HEALTH: KIDS UNDER THE KNIFE

Ruby Juarez grew up feeling self-conscious about what she calls her "superbig" nose. When talking to friends, she often covered part of her face out of embarrassment. Classmates took to calling her "Shrek nose." For her 17th birthday, Juarez's father finally agreed to pay for a rhinoplasty, which Beverly Hills cosmetic surgeon Robert Kotler performed last June. Now fully healed, Juarez no longer gets teased. "I look normal now," she says. Her advice: "Get whatever your flaws are fixed, because it's really worth it."

To most parents, that must sound like a terrifying prospect. But more teenagers like Juarez are asking for--and getting--cosmetic procedures. Last year doctors performed 331,886 of them on Americans 18 and younger--a 48 percent jump over the previous year, reports the American Society of Plastic Surgeons (ASPS). The increase comes partly from the popularity of TV shows like "Extreme Makeover" and "The Swan," which have captured the imaginations of younger and older viewers alike. "I'm doing the nose jobs on the kids, and the wrinkle removers on the moms," says Kotler, author of "Secrets of a Beverly Hills Cosmetic Surgeon."

Parents need to weigh several factors before allowing surgery for their children. First, make sure they really want it. "As a crude rule of thumb, for most things that are optional or elective, wait for your child to point it out to you," says Scott Spear, president of the ASPS. Many operations are performed on kids with physical flaws that are clearly stigmatizing, like misshapen breasts or ears that stick way out. In such cases, and even in a few less obvious ones, surgery may boost self-esteem. "It's made me a lot more confident," says Danielle Jacoby, 18, a USC student who got her nose reshaped at 15, well before her senior picture.

Next, make sure your child has realistic goals and sufficient maturity. Procedures like rhinoplasty and breast augmentation should be performed only on kids who are fully grown. Otoplasty (pinning back the ears), however, can be done starting at the age of 5 or 6. The ASPS advises against plastic surgery for teens who are being treated for depression or other mental illness, who are prone to mood swings or erratic behavior or who are abusing drugs or alcohol. Smokers also make poor candidates--smoking makes anesthesia more challenging to administer and delays healing. Also, liposuction for teens is typically frowned upon. "It is becoming some--what of a crutch," says Beverly Hills plastic surgeon Athleo Cambre.

Cost is also a major factor. Rhinoplasties, otoplasties and breast augmentations start at about $6,000, including the physician's fee, anesthesia and outpatient hospital fees. Insurance will cover a nose reshaping--the most common surgical procedure--only when it's used to correct a breathing problem, and a breast reduction only to correct medical problems like back and neck pain.

Shop for a top plastic surgeon by looking for someone who's board certified (see sites like the ASPS's plasticsurgery.org or the American Society for Aesthetic Plastic Surgery's surgery.org), or ask your fam-ily doctor and friends for recommendations. Parents should also talk to their kids' pediatricians to find out about physical growth and any underlying health conditions. And, most of all, be cautious. "When in doubt, do without," says Kotler. Weigh each case. "For things that are clearly image-threatening or stigmatizing, fix them--cleft palate, buck teeth, severe acne, big stick-out ears. If your nose is really badly deformed, fine," says University of Pennsylvania bioethicist Arthur Caplan. "Other than that, the more maturity, the better." His advice: "If you want to give your kid something when they graduate from high school, give them a book, not breasts."