Complications of auricular cartilage harvest in rhinoplasty: Keloid and epidermal cyst formation

Few reports have described epidermal cysts (ECs) arising from scar tissues, and the standard course of treatment has not been established. We aimed to report the findings of a Korean patient series with ECs arising from scar tissues, to describe patient management in the context of previous publications, and to present a simple algorithm for managing ECs arising from scar tissues.We managed 6 patients with ECs arising from scar tissues, and retrospectively reviewed their demographic and clinical data.The scars were located on the anterior chest wall (n = 3), shoulder (n = 1), forehead (n = 1), and ear lobule (n = 1). Two patients with anterior chest wall scars, 1 with a shoulder scar, and 1 with an ear lobule scar had keloid scars, whereas the other patients had hypertrophic scars. The scar sizes ranged from 2 × 1 cm to 9 × 7 cm. The EC sizes ranged from 0.2 × 0.2 cm to 2 × 1.5 cm. Three patients underwent total scar revisions with complete EC excisions, 2 underwent partial scar tissue excisions with complete EC excisions, and 1 had laser therapy for the scar and EC. No complications occurred, and all patients’ final outcomes were satisfactory during the mean follow-up period of 14.8 months.We successfully managed the patients with ECs arising from scar tissues. We recommend that surgeons and patients first decide whether the ECs and scar tissue should be completely removed. Moreover, consideration should be given to the options chosen for the management of ECs. Finally, postoperative scar care is necessary to prevent hypertrophic and keloid scar recurrences.

Background. Scars are an inevitable consequence and the final outcome of the restoration of the skin, after injuries, thermal effects on the skin, and are also formed as a result of the resolution of rash elements in various infectious skin diseases, with adverse wound healing after plastic surgery and cosmetic procedures. According to WHO data for 2020, scar complications affect about 10% of the world's population, which is approximately 600 million people. High-intensity laser therapy technologies are considered by experts to be the "gold" standard in the correction of pathological scars, but a significant number of them are updated by the personalized approach developed in the last decade, aimed at individualizing treatment, searching for predictors of the effectiveness of various methods, taking into account a number of basic mechanisms of pathogenesis.
 Aims: Scientific substantiation of the concept of personalized high-intensity laser therapy for patients with pathological skin scars.
 Materials and methods. We studied 306 patients with atrophic (n=115), hypertrophic (n=100) and keloid (n=91) scars, which were divided into subgroups with emerging (formation period up to 1.5 years) and mature scars. Genetic, phenotypic, clinical, instrumental, laboratory, and medical-sociological methods were used to study the patient's condition and scar tissue. Laser therapy combinations were used: fractional ablative photothermolysis, homogeneous photothermolysis, planar ablative photodestruction, selective angiophotothermolysis, and fractional selective photothermolysis.
 Results. It was found that various combinations of high-intensity laser therapy in patients with pathological skin scars cause a significant regression of clinical signs, restore the microrelief of tissues, improve the functional properties of scars (elasticity, elasticity, moisture, vascularization, etc.), which is accompanied by an improvement in the quality of life of patients. The complex of laser technologies forms a pronounced refibromodeling therapeutic effect in patients with pathological skin scars.
 Conclusion. The concept of personalized (variant) high-intensity laser therapy in patients with atrophic, hypertrophic and keloid scars, which determines the dependence of the effectiveness of various options for laser correction of pathological scars on the genetic, phenotypic, clinical, morphofunctional and medical-sociological characteristics of patients, is scientifically substantiated. The determinants of the effectiveness of laser technologies have been identified, taking into account which allows the productive use of high-intensity laser radiation in patients with atrophic, hypertrophic and keloid skin scars.

So what is a keloid scar?

Hypertrophic and keloid scarring is a known complication of dermabrasion facial resurfacing, although only a very small fraction of patients experience it. Treatment with intralesional corticosteroid injections and flashed pumped vascular dye laser is recommended in the literature. The treatment of keloid and hypertrophic scars using intralesional 5-fluorouracil (5-FU) injections has been well described, but there is no literature regarding use of the same treatment for postdermabrasion hypertrophic and keloid scars. In this case report, we describe a 67-year-old woman with persistent postdermabrasion facial hypertrophic and keloid scars that were treated at our scar clinic using intralesional 5-FU injections.

Acne scarring can be divided into 2 types: atrophic and hypertrophic scars. Papular acne scars are commonly encountered, skin-colored papules on the chin and back. This study aimed to estimate the prevalence of each acne scar type and to investigate the clinical manifestations of papular acne scars. This retrospective study included 416 patients with acne scars. Dermatologists classified the scars into 3 types (atrophic, papular, and keloid type) based on clinical photographs and analyzed the clinical and histologic features of papular acne scars. Among 416 patients with acne scars, 410 patients (98.56%) had atrophic scars, 53 patients (12.74%) had keloid scars, and 46 patients (11.06%) had papular acne scars. Twenty patients (4.81%) had both papular and keloid acne scars. Histologic analysis showed fibrotic tissue in both keloid and papular acne scars. Fibrosis of the papular scar was limited to the upper dermis. Papular acne scars were significantly more prevalent in patients with keloid scars than in those without keloid scars. These results provide a basis for understanding papular acne scars, which have been under-recognized. The association between papular and keloid acne scars can suggest the decision for scar treatment.

Laser therapy for treating hypertrophic and keloid scars.

Keloid and hypertrophic scars are common and are caused by a proliferation of dermal tissue following skin injury. They cause functional and psychological problems for patients, and their management can be difficult. The use of silicon gel sheeting to prevent and treat hypertrophic scarring is still relatively new, and started in 1981 with treatment of burn scars. To determine the effectiveness of silicon gel sheeting for: (1) prevention of hypertrophic or keloid scarring in people with newly healed wounds (e.g. post surgery); (2) treatment of established scarring in people with existing keloid or hypertrophic scars. Trials were identified from searches of the Cochrane Wounds Group Specialised Register (searched September 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2005); MEDLINE (1989 to June 2002); EMBASE (1988 to May 2002); CINAHL (1982 to May 2002) and reference lists of articles and relevant reviews. The major supplier of silicon gel sheeting (Smith and Nephew) was approached for details of unpublished, ongoing and recently published trials. Any randomised or quasi-randomised controlled trials, or controlled clinical trials comparing silicon gel sheeting for prevention or treatment of hypertrophic or keloid scars against no treatment, placebo, or any other treatment type except surgery. All relevant trials were assessed for methodological quality. Data were extracted independently by both reviewers using a standardized form, and the results cross-checked. All trials, meeting the selection criteria were assessed for methodological quality. Thirteen trials, involving 559 people, ranging in age from 2 to 81 years, were included in the review. The trials compared adhesive silicon gel sheeting with control; non-silicon gel sheeting; silicon gel plates with added Vitamin E; laser therapy; triamcinolone acetonide injection, and non-adhesive silicon gel sheeting. In the prevention studies, when compared with a no treatment option; whilst silicon gel sheeting reduced the incidence of hypertrophic scarring in people prone to scarring, (RR 0.46, 95% CI 0.21 to 0.98) these studies were highly susceptible to bias. Silicon gel sheeting produced a statistically significant improvement in scar elasticity, (RR 8.60, 95% CI 2.55 to 29.02), but again these studies were highly susceptible to bias. Trials evaluating silicon gel sheeting as a treatment for hypertrophic and keloid scarring are of poor quality and highly susceptible to bias. There is weak evidence of a benefit of silicon gel sheeting as a prevention for abnormal scarring in high risk individuals but the poor quality of research means a great deal of uncertainty prevails.

Clinical Challenge and Call for Research on Keloid Disorder: Meeting Report from The 3rd International Keloid Research Foundation Symposium, Beijing 2019

Wound healing and skin regeneration after injury are complex biological processes, and deep injuries with a high degree of tissue destruction may result in severe scar formation. Clinically, scars can be classified into normal, hypertrophic and keloid scars. However, the molecular signature of each scar type is currently not known. The aim of this study was to reveal the transcriptional landscape of normal, hypertrophic and keloid skin scars following hand and plastic surgery based on total RNA sequencing. Eighteen skin scar samples from hand and plastic surgeries of human donors were minced directly after removal and stored in TRIzol (Thermo Fisher, USA). Samples were then subjected to RNA isolation, cDNA library preparation, bulk RNA sequencing and bioinformatics analysis. We show that keloid scars transcriptionally differed from normal and hypertrophic scars. Normal and hypertrophic scars presented overlapping clustering, and eight genes were shown to be commonly expressed between hypertrophic and normal scars. No genes were specifically expressed at a higher level in keloid and normal scars. Based on gene ontology pathway analysis, genes with a higher level of expression in keloid scars lead to increased (extra-) cellular matrix proliferation and cell interaction. Moreover, tumour-like genes were more highly expressed in keloid scars, supporting the clinical impression of strong and diffuse growth. This study furthers our understanding of the classification of differential scar types based on molecular signature, which may shed light on new diagnostic and therapeutic strategies for keloid scars in the future.

Objective This study aims to explore the influence of the serine and arginine rich splicing factor 2 (SRSF2) on the biological characteristics of keloid fibroblast, by comparing the expression levels of SRSF2 in normal skin and keloid, with the purpose to provide a new method to study the pathogenesis of keloid. Methods Samples of normal skin were derived from excess tissue of skin grafts, collected from 8 patients, aged 8-53 years old, while the specimens of keloid were from 12 keloid patients, aged 18-24 years old. All the patients were admitted in the Plastic Surgery Hospital, Chinese Academy of Medical Sciences. The expression of SRSF2 was assessed by immunohistochemistry and immunofluorescent staining in both normal and keloid tissue. Keloid fibroblasts were cultured in vitro to detect the relationship between TGF-β1 stimulation and SRSF2 expression. After constructing the lentiviral sh-RNA-expression vector, targeting SRSF2 and infecting keloid fibroblast, the apoptosis and proliferation of cells were analyzed by the MuseTM Cell Analyzer. The expression of CyclinE1 was analyzed by real-time PCR and western blot, and the secretion and expression of extracellular matrix and TGF-β1 were detected by real-time PCR and ELISA.The software SPSS 21.0 was used to do the statistical analysis. Results The expression of SRSF2 was significantly higher in the keloid samples than in the normal skin samples. The percentage of SRSF2 positive cells in keloid was (77.04±4.37)% , while the percentage of SRSF2 positive cells in normal skin was (25.10±1.24)%. TGF-β1 promotes the expression of SRSF2 to (159.73±17.03)% times in keloid fibroblasts. After the SRSF2 knock-out, the apoptosis rate of the keloid fibroblasts increased, its cell cycle arrest was observed at the G0/G1 phase, and the expression of Cyclin E1 decreased. Apoptotic cells in control group was about (18.83±1.24)% , while (25.81±7.09)% and (26.71±6.14)% were in the two knock-out groups respectively. Cells in G0/G1 phase was about (58.97±1.73)% in control group, while (63.95±2.07)% and (64.65±3.23)% were in the two knock-out groups respectively. Compared to the control group, the expression of Cyclin E1 mRNA in the two knock-out groups were (31.60±6.81)% and (33.01±11.39)% respectively. Additionally, the expression of COL3A1 FN1 mRNA decreased, and the expression and secretion of TGF-β1 was declined. Compared to the control group, the expression of COL3A1 mRNA in the two knock-out groups were (64.90±23.71)% and (67.97±13.50)%, the expression of FN1 mRNA in the two knock-out groups were (59.10±8.11)% and (70.70±18.26)%, the expression of TGFB1 mRNA in the two knock-out groups were (53.37±15.51)% and (67.53±19.33)% respectively. The concentration of TGF-β1 in the medium of control group was (115.60±18.17)pg/ml, while (75.35±12.25) pg/ml and (72.06±14.66) pg/ml were in the two knock-out groups respectively. Conclusions The expression of SRSF2 increased in keloid. The inhibition of SRSF2 in keloid fibroblast resulted in the growth restriction and apoptosis of cells, and decreased the secretion of extracellular matrix and TGF-β1, which providing a new insight into keloid pathogenesis, and suggesting that SRSF2 could be a new therapeutic target for keloid conditions. Key words: SRSF2; Keloid; Fibroblast; Biological characteristics

Abnormal fibroblasts have been implicated in keloid formation, a benign but fibroproliferative skin disorder. However, the exact source of these cells remains unknown. Fibrocytes are considered to be hybrid mesenchymal/hematopoietic cells, having been identified in various fibrotic disorders as the precursors of fibroblasts. Therefore, we hypothesized that a population of fibrocytes is present in keloid tissue as opposed to the mesenchymal stem cells (MSCs). We compared the proportion of MSCs in keloid versus bone marrow-derived cells and compared fibrocytes in keloid as opposed to normal scar tissue. We also investigated the propagation of fibrocytes in serum-supplemented versus serum-free media. Using multicolor fluorescence-activated cell analysis, we found distinct populations of MSCs (CD34(-)CD73(+)CD90(+)CD105(+)) that were different from CD45RO(+)25F9(+)MRP8/14(+) fibrocytes present in keloid tissue, while very few fibrocytes were observed in normal scar tissue. The proportion of keloid-derived cells in serum-free or serum-supplemented cultures expressing these fibrocyte markers was greater than from cultures derived from normal scar tissue (p<0.05). We found that the proliferation of CD45(+)/Col1(+) keloid cells in vitro was greater in serum-free media compared to serum-supplemented media. This is the first study to have identified fibrocytes isolated from keloid tissue and normal scars, utilizing a specific set of markers for fibrocytes. This finding may aid our understanding of the origin of abnormal fibroblasts identified in keloid scarring. The identification of fibrocyte populations distinct from MSCs in keloid scar tissue could lead to novel targets for therapeutic intervention, treatment and prevention of recurrence.

Keloid and hypertrophic scars are common and are caused by a proliferation of dermal tissue following skin injury. They cause functional and psychological problems for patients, and their management can be difficult. The use of silicone gel sheeting to prevent and treat hypertrophic scarring is still relatively new and started in 1981 with treatment of burn scars. To determine the effectiveness of silicone gel sheeting for:(1) prevention of hypertrophic or keloid scarring in people with newly healed wounds (e.g. post surgery);(2) treatment of established scarring in people with existing keloid or hypertrophic scars. In May 2013 we searched the Cochrane Wounds Group Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL for this second update. Any randomised or quasi-randomised controlled trials, or controlled clinical trials, comparing silicone gel sheeting for prevention or treatment of hypertrophic or keloid scars with any other non surgical treatment, no treatment or placebo. We assessed all relevant trials for methodological quality. Three review authors extracted data independently using a standardised form and cross-checked the results. We assessed all trials meeting the selection criteria for methodological quality. We included 20 trials involving 873 people, ranging in age from 1.5 to 81 years. The trials compared adhesive silicone gel sheeting with no treatment; non silicone dressing; other silicone products; laser therapy; triamcinolone acetonide injection; topical onion extract and pressure therapy. In the prevention studies, when compared with a no treatment option, whilst silicone gel sheeting reduced the incidence of hypertrophic scarring in people prone to scarring (risk ratio (RR) 0.46, 95% confidence interval (CI) 0.21 to 0.98) these studies were highly susceptible to bias. In treatment studies, silicone gel sheeting produced a statistically significant reduction in scar thickness (mean difference (MD) -2.00, 95% CI -2.14 to -1.85) and colour amelioration (RR 3.49, 95% CI 1.97 to 6.15) but again these studies were highly susceptible to bias. There is weak evidence of a benefit of silicone gel sheeting as a prevention for abnormal scarring in high-risk individuals but the poor quality of research means a great deal of uncertainty prevails. Trials evaluating silicone gel sheeting as a treatment for hypertrophic and keloid scarring showed improvements in scar thickness and scar colour but are of poor quality and highly susceptible to bias.

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Comparison of elliptical excision versus punch incision for the treatment of epidermal inclusion cysts: A prospective, randomized study

Epidermal cyst is a benign lesion which is commonly encountered in practice, and malignant transformation of it is rare. There are few case reports in the literature about malignant transformation of an epidermal cyst into a squamous cell carcinoma. We present a case of squamous cell carcinoma arising from a 3-year epidermal cyst in the right temporal area of a 68-year-old man. The epidermal cyst was initially identified as a spot and treated with laser therapy. However, it recurred, leading to three surgical interventions at a different surgical clinic. Despite these procedures, the cyst persisted, leading to presenting to our department of plastic and reconstructive surgery. He presented with a 2.5cm sized subcutaneous mass with skin ulcerative lesion. After excision, histopathological examination confirmed squamous cell carcinoma from a ruptured epidermal cyst, with clear resection margins. This case underscores the importance of routine histological examinations in excision of epidermal cysts.