Keloid Excision Research Articles

Split-thickness skin grafting and local immunosuppressive therapy to repair a large keloid excision defect following use of a dermal regeneration template

Split-thickness skin grafting and local immunosuppressive therapy to repair a large keloid excision defect following use of a dermal regeneration template

Keloid Excision and Adjuvant Treatments: A Network Meta-analysis.

Keloid disease treatment continues to be unsatisfactory with high recurrence rates. We evaluated the literature regarding the effectiveness of keloid excision with various adjuvant treatments following surgery and assessed recurrence rates. We systematically searched databases through November 2016. We performed pairwise meta-analyses and Bayesian network meta-analyses on the number of recurrences. Following screening, 14 studies including 996 patients with various types of keloids were eligible for inclusion. Patients were categorized based on the receipt of surgery and the type of adjuvant treatment employed afterward. Paired meta-analysis (6 meta-analyses) showed that "excision + 1 adjuvant drug" led to statistically significantly higher odds of recurrence compared to "excision + radiation" (odds ratio [OR], 3.22; 95% confidence interval [CI], 1.35-7.67). Based on the network meta-analyses, the ORs of keloid recurrence following various treatments compared to no excision were as follows: "excision + pressure, 0.18 (95% CI, 0.01-7.07); excision + 2 adjuvants drugs, 0.47 (95% CI, 0.02-12.82); excision + radiation, 0.39 (95% CI, 0.04-3.31); excision + skin grafting, 0.58 (95% CI, 0.00-76.10); excision + 1 adjuvant drug, 1.76 (95% CI, 0.17-21.35); and excision only, 2.17 (95% CI, 0.23-23.95). According to our results, "excision + radiation" had significantly better outcomes than excision alone. "Excision + pressure" had better outcomes than excision + any other treatment modality, and excision + nonradiation adjuvant therapies were also better than "excision only," although these findings did not reach statistical significance.

Surgical Excision of Keloids Followed by In-office Superficial Radiation Therapy: Prospective Study Examining Clinical Outcomes.

Background:Keloids are benign proliferative scars that often occur among individuals of color, and are thought to be the result of excessive collagen deposition that occurs after injury to the skin. The treatment of these scars is difficult with often poor outcomes. This study aimed to evaluate the effectiveness of surgical excision followed by in-office superficial radiation therapy (SRT) as a method to improve keloid remission.Methods:Participants for this study were recruited from June 2016 through February 2017 with 48 subjects enrolled and completed this study. All keloids were surgically resected and participants received 3 consecutive days of a customized dose of SRT, with a maximum cumulative dosage of 18 Gy. Patients were followed over the course of 12 months to monitor outcomes.Results:In this cohort, we found 39 (81%) to have achieved successful remission with 9 (19%) being classified as refractory. There were no adverse effects or medical complications reported as a part of this study.Conclusion:Study outcomes support the clinical benefits of surgical excision followed by SRT as a practical and efficient treatment for keloids.

Z-plasty and Postoperative Radiotherapy for Anterior Chest Wall Keloids: An Analysis of 141 Patients.

Background:The therapies for anterior chest wall keloids include surgical excision, postoperative radiotherapy, silicone taping stabilization, and steroid plaster. However, to date, there is no universally accepted combination treatment strategy for anterior chest wall keloids.Methods:All consecutive patients with single or multiple anterior chest wall keloids who underwent keloid excision, tension-reducing suturing, z-plasty, and postoperative radiotherapy in 2013–2016 in Nippon Medical School were included in this case series study. Only keloids that arose from small injuries such as folliculitis or acne were selected. The surgery was followed by tension-reducing self-management of the wounds with silicone tape and steroid plaster. The postsurgical radiotherapy modality was 18 Gy administered in 3 fractions over 3 days. The primary study outcome was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the development of stiff and red lesions in even a small part of the scar that did not respond to 6 months of steroid plaster therapy.Results:In total, 141 patients with 141 lesions were enrolled. Of the 141 lesions, 15 (10.6%) recurred. All recurrences were successfully treated by steroid plaster and steroid injection. The recurrence patients did not differ from the nonrecurrence patients in terms of the size of the original keloid or gender distribution.Conclusions:Anterior chest wall keloids can be successfully treated by customized plans that involve appropriate surgical modalities (including z-plasty) followed by postoperative radiotherapy (18 Gy in 3 fractions over 3 days) and scar self-management with silicone tape and steroid plaster.

Analysis of Keloid Response to 5-Fluorouracil Treatment and Long-Term Prevention of Keloid Recurrence.

Keloids are benign fibroproliferative skin tumors that can cause disfigurement and disability. Although they frequently recur after excision or medical management and can affect 6 to 16 percent of African Americans, there is no gold standard therapy. Keloids are challenging to study because there are no animal or in vitro models of this disorder. This makes it very difficult to validate data from treated tissue samples or cells and develop targeted therapies for this disease. In this study, the authors demonstrate that intralesional 5-fluorouracil injection after keloid excision prevents recurrence for 2 years, with no reported adverse events. The authors analyze the expression of treated and untreated biopsy specimens of the same keloids in their native context to capture insights that may be missed by in vitro cell culture models and correct for intrakeloid variability. Random forest analysis of the microarray data dramatically increased the statistical power of the authors' results, permitting hypothesis-free creation of a gene expression profile of 5-fluorouracil-treated keloids. Through this analysis, the authors found a set of genes, including YAP1 and CCL-2, whose expression changes predict 5-fluorouracil therapy status and include genes that have not previously been associated with keloid biology and are of unknown function. The authors further describe keloid heterogeneity for the first time using multidimensional analysis of their microarray results. The methods and tools the authors developed in this research may overcome some of the challenges in studying keloids and developing effective treatments for this disease. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

Adjuvant Radiotherapy After Keloid Excision: Preliminary Experience in Taiwan.

Surgical excision with adjuvant radiotherapy has gained attention as an effective treatment of keloid. The Asian population is challenged with a high incidence of keloid occurrence with a specific genetic predominance. The annual reported incidence of new keloid cases in Taiwan is around 30,000, but the disease control rate and effectiveness by means of surgical excision with adjuvant radiotherapy is not yet clear. A retrospective chart review of the included consecutive keloid patients receiving surgical excision and radiotherapy was performed from 2013 to 2016 in a single institute. The reported risk factors were collected to investigate according to the outcome analysis. The Vancouver Scar Scale and the Japan Scar Workshop (JSW) Scar Scale were used to evaluate the correlation with keloid recurrence. In this series, the overall recurrence rate was 32%, reported with an average follow-up of 28 months. Independent risk factors varied according to the different outcome variables. Only JSW classification score independently predicted the risk of keloid recurrence (odds ratio, 1.305; P = 0.02). Both the Vancouver Scar Scale and the JSW system showed a good correlation with keloid recurrence (correlation efficiency, 0.529 and 0.54; P = 0.0437 and 0.0165, respectively). This preliminary report revealed convincing evidence of feasibility and effectiveness of applying adjuvant radiotherapy after keloid excision in the Taiwanese population. A more delicate biological equivalent dose of radiotherapy with an effective local control should be considered to improve the final outcome.

Surgical excision and postoperative radiotherapy for keloids.

Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%–80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (β-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / β ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.

Outcome of Keloid's Treatment in a Tertiary Care Hospital

Introduction: Keloids are characterized by their continued growth following trauma, extension into normal tissue and their high recurrence rate following excision. Keloids are common following ear piercing or flame burns. These lesions are highly conspicuous and cosmetically unappealing. Multiple methods including surgery, radiotherapy, antimitotic agents, silicone sheet, pressure clipsand cryotherapy have been advocated. The risk of recurrence and the need to prevent distortion of following resection is a challenge to the surgeon.
 Material and Methods: A total of 46 patients with keloid were treated at the plastic surgery department of the Nepalgunj Medical College between January 2013 to March 2017. The patients were divided in two groups. Group A consisted of 24patients with keloid in their ear where complete excision of keloid was done with tension free repair and was supplemented withintralesion triamcinolone injection at the time of operation and thereafter as and when needed. Group B consisted of 22 patients. Out of these 15 patients had keloid over the anterior chest wall and rest 07 had keloid over the deltoid region. These cases receivedintralesional triamcinolone only, a total of 5 such injections at month interval as a tension free repair after excision was notconsidered feasible.
 Results & Conclusion: Patients in Group A underwent surgical excision and intra and post operative intralesionalsteroids and patients in Group B received 4 weekly intraregional injection of triamcinolone injection 40 mg. Out of 24 keloid in Group A two developed post-excision recurrence during a mean follow-up period of 24 months. However they regressed with subsequent local injection of steroid. The group B consisting of scar over the deltoid region and anterior chest wall were not found suitable for excision as a tension free repair (a must to prevent recurrence) was not considered possible. Complete Excision of keloids with tension free suture and local steroid injection is a simple & favored technique for the management of keloid, it preserves contour &skin quality and has a low recurrence rate. Unfortunately all cases are not suitable for total surgical excision. In such cases, steroid locally has to given locally at monthly intervals. The keloids regresses, but atrophy and depigmentation at the site of injection are the complications.

Effectiveness of internal mammary artery perforator propeller flap repair combined with radiotherapy for chest keloid in female patients

To investigate the effectiveness of internal mammary artery perforator (IMAP) propeller flap repair combined with radiotherapy for chest keloid in female patients. Between January 2015 and December 2016, 15 female patients with chest keloids were treated, aged 28-75 years (mean, 45.2 years). The keloid disease duration was 1-28 years (median, 6 years). The causes of disease included secondary keloid caused by folliculitis in 7 cases, cardiac surgery in 4 cases, skin abrasion in 2 cases, mosquito bite in 1 case, and unknown etiology in 1 case. The size of keloid ranged from 5 cm×3 cm to 17 cm×6 cm. The IMAP propeller flaps were used to repair the defects after chest keloid excision. The size of flaps ranged from 7 cm×5 cm to 14 cm×8 cm. The donor sits were sutured directly. The routine radiotherapy was performed after operation. All IMAP propeller flaps survived well, and the donor site healed by first intention. All 15 patients were followed up 12-24 months (mean, 16 months). No telangiectasia or incision dehiscence occurred. No radiation-related carcinogenesis occurred during follow-up. The patients were satisfied with the breast shape and symmetry after operation. The symptoms of pain and itching were relieved at keloid area in 13 cases (86.7%), with no obvious recurrence of keloid at the donor site and the primary site. Only 2 cases (13.3%) recurred and were treated with continuously conservative treatment. IMAP propeller flap is an ideal reconstruction method for repairing the wounds after chest keloid excision in female patients, which can preserve the good breast shape. The IMAP propeller flap repair combined with early postoperative radiotherapy can effectively reduce the recurrence rate, and the effectiveness is satisfactory.

The Effects of Postoperative Intralesional Corticosteroids in the Prevention of Recurrent Earlobe Keloids: A Multispecialty Retrospective Review.

Effective treatment of keloids is challenging because the recurrence rate after surgical excision is high. Data on the best treatment practices are lacking. To investigate the recurrence rate after surgical excision of earlobe keloids based on a postoperative intralesional corticosteroid injection protocol. Retrospective chart review was performed from January 1, 2005, to March 31, 2016, of patients who had excision of ear keloids within the departments of dermatology, otorhinolaryngology, and plastic surgery. The number of postoperative injections was recorded, recurrence was reported by the patient, and the efficacy of an injection protocol was evaluated. There were 277 charts reviewed. Appropriate data were available for 184 patients. A statistically significant difference was found with recurrence associated with a lower number of injections (p < .001). Keloids were more likely to recur if they were not treated with a planned serial injection protocol (p < .001) or if they were treated outside the department of dermatology (p < .001). Intralesional corticosteroid injection after surgical excision of earlobe keloids statistically minimizes the risk of recurrence.

Dose Effect in Adjuvant Radiation Therapy for the Treatment of Resected Keloids

Surgical excision of keloids can result in an insidious cycle of tissue injury and repeat keloid formation unless combined with adjuvant therapy to halt this cycle. We present our results of postoperative radiation therapy for keloids with various dose regimens. A retrospective review of 124 patients with 250 keloid lesions treated with postoperative radiation therapy was analyzed. In this institutional review board-approved study, 125 keloids were treated to 20 Gy in 5 fractions and 125 keloids were treated to 12 to 16 Gy in 3 to 4 fractions. Local failure was defined as redevelopment of any clinically apparent keloid at the treated site. The median age was 34 years (14-84 years). Keloids were located on the ear (34%), neck/shoulder (19%), abdomen (13%), chest (10%), face (9%), breast (7%), extremities (4%), and back (3%). Median keloid size was 4 cm (0.5-20 cm). At a median follow-up of 40 months, the recurrence rate for all lesions was 5.6%. Lesions treated to 20 Gy had a recurrence rate of 1.6% compared with 9.6% with <20 Gy and an odds ratio of 0.16 (P = .02). Upon univariate and multivariate analysis there were no differences in recurrence rate with respect to location, race, gender, age, previously treated lesions, and presence of multiple keloids. The lone predictor for improved control rate was the dose of 20 Gy in 5 fractions compared with less than that. Control rate for lesions treated to a biologically equivalent dose2 of 35 to 36 Gy2, 48 to 52.5 Gy2, and 60 to 72 Gy2 were 10% (P = .007), 8.9% (P = .16), and 1.6% (P = .02), respectively. Surgical excision followed by immediate adjuvant radiation therapy for keloids provides excellent local control and cosmesis. Treatment with a biologically equivalent dose2 > 60 (20 Gy in 5 fractions) yielded superior local control over lower dose regimens.

A skin stretch system for the immediately closing of the large skin defects of the anterior chest wall following large keloid excision

Large anterior chest wall skin defects following keloid resection, which are not suitable for primary closure, represent a substantial reconstructive challenge, partly due to the expected high tension closure and the considerable rate of recurrence. The TopClosure® Tension Relief System (TRS) is a novel skin stretching and wound closure-secure system which has been shown as a substitute for skin grafts, tissue expanders, and flaps. A 36-year-old man presented with a large keloid with ulcerations on the anterior chest wall. The patient underwent surgical resection of the keloid with immediate primary closure of the chest wall skin defect using the TRS. The surgical procedure and the postoperative period were uncomplicated. The wound was completely closed with a slightly raised scar after the 15th month follow-up. This is a rare case of immediate primary closure of a skin defect following resection of a large keloid of the anterior chest wall by the application of a skin stretching technique named as TRS. The TopClosure® TRS can help simplify the surgical procedures and shorten the operative time. Furthermore, the appliance can also be used for cosmetic improvements of the scar and minimize the need for future reconstructive procedures as well. Level of Evidence: Level V, therapeutic study

Intralesional cryotherapy versus excision with corticosteroid injections or brachytherapy for keloid treatment: Randomised controlled trials

Keloids are a burden for patients due to physical, aesthetic and social consequences. Treatment remains a challenge due to therapy resistance and high recurrence rates. The main goals of treatment are to improve scar appearance and symptoms and patients' quality of life (QoL). Two multicentre, randomised controlled open trials that compared 1) intralesional cryotherapy with excision and corticosteroid injections for primary keloids, and 2) intralesional cryotherapy with excision and brachytherapy for therapy resistant keloids. Primary outcome was scar appearance assessed with the Patient and Observer Scar Assessment Scale. Secondary outcomes were patient reported QoL (Skindex-29, SF-36, EQ-5D-5L), recurrence rates and scar volume reduction. For analysis, a linear mixed model was used. Power analysis indicated 33 patients in each group were needed. The trial was prematurely terminated after inclusion of 26 patients due to unexpectedly inferior outcomes after intralesional cryotherapy. For primary keloids no convincing difference between treatments was found, but surgery improved scar appearance while cryotherapy did not. For resistant keloids, excision followed by brachytherapy improved scar appearance (POSAS) and scar symptoms (itch and pain) significantly (p < 0.001, p < 0.001 and p = 0.006 respectively) while cryotherapy did not. Neither of the treatments caused indisputable improvements in QoL. Intralesional cryotherapy is inferior to keloid excision followed by brachytherapy for resistant keloids. In primary keloids, intralesional cryotherapy reduced keloid volume and, therefore, may be used in these patients and specific cases. Primary keloid group size was too small to draw valid conclusions, further research on the efficacy of intralesional cryotherapy for primary keloids is warranted.

Piercing Ear Keloid: Excision Using Loupe Magnification and Topical Liquid Silicone Gel as Adjuvant.

Background:Keloid is an abnormal growth of scar at the site of skin injury, which usually does not regress. It proliferates beyond the original scar. The ear keloid usually develops after piercing injury to wear ornaments. A patient usually asks for removal of keloid, as it is aesthetically unpleasant. Patient may sometimes complain of itching and pain.Aim:The study was conducted to analyze results following excision of keloid with its tract and topical silicone gel as the postsurgical adjuvant.Materials and Methods:Ear keloids measuring less than 0.5cm or more than 5cm in maximum dimension were excluded from the study. Nonpiercing causes such as burns, trauma, and recurrent keloid were excluded from the study. The study was carried out on 22 patients who had keloid because of piercing injury, including 4 cases with both ear keloids. Of 26 ear keloids, 19 had the tract or connecting tissue. The lesion was excised under anesthesia using magnification. For all the operated cases, topical liquid silicone gel was used as postsurgical adjuvant therapy. The method of application of topical silicone gel was taught to each patient and was considered significant.Result:The magnification helped in identification of tract in 73% of the cases in this study. Twenty patients had successfully responded to proposed treatment, and two patients developed recurrence while using topical silicone gel as the adjuvant. These two patients were managed with conventional triamcinolone injection.Conclusion:The topical silicone gel as postsurgical adjuvant therapy avoided the use of painful postsurgical injection or radiotherapy for the 1–3cm primary ear keloids. The advantages of magnification were better clearance of keloid tissue, easier identification of tract and removal of keloid pseudopods, meticulous suturing, and comfortable elevation of a small local flap.

Optimal High-Dose-Rate Brachytherapy Fractionation Scheme After Keloid Excision: A Retrospective Multicenter Comparison of Recurrence Rates and Complications

Todetermine the optimal brachytherapy dose and fractionation scheme for keloid treatment. Patient cohorts from 3 centers treated with keloid excision followed by 2×9Gy, 3×6Gy, or 2×6Gy high-dose-rate brachytherapy were retrospectively compared regarding recurrence (after at least 12months' follow-up) and complications (after at least 1month's follow-up), using logistic regression analyses. A total of 238 keloids were treated. An overall full recurrence rate of 8.3% was found. After correction for confounders (sex, skin color, keloid location, keloid duration) no statistically significant differences in recurrence rates could be discerned between fractionation schemes. There were 12.8% major and 45.6% minor complication rates. Lower radiation dose resulted in significantly fewer complications (odds ratio 0.35, P=.015). After excision of resistant keloids, high-dose-rate brachytherapy with a biological equivalent dose of approximately 20Gy is recommended, on the basis of low recurrence and complication rates.

Keloid Excision and Adjuvant Treatment: A Systematic Review and Network Meta-Analysis

Siotos, Charalampos MD; Hong, Hwanhee PhD; Uzosike, Akachimere; Seal, Stella M.; Rosson, Gedge D. MD; Cooney, Carisa M. MPH; Cooney, Damon MD Author Information

Intralesional excision with topical intralesional cryotherapy improves the treatment of keloid scarring in a paediatric patient

Recurrent keloid scarring has a significant impact on quality of life. Management is complex, particularly for scars resistant to conventional treatments and in paediatric cases where radiotherapy is not a suitable adjunct to surgical excision. We present the case of a nine-year-old African Caribbean girl with multiple large and recurrent keloid scars on both ears and bilateral sensorineural deafness. Following repeated intralesional excisions, corticosteroid and botulinum toxin injections, she continued to experience rapid recurrence of her keloids, worsening pain and pruritus. She was no longer able to wear her hearing aids because of the large size of the keloids. We employed a novel technique using topical intralesional cryotherapy, applying liquid nitrogen intraoperatively to the inside of the skin flaps immediately post-intralesional keloid excision and before wound closure. At 26-month follow-up a good aesthetic and symptomatic result was achieved, with minimal hypopigmentation, significantly reduced scar volume and significantly slowed recurrence. We discuss this case and review the current literature on the use of topical intralesional cryotherapy for keloid scarring.

Advancing Keloid Treatment: A Novel Multimodal Approach to Ear Keloids.

Management of keloids of the pinna, in particular, those located in the helix and antihelix and lobule that occur as complications of ear piercing. Retrospective analysis of 49 patients treated with extralesional surgical excision of keloids localized to the ear followed by the application of autologous platelet-rich plasma (PRP) to wound site and postoperative in-office superficial radiation therapy (SRT). Radiation protocol consisted of 1 to 3 fractions, with cumulative dosage ranging from 1,300 to 1,800 cGy. Average follow-up was 24 months to assess for evidence of recurrence and adverse side effects. Fifty ear keloids were treated with this method, age from 15 to 66 (mean = 32, SD = 16) of which 14 were male and 35 female. Almost 30% (n = 14) of patients acknowledged the source of injury that led to the development of the keloid was ear piercing. Treatment protocol achieved a 94% success rate with 3 patients who reported recurrence. Surgical excision combined with intraoperative PRP, adjuvant postoperative in-office SRT achieved a 94% nonrecurrence rate on follow-up over a 2-year period. Outcomes provide preliminary, albeit, strong evidence to support this multimodal method as a viable alternative in the management of keloids localized to the ear.

Reconstruction of a large defect of the female chest following keloid excision with use of the rectus abdominis myocutaneous flap

Aim: This study aimed to investigate the efficacy of the myocutaneous flap of the rectus abdominis in the surgical treatment of a large defect on the female chest following keloid excision.

S-shaped Wound Closure Technique for Dumbbell-shaped Keloids.

Summary:Dog-ear collection, Z-plasty, and W-plasty are often performed for excision of dumbbell-shaped keloids; however, these procedures require additional incisions or excision of normal skin. Thus, an S-shaped wound closure technique was performed. The keloid lesions were extralesionally excised above the deep fascia, and the wound edges were shifted in opposite directions along the major axis to form an S-shape. The incision was closed by applying deep fascial sutures, subcutaneous sutures, and superficial sutures. Postoperative external beam radiation therapy was started within 6 hours after surgery at a dose of 20 Gy applied in 4 fractions. All wounds were covered with silicone-gel sheeting and fixed with tape after suture removal. No intralesional corticosteroid injection or oral tranilast was administered. Corticosteroid tape was applied in cases with suspected postoperative recurrence. Scoring was performed using the Manchester Scar Scale. A total of 8 lesions were treated. Temporary erythema and scar elevation were observed in 2 chest lesions; however, both were flattened and turned white using corticosteroid tape. Other than these 2 lesions, there was no recurrence or complication. The mean score improved from 15.8 to 7.2. The S-shaped wound closure technique has 3 advantages. First, no additional incision or excision is required, and additional scarring and keloid recurrence can be avoided. Second, aesthetic results are good, and noticeably long and zigzag-shaped scars can be avoided. Third, dispersion of tension on the scar can be expected. Although the S-shaped wound closure technique has limited application, it is a useful option for keloid treatment.