SAN ANTONIO — Though not all high school graduation presents are created equal, Leslie Smith is glad hers came in exact proportions. Smith received two big gifts last month — one in her left breast and one in her right.

Smith, 18, is still recuperating from her second cosmetic surgery procedure.

She is part of a plastic surgery clientele that has grown significantly over the past decade. More than 240,000 procedures were performed on teens during 2006, according to the American Society of Plastic Surgeons.

Ten years earlier, only about 14,000 procedures were performed on clients of a similar age range. Though procedures have become more common, debate persists over the physical and psychological maturity of such youthful patients.

When she was 16, Smith had liposuction of her stomach and legs. Afterward, her weight dropped from 140 to about 120.

Since then, she's enjoyed shopping for clothes in size 5 to 7 rather than 11 to 13. And she's happily donned her swimsuit for games of water polo.

Now she's on to bigger and, in her opinion, better things. Larger breasts to be specific.

And she's not afraid to admit she's left her B's behind for C's and had her breast asymmetry corrected in the process. Smith says she didn't tell her friends about her liposuction because she felt it was a "taboo" subject. She simply told people she had been dieting.

But Smith, who splits time between her mother in Austin, Texas, and her father in California, feels differently about breast augmentation.

"All my friends are pretty big-chested, so they're just excited that I'm joining the club."

That particular club is growing in more ways than one.

In 2006, more than 9,000 breast augmentation procedures were completed on 18- and 19-year-olds, a 12 percent increase over 2005, according to ASPS. Other procedures that have gained popularity are breast reduction in men, Botox injections, laser hair removal, microderm abrasion and soft-tissue fillers such as fat and collagen.

But the procedure beating out the competition by more than a nose is rhinoplasty. In 2006, about 48,000 nose jobs were performed to reshape teenagers' most prominent facial feature.

Such confidence doesn't come cheap.

The average surgeon's fee alone is more than $3,800 for nose reshaping, $3,600 for breast augmentation and more than $2,700 for liposuction. This charge varies by location and the difficulty of the procedure and doesn't include the cost of anesthesia or hospital stays. Most insurance doesn't cover cosmetic surgery.

Smith, who recently graduated from high school in Santa Maria, Calif., guesses her dad spent about $13,000 for her liposuction and breast augmentation procedures.

Some parents give their teens a choice between two pricey gifts.

Denise and Diana Acevedo chose rhinoplasty (costing about $4,000 each) over a Spring Break vacation to Hawaii.

"We can always go to Hawaii later," said Diana. "This (rhinoplasty) is a lifetime deal."

Fernando Burstein, who leads the plastic surgery section of the American Academy of Pediatrics and directs the Center for Craniofacial Disorders at Children's Healthcare of Atlanta, says it is acceptable for adolescents to undergo otoplasty, also known as ear pinning, and for patients as young as 13 (slightly older for boys) to have rhinoplasty.

However, breast augmentation is a more controversial procedure. Both the U.S. Food and Drug Administration and ASPS recommend patients be at least 18 before having aesthetic breast augmentation.

Some cosmetic surgeons refuse to operate on those under the age of 18. Mario Diana, a San Antonio plastic surgeon, doesn't believe that teens younger than 18 are physically and mentally mature enough to make such a lasting decision.

"I personally feel that the bodies and faces of teenagers under 18 are still in the development process and will continue to change until they are 18 and sometimes beyond," writes Diana in an e-mail. "There is an intense amount of pressure put on young people to conform to what is considered a 'standard' beauty. Most young people under 18 have not yet learned to appreciate what makes them unique, and I feel this comes with maturity."

Even youths who are happy with the results overall may feel the long-term effects from the surgery. About six months after her breast reduction, Amoretti says, her left nipple is still numb. And though pleased with the outcomes of her surgeries, Smith says her sides are slightly uneven from the liposuction, and she has shooting pain running from her left arm to her neck due to a complication during her breast augmentation. She expects the pain to subside in about a month.

Doctors don't believe watching reality television, such as Fox's recent "The Swan," ABC's "Extreme Makeover" and MTV's "I Want a Famous Face," is the best source of information about surgery.

"The troubling thing is that kids watch plastic surgery on TV, and it may not be realistic," says Burstein. "The problem is not solved in a half-hour TV segment. They are very heavily edited, and it may not present a true picture. Plastic surgery may not solve all your problems."