While thoracic outlet syndrome (TOS) is known to afflict teenaged patients, reported data are limited to small groups or individual cases. Management of TOS in teenagers presents many issues, including performing surgery in patients whose skeletal growth may not be completed. Additionally, surgical intervention may result in loss of school time. The aim of this study was to assess our results with a large series of young TOS patients in order to provide insight toward achieving optimal care. Via a retrospective chart review, we identified all patients <20 years of age undergoing first rib resection for TOS during an 11-year period (August 1994-September 2005) at a single university hospital. History, indication, operative details, and pertinent follow-up were obtained from the records. There were 18 patients <20 who underwent first rib resection in the study period (all but one via a transaxillary approach). Ages ranged 13-19 years. Twelve patients had disabling neurogenic (NG) TOS, and six presented with Paget-Schroetter syndrome (PS). Seventy-two percent of patients were female. Most students (14/18) were forced to take a leave from school due to severity of symptoms. Eighty-five percent of female patients presented with NG TOS, whereas PS TOS affected 80% of male patients. All PS TOS patients were involved in high-intensity athletics, while 75% of NG TOS patients were student athletes. Follow-up ranged from 30 days to over 12 years. There were no significant operative complications in either group. Forty-two percent of NG patients experienced continued symptoms leading to anterior scalenectomy. All PS patients had successful lysis of their thrombotic processes. Overall, 25% of NG TOS patients also required postoperative trigger point injections. All patients eventually recovered and were able to resume academic as well as competitive athletic activities. TOS can be effectively and safely treated in the teenage years. PS responds well to standard thrombolysis and surgical decompression. NG TOS presenting in these young patients appears more likely to require extensive surgical decompression (both rib resection and total scalenectomy) in order to achieve optimal results. Given the psychosocial and academic implications of this disease, careful diagnosis and appropriate treatment are imperative.