Case Report

An Analysis of Pediatric Scar Progression Over Time

Blaire Slavin Roberta Torres, MSN, RN, PNP-BC; Anne C. Fischer, MD, PhD, MBA

Disclosures

ePlasty. 2018;18(e18) 

In This Article

Abstract and Introduction

Abstract

Objective: The advances in surgical approaches for a pyloromyotomy have all focused on creating smaller incisions from a right upper quadrant now to a laparoscopic umbilical incision. A key assumption is that the final scar retains the size of the original incision as the child matures. Our case reports on a family with several members, now adults, with the same surgery and same surgeon who had the right upper quadrant incision as infants to elucidate the extent of how infantile scars grow over time, significantly exceeding the original incision.

Methods: We evaluated the various pyloromyotomy scars of our newborn patient, his maternal grandmother, and his two maternal twin aunts. One aunt (#1) was of normal stature, whereas her twin (#2) never went through a full vertical growth phase due to being stunted by Cornelia de Lange syndrome. For each member, we compared the length of the original incision with the current scar length to determine how much the scar has grown over time.

Results: Significant scar growth was seen in the grandmother and aunt 1. In contrast aunt 2's scar did not grow significantly due to her stunted vertical growth from Cornelia de Lange syndrome.

Conclusions: This case supports the notion that surgical incisions in infants grow more substantially than realized with age, resulting in larger scars than anticipated. Our findings suggest the reason why the laparoscopic pyloromyotomy has been popularized due to its incisions being so small that they continue to present a cosmetic advantage over time.

Introduction

Infantile hypertrophic pyloric stenosis (IHPS) is a common surgical condition in newborns typically between 2 and 8 weeks of age.[1] The narrow pyloric channel results in gastric outlet obstruction.[2]

Several surgical approaches to pyloromyotomy have evolved over the years. The first pyloromyotomy was performed by Ramstedt in 1912 and typically reported a 3 cm transverse right upper quadrant (RUQ) incision, which was the most popular incision until the late 1980s.[2] Although the open RUQ pyloromyotomy left a small scar as a baby, the scar was not appreciated as increasing in size as the child reached adulthood. In 1986, Tan and Bianchi proposed an equally successful approach to an open pyloromyotomy via a supraumbilical incision that would leave a smaller, less noticeable scar.[3] This supraumbilical incision uses the proximity to the umbilical folds to trick the eye into appreciating the scar to be a skinfold. The 2000s saw the popularization of the laparoscopic pyloromyotomy, which requires two 3 mm left/right paramedian stab incisions and 1 imperceptible 5 mm or less umbilical incision hidden in the umbilical skinfolds.[1] Because cosmesis is so important, the laparoscopic approach currently supersedes open pyloromyotomy as the most popular surgical approach to treat IHPS.[4] However, many surgeons still advocate the open procedures since they claim the scars are small, overlooking their potential for growth.

Our case report utilizes a family with several members treated by an RUQ pyloromyotomy as infants to show how much infantile scars can actually grow. Although the RUQ incision is rarely seen now due to the evolution of the surgical approach to pyloromyotomy, the comparison of this simple, transverse incision from infancy to adulthood effectively illustrates how much a scar can grow. The change in surgical approach over time and the extent of scar growth into adulthood is documented in this multigenerational family who has a history of IHPS in 3 generations.

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