When Do Children’s Scars Need Surgical Correction?

Pediatric Scars

Treatment of scars in children differs in many ways from treatment in adults, because children are still growing and developing, and their skin, muscles, bones, and joints continue to change.

Normal skin can stretch as the body grows, but scar tissue has poor elasticity and often cannot keep pace with growth. For this reason, a child's scar may at first only look firm, red, and tight, yet over several years it may gradually begin to pull, contract, deform nearby structures, and limit movement.

Management of pediatric scars usually starts with conservative treatment, such as silicone, pressure therapy, laser treatment, medication injections, sun protection, tension reduction, and rehabilitation exercises.

Surgical correction is generally used when a scar has already caused a clear structural problem, or when conservative treatment can no longer stop functional damage from continuing to progress.

In addition, children are in a stage of both physical and psychological development. Scar prevention and treatment should be selected according to age, stage, severity, and scar classification, and parental cooperation also directly affects the treatment result.

When Joint Movement Becomes Limited

Once scars in areas such as the fingers, palm, wrist, elbow, axilla, knee, ankle, or neck become hard and shortened, they may restrict movement. This can lead to a range of problems in children, such as inability to fully straighten the fingers, difficulty making a fist, inability to open the thumb-index web space, difficulty raising the arm, changes in walking posture, and limited neck rotation.

If the range of motion has already decreased, topical medication or silicone alone is far from enough. In the early stage, splints, pressure therapy, rehabilitation stretching, laser treatment, and injections may help control the problem; if the scar has already formed an obvious contracture, surgical release is needed to free the pulled skin, tendons, and joints and restore room for movement.

In addition, because children grow quickly, have thin skin, are active, and often have poor treatment adherence, they are more likely to develop scar hypertrophy and contracture. Limb dysfunction caused by contracture deformity can also have psychological effects.

When Scar Contracture Affects Growth and Development

Scar contracture in children may worsen as the body grows. For example, after facial trauma in early childhood, scar tissue may not grow proportionally with normal skin, and facial contracture and deformity may gradually develop. Age-stratified studies of facial trauma scars have noted that children's facial skin is thin and delicate, with active collagen metabolism and a higher risk of scar formation; if scars in early childhood are not treated in time, they may develop into contractures during growth and lead to facial deformity.

This situation is more common after burns. For example, scars of the neck, chest, face, and hands caused by burns in childhood may, if they remain under long-term traction, affect development of the mandible, fingers, joints, and even overall posture.

Do not take the attitude of 'wait until the child grows up,' because this may very likely miss the right window for intervention.

When Hand Scars Affect Grasping and Fine Motor Skills

The hand is a very important area in pediatric scar surgery. Children need their hands to eat, write, draw, dress, grasp toys, and complete fine motor tasks. Palmar scar contracture can prevent the fingers from straightening, dorsal hand scars can affect making a fist, first web space scars can affect thumb abduction, and web space scars can affect separation of the fingers.

For children with severe palmar scar contracture deformity, surgery fully releases scar contracture, tendons, and joints to restore finger extension, then uses a free medial plantar flap and partial skin grafting to cover the defect. After surgery, flap appearance, sensation, hand function, and scar condition are evaluated.

If a child already has obvious difficulty grasping, difficulty extending the fingers, or narrowing of the first web space, plastic surgery evaluation as early as possible is recommended. The longer the delay, the more obvious tendon adhesions and joint stiffness become, and the harder later recovery will be.

When Scars of the Axilla, Elbow Crease, Popliteal Fossa, or Groin Affect Daily Movements

Axillary scars can affect shoulder elevation, and a child may have difficulty dressing, bathing, or combing hair. Scars in the elbow crease can affect elbow extension or flexion. Scars in the popliteal fossa can affect standing, running, jumping, and going up and down stairs. If scars in the groin area contract, they may affect hip movement, squatting, and walking, and may also pull on the skin of the perineum and upper inner thigh.

The English abstract of a study on surgery for scar contracture in the pediatric groin area shows that the study subjects were children with post-burn groin scar contracture. The surgery used groin-region related flaps for repair, with the goals of releasing scar contracture and restoring function in that area while minimizing the effect of donor-site injury on children's physical and psychological development.

For scars in these areas, the key factor in deciding whether to operate is function. Once they affect walking, standing, sitting, squatting, lifting the leg, or dressing, they should not be treated merely as an appearance issue.

When Facial Scars Affect the Shape of Facial Features and Psychology

Not all facial scars in children need surgery. Mild red marks, superficial scars, and early hypertrophic scars can first be managed with sun protection, silicone, laser treatment, medication, tension reduction, and other methods.

However, if a scar has already caused eyelid ectropion, incomplete eye closure, pulling at the mouth corner, lip deformity, nasal ala deformity, eyebrow-eye asymmetry, or obvious effects on facial expression, plastic surgery evaluation for surgery is needed.

In addition, the prognosis of pediatric facial trauma scars differs by age, so individualized diagnosis and treatment based on age stratification are needed.

The main surgical goals for facial scars are to improve shape, reduce traction, make the scar better follow the skin lines, and at the same time protect the functions of the eyes, mouth, and nose. School-age children have begun to care about appearance and peer evaluation, and obvious facial scars may also cause low self-esteem and social avoidance, so psychological factors should also be included in treatment decisions.

When Keloids Keep Enlarging, Cause Pain or Itching, or Extend Beyond the Original Wound Area

Children can also develop keloids, commonly on the earlobe, auricle, anterior chest, shoulders and back, and mandible. Keloids are characterized by extending beyond the original wound area, continuous growth, invasion into surrounding normal skin, a firm texture, and frequent itching or pain.

Keloids should not be casually treated by simple excision, because the recurrence rate after simple surgical removal is high. For example, the skin of a child's auricle is thin and the ear cartilage is fragile, so methods commonly used in adults cannot simply be copied.

Therefore, when pediatric keloids require surgery, treatment is usually combined with injections, laser treatment, pressure therapy, silicone, and long-term follow-up.

When There Is Recurrent Breakdown, Infection, and Obvious Pain

If a child's scar repeatedly breaks open, bleeds, drains fluid, or becomes infected, this indicates poor local skin quality, high tension, or poor deep-tissue conditions. Long-term breakdown increases the risk of infection and may make the child avoid movement because of pain, further worsening joint stiffness.

In this situation, the doctor will assess whether the unstable scar needs to be excised and repaired again with a skin graft, flap, or composite tissue. For example, autologous split-thickness scar tissue composite skin can be used to repair scar contracture deformities in functional areas in children; the operation is used for children with functional-site scar contracture deformities after severe burns, with complete intraoperative release of scar contracture, restoration of joint movement, and preparation of composite skin grafts according to the defect.

What Factors Do Doctors Consider Before Deciding on Surgery?

Doctors generally make a comprehensive judgment based on the following: the child's age, how long the scar has been present, whether the scar is still in the proliferative phase, whether it affects joint movement, whether it affects facial-feature function, whether it continues to enlarge, whether there is a keloid tendency, the effect of previous treatments, and whether the parents and child can cooperate with postoperative rehabilitation.

Pediatric scars can cause pain, itching, abnormal sensation, functional impairment, and psychological problems. Children also have characteristics such as growth and development, sensitive skin, poor adherence, and high parental involvement; scar contracture is a common complication, and all of these factors influence surgical timing and the choice of procedure.

Long-Term Rehabilitation and Anti-Scar Management Are Still Needed After Surgery

After pediatric scar surgery is completed, treatment has not ended. The new incision will still form a new scar, and postoperative care still requires silicone, pressure therapy, tension reduction, sun protection, laser treatment, injections, splints, stretching exercises, and regular follow-up.

Areas such as the hands, axilla, neck, and knee especially require rehabilitation exercises; otherwise, the scar may contract again.

Parents should observe whether the child is willing to move the affected area, whether the joint angle is becoming smaller, whether the scar is becoming red and thick again, and whether pain or itching appears. Children's treatment adherence is limited, and many outcomes depend on whether the family can persist over the long term.