Do Children with Facial Hematomas Always Need Surgery? Expert Insights

Does a child with a hematoma on the zygomatic bone always need surgery? (II)

Good morning, Dr.
Chou! Thank you for your response! The hematoma is located on the upper cheekbone of the child's right face, approximately the size of a 10 NT dollar coin.
It occurred during an accident on December 21, and the child was urgently taken to the emergency department at Taipei Medical University.
Initially, the doctor performed an X-ray and stated that there were no fractures, but did not mention whether the injury involved "rupture of small blood vessels, arteries, or capillaries" as you indicated.
We thought that since there was a bump, bruising was normal, and we did not ask further questions.
The child's coagulation function should be normal, and there are no related diseases.
The accident happened around 10 PM, and after handling everything, we returned home and rested around 1 AM, so we let the child sleep (only applying ice for a while while waiting at the hospital).
However, we have been applying heat and massaging the area since then.

My question is: how can we determine whether the ruptured blood vessels during the injury were small vessels, arteries, or capillaries? Besides surgery, are there any other methods? Is it more likely that the hematoma will gradually resolve on its own, or is there a higher chance of it becoming fibrotic? How quickly does fibrosis occur? If we do not opt for surgery and the hematoma does indeed become fibrotic, is it true that subsequent surgery to remove the fibrosis will result in a depression in the area? I am really getting anxious and don’t know what to do.
Could you please provide some advice, Dr.
Chou? Thank you very much!

HONEY, 30~39 year old female. Ask Date: 2009/01/20

Dr. Zhou Hongzhang reply Plastic Surgery

On December 21, an accident occurred, and it has been one month since then.
The recommended actions now are: 1.
If the hematoma is large (approximately 3-4 cm in diameter) and feels like there is a "water balloon" under the skin (fluctuation), then incision and drainage surgery may be indicated.
2.
In other cases, I personally recommend observation first.
Conservative treatment, such as warm compresses or administering anti-inflammatory medications, should be considered until the hematoma (or fibrosis) matures, at which point we can reassess (wait and see).
Generally, fibrosis maturation takes about one year, so it can be addressed after a year.
The appearance of the wound (bruising, hard lump) can look the worst between two weeks to two months.
Therefore, your concerns are normal.
In my opinion, this case can be managed conservatively, with further intervention considered after one year.

Reply Date: 2009/01/20

More Info

When it comes to facial hematomas in children, the decision to pursue surgical intervention is nuanced and depends on several factors, including the size of the hematoma, the child's age, the location of the injury, and the presence of any underlying conditions. Here’s a comprehensive overview based on the information provided and general medical knowledge.

Understanding Facial Hematomas
A hematoma is a localized collection of blood outside of blood vessels, often resulting from trauma. In children, facial hematomas can occur due to falls, accidents, or sports injuries. The size of the hematoma, in this case, is about the size of a ten-dollar coin, which is relatively significant and warrants careful evaluation.

Surgical Necessity
1. Observation vs. Surgery: Many small to moderate-sized hematomas can resolve on their own without surgical intervention. The body often reabsorbs the blood over time, leading to a gradual decrease in swelling and discoloration. However, larger hematomas or those that are causing significant cosmetic concerns or functional impairments may require surgical drainage.
2. Indicators for Surgery: If the hematoma is causing pressure on surrounding structures, such as nerves or blood vessels, or if there is concern about infection or persistent swelling, surgical intervention may be necessary. In some cases, if the hematoma is not resolving and is fibrosing, surgery may become more complicated later on.

Factors Influencing Treatment Decisions
1. Age and Health of the Child: Younger children may have different healing responses compared to older children or adults. Their skin and underlying tissues are more pliable, which can influence the decision to wait and observe versus immediate surgical intervention.

2. Location and Size: The specific location of the hematoma on the face can also impact the decision. Hematomas located near the eye or in areas where they could affect vision or other functions may require more urgent attention.

3. Fibrosis Concerns: If a hematoma does not resolve and begins to fibrose, it can lead to complications such as deformity or functional impairment. Fibrosis can occur relatively quickly, and if left untreated, it may necessitate more complex surgical procedures later on.

Non-Surgical Alternatives
1. Observation: In many cases, especially if the hematoma is not causing significant issues, careful observation is a valid approach. Regular follow-ups with a healthcare provider can help monitor the situation.

2. Physical Therapy: Gentle massage and heat application, as you mentioned, can sometimes help in the healing process. However, care must be taken to avoid further trauma to the area.

3. Medication: Pain management and anti-inflammatory medications may be prescribed to help alleviate discomfort and reduce swelling.

Risks of Delayed Surgery
If a hematoma becomes fibrotic, surgical removal may lead to cosmetic concerns such as indentations or asymmetry in the facial structure. Therefore, if there is a high likelihood of fibrosis, timely intervention may be beneficial.

Conclusion
In summary, while many facial hematomas in children can resolve without surgery, the decision to operate should be made in consultation with a pediatrician or a pediatric surgeon. They will consider the size, location, and symptoms associated with the hematoma, as well as the child's overall health. Regular monitoring and open communication with healthcare providers are essential to ensure the best outcomes for your child. If you have concerns about the progression of the hematoma or the potential for fibrosis, do not hesitate to seek a second opinion or further evaluation from a specialist.

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