Techniques for tots

National report - Achieving positive cosmetic results in pediatric surgery is as easy as following some simple rules and guidelines, according to one expert.

Annette M. Wagner, M.D., assistant professor of pediatrics and dermatology at Northwestern University Feinberg School of Medicine, Chicago, offers valuable pediatric surgery pearls and simple tips for maximizing cosmetic outcomes in children.

Flexibility nets improved outcomes

"Allowing for a certain degree of flexibility in surgery scheduling can significantly help in achieving very positive cosmetic results. Surgeries should never be done in the summertime, nor in a favorite sport season of the patient. Furthermore, local anesthesias can be best administered to patients in the fourth or fifth grade, if the surgery can wait," Dr. Wagner tells Dermatology Times.

The flexibility concerning the nature of the lesion is not as fluid. According to Dr. Wagner, scalp lesions greater than 1 cm in diameter are best removed within the first year of the patient's life. Persistent, disfiguring hemangiomas should be removed when the patient is around 4 to 5 years of age, and lesions on the trunk or extremities should be approached after the seventh year. She says that a facial pilomatricoma, however, must be removed as soon as possible to prevent continued growth and larger scars.

Tying up loose ends

Dr. Wagner says that when closing a surgical wound, she likes to use twice the number of sutures for a more stable hold, as children are much more active than adults and their compliance with post-op do's and don'ts concerning rest can be difficult.

She suggests using several deep interrupted sutures of 4.0 to 5.0 clear nylon or prolene and to set the sutures (preferably square knots) deep - meaning more than 3 mm beneath the skin's edge, so the knots are not palpable when the scar heals.

"Placing a running subcuticular suture can also help achieve very nice cosmetic results. They can remain much longer in the surgical site and do not leave any 'train track' marks when pulled. Also, this type of suture is absolutely painless upon removal," Dr. Wagner says.

When operating larger skin lesions such as large congenital nevi, Dr. Wagner likes to perform a staged closure, with six to eight weeks between the surgeries. The benefits are that there is a decrease in the length of the scar and there is less tension on the wound, which decreases the chance of wound dehiscence and scar spreading.

When performing surgery on a round lesion, Dr. Wagner suggests closing the resulting defect with a purse-string closure technique. This simple, yet valuable, technique can help reduce the scar length by 50 percent.

"When excising residual hemangiomas, I often perform a partial resection of the hemangioma to preserve skin and reduce the scar length. When the surgery is complete, I then use pulsed dye laser therapy to improve the color and texture of the site," Dr. Wagner says.

Post-op pearls

To decrease postoperative complications, Dr. Wagner suggests bulking up the wound bandage and immobilizing the area if possible.

She tells her patients to leave the area alone, and advises that they refrain from physical activity for a month. She adds that the bulkier and more colorful the dressing, the happier and more compliant the child. According to Dr. Wagner, surgical wounds can be bandaged with more glue and more padding and they must be kept dry to reduce the risk of infection.

To improve scars and scar healing, Dr. Wagner suggests that surgical wounds be massaged for five to 10 minutes a day with Mederma (Merz). She says that patients should be followed closely because, if a complication does arise, early intervention can be pivotal for achieving good cosmetic results. For complicated hypertrophic or keloid-like scars, intralesional Kenalog (Bristol-Myers Squibb) once a month, silicone gel sheeting or a pulsed dye laser can be used, if necessary.