SKIN SUTURES IN CHILDREN
Reconstructive surgery.
SOME SKIN WOUNDS OF THE CHILD MAY BE A SUTURED BY AN EXPERIENCED GENERAL PRACTITIONER, OTHER MUST BE ADDRESSED TO THE SURGEON TO ASSURE THE BEST POSSIBLE HEALING.
Plastic Surgery Unit, Hospital Saint Vincent de Paul, Paris
«Doctor, Thomas fell at the nursery last month, my doctor put him a Steri-Strip, the scar on his forehead is horrible, what can we do?» «Doctor, my daughter Louise was bitten by the dog of her grandmother during the Easter holidays, three months ago, it was not sutured, the scar is very red, swollen, when could be corrected by surgery?» «Should we expect until she has finished her growth to correct her cheek scars?» «Doctor, my son Roman has been born with a birthmark on his right cheek, when can it be removed?».
All these questions are common during paediatric surgery consultation: when a child has an accident with skin wounds, what should the paediatrician or general practitioner do? Which wounds can they suture? How to suture them? Which sutures? Which wounds should be sent to the surgeon? What will be the evolution of scars? How to improve them? Which is the responsibility of the doctor? When can we correct unsightly scars? To answer all these questions, it seems to me indispensable to recall the anatomy of the covering tissues, the evolution of scars depending on age, location, terrain, quality of the suture, to clarify any need for techniques of anaesthesia, and the treatment of scars.
ANATOMY OF COVERING TISSUES
The skin consists of two elements: the epidermis and the dermis, separated by the basement membrane. The hypodermis or subcutaneous tissue, is made up of fat in which travel the blood vessels and nerve endings. This tissue covers the muscles and fascia. It is loose, easy to stretch and may be the location of effusions and haematomas, factors of infections; it is from these that the wound is being broken or fibrosis is formed.
SKIN HEALING
In children the evolution of the scar is variable, depending on their age, location and orientation of the scar, and well as the wound and the ground. A number of external factors are changing this trend, and we must also emphasize the role of sun exposure on hypertrophy. The final quality of the scar is much better when the evolution is little inflammatory and of short duration.
Age is a major factor in the evolution of scars (Figure 1). The scar is very little progressive in the newborn, as evidenced by the beautiful scars after neonatal surgery. Thus one could propose surgical treatment of severe facial deformities in this period.
With growth, the hypertrophic nature of the scars will increase to maximize at puberty: the final scar will be much broader as it is hypertrophic. It is also at puberty when the risk of keloids is most important.
The location of the wounds and scars is also of great importance in their evolution. In the face, the evolution is less important and less long. It is on the eyelids where the skin is thinnest and the scars are the most beautiful. On the limbs and trunk, the scars are much more progressive, especially in the proximal areas of the limbs and in the region of the sternum, where the risk of keloids is most important.
The orientation of the scar puts into question their status. It is the tension in the axis of the scar that stimulates inflammation and the formation of fibrous tissue. Thus every wound that crosses a flexion crease deserves a local plasty designed to redirect the final scar, why not send it to the surgeon as with the deep wounds of the fingers?
The ground is an important element in the prognosis of the quality of the scar. The black skin is at risk of poor wound healing, as well as the skin of Asians; other skin types, thick and rich in elastic fibres, have an increased risk of progression, such as the skin of children with Turner syndrome.
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The quality of the suture and skin repair is certainly one of the most important factors affecting the result of the scar. It is this quality that involves not only the reputation, but also sometimes the responsibility of the practitioner. The repair of the wound should interest all levels, and it is essential to remove any dead space that could be home to a collection that can cause breakage or scarring (Figure 2).
The subcutaneous layer is made with interrupted sutures tied upside down, with absorbable sutures on the trunk and limbs. In the face, I usually use colourless nylon, but with a risk of intolerance sometimes requiring the removal of one of them. The need for careful repair of the subcutaneous layer explains that the use, alone, of biological glue or adhesive sutures does not seem to me sufficient to get a quality scar despite their ease of use and painless nature of the application (Figure 3).
The skin is done either by interrupted sutures or by intradermal sutures. On the face and uncovered regions, I use non-absorbable sutures, little tight. The absorbable sutures seem to accentuate the inflammatory character, and thereby affecting the evolution of scars. The sutures are removed in the fourth or fifth day. On the face again, if the subcutaneous plane is fully repaired, it could be indicated the use of biological glue or adhesive sutures. Their placement is painless, they do not leave marks, and they mostly avoid the "ceremony" of the removal of the stitches. On the trunk and limbs we use an intradermal suture: sutures of slower absorption (provided they are colourless). The fine staples, called aesthetic, can be very useful, rapid and painless for a small wound of the eyebrow or scalp that does not require the placement of more than two staples.
Today, anaesthesia is a time of the skin suture in children. It is unacceptable and impossible to perform a proper suturing with uneventful and aseptic course with the aid of the muscular restraint of the young child by two or three adults.
Local anaesthesia should be the rule for any child over five years without a seizure history. Single Xylocaine or, better, with adrenaline promotes the achievement of a deep plane in the best conditions. It is still possible to get the help of the application of an anaesthetic cream, like Emla, either before the injection of local anaesthesia, or for the placement of one or two staples. In the hospital, in young children, we usually perform the sutures under Entonox (a mixture of nitrous oxide and oxygen).
Any large, confusing, dirty wound, needing a major trimming, should be treated under general anaesthesia.
This is particularly the case of animal bites. It seems worthwhile to recall the need to explore a hand wound under general anaesthesia if an injury of a tendon or a collateral nerve is suspected.
Failure to do so could incur liability of the physician. The human or animal bites, if the are punctiform or small, require only disinfection.
SECONDARY OR POSTOPERATIVE CARE
It’s very important for obtaining a good scar.
Sun protection
Sun protection is the rule for three to six months, by wearing a light dressing or a total sun block (index > 20) or even by using a barrier cream and face makeup.
Pressotherapy
The application of pressure on the scar is an excellent way to reduce the intensity and duration of the progression of the scar. It can be done by wearing an elastic band or a custom-made pressure garment on the hypertrophic and large scars.
Corticosteroids
Corticosteroids should be reserved only to scars progressing to keloids. The current trend is to prescribe the wearing of a silicone gel sheet twelve hours daily during the entire evolution of the scar, held together by an adhesive bandage or a compression bandage.
When should be treated an unsightly scar?
It is necessary to wait at least a year and sometimes two before revising a scar. It is especially necessary to avoid surgery during puberty and choose a date, preferably before the age of 10 years.