Pediatric Hand Surgery Scarring

All wounds heal with scar but how can we decrease scarring for our patients? There is no magic cream but there is a formula.

1. Surgery. Our surgery is the most important aspect, that we had an efficient surgery that was quick, efficient and safe.. Resulting in maintaining blood supply to tissues so they heal and that the skin graft site has healthy tissue. Keep the tissue moist during the case (dessication or drying out results in tissue death). Tissue death results in more scarring rather than primarily healing. We want primary healing!! Our goal is to do an efficient surgery (have a great assistant) to get good healing. Put a dressing on and cast it for four weeks (dressing changes do not do much.. In congenital hand surgery everything will heal well if all the tissues lined up well). Use absorbable sutures.

2. Cast Education. Our surgery is “easy” (compared to the after care) because the child is under general anesthesia and we can do the surgery precisely. Once the child is awake the key component is keep the the surgery exactly as we performed it. For example if we do a large surgery and placed a pin and then the cast comes off after the first week and the pin is removed early.. That defies our goal of leaving it exactly as we made it and so take your time place a long arm club cast (2 inch soft cast is a great option). Therefore the education that we perform with the family becomes important on keeping the cast rules (keep the cast, clean, dry, elevated and supervision). 

3. Scar Education: After the cast if off there are no wounds! The role is now for the parent to perform aggressive scar massage for a few months after surgery with scent-free lotion multiple times daily. Scar massage helps with breaking up scar tissue in the short term to soften the scar and avoid hypertrophic scarring (make sure to tell family to massage into the webspace as well). Scar massage promotes flexibility of the scar by mobilizing the collagen fibers, helping to reduce stiffness and adhesions to underlying tissues, and decrease edema (help with sensitivity to). Show them how to do this (have your nursing staff and pediatric hand therapy also help teach) and can be performed at nighttime when child is sleeping. Never have an adolescent do their own scar massage (they will unlikely do this). Splinting is another adjunct that helps with scarring (avoids constant motion across a child) fo example custom thermoplastic splinting by pediatric hand therapy for webspace for syndactyly and small thumb spica for thumb polydactyly. After casting (4 weeks post operatively) splints can be worn for a few weeks during the day and then nighttime only for up to 6 months. We also recommend silicone taping that can be placed at night time (not on palmar tissue because sweating does not allow these to stick down). We follow patients over time (clinic visits or telemedicine) to ensure that scar massage is being performed.