Children’s Plastic Surgery
Paediatric Plastic Surgery specialises in reconstructive and aesthetic procedures for babies, children, and adolescents, restoring function and appearance for congenital differences, injuries, and complex conditions.
Common Conditions managed by a Paediatric Plastic Surgeon
Removal of Birthmarks and congenital moles
Ear
anomalies
Facial Injuries
Burn injuries
Hand Injuries
Scar management
Complex
wounds
Background
Trigger thumb is a common condition in children. Triggering or locking of the other fingers is common in adults, but relatively rare in children.
The condition usually develops in the first year of life. Patients may present with a thumb that cannot be extended, or the thumb may “trigger” in and out of a flexed position. There is often a firm nodule on palm side of the thumb, near the crease where the thumb joins the hand (“Notta Nodule”). Trigger thumb is not usually painful but the inability to extend the thumb can cause functional issues in older children who are learning to grasp.
Trigger thumb is caused by a loss of gliding between the thumb flexor tendon (flexor pollicis longus) and the surrounding tendon sheath. The tendon sheath may be tightened, and inflammation may occur surrounding the tendon (tenosynovitis).
The treatment of trigger thumb includes a range of approaches, from observation, to splinting, and surgery.
Observation as management
Literature reports vary in the frequency of spontaneous resolution of trigger thumb with observation only. It is thought that approximately 30% of cases diagnosed before the first birthday will resolve within 12 months, without any intervention. As the observation period becomes longer, the likelihood of spontaneous resolution increases. One study reported that just over 50% of patients went on to spontaneously resolve after 5 years of observation.
While observation may lead to spontaneous resolution, it must be balanced against the risk of functional issues resulting from delayed development of pinch grasp movements.
Non-surgical management
Non-surgical management of trigger thumb consists of some combination of exercises and splinting.
Flexion and extension exercises may be prescribed, either with or without use of a splint. Splint regimes may consist of application of a thumb extension splint during nap-time and night time sleep.
These approaches are attractive because they avoid the need for anaesthetic and surgery. However, the main drawback is the need for a prolong period of very vigilant treatment, ensuring exercises are carried out regularly and splints are always placed during rest periods (often for a duration of six to twelve months).
The reported results of non-surgical management vary widely. Approximately 70-75% of patients experienced resolution with non-surgical management, however reported results were better in patients who had “reducible” (non-locked) trigger thumbs.
Surgical management
Surgical management of trigger thumb involves a small incision on the palm side of the thumb to release the tendon sheath and remove any adhesions between the tendon and its sheath.
The surgery requires an anaesthetic to keep the patient comfortable. A tourniquet is often used to minimise bleeding and allow clear visualisation of the tendon and its sheath.
The surgery is usually carried out as a day procedure and patients will have a bandage afterwards for one-to-two weeks while the surgical incision heals. The locking of the thumb typically resolves immediately.
The right approach to management of your child’s trigger thumb requires a careful discussion between you, your family, and your surgeon. Offspring Health is pleased to offer consultations to discuss which treatment option best suits your child’s situation.
Background
Otoplasty, commonly referred to as ear reshaping surgery, is a procedure aimed at correcting prominent or misshapen ears. It is often performed on children to address aesthetic concerns regarding ear position or structure. While some children may experience teasing or bullying due to the appearance of their ears, otoplasty is a highly effective way to improve both the function and appearance of the ears, often leading to enhanced self-esteem and confidence.
Otoplasty can be performed at a young age, typically when the ear cartilage has matured enough to be reshaped, which is usually around 4-6 years old. The surgery can correct conditions such as protruding ears (when the ears stick out more than normal), asymmetry, or structural deformities caused by congenital conditions or injury.
Diagnosis and Assessment
A paediatric plastic surgeon will assess the child’s ear shape and size, looking at the underlying cartilage and ear anatomy. In cases of prominent ears, the surgeon will consider factors such as the degree of protrusion, the structure of the ear folds, and how these factors impact the child’s appearance and self-esteem. The patient’s and their family’s situation will be considered to ensure optimal timing of the surgery, and to enable adherence to the post-operative requirements.
Management
Otoplasty is a surgical procedure, typically performed under general anesthesia. The surgeon makes small incisions behind the ear to access the cartilage. Depending on the desired outcome, the cartilage may be repositioned, reshaped, or reduced. In some cases, stitches are used to hold the cartilage in place to create a natural-looking fold. The procedure generally takes 1-2 hours.
After the surgery, children will wear a headband or bandage for a few days to help maintain the new ear position and minimize swelling. Pain after surgery is usually mild and can be controlled with over-the-counter pain relievers. The child will need to avoid contact sports or activities that may put strain on the ears for several weeks.
Long-term Outcome
The result of otoplasty is typically a permanent improvement in the shape and/or size of the ear. The incisions are hidden behind the ear, so scarring is minimal. Most children can return to normal activities within a few weeks, though longer may be required for contact sports. Otoplasty can have a significant impact on a child’s self-esteem and help them feel more confident, especially if they’ve previously been self-conscious about the appearance of their ears.
If prominent or misshapen ears are an area of concern for your child, Offspring Health is pleased to offer consultations with an experienced paediatric plastic surgeon to discuss whether otoplasty may be appropriate.
Background
Congenital moles and birthmarks are common skin conditions present at birth or appearing shortly thereafter. They can vary in size, shape, and colour and are often harmless, but in some cases, they may need to be monitored or treated depending on their location, appearance, or potential for complications. Common types of congenital moles include melanocytic nevi (benign moles) and congenital hemangiomas (vascular birthmarks).
While many moles and birthmarks do not pose any health risks, some can grow or change in ways that may require medical attention. It’s essential for parents and healthcare providers to monitor any birthmarks or moles for changes, especially for children with a family history of skin cancer or other related conditions.
Diagnosis and Assessment
When examining a mole or birthmark, a doctor will assess the size, shape, and colour of the lesion. If there are any concerning features (e.g. signs of rapid growth, irregular borders, or colour changes) further evaluation may be necessary. In some cases, a biopsy may be performed to rule out any cancerous changes or to gain a better understanding of the mole’s nature.
For vascular birthmarks like hemangiomas, their behaviour may often be observed. These lesions can sometimes shrink or disappear on their own over time, particularly if they appear in infancy. Some vascular birthmarks are associated with other syndromes, which may be considered as part of the patient’s work-up.
Management
Treatment for congenital moles and birthmarks depends on several factors, including the size, location, and type of lesion. Some birthmarks and moles require no intervention at all, and simple observation over time is all that is needed. Therapeutic intervention, for example laser or surgery, may be needed in certain cases. Firstly, for moles that pose a risk of becoming malignant (cancerous), surgical management is typically required. Secondly, birthmarks that may affect a child’s function (such as blocking vision or causing discomfort), or social interaction (if in an aesthetically sensitive area), require a sensitive discussion regarding the risks and benefits of various treatment options.
Surgical Removal
If a congenital mole or birthmark is raised, growing, or causing functional issues, surgical removal may be recommended. Surgical procedures typically involve excising the mole or lesion with a small margin of surrounding tissue to ensure complete removal. In some cases, laser therapy may be used to remove or lighten certain types of birthmarks, particularly those that are superficial or vascular in nature. Larger lesions may require complex reconstructive approaches, such as serial excisions, re-arranging adjacent skin, or tissue expansion. A paediatric plastic surgeon is best trained to discuss the treatment options for any lesion that requires surgery.
In most cases, congenital moles and birthmarks are harmless and can be managed conservatively. However, some children will require intervention for concerning lesions. Some children with moles or birthmarks that are removed may require ongoing skin checks to monitor for any signs of new or changed lesions. For vascular birthmarks, regular follow-up appointments may be needed to determine if further intervention is required as the child grows. Offspring Health has clinicians that are able to comprehensively assess and monitor paediatric skin lesions, as well as guiding you and your family towards tailored treatment options.
Background
Scarring is a natural part of the healing process after an injury or surgery. In children, scar formation is a common concern, especially since they are more active and may be prone to accidents or injury. Scars can vary in size and appearance, and some children may develop hypertrophic or keloid scars, which can be more prominent and raised. Scar management is an essential part of paediatric wound care, as it not only improves the cosmetic appearance of scars but also helps to ensure that the scars do not interfere with function or cause discomfort.
Diagnosis and Assessment
Scars are typically diagnosed and evaluated based on their size, location, and appearance. Some scars heal smoothly with minimal intervention, while others may become thicker, darker, or raised. The type of scar will influence the treatment approach. Hypertrophic scars are raised but stay within the boundaries of the original wound, while keloid scars grow beyond the wound’s borders and can be more difficult to manage.
The paediatric plastic surgeon will assess the child’s scar and determine the most appropriate course of treatment based on factors such as the scar’s size, cause, age, and whether it is causing any functional limitations or cosmetic concerns.
Management
Basic scar management can be started at home without any special equipment:
- Sun protection: Avoidance of sun is crucial for scars, particularly in the early stages. Sun exposure can result in hyperpigmentation (darkening) of scars which can be very difficult to treat later, if it becomes established.
- Massage Therapy: Gently massaging the scar with a moisturizing lotion can help soften and re-align the collagen fibres in the scar tissue and promote flexibility in the skin.
More advanced scar management techniques can be divided into both non-surgical and surgical options. Non-surgical treatments are typically the first line of treatment, and several approaches can help minimize the appearance of scars.
Non-surgical Treatments
- Silicone Sheets and Gel: These are commonly used to flatten and soften raised scars. They work by keeping the scar moisturized and reducing the tension on the tissue. These products can be applied daily for several months.
- Pressure Garments: For larger or more prominent scars, such as those resulting from burns, pressure garments are often used. These garments apply constant pressure to the scar area, which can help flatten the scar and reduce its size. The garments are often custom made for each child and require monitoring to ensure a comfortable, effective fit.
- Steroid Injections: For hypertrophic or keloid scars, steroid injections can be used to reduce inflammation and shrink the scar tissue. These are typically performed by a paediatric dermatologist or plastic surgeon.
Surgical Management
If a scar is particularly large, painful, or affecting a child’s function, surgical options may be considered. Scar revision surgery involves excising the scar tissue and then rejoining the wound in a way that minimizes the appearance of the scar. In some cases, skin grafts or other techniques may be used to improve the scar’s final appearance.
Plastic and Reconstructive surgeons are comprehensively trained to assess scars and plan surgical management to reduce their impact. For large scars, re-arranging the skin to minimise appearance and reduce tension can be challenging and may require multiple procedures, or complex techniques such as tissue expansion.
Long-term Outcome
With early and effective treatment, many scars in children can be minimized to the point where they are barely noticeable. Scars that are well-managed early on are less likely to become problematic as the child grows. However, some children may require follow-up care to address ongoing scarring concerns, and treatments may need to continue into adolescence or adulthood, depending on the nature and location of the scar.
If your child has a wound or scar that you think would benefit from specialist advice, please contact Offspring Health to arrange a consultation.
First Aid
Treatment of burns starts with first aid. Burns should be cooled, with cool, clean running water for 20 minutes. Burns first aid is effective within the first four hours after the burn
In younger children with larger burns, be mindful of keeping the child’s overall body temperature warm. If children start shivering or showing other signs of low temperature, cease cooling and wrap them in a warm, clean blanket or towels.
Avoid applying ice packs, cold compresses, gels, or non-medical agents (some patients have used butter or toothpaste – neither of which is advisable).
Once 20 minutes of cooling has been completed, cover the burn lightly in clean cling film (glad-wrap) and seek emergency care. Blisters may develop, indicating a dermal (previously called “second-degree”) burn.
Seek emergency care by calling 000 or attending an emergency department for all severe or large paediatric burns.
Measuring Burn Surface Area
Burns are measured as a percentage of total body-surface area. The patient’s palm and fingers make up approximately 1%. A burn’s surface area can be estimated using this method, or others such as the modified “rule of nines.” In children, burns resulting in blistering or deeper burns to more than 10% of the body surface area are a significant emergency and patients should be transferred by ambulance to the nearest burns hospital.
Measuring Burn Depth
Burns were previously labelled as first-, second-, or third-degree burns, depending on the depth of the burn. Current burn terminology refers to the anatomical layers of the skin to allow better description of the burn.
Epidermal burns are those that result in redness only. These burns are very painful, but the skin does not blister, and patients rarely become generally unwell as a result. Sunburn commonly results in an epidermal burn. While patients may require pain relief, further intervention (e.g. dressings or surgery) is seldom required.
Dermal burns vary widely in severity and management. In children, these burns often result from scalds due to hot water, tea, or soup. Dermal burns may be superficial-, mid-, or deep-dermal. The treatment prescribed depends on the depth of the dermal burn, as well as the affected surface area. Small, superficial dermal burns may be treated with dressings only. Larger, or deeper dermal burns may require surgical treatment to optimise the final outcome and reduce scarring. Dermal burns require assessment by a qualified medical practitioner.
Full thickness burns occur when all layers of the skin are burned. Deeper tissues, such as fat and muscle may also be affected. In children, these burns may occur due to contact with a hot surface such as an oven or heater. Severe scald burns may also result in full thickness injury. Full thickness burns frequently require complex surgical management and require assessment by a qualified medical practitioner.
Medical Management of Burns
Burns may frequently be managed with a combination of dressings and surgery. The exact management varies from patient to patient.
Dressings are often silver impregnated to help reduce the risk of infection.
Surgery for burns may include cleaning the burn to remove contamination and blisters, application of sterile dressings, or skin grafting may be required for more severe burns.
Once a burn is healed, the scar management phase commences (hyperlink to scar management page). Sun avoidance is crucial to prevent pigment changes. For mild burns, sun avoidance and moisturiser may be all that is required. For more severe burns, or thicker scars special dressings, tapes, or custom-made garments may be used. Burns that result in joint contractures may require splinting or surgery.
Emergency medical treatment should be sought for all major paediatric burns. For smaller burns or after acute burn treatment has been completed, Offspring Health has experienced medical, surgical and allied health practitioners who can offer advice and treatment. This includes both in the immediate post-burn period and to help manage the impact of any scarring that has occurred as a result of previous burns.
1800 54 37 37Related Specialists
Related Services
TBC
Resources
The Royal Children’s Hospital Melbourne – Plastic and Maxillofacial Surgery
American Society of Plastic Surgeons – Pediatric Plastic Surgery
Great Ormond Street Hospital – Plastic Surgery Department
AboutKidsHealth – Plastic Surgery in Children
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