Devices used in corrective surgeries during adolescence

The period of adolescence makes up most of the second decade of life. Guidance issued by the CDRH, defining the pediatric age range up to 21 years, supports the consideration that issues of physical and hormonal growth and emotional/behavioral development should be carefully addressed with device use in adolescent patients [63]. Human factors in device use should be considered as teenagers strive to become independent and take over their own medical care. One cannot always assume there will be parental supervision and goodjudgment in the use of medical devices. This is an age group known for its risk-taking behavior and noncompliance. Also, teens have heightened concerns about their bodily appearance and self-image.

In order to optimize the clinical outcome of elective surgery during adolescence, timing is crucial. Adolescence is the second most dramatic period of body growth (second only to the fetal growth period). Girls and boys may grow 6 to 12 inches in height during their growth spurt and undergo dramatic sexual maturation changes. Many of the body organ systems are completing their final growth. While elective orthopedic surgeries will frequently be postponed until skeletal maturation has been attained, some surgeries, such as scoliosis repair, must be done before spinal growth disturbances compromise lung function and negatively impact the postoperative cosmetic results. Umbilical and inguinal hernias that were undetected in earlier years may also be repaired when they are discovered in teenage years. In boys, large varicoceles in the scrotum and hypospadias (birth anomaly with misplaced urethral opening) repairs may be performed, with hopes to improve both aesthetics and function. Frequently, cosmetic surgeries, including rhinoplasty (nose reshaping), otoplasty (ear surgery), and various breast surgeries, including augmentation surgeries, are performed. According to American Society of Plastic Surgeons (ASPS) website and see that for 2005 there was a total of more than 333 000 cosmetic procedures performed on young patients under age 19.

It is important to understand the patient motivation and expectation for having surgery [52,53]. An increasing demand for plastic surgical procedures may in part be related to increased media coverage about enhancing cosmetic procedures. Appropriate selection of patients and assessment of their physical and emotional maturation is crucial [54]. Few articles in the literature address teen attitudes regarding cosmetic surgery issues [53]. One small study of boys and girls examining their attitudes towards cosmetic surgery supports that teens should be screened for underlying depression and self-image disturbance to be sure they will not continue to seek body improvement surgeries. They emphasize that possible underlying psychological disturbance and underlying psychiatric problems should be appropriately identified, and addressed and treated before cosmetic surgery is performed.

Recently there has been an increase in the number of teens undergoing breast implant surgery. Saline breast implants are FDA-approved in persons 18 years and older. However, being bombarded by the media images, small-breasted girls may feel inadequate and opt for a breast implant augmentation with unrealistic expectations. A large Danish cohort study of young women opting for enhancing breast augmentation with implants also supported the need to evaluate young women for underlying psychiatric problems [55]. The American Society of Plastic Surgeons website reports 3841 breast augmentations among women aged 18 years or younger. This 'cup and gown' procedure is sometimes paid for by parents as a high school graduation gift.

Elective cosmetic surgery and other reconstructive technologies which are offered to teens may not always be appropriate and pose risks different from those seen in adults. Operating on tissues that have not fully developed may be problematic, and surgery might interfere with growth or cause problems years later. While most would agree that breast surgery should be postponed until the breast has completed its growth, the breast becomes mature during adolescence but is not fully complete until about age 25. Further maturation occurs with pregnancy [56].

In males, gynecomastia is a common condition that occurs during adolescence and usually regresses spontaneously within 1 year, but moderate to severe cases that do not resolve may undergo reduction mammoplasty surgery for cosmetic and psychological sequelae. While surgery in the past has used open excision techniques, newer liposuction technology has been used with the aim of avoiding large areas of scarring and nerve and vessel injury. Ultrasound-assisted liposuction (UAL) has been recently used to treat gynecomastia in both adolescent and adult males. UAL selectively destroys adipose tissue and proponents report that it offers benefits of less swelling, bleeding and can be used in more fibrous breast tissue areas [57,58]. Disadvantages include increased operative time and the involved training. However, most studies involve case series by one surgeon and a wide age range of patients. Further investigations need to carefully examine patient satisfaction, cosmetic results, and incidence of complications for the adolescent age group.

It is important that indications for device intervention during adolescence be conservative until appropriately designed clinical studies have demonstrated the safety and efficacy of these techniques when applied to teens. Studies should be conducted to better understand what adverse events are unique for teenagers and what preventive measures may be taken to ensure successful outcomes with device use.

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