increasing in the United Kingdom and across the Globe [4,5]. For plastic surgeons operating adolescents, it is important to have in consideration the age and global psychological conditions at which these interventions are done, as childhood and adolescence represent a period of important body and mind transformations and in which body image rapidly develops . Also, peer acceptance is very important for adolescents and sometimes they fantasize that physical changes would result in more attention and popularity. These beliefs act as external motivators and risk of letting them down once they face reality.
Corrective surgeries, as for cleft lips and palates, or situations resulting from severe injuries can be performed early as to restore body parts to its previous appearance or to provide normal functioning, but cosmetic procedures aimed at correcting undesired facial features (such as a prominent nose or ears, a chin reshaping or augmentation, correction of asymmetrical breasts, breast augmentation or reduction, among many others) modifies one's natural look. Focusing in the latter, cosmetic procedures in adolescents always require parents' consent. Clear information should be given by the surgeon to both the adolescent and parents about the technique and the risks associated with surgery. Realistic goals should be discussed and motivation for undergoing surgery must be clarified, as it can compromise surgery outcomes. Patients who are driven by internal desires (stating ideas such as "I will feel more confident", "I will be happier with how I look") seem to have more realistic understanding of the benefits of surgery and better outcomes than those driven by external motivators ("I will be more romantic appealing", "People will like me more") . It seems that teasing about appearance in childhood and adolescence predicts motivation to undergo surgery, possibly affecting a teen's sense of self and the strength of body image [7,2].
Furthermore, we advise that a child and adolescent psychiatrist and/or a psychologist should be consulted in all cases, as these patients should undergo psychological evaluation priory to the intervention. This evaluation should help understand better the motivation to perform the surgery, personality traits, cognitive development, emotional maturity and ability to make autonomous decisions free from peer or family pressures. Also, screening for other mental diseases is mandatory as the presence of behavioral or severe emotional disorders can advise against cosmetic surgery. The final decision about proposing plastic surgery to the young patient should be discussed by both the surgical and the mental health team and then transmitted to the patient and its parents. A period of time for contemplation should always be given to the patient, before making the final consent.
In the postoperative period, it is advised to maintain a psychological consultation in order to support the process of acceptance of the body changes that were made. One of the goals of psychiatric and psychological assessment is to prevent interventions based on external drivers or from distorted perception of body image. As far as we know, body dissatisfaction ranges from a simple desire to change one specific body part to a pathological condition in which the patient exaggerates a flaw, sometimes imagining a minor imperfection as a hideous disfigurement, reaching the point of delusion - as occurs in severe Body Dysmorphic Disorder. Frequently, patients suffering from BDD have poor surgical outcomes as they continue to perceive the reported flaw or simply become fixated on another body part, asking for more and more surgeries, as if the perceived abnormality kept moving (for more information see DSM 5) .
So, I do defend that some cosmetic surgery like rhinoplasty, otoplasty, chin augmentation or reshaping or breast correction can be done in an appropriate age that should be individually determined, as they can prevent peer victimization and improve psychological wellbeing. Peer victimization or bullying acts as a childhood trauma, negatively affecting the psychological development and the construction of a secure body image and self-concept. This effect on psychological development causes children who are bullied to be more anxious, have more depressive features, avoid school or social meetings. In extreme cases they may have suicidal thoughts. Adolescents who seek cosmetic surgery for other purposes should be advised against it, as it is known that as they progress to adulthood their body image may improve. The decision about cosmetic surgery should be postponed for after 18 years old .
In conclusion, I do defend that a mental health team should be involved in both pre-operative and post-operative periods, helping to evaluate the presence of the conditions required to perform the operation and to support the patient on its adaptation to the new body image on regular consultation. But I also think that there is a lot of work to be done in schools to prevent bullying in this situation. Children and specially adolescents should be taught about individual differences both physical and psychological and about respecting each other as individuals.