The Medicolegal Challenges of Paediatric Plastic Surgery and Reconstruction
While the majority of plastic surgery procedures undertaken each year are performed in adults, a significant number are actually performed on children. In the paediatric population, plastic surgery is generally used to correct deformities caused by congenital birth defects, tumours or traumatic injuries and to assist in wound management. These procedures are performed with the aim of returning the child’s appearance and function to as close to normal as possible, thereby improving quality of life. All plastic surgery is complex and challenging, but surgery in children raises some particular issues that surgeons need to be aware of.
Children are not simply small adults. The term ‘child’ encompasses everything from a pre-term infant to a young adult approaching their 18th birthday. As children are still growing, their bodies are constantly changing. This can make a surgeon’s task much more difficult, as they must take account of potential changes due to growth. For example, future skeletal development may significantly alter the desired outcome. Furthermore, the technical elements of a procedure can be more challenging, as the structures involved are so small. There may also be a lack of suitable donor material for reconstruction. Young bodies do not respond in the same way to surgery, and compliance rates are different in children than in adults. However, children are often considered to heal and adapt better than adults. Bones achieve union faster and peripheral nerves regenerate more easily, preserving sensory and motor function. As the permanent teeth have often not yet erupted, problems with dentition may resolve themselves over time.
All surgical procedures carry risks. Complications from plastic surgery include infection, poor wound healing and scarring, though perhaps the commonest complication is an “unsatisfactory outcome”, where the appearance or function of the final result does not live up to expectation. Though some subspecialities of plastic surgery can carry particularly significant risks. For example complications following craniofacial surgery can also lead to feeding difficulties, visual loss or brain injury.
A child is constantly changing size and shape so excessive scarring may lead to the abnormal growth of surrounding tissues which may be tethered or prevented from developing normally. When this occurs on the face, major features may become misaligned and require further corrective surgery. Burn injuries, particularly those occurring on the face, can be particularly disfiguring. Coping with this type of injury, and the inevitable impact on body image and self-confidence, can be difficult for a child. It is important that any changes to the child’s appearance do not alter their sense of identity. These issues need to be considered when planning the management of such injuries and are especially relevant regarding the timing of corrective surgery.
Surgeons must review the benefits and burdens of both the proposed surgery and the original condition if left untreated, as with adult plastic surgery. But unlike adult surgery, in paediatric plastic surgery it is ultimately usually the parents who are the ones who provide consent. Parental consent is not required once the child has reached the age of 16, though it is still recommended. However, even for younger children, while not mandatory, where possible it is seen as good practice to involve the child in the decision making process. After all, they are the one who will have to live with the consequences of having surgery performed, or not. Ideally, this will ensure that the child is an integral part of any decision making, rather than just having a procedure performed on them, although this will depend on the child’s maturity and capacity to understand the issues involved.
As well as technical, physical and psychosocial challenges, paediatric plastic surgery raises some specific moral and ethical dilemmas. One particularly difficult, although thankfully rare, issue is the separation of conjoined twins. Often, this type of surgery is not directly life-saving and may carry unknown risks. A procedure that benefits one twin may cause irreversible harm to the other. This raises the difficult question of which twin should have precedence, if either. Performing this type of surgery may also require huge resources. As these are invariably limited in most healthcare systems, this could mean that many other children with less complicated conditions miss out on treatment.
An issue that has become increasingly important in recent years is the question of cosmetic surgery in children for purely aesthetic reasons. While teenagers have always been uncomfortable with their changing bodies, media attention and the rise of ‘Instagram culture’ have exacerbated the problem. Procedures such as liposuction, breast augmentation and rhinoplasty have increased in popularity. None of these is a life-saving operation, but if the child is being bullied or suffering severe psychological distress as a result of any visible abnormality, there is an argument that surgery may indeed be indicated. It is therefore vital to evaluate the child’s reasons for requesting surgery and to ensure that their expectations about the outcome are realistic. The UK General Medical Council’s guidelines state that a surgeon should only provide interventions that are in the best interests of the child. Often, it is better to defer any decision about surgery for as long as possible. Surgeons should remember that they are under no obligation to operate on a patient unless failure to do so would be negligent. But similarly, where an “aesthetic” procedure can genuinely benefit a child, it should not be dismissed out of hand simply because the patient is a minor.
Paediatric plastic surgery and reconstruction can be an incredibly rewarding field in which to work. A surgeon can make a real difference to a child’s quality of life, the effects of which will be felt for many years to come. An awareness of the potential issues that may be encountered, be they physical, psychological or ethical, should help to reduce the possibility of a future claim being made.
About Mr Pundrique Sharma
Mr Pundrique Sharma is a Consultant Plastic Surgeon at Alder Hey Children’s Hospital in Liverpool. He accepts instructions as an expert witness in adult and paediatric cases involving general plastic surgery, reconstruction and burns surgery.
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Bermant MA. Ethics of cosmetic plastic surgery in adolescents. Virtual Mentor. 2005;7(3):257-261. doi: 10.1001/virtualmentor.2005.7.3.oped2-0503.