Reconstructing Large Keloids with Neodermis

Abstract

Sir:FigureA predictable treatment option is needed for large keloids, as these debilitating scars have high variability in clinical response to current therapies. We have found that incorporation of a neodermal layer (dermal-like tissue that can be incorporated in continuity with recipient skin) in large keloid reconstruction provides a symptom-free and recurrence-free treatment option to these patients. The theory is that incorporation of a neodermal layer alters the wound-healing environment from one of inflammation to one of regeneration, with replacement of the diseased “keloidogenic” dermal layer. We performed a systematic review of the OVID and PubMed databases for studies before July of 2010 that incorporate a neodermal product in the reconstruction of large keloids. A “large” keloid was defined as one that cannot be closed primarily once excised. Three studies (five keloids) met criteria1–3 (Table 1), and products encountered included Bilayer Matrix Wound Dressing (Integra LifeSciences Corp., Plainsboro, N.J.) and Apligraf (Organogenesis, Inc., Canton, Mass.). AlloDerm has been used in this manner for small earlobe keloids.4 At an average follow-up of 15 months, all studies reported excellent clinical results and patient satisfaction.Table 1: Study CharacteristicsThe neodermal keloid reconstruction occurs in three stages. First, the scar is excised down to subcutaneous tissue, and the Integra Bilayer Matrix Wound Dressing is secured with staples into the wound bed, with care taken to not penetrate epidermis with the staple. Second, once the Bilayer Matrix Wound Dressing is incorporated, after approximately 4 weeks, the silicone sheet overlying the Integra is removed and covered with an epidermal graft (0.006 inch). Between 6 and 9 months, a rim of proliferative scar tissue forms on the perimeter of the reconstruction and the native skin. This is the transition zone between regenerative and inflammatory wound healing. The third stage consists of excision of this rim and injection of each 10 cm of wound edge with 1 cc of 5-fluorouracil (50 mg/cc) and 1 cc of Kenalog 40 (Bristol-Myers Squibb, New York, N.Y.). The site is then irradiated with 1200 cGy divided into three equal fractions over the following 48 hours. We present our experience using this technique with the case of a 23-year-old man with large keloids on his neck and shoulder. After multiple attempts to treat his scars, he opted for the above treatment protocol with Integra Bilayer Matrix Wound Dressing. Preoperatively, the patient experienced pain, pruritus, limited range of motion, skin breakdown, recurrent infection and, perhaps the most significant, social exclusion (Fig. 1, left, and Fig. 2, left). Twelve months after the staged procedures were complete, he was completely asymptomatic and recurrence-free (Fig. 1, right, and Fig. 2, right). In addition, the patient's epidermal graft donor site showed no sign of keloid formation. The patient is now socially active and gainfully employed, lives in his own apartment, travels, and is engaged to be married.Fig. 1: (Left) Our patient presented with a symptomatic neck keloid spanning from ear to ear (35 × 11 cm) from shaving. His neck keloid had symptoms of restricted mobility, pruritus, recurrent infection and, most importantly, severe embarrassment resulting in social isolation. (Right) The patient is shown 9 months postoperatively.Fig. 2: (Left) The shoulder keloid was large and elevated and could not be closed primarily as evaluated by a skin pinch test. (Right) Eight months after the rim of proliferative scar was excised, the Bilayer Matrix Wound Dressing was hyperpigmented and had less pliability than normal skin.Learning points we discovered are as follows. First, when fastening the neodermis and skin graft, a subdermal stapling technique should be used to avoid keloid formation at the staple marks. Second, using Integra Bilayer Matrix Wound Dressing allows the surgeon to harvest an ultrathin epidermal graft that avoids donor-site keloid formation. Lastly, it was observed that the recurrent rim of proliferative scar tissue exhibits properties of healthier scar and responds more sensitively to conventional treatments. Sean M. Bidic, M.D. Phillip B. Dauwe, M.D. Justin Heller, M.D. Spencer Brown, Ph.D. Rod J. Rohrich, M.D. Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. PATIENT CONSENT The patient provided written consent for the use of his images.