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the case of a 39-year-old woman with an upper-arm keloid. a, Preoperative view. B, immediately after excision. c, immediately after superficial fascial suturing and the design of the z-plasties. D, immediately after the operation. e, two years after the operation.
Source publication
Therapies for upper arm keloids include surgical excision followed by postoperative radiotherapy, silicone tape stabilization, and steroid plaster. However, a universally accepted therapeutic strategy for upper-arm keloids is lacking.
Methods:
All consecutive patients with single upper-arm keloids who underwent keloid excision followed by tension...
Contexts in source publication
Context 1
... postoperative scar width at 24 months ranged from 1 to 3 mm (Figs. 2-5). The scars tended to be wider on the edge of the z-plasties and at some points of the w-plasties (Figs. 4 and ...
Context 2
... on the irradiated area in 1 case (2.6%) 3 months after surgery; it improved spontaneously over the next 12 months. Two cases (5.3%) exhibited telangiectasia 24 months after surgery that was treated by long-pulsed Nd:YAG laser. There were no cases of depigmentation or wound dehiscence after radiotherapy. All mature scars were soft and white (Figs. ...
Similar publications
Background:
A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection.
Methods:
All consecutive patients with umbilical keloids that developed from endo...
Citations
... The radiation therapeutic strategy was determined by one skilled radiologist and radiotherapy was performed 1 cm outside the incision border at a source-toskin distance of 100 cm using Synergy (Elekta™). A total dose of 18 Gy for 3 consecutive days was administered within 24 h after surgery for all our patients as recommended [21][22][23][24]. ...
Background
An ideal tension-relieving suture should be efficient for >3 months to retrieve normal tensile strength. Most preexisting suturing techniques provided tension elimination followed by relapse and scar proliferation due to absorption and cut-through of the sutures. This study introduces a simple but effective suture technique developed by a senior author (ZYX) to solve this problem.
Methods
A total of 120 patients with pathological scar (PS) had intervention treatment with the proposed suturing strategy at three centers from January 2018 to January 2021. A slowly absorbable 2–0 barbed suture was used for subcutaneous tension relieving with a set-back from the wound edge and a horizontal interval between proposed inserting points of 1 cm. The Patient and Observer Scar Assessment Scale (POSAS), scar width, perfusion and eversion of the wound edge were evaluated at 3-, 6- and 12-month follow-up. The time needed to place the tension-relieving suture was recorded and relapse was monitored for 18 months postoperatively.
Results
In total, 76 trunks, 32 extremities and 12 cervical PS were included, with an average subcutaneous tension-relieving suture time of 5 min. The Patient and Observer Scar Assessment Scale (POSAS) score decreased from 84.70 ± 7.06 preoperatively to 28.83 ± 3.09, 26.14 ± 1.92 and 24.71 ± 2.00 at 3, 6 and 12 months postoperatively, respectively (p < 0.0001). The scar widths were 0.17 ± 0.08, 0.25 ± 0.09 and 0.33 ± 0.10 cm, respectively, with perfusion significantly decreased from 213.64 ± 14.97 to 112.23 ± 8.18 at 6 months (p < 0.0001). The wound edge flattened out during the first 3 months in most cases with only two scar relapses.
Conclusions
Zhang’s suture technique provides a rapid and long-lasting tension-relieving effect with ideal scar appearances and lower relapse rates in the surgical management of PS.
... Considering a site-specific strategy, for instance, trunk of the body can be sutured from deep fascia while limbs can suture from superficial fascia depending keeping in mind the ordinary movement and anatomical structures. 37 Finally, Dr. Rennekampff highlighted an important concept that can contribute to improving scar formation by avoiding longitudinal stretch on incisions and thereby minimizing the resultant pathologic scars with respect to defined anatomical considerations. 38 ...
Pathological scars (including keloids, hypertrophic scars, and scar contractures) are present with high severity among certain populations, particularly in Asians and Africans who are highly prone to develop scars. Understanding the patho-mechanism that underlies scarring, such as mechanosignaling, systemic, and genetic factors, as well as optimal surgical techniques and integrated noninvasive therapeutic methods can guide clinicians to develop treatment protocols that can overcome these issues. This report summarizes a congress at Pacifico Yokohama (Conference Center) on December 19, 2021 involving researchers and clinicians from diverse disciplines who convened to discuss current clinical, preclinical, and most recent research advances in understanding pathological scarring, keloid and hypertrophic scar management, and research progress in wound healing. Presenters described the advances in scar therapies, understanding scarring mechanisms, and scar prevention and assessments tools. Moreover, presenters addressed the challenges during the COVID-19 pandemic and using telemedicine in management of scar patients.
... However, evidence has indicated that the bioequivalent dose (BED) of postoperative radiotherapy for keloids should reach 30 Gy (19). One study showed that the local recurrence rate of keloids after 18 Gy/3 times (BED: 28.8 Gy) postoperative Frontiers in Surgery radiotherapy was 5.3% (20). Another group used 15 Gy/3 times (BED: 22.5 Gy) radiotherapy and obtained a recurrence rate of 26.7% (21). ...
Background:
Keloids are benign skin hyperplasias but have a tumor-like appearance. Clinical management of keloids remains challenging.
Aims:
We retrospectively evaluated the safety and efficacy of internal mammary artery perforator propeller flaps combined with timely radiotherapy in the treatment of large chest keloids.
Methods:
From June 2017 to May 2020, 25 patients with large chest keloids (average size 4.82 cm ± 2.53 cm × 9.04 cm ± 4.86 cm) who received both radiotherapy and internal mammary artery perforator flaps transplantation in our department were included. After surgical removal of the keloids, various propeller flaps based on the unilateral internal mammary artery were designed and applied to repair the defects. Timely and full-dose radiotherapy was performed for these patients after the operation.
Results:
After keloid resection, the dimensions of the defect area were 3 cm-15 cm × 4 cm-25 cm, and the sizes of the flaps were 3 cm-16 cm × 4 cm-27 cm. For all 25 patients, the flaps survived, and the incisions healed in one stage. During the follow-up (median 18 months), no local recurrence was observed, and the itching and pain symptoms in the scar area were significantly relieved. Both physicians and patients were satisfied with the results.
Conclusions:
The application of internal mammary artery perforator propeller flaps combined with radiotherapy in the treatment of chest keloids can effectively reduce the recurrence of keloids and relieve the related symptoms. It also has advantages including minimized donor site damage, short operation time and speedy postoperative recovery, suggesting its great clinical value.
... For the same reason, the fascial-suturing method should be used for closure. 2,3 We describe here the case of a giant keloid that spread from the left shoulder to the chest, shoulder, and upper arm over the anterior axillary line. It was treated by combination therapy composed of partial resection and a transposition local flap followed by postoperative radiotherapy and steroid-plaster therapy. ...
... [4][5][6] This fact, and the resulting great importance of limiting tension on the wound, underpins all surgical methods that are used to treat keloids, including the fascial-suturing 8 method and the use of Z-plasties and flap transfer. 2,3,7 Resection of severe keloids leaves large defects whose primary closure would lead to unacceptably high tension on the wounds: consequently, a transfer flap is needed. Skin grafting is a less favorable option because it is prone to secondary contracture and requires considerable donor-skin sacrifice. ...
Keloids are laterally growing fibroproliferative skin disorders. In severe cases, keloids spread widely, sometimes over joints, thus significantly limiting motor function. Severe keloids also associate with repeated and very painful draining infections. Here, we report the case of a giant keloid that was successfully treated by combination therapy composed of surgery (partial resection followed with local flap transposition) followed by radiotherapy and steroid-plaster therapy. The keloid of the patient started growing at the age of 7 from the BCG injection that she received on her left shoulder in infancy. The keloid grew rapidly and widely after adulthood. Malignant tumor was suspected at another hospital but a biopsy at the age of 45 indicated it was a keloid. Thereafter, the keloid grew from the shoulder onto the chest and back and over the anterior axilla. At 62 years of age, the patient was referred to our hospital. After providing general anesthesia, the keloid was partially resected and the wound was covered with a local flap. Postoperative radiotherapy was performed 1 week later. The residual keloid was treated for 18 months with steroid tape. Eighteen months after surgery, keloid recurrence was not observed. The patient had no pain or movement restriction. She was extremely satisfied with the results and considered the treatment to have improved her quality of life. While a standard strategy for severe keloid remains to be established, combination therapy composed of surgery, postoperative radiotherapy, and steroid-plaster therapy that aims to reduce inflammation and skin tension may be an option.
... Radical resection should always be combined with adjuvant therapies (e.g., radiation therapy) because surgery alone results in 45 to 100 percent recurrence rates. 64 Surgery should involve tension-reducing techniques, namely, subcutaneous and deep fascial tensile-reduction sutures, 31,92,93 Z-plasties, [111][112][113] and local-flap transfer. 114 Tensile-reduction sutures elevate the wound edges smoothly and relieve dermal tension. ...
... Regarding Z-plasty, case series studies of anterior chest wall keloids 111 and upper-arm keloids 113 showed that excision, tension-reduction suturing, Z-plasty, and radiotherapy led to respective recurrence rates of 10.6 and 5.3 percent, at 24 months. All recurrences were readily extinguished by steroid plaster and injections. ...
Background:
In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.
Methods:
All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.
Results:
Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.
Conclusions:
Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.
... Regardless of whether umbilicoplasty was performed or not, the fibrous membrane in the fatty tissues just below the subdermal vascular network (ie, the upper superficial fascia) was then sutured with 3-0 or 4-0 PDSII. 10 After confirming that the wound edges were smoothly elevated without any tension by the underlying sutures, the dermis was closed with 5-0 or 4-0 PDSII sutures. 11 In our case series, the average pitch between each dermal suture was 1-1.5 cm. ...
Background:
A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection.
Methods:
All consecutive patients with umbilical keloids that developed from endoscopic surgical scars and underwent minimal-margin keloid excision followed by umbilicoplasty with a flap if needed, tension-reduction suturing, and postoperative radiotherapy in 2013-2017 in the keloid/scar-specialized clinic at the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School. The postsurgical radiotherapy regimen was 15 Gy administered in 2 fractions over 2 consecutive days. Radiotherapy was followed by tension-reducing wound self-management with silicone tape or, if needed, steroid plaster. The primary study focus was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the growth of stiff red lesions in even small areas of the scar that was refractory to 2-6 months of steroid-plaster therapy.
Results:
The case series consisted of 34 patients with 34 lesions. Three lesions (8.8%) recurred. One recurrence was successfully treated by concomitant steroid plaster/injection. The other 2 cases were resistant to steroid injection and underwent reoperation without radiotherapy followed by 6 months of steroid-plaster therapy. None of the 3 cases recurred within 2 years of steroid plaster/injection completion or reoperation.
Conclusion:
Umbilical keloids can be successfully treated by customized treatment plans that involve appropriate surgical modalities (including umbilicoplasty, if required), postoperative radiotherapy (15 Gy/2 fractions/2 days), and wound/scar self-management with silicone tape and steroid plaster.
Keloids are benign dermal fibroproliferative tumors that result from trauma to the skin, including piercings, insect bites, and surgical incisions. There is limited literature on the effect of keloids and scars on patients by gender. Nevertheless, scars are of important consideration for male patients and their body perceptions. In this chapter, we discuss preoperative planning, patient selection, and different surgical techniques and adjuvant therapies in treating keloids.
Background
Surgical excision combined with radiotherapy is considered an effective treatment for keloids, while the efficacy and safety of this regimen for huge keloids in patients who need reconstruction after excision is still unclear. Therefore, this study aimed to evaluate the efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids in a single center with 13 years of experience.
Methods
All consecutive patients with huge keloids who underwent surgical excision and reconstruction combined with radiotherapy were identified. Demographic information, prior interventions for keloids, parameters and complications, and recurrence rates were documented.
Results
Twenty‐one patients (10 males; mean age, 43.19 ± 18.15 years) were included, 14 patients reconstructed with z‐plasties, 5 with skin grafts, and 2 with skin flaps. During a mean follow‐up of 75 months, one patient developed local necrosis without the need for revision surgery and two patients developed temporary hyperpigmentation. Two patients with the z‐plasties suffered partial keloids recurrence, which was healed with corticosteroid injection. No wound infection, hematoma, telangiectasia, or new keloids at donor sites were observed. The overall appearance of reconstructed defects was aesthetically acceptable.
Conclusion
Surgical excision and reconstruction combined with radiotherapy may be safe and effective for huge keloids.
Postoperative scar formation remains a morbidity for patients even with the advent of minimally invasive techniques. Furthermore, the significant difference between the Asian and Caucasian skin results in poorer postoperative scar outcomes in Asians, supporting the need for an evidence-based scar management protocol.
Following a literature review of the PubMed and the Cochrane databases over the past 10 years, we constructed a novel postoperative scar management protocol for the Asian skin, utilized in a Singaporean tertiary healthcare institution.
We describe a timeline-based scar protocol from the point of skin closure to a minimum of 1 year of follow-up. We support the use of intraoperative botulinum toxin for selected high-risk individuals upon skin closure with a follow-up regimen in the postoperative setting. For recalcitrant keloids, we have described a multimodal therapy comprising elements of intralesional steroids, botulinum toxin, lasers, surgery, and radiotherapy.
A consolidated postoperative scar management protocol provides the necessary guidance for improved scar outcomes in the Asian skin. There is inherent potential in expanding the protocol to include post-traumatic and burn wounds or support other skin types including the Caucasian skin.
This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.
Background:
Key risk factors for hypertrophic scarring and surgical site infections are high tension on the wound, fat necrosis, and dead space. All could be prevented by appropriate superficial fascia (SF) suturing. To improve SF suturing, the as-yet poorly researched anatomy of the SF should be delineated. This study is the first to quantify SF throughout the human body in-vivo.
Methods:
Ultrasound was used to analyze the SF and deep fascia (DF) of ten volunteers at 73 points on 11 body regions, including the upper and lower trunk and limbs. Number of SF layers, average SF-layer thickness, total SF thickness, percent SF relative to subcutaneous-tissue thickness, and DF and dermis thickness were measured at each point.
Results:
730 ultrasound images were analyzed. Body regions varied markedly in terms of subcutaneous variables. Posterior chest had the thickest DF and dermis and the highest average SF-layer thickness (0.6 mm; 95%CI=0.6-0.7 mm). Anterior chest had the most SF layers (3.7; 95%CI=3.5-3.8). Posterior and anterior chest had among the highest percent SFs. Abdomen and especially gluteus had low percent SFs (32%, 95%CI=29-35%; and 23%, 95%CI=19-27%, respectively). Covariate analyses confirmed that posterior and anterior chest generally had higher SF content than gluteus and abdomen (both P<0.001). They also showed that the dermis in the posterior and anterior chest increased proportionally to total fascia (SF+DF) thickness.
Conclusions:
The SF, DF, and dermis tend to be thick in high-tension areas such as the upper trunk. A site-specific surgical approach is recommended for subcutaneous sutures.
