For those patients with keloids and active infection, surgical excision is the most appropriate approach because the active infected lesions can grow rapidly.1,2 After the removal of the entire lesion, the wound is usually repaired with direct sutures, skin grafts, or skin flap. Extra tension because of direct sutures would cause recurrence, involuting the dermis using a specific absorbable suture could generally reduce the tension.3 However, it is not suitable for massive lesions, particularly those in the chest, because breathing pain is frequently unbearable. Besides, skin grafts or flaps were usually used to repair wounds,4 but it would cause damage to normal tissue and often require additional radiation doses in the donor area. Therefore, we introduce a new technique to reduce the tension by tightening the fascia layer, wherein active muscle-derived tension stimulation is blocked during the healing process. Moreover, all large incisions could be successfully sutured without skin grafting or flaps. We have used this therapeutic modality for 15 patients with keloids and achieved satisfactory results. Technique and Results Before surgery, the incision was marked, and 2 mL of 1% lidocaine with 1:400,000 adrenaline was administered for local anesthesia. The skin surface was cut along the incision, down to the subdermal vascular network level. First, the focus core, including infected tissue, was peeled off the keloid skin using a No. 11 blade, retaining an approximately 1-mm thick epidermis (Figure 1). For large lesions wider than 5 cm, the distal end was further thinned, to ensure no clamping of the epidermis during the process that would help insure wound healing well. Then, bipolar electrocoagulation was applied for intraoperative hemostasis. The needle with PDS II (polydioxanone) synthetic absorbable suture suture (ETHICON Johnson & Johnson, NJ) (3-0 to 4-0 according to the tension) entered the up layer of superficial fascia 3 to 4 mm from the wound edge and exited the adjacent point before advancing the needle to the next marked suture interval. Next, the suture depth penetrated the deep layer of the fascia without reaching the muscles, after sewing to the opposite edge, return to the starting point and tighten the knot (Figure 2). Finally, the incision was sutured, followed by a compression bandage. Within postoperative 24 to 48 hours, the patients received electron beam radiotherapy, 4 times in 4 consecutive days, with a total dose of 18 to 20 Gy. Stitches were removed on the seventh postoperative day. The postoperative follow-up after 6 months is shown in Figure 3. The institutional review board of Huashan Hospital Fudan University approved the experimental protocols, and all patients had previously provided informed consent.Figure 1.: Keloid with infection focus in the chest (A). Infection focus was removed, and keloid core was resected (B). Surrounding tissue was excised (C) and incision tension was reduced by tightening fascial layer for the closure of wound. Immediately after surgery (D).Figure 2.: Schematic illustration of incision tension reduction by tightening fascial layer. The dotted line is the suture after folding; knot is tied by the solid and dotted lines.Figure 3.: Six months after operation.Discussion To date, surgery is irreplaceable in treating keloid, especially for patients with infections. The inflammatory stimulation of infection foci not only causes the keloid to grow quickly, but also limits the use of some treatment methods, such as glucocorticoid injection and compression therapy. According to our previous experience, keloids recur more frequently after direct suture or the use of skin flap to repair the incision. Skin grafting for wound closure also owes to risk of keloids formation in the border of the lesion.5 Because original tension would amplify after lesion removal, tension reduction is important. Different from the conventional methods of reducing tension, we embedded the absorbable thread in the superficial fascia layer instead of dermis. By tightening the superficial fascia layer, the tension of the incision is reduced. Our technique caused less immune response in the incision and greater tension reduction than the conventional method because the suture can be buried more deeply and widely. Besides, active tension is derived from the movement of muscle underlying the wound, which is gradually transmitted to the skin through the fascia layer. This tension transfers from the muscle (joint) to the fascia layer, dermis, and epidermis. Therefore, blocking the fascia layer can also alleviate tension, thereby reducing the relapse rate. The recurrence rates of keloid increase gradually as healing time increases. In our cases, some patients suffer delayed wound healing because the focus is too large, resulting in insufficient blood supply in the distal end, or blocked venous reflux. Moreover, they may have received excessive radiation dose or are severely sensitive to radiation. Thinning the distal end of the flap as much as possible and maintaining continuous compression, similar to the process of skin grafting, especially after radiotherapy, would aid wound healing. Corticosteroid + 5FU therapy 2 to 3 times once a month can relieve a minimizing relapse. When removing the keloid core, preserving the subdermal vascular network aids incision healing. Nonetheless, our sample size is small, and no comparison with traditional surgical methods has been made. Conclusion Tension reduction by tightening the fascia layer can immediately block the active stimulation generated by muscle movement. Thus hard-to-close keloid incisions can be sutured smoothly without skin grafting. Tension reduction also has a long-lasting effect on preventing keloid recurrence. This will provide new ideas for keloid surgery.