Teenage Breast Augmentation: Validating Outcome Data and Statistics in Plastic Surgery

Abstract

When a controversial topic arises, such as teenage breast augmentation for purely cosmetic reasons, it is important to have reliable statistical methods and sound data to report to the media and other interested parties. Recent public interest and media coverage of teenagers seeking breast augmentation was a result of reports that point to statistics stating that teenage patients may account for up to 4 percent of breast augmentations. This does not seem valid based on our personal practices or those of our colleagues. The American Society of Plastic Surgeons (ASPS) issued a statement that breast implant surgery for purely cosmetic reasons is not commonly performed by board-certified plastic surgeons on patients under 18 years of age. The ASPS does not recommend teenage breast augmentation except after careful and thoughtful discussion with the patient and the patient’s family. The Food and Drug Administration’s position is somewhat more strident, stating that teenage breast augmentation before age 18 should not be done. Obviously the controversy over this topic is broad and deep and would fill another editorial or article; however, it does point out that one can be burdened, challenged, and even misled by statistics. The way statistics are derived and presented can be misleading to physicians, the public, and the media. When we look at outcomes data from the ASPS/Plastic Surgery Educational Foundation (PSEF) Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database, for cases reporting only bilateral breast augmentation Current Procedural Terminology, or CPT, codes and no other procedures, it is interesting that the number of teenage breast augmentations actually declined from June of 2003 to June of 2004. Although the time frame for data capture is slightly different, these data are in sharp contrast to procedural statistics reported by both the ASPS and the American Society for Aesthetic Plastic Surgery (ASAPS). For example, ASAPS data for the year indicated that 4 percent of total breast augmentations were performed on patients under 18, in contrast to 1.6 percent in 2002. If true, that would represent a 195 percent increase over the period. ASPS media releases presented similar but lower estimates. In resolution of this issue, the data from TOPS, the outcome-based system developed by ASPS/PSEF and the American Board of Plastic Surgery, present a different message. According to TOPS data, the rate of teenage breast augmentation went from 0.31 percent in 2003 (95 percent CI, 0.19 percent to 0.46 percent) to 0.19 percent (95 percent CI, 0.12 percent to 0.28 percent) of the total number of breast augmentations performed in 2004. The estimated total number of breast augmentations performed on patients under 18 years of age in 2001/2002 was approximately 640. The estimated number in 2002/2003 and 2003/2004 dropped by 21 percent to approximately 505, even though the estimated number of breast augmentations overall rose by 8 percent to 264,495. This statistic is more in parallel with observations of our clinical practices. These statistics affirm that plastic surgeons, overall, are abiding by the Food and Drug Administration’s guidelines when teenage girls approach them to consider breast augmentation. These patients are given all the information and the procedure is discussed with them in detail. Clearly in some cases these underage girls and their parents decide to proceed with surgery after an informed discussion of the procedure, but the incidence is low, and decreasing, while the overall frequency of breast augmentation is increasing. This controversy validates the role and importance of having a valid mechanism for collecting outcomes data from all board-certified plastic surgeons. Only this rigorous contemporaneous collection of data can provide truly scientific data for all plastic surgeons, regulatory bodies, and the media. It is important for all plastic surgeons certified by the American Board of Plastic Surgery not only to input data but also to remain involved in the TOPS database. We have been involved in providing data to TOPS for more than 2 years, and the ability to resolve questions such as those related to teen breast augmentations is proof of the value of the process for plastic surgery. Acquiring such data is not only important for enhancing overall safety in plastic surgery, it also helps to provide grades of difference between plastic surgeons and other cosmetic surgery providers. The magnitude of this simple difference becomes more important every day. It signifies that board-certified plastic surgeons care about their patients and are willing to prove it with their own efforts. Plastic surgery also wants to maximize its interests in statistical and outcome-based medicine and to generate valid measurements of practice performance, for this is the yardstick by which we will be judged in the future.