An Analysis of Pediatric Scar Progression Over Time

CASE REPORT

Our patient was a male infant born at 36 weeks who by 4 weeks of age displayed a 5-day history of nonbilious, nonbloody emesis either directly after his feeds or several hours later. A laparoscopic pyloromyotomy was attempted, which was converted into a supraumbilical open pyloromyotomy due to inability to tolerate sufficient insufflation. The size of the surgical incision for the laparoscopic approach was 8 mm to accommodate a 5 mm umbilical port, followed by a 3 cm incision for the supraumbilical conversion.

The patient's family history was significant for pyloric stenosis across 3 generations since the newborn, his maternal grandmother, and his 2 maternal twin aunts all had IHPS. The grandmother had an oblique RUQ pyloromyotomy at 4 weeks of age in 1959 with an original scar incision of ∼4 cm. Since her procedure 58 years ago, the grandmother's scar has grown 8 cm in length, with a current scar length of 12 cm. Aunt 1 underwent a transverse RUQ pyloromyotomy at 4 weeks of age in 1994, with an original incision length of 4 cm and a current scar length of 8 cm. Aunt 2 required a transverse RUQ pyloromyotomy at 6 weeks of age with an incision of 4 cm and a current scar length of 4 cm. Both aunts had the same surgeon and the same diagnosis within 2 weeks of each other. Aunt 2’s scar size of 4 cm was smaller than her twin sister's 8 cm scar due to her short stature from Cornelia de Lange syndrome (Table 1).

RESULTS

See Table 1 and Figures 1 and 2.

Figure 1. Significant growth in scar length since initial procedure, as seen in grandmother and aunt 1 but not aunt 2, due to stunted growth from Cornelia de Lange syndrome. RUQ indicates right upper quadrant.

Figure 2. Twelve-week-old patient's scar from supraumbilical incision. No scar growth detected because he is still a newborn.

DISCUSSION

The case that we present serves as a unique opportunity to analyze scar sizes following a procedure to correct the same disease, given that the patients considered are all from the same family with the same diagnosis and similar surgery. The body of scientific literature discussing scar growth from procedures performed during infancy is relatively limited. In 1860, James Paget challenged the assertion that childhood scars do not grow with age. In a lecture to the Royal College of Surgeons of England, he stated, “The scar of the child, when once completely formed, commonly grows as the body does, at the same rate, and according to the same general rule.”⁵ In 1873, Adams supported Paget's words when he observed that a 21-month-old patient who underwent a surgical procedure to correct congenital varus of both feet had scars that increased in length by approximately 2.5 cm in the span of 7 years.⁶ In terms of scarring resulting specifically from open RUQ pyloromyotomy, Harmon⁴ noted that the adult patient's scar had grown in both length and width, puckered because of adherence of skin to abdominal muscular fascia, and deepened because of an increase in thickness of subcutaneous adipose tissue since infancy. Harmon's⁴ descriptions were also observed in our case report, as seen in the patient's grandmother whose oblique RUQ scar grew 8 cm in length since the procedure was performed in infancy. This was similar to the 4 cm scar growth seen in aunt 1. The grandmother and aunt 1 are perfect illustrations of the potential scar growth often underestimated in surgery on infants. Because of her stunted growth, aunt 2’s scar did not see the same drastic growth as her twin, aunt 1. Aunt 2’s body did not grow significantly, nor did her scar.

The drive to modify the surgical technique to pyloromyotomy over the years is largely due to wanting to minimize the size of the initial scar, yet the potential for scar growth into adulthood is still highly unappreciated. Haricharan et al⁷ revealed that 88% and 85% of the study's subjects would pay more money for their daughter and son, respectively, to have the laparoscopic pyloromyotomy because they prefer its cosmetic outcome over the open RUQ pyloromyotomy. This percentage would most likely increase if the parents were made aware that the initial incision from an open pyloromyotomy may grow significantly in length as the child ages, as evidenced by our case report.

CONCLUSION

Significant scar growth from a standard RUQ pyloromyotomy incision was observed in the 2 patients who reached normal stature by adulthood, supporting the notion that scars resulting from surgical procedures in infancy grow more substantially with age than previously realized. This case series is small but has a perfect internal control of all being from the same family treated by the same surgeon, with those scars increasing in size until reaching adult stature. Although this case report did not assess the scar growth following an umbilical 5 mm port site from a laparoscopic incision, we believe that our results further support the public's preferential satisfaction with laparoscopy, given the dramatically smaller incisions at the time of surgery and the fact that scars can proportionally increase in size over time. It is critical to inform the patient's parents that the initial incision size will most likely not be the length of the final scar.