The increasing incidence of childhood trauma may be attributed to the increasing risk-taking and aggressive behaviors among children, who are more commonly seen playing with toys alone and without close supervision. Injuries continue to be the number one killer of children, accounting for a large percentage of deaths associated with head injuries. Soft Tissue Injuries Soft tissue injuries are more common than fractures in children with facial trauma, especially in younger children whose facial bones are resistant to fracture. During the initial evaluation of any facial injury, it is important to review the cause and timing of the injury and to determine if anyone witnessed the injury. Knowing the cause of the injury will be valuable later during wound exploration, debridement, and prediction of subsequent wound healing. Maximize wound cleansing and removal of all foreign bodies; this must be done under anesthesia in the operating room. If there is an open wound, the child’s tetanus status should be assessed and appropriate management started early. Several key elements of wound care are important in predicting the quality of wound healing in children: Elimination of foreign body contamination and resulting severe inflammatory response Protection of subcutaneous structures if possible Use of supportive skin coverings, such as a wound support bandage, during the first 6 weeks of wound repair Prevention of secondary wound injury, excessive dryness, moisture, or temperature changes Involvement of parents in postoperative wound care, such as cleaning of wound debris and scabs, application of coverings Involve parents in postoperative wound care, such as cleaning debris and scabs, applying coverings, and massaging the scar Children’s wound healing response is often dramatic and rapid because they usually do not have life-threatening systemic illnesses or indulge in abusive habits such as drinking alcohol or smoking cigarettes. However, despite the rapid and predictable healing in children, increasing collagen deposition in wounds predisposes to gross scarring. Clean or only mildly contaminated and soft tissue wounds with minimal tissue necrosis can be cleaned and closed. Antibiotics are generally not used unless there is an issue with the host immune status. Wounds can still be closed 24 hours after injury. More old wounds should be thoroughly cleaned and the margins made fresh before suturing. Pediatric trauma patients must be observed for 3 days after wound closure to alert for wound deterioration. Blunt force trauma may result in extensive, delayed tissue damage with subsequent thick scarring and poor aesthetics. Nerve and Ductal Injuries Generally, a line is drawn from the lateral canthus to the middle portion of the mandible, and wounds away from this line do not require facial nerve exploration or repair. Wounds close to this line should be explored under magnification for possible nerve injury and the need for repair. Preoperative clinical evaluation might show nerve damage and facial paralysis. Exploration of subcutaneous fat injury in the parotid area to detect parotid duct injury. Insertion of a small catheter or lacrimal probe through the parotid duct will show ductal injury proximal to the wound. All nerve conduit injuries require microscopic repair with permanent sutures. In addition, the inserted catheter should be retained for at least 2 weeks or until continuity of the luminal epithelium has been restored. While the catheter is in place, the patient should be given antibiotics for 7-10 days, as the gland may be somewhat quiescent in its secretion and prone to obstructive salivaritis. Chewing gum or the use of sugar-free cough drops may be considered at this time. Bites Animal bites require confirmation of rabies status and require thorough wound exploration and irrigation as well as immediate closure of the wound’s linear wound margin. Penetrating wounds should be irrigated to their depth, kept open, and observed frequently to detect infection. All animal bites cause severe but transient (2-3 days) inflammation that will subside. Human bites are more problematic due to the presence of viral organisms and resistant organisms. If there is any concern about tissue survival, the wound should be thoroughly cleaned and then approximated rather than completely closed. We must determine and document the infectious status of this biter (hepatitis, HIV, etc.), and appropriate management must be initiated. Antibiotic prophylaxis is desirable for both animal and human bites. Amoxicillin capsules are generally recognized as the gold standard in the treatment of animal bites and human bites. In patients with penicillin allergy, antibiotic therapy is more controversial. Clindamycin in combination with methotrexate-sulfamethoxazole is an appropriate choice among children, and azithromycin may be an option for pediatric patients with penicillin allergy. Avulsion Injuries Facial avulsion injuries are caused by high-speed recreational activities, such as bicycling and skateboarding, or by motor vehicle accidents including roadside transportation. Under general anesthesia in the operating room, the wound requires careful exploration under magnification, debridement, sedation with antibiotic-containing fluids, conservative trimming of the edges of necrotic tissue, and early suturing if possible. Avulsed or extensively disrupted soft tissue flaps require appropriate drainage to prevent hematoma formation, and appropriate pressure or adjunctive coverings to allow arterial blood inflow and venous blood outflow. To determine the likelihood of tissue necrosis, it is important to observe the wound frequently. If necrosis is a concern, we should take steps to optimize tissue blood flow by removing sutures, improving tissue support, or promoting wound drainage. Adjunctive treatments like hyperbaric oxygen are beneficial in wounds with viable or hypoxic margins. When tissue defects are extensive, staged reconstruction is required. Initial efforts are made to clean the wound and debride it to prevent infection and further tissue loss. Multiple debridement sutures and overlay changes may be necessary during the first 2 weeks after injury. Negative pressure drainage helps to remove debris, reduce wound circumference, and stimulate the vascular bed in preparation for final repair. Large scalp avulsions require staged tissue expansion and local flap reconstruction. Specialized Wounds Specialized wounds, including nasal and ear cartilage, require thorough cleaning and removal of foreign material, followed by careful approach to cartilage and skin. Cartilage requires less oxygen than bone, but still requires complete tissue coverage and a secondary or maintenance overlay to eliminate hematoma and seroma formation. Maintenance overlays are usually removed after 5-7 days. Cartilage breakdown, especially of the nasal septum cartilage, predisposes to developmental disorders. Eyelid injuries initially require ophthalmologic evaluation as well as possibly a magnified slit lamp examination to rule out ocular injury. Fluorescein staining will show corneal epithelial and lacrimal gland damage. If the tear duct is damaged, ductal obstruction, quiescence of tear production and infection will follow, so immediate and thorough evaluation is necessary. If the child is unable to tolerate tear and tubular evaluation, then a detailed examination should be performed in the operating room. Placement of a silicone rubber hose through a functional tear duct will protect the tubules and lacrimal system. The eyelid consists of anatomical layers called laminae (anterior, middle, and posterior), each of which must be repaired or supported in order to ensure proper function of the eyelid. Under general anesthesia in the operating room, the patient is anesthetized to prevent unintentional movement and surgical treatment of the eyelid injury is performed. The tissue is thoroughly flushed and the flap is loosened to clear the skin and sutures are applied. Corneal abrasion can be painful and cause postoperative sequelae, and corneal shields are often used to prevent this. Just as the red lip rim and peak of the lip are important landmarks for lip repair, the gray line of the eyelid is the key to eyelid repair. Eyelid cartilage, the supporting structure of the eyelid, must also be repaired. If the orbital septum is displaced, yellow orbital fat will be seen breaking through this membrane. Careful hemostasis before closing the septum reduces the risk of retrobulbar hematoma, which can cause excessive pressure on the eye and optic nerve and may lead to blindness. Although this treatment is controversial, some surgeons observe the eye in the hospital for 24 hours and give the patient steroids to prevent increasing edema and pressure. Management of Scarring Because children have a tendency to heal with scarring, it is important to observe the wound during active healing. All permanent sutures should be removed after 3-5 days, and wound supportive coverings should be applied for 10-14 days to remove tension from the wound, although this can increase collagen deposition. During this time, any infection and scabs should be removed from the wound, keeping the area moist and covered. topical antibiotic ointment is not applied after 7 days to prevent tissue reaction. Usually after 7-10 days, when the wound has good epithelialization, a silicone sheet or topical scar gel can be used for a few weeks. These preparations, in addition to putting slight pressure on the wound, will keep the wound tension free and help minimize excess collagen deposition on the scar. During this time, it is important to avoid excessive moisture, dryness, excessive temperatures, or irritating antigens, which may exacerbate the inflammatory response. If possible, patients should use sunscreen with a strong sunscreen factor when going outside, wear a wide-brimmed hat to cover the face, and adhere to this until 1 year after the injury to avoid UV stimulation of melanocytes in the wound and concomitant hyperpigmentation. Children with dark skin pigmentation may be prone to excessive scarring (keloids) and hyperpigmentation changes. If the scarring extends beyond the edges of the wound, then a keloid may be forming. Topical hydrocortisone, injectable dexamethasone, and even low-dose irradiation may be helpful in reducing keloids. Eventually, the faded keloid can be tattooed with permanent medicated pigment to match the surrounding skin. Revision of the keloid should be delayed until finally its full maturity-roughly 6 to 12 months after the injury.