At what age can you start botulinum toxin type A treatment? This is a question that many of my patients ask me on a day-to-day basis. When defining age boundaries, safety should be considered first, followed by an evidenced-based approach. Additionally, the question of ethics is something that cannot be underestimated during the pre-treatment assessment. In 2017, the Nuffield Council on Bioethics produced a report in on cosmetic procedures. It found that pressure from social media platforms, celebrities and influencers, postproduction techniques and anatomical changes in adolescence all had a significant impact on the decision-making process of young people. Furthermore, in a statement from the Youth Select Committee, they highlighted issues of ‘body dissatisfaction by women, and the increasing danger and challenges faced by young men, LGBT and youth, ethnic minorities and those with disabilities or serious illnesses, which were overlooked in the Nuffield Council report’ (UK Parliament, 2017). When carrying out assessments in these groups, we, as clinicians, must take on board even greater responsibility when using clinical judgement.
The changes in the face and body has a great impact on adolescents. The development of more adult-like physical features, as well as increased height and weight, sexual maturity and the forming of intimate relationships, can often lead to both rational and irrational behaviour patterns when looking for a ‘solution’ in the aesthetics arena. In particular, it is not uncommon for young women to wish to transform their image through non-surgical and surgical intervention, which is undermining their physical and mental wellbeing.
An ever-increasing frequency of patients of all ages are attending aesthetic clinics with an underlying mental health condition: body dysmorphic disorder (BDD) or body dysmorphia. This can develop when a patient sees a flaw in their body that is often unnoticeable to others. BDD is most common in teenagers and young adults and it affects women more commonly than men. Alarmingly, 66% of people with BDD experience symptoms before reaching the age of 18 (Bjornsson et al, 2013). Having BDD does not mean that the patient is vain; self-obsession with an increased suicide ideation are fateful traits. Patients with BDD can worry about many specific areas of their body. Every effort is made to hide these perceived flaws, for example, by applying concealing makeup or choosing clothes that are ill fitting. Understandably, such patients can have serious issues in their day-to-day lives, including at work, socially and in relationships.
So, age does matter! The adolescent brain is still developing and is reliant on the developing prefrontal cortex and amygdala. Amygdala dependence is associated with emotive, impulsive and, sometimes, irrational decision-making. Therefore, as clinicians, we have an even greater responsibility when dealing with adolescents.
Recently, an amendment to the Health and Care Bill to improve the safety and regulation of cosmetic treatments has reached the committee stage (Chartered Institute of Environmental Health, 2021). The amendment is seeking to bring into force a national licensing scheme for cosmetic procedures in England. The need for this has been perpetuated by the growing body of evidence of complaints and complications following aesthetic procedures.
As we go to press, from 1 October 2021, in England, it will be an offence for a person to administer botulinum toxin or a dermal (or mucous membrane) filler for a cosmetic purpose to a person under the age of 18 years (UK Parliament, 2021). This is a welcome move that will hopefully encourage further legislative action to help drive public safety.