The challenge of hypertrophic scars in pediatric surgery

After non-burn-related pediatric surgery, the formation of hypertrophic scars (HS) goes beyond a simple aesthetic concern: it leads to functional consequences, pain, and pruritus, often exacerbated by the child's growth. Until now, incidence data remained fragmented across different specialties (orthopaedics, urology, plastic surgery), preventing practitioners from providing accurate and site-specific estimates during preoperative counseling.

This systematic review with meta-analysis specifically aimed to synthesize the incidence of CH formation in patients aged 0 to 18 years following non-thermal surgical procedures. The study aimed to quantify this overall risk while identifying the most vulnerable anatomical areas in order to guide postoperative monitoring strategies.

The authors tested the hypothesis of a significant variation in incidence according to the anatomical site and the type of procedure, suggesting that skin tension, incision orientation, and tissue mobility play a determining role in scar maturation. The analysis is based on 14 rigorously selected pediatric studies, gathering a total of 9,319 surgical observations.

Methodology of the systematic review

This systematic review with meta-analysis was conducted in accordance with the PRISMA 2020 principles. The authors performed an exhaustive search in the MEDLINE/PubMed, Embase, Scopus, Web of Science, and Cochrane CENTRAL databases, covering the period from the inception of the databases until July 31, 2026.

Eligibility criteria included:

• Population: Pediatric patients aged 0 to 18 years.
• Interventions: Surgical procedures (excluding burn treatment).
• Data: Presence of a precise numerator and denominator allowing for the calculation of the incidence of hypertrophic scars (HTS).
• Design: Human clinical studies (randomized trials, cohorts, case series with n > 10).

Out of 170 identified records, 14 studies were selected for quantitative synthesis, totaling 9,319 surgical observations. Data were stratified according to six anatomical sites: head/neck, trunk/pelvis, upper limb, lower limb, genital/urological, and mixed or imprecise sites.

Statistical analysis was based on a random-effects model (logit-proportion) to estimate the pooled overall incidence. Heterogeneity was quantified via Q, tau², and I² statistics. Risk of bias was assessed using a tool specific to incidence studies, examining in particular the representativeness of the population and the definition of healing outcome criteria.

Global incidence and statistical heterogeneity

This meta-analysis, synthesizing data from 14 paediatric studies, is based on a total sample of 9,319 surgical observations. The authors report 331 cases of hypertrophic scars (HTS), corresponding to a crude incidence of 3.55%.

The application of a random-effects model (logit-proportion) allows for the estimation of a pooled incidence of 3.96% (95% CI: 2.30 – 6.75). The study highlights substantial statistical heterogeneity with an I² index of 85.3%, reflecting the wide diversity of procedure types and clinical follow-ups included in the synthesis.

Variability according to the anatomical site

The analysis reveals marked disparities depending on the location of the intervention. Reconstructive and orthopedic procedures impact the scar maturation process differently.

Anatomical site	Reported gross incidence
Upper limbs	10.27 %
Head and neck	3.50 %

Although the head and neck region constitutes the most important denominator of the study (including notably cohorts of cleft lips and otoplasties), the risk of hypertrophic scarring is significantly lower there than for interventions on the upper limbs.

Qualitative observations and risk factors

• Skin tension: Wound tension and tissue mobility, which are particularly high at the joints of the upper limbs, are correlated with an increased incidence of HTS.
• Technical complexity: Reconstruction procedures, involving specific flap designs or grafts, present higher risk profiles than minor surgeries.
• Clinical context: Scar maturation is influenced by incision orientation and closure strategies, highlighting the importance of site-specific postoperative monitoring.

Analysis of hypertrophic scars in pediatric surgery: an underestimated incidence?

This meta-analysis, covering 14 studies and over 9,300 surgical observations, clarifies a risk often perceived as anecdotal: the overall incidence of hypertrophic scars (HTS) in non-burn pediatric surgery is 3.96%. While this figure may seem modest, it masks major anatomical disparities that directly challenge the practitioner. The gross risk climbs to 10.27% for upper limb interventions, compared to 3.50% for the head and neck area, which nevertheless represented the largest contingent of data. These results confirm that localization and, by extension, skin tension and tissue mobility, remain determining vectors of cicatricial fibrosis in children.

The strength of this review lies in its "non-burn" specificity, providing concrete data for preoperative counseling. However, the marked statistical heterogeneity (I² = 85.3%) constitutes a notable limitation. It reflects the variability in follow-up protocols, clinical definitions of hypertrophic scars, and calculation methods (some studies counting patients, others surgical sites). For the surgeon, this means that the reported rates are indicators of robust trends rather than mathematical certainties.

The study suggests that technical choices, such as flap design or the timing of the intervention, impact scar maturation. These data encourage targeted postoperative monitoring: vigilance should not be uniform but proportional to the risk inherent to the anatomical site, particularly during complex reconstructions or in areas subject to high mechanical stress.

Summary of results

This meta-analysis, including 9,319 pediatric surgical observations, reports an overall incidence of hypertrophic scars of 3.96% (95% CI: 2.30–6.75). The data highlight a major anatomical disparity: the rate reaches 10.27% for the upper limbs, compared to 3.50% in the cephalic area, with high statistical heterogeneity (I² = 85.3%).

In concrete terms, for the practitioner:

• Adapt your informed consent: inform families that the risk of hypertrophic scarring is three times higher for limb surgery (syndactyly, fracture reduction) than for facial surgery.
• Targeted monitoring: establish rigorous postoperative healing follow-up for reconstructive and orthopedic procedures, areas where skin tension and tissue mobility increase the risk of complication.
• Caution on averages: the high heterogeneity of the results (I² = 85.3%) shows that the choice of closure technique and the management of local tension remain determining variables for the final prognosis.

Postoperative scar management in children goes beyond simple aesthetic concern. Between tissue growth and joint mobility, a hypertrophic scar (HTS) can quickly become a functional hindrance or a source of psychological distress. However, data on their incidence outside the context of burns had remained fragmentary until now. This systematic review and meta-analysis, following PRISMA 2020 principles, provides necessary clarification for clinical practice.

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