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A New Surgical Treatment of Keloid Keloid Core Excision
A New Surgical Treatment of Keloid Keloid Core Excision
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A New Surgical Treatment of
Keloid: Keloid Core Excision
Yoonho Lee, MD*
Kyung-Won Minn, MD*
Rong-Min Baek, MD
Jin Joo Hong, MD*
Keloids and hypertrophic scars result from excessive collagen itary, such as puberty and pregnancy.5 Keloids
deposition, the cause of which is not yet known. Unlike hypertro- are seen more commonly between the ages of 10
phic scars, keloids frequently persist at the site of injury, often
and 30,6 and tend to run more in families than
recur after excision and always overgrow the boundaries of the
original wound. There have been many trials to control keloids, hypertrophic scarring.7 Wounds in the presternal
but most of them have been unsuccessful. The authors propose a and deltoid regions, wounds that cross skin ten-
new surgical technique to treat keloids and name it keloid core sion lines, wound closed under tension, and
extirpation. They excise the inner fibrous core from the keloid and
wounds in thicker skin have a greater tendency to
cover the defect with a keloid rind flap, which is arterialized by the
subcapsular vascular plexus. The authors treated 24 keloids of
heal with an abnormal scar. Some locations al-
the ear, trunk, face, and genitalia with keloid core excision. Four most never develop abnormal scars, such as the
cases of partial rind flap congestion or necrosis occurred. Those genitalia, the eyelid, the palm of the hand, and
patients who healed primarily after surgery showed no evidence of the sole of the feet.8
keloid recurrence as long as they were followed. The authors have
Despite the disfigurement and symptoms like
found the keloid core extirpation technique to be excellent in
preventing keloid recurrence, with no adjuvant therapy after pain or pruritus from keloids, the literature offers
surgery. little consensus about appropriate therapy. Ke-
Lee Y, Minn K, Rong-Min Baek, Hong JJ. A new surgical treatment of
loids that are resistant to nonsurgical treatment
keloid: keloid core excision. Ann Plast Surg 2001;46:135140 modalities such as corticosteroid injection, pres-
sure therapy, or silicon gel sheeting should be
From the *Department of Plastic and Reconstructive Surgery, College of considered for surgical excision. According to a
Medicine, Seoul National University; and Inje University Medical Center,
Seoul, Korea. review of the literature, surgical excision alone
Received Dec 20, 1999, and in revised form Sep 6, 2000. Accepted for leads to recurrence rates that range from 45% to
publication Sep 6, 2000. 100%.9
Address correspondence and reprint requests to Dr Lee, Department of When surgery is combined with intralesional
Plastic Surgery, Seoul National University Hospital, 28 Yongon-Dong
Chongno-Gu, Seoul, 110-744, Korea. corticosteroids, the recurrence rate in the major-
ity of studies falls below 50%.9 Surgery com-
bined with button compression therapy on the
earlobe led to no recurrence.10 External surface
radiation after excision, often combined with
Keloids and hypertrophic scars are benign fibrous other therapies, has been associated with recur-
growths that usually occur after trauma in predis- rence rates of less than 10%.11 Various lasers
posed individuals. Alibert1 first clearly described have been used in the treatment of keloids with
surface overhealing and proposed the word che- great variability in the recurrence rate, but in
loide in 1817 to differentiate keloids from cancer- general they result in recurrence rates similar to
ous overgrowths. The term is derived from the conventional surgery.12 Interferon--2b injected
Greek word chele, which means the claw of a after keloid excision demonstrated an 8% recur-
crustacean. Keloids extend beyond the confines rence rate in a small series of patients.13 We
of the original wound and tend to recur after developed a new surgical technique to treat ke-
excision.2 loids, for which adjuvant therapy to prevent
The incidence of keloid formation is difficult to keloid recurrence is unnecessary.
assess, ranging from 4.5% to 16% in black and Our treatment consists of excising the fibrous
Hispanic populations,3,4 and is higher during core of the keloid, which leaves a shell or rind of
times of physiological hyperactivity of the pitu- the keloid attached to the normal skin as a flap
and a rim of scar as a splint. We then resurface congestion, the patient is placed in the hyper-
the defect with a keloid rind flap that is well baric oxygen chamber at 2.4 atm three times a day
nourished by the subcapsular vascular plexus. for 3 to 5 days. No adjuvant therapy to prevent
keloid recurrence was necessary after surgery.
136
Lee et al: Keloid Core Excision
Patient Characteristics
Age,
Patient Sex yr Location Size, cm Complication/Treatment Result
JKL M 22 Bilat. preauricular 2.2 1.8/3 1.7 None G
JNL F 40 Bilat. earlobes 2.4 2.4/2.1 2 None G
EHK F 27 Presternal 4.5 2 None P
KSH F 38 Bilat. earlobes 3 3/2.3 2.3 Partial flap congestion/HBO therapy G
HHL M 16 Lt. upper helical rim 4.6 2.6 None G
JSP M 17 Lt. retroauricle 2.8 2.3 None G
HAP F 19 Rt. earlobe 2.1 2.2 None F
EKO F 25 Lt. shoulder 1.8 1.8 None F
YSL M 40 Rt. retroauricle 2.5 1.7 None G
DHC M 19 Rt. retroauricle 32 None G
JYK F 22 Lt. upper lip 1.5 1.2 None P
JDH M 23 Lt. chin 2 2.1 None Recurrence
YOC F 16 Lt. scapula 5 5.8 Partial flap congestion/HBO therapy F
YYA F 33 Lt. earlobe 2.8 2.5 None G
NSC M 33 Lt. helical rim 2.1 2.3 None G
WHH M 13 Penile prepuce 1.4 1.6 None G
IJK F 21 Rt. earlobe 1.9 1.9 None G
JDH M 24 Rt. cheek 56 Partial flap loss/HBO therapy and Partial recurrence
secondary healing
CYL M 17 Lower abdomen 36 Partial flap loss/HBO therapy and Partial recurrence
secondary healing
SOP F 35 Lt. upper lip 1 1.5 None F
MYC F 23 Lt. labium majora 3.8 2.4 None G
M male; F female; Bilat. bilateral; Rt. right; Lt. left; HBO hyperbarric oxygen; G no recurrence of keloid and good
aesthetic result; F no recurrence of keloid and fair aesthetic result; P no recurrence of keloid with poor aesthetic result.
Fig 1. (A, B) The subcapsular vascular plexus is identified just beneath the fibrous capsule of the keloid.
Hematoxylin eosin stain, original magnification 50 (A) and 100 (B) before 37% reduction.
and hypertrophic scars.14 The result is a tissue tration of collagenase is increased in keloids,
mass with overabundant extracellular matrix. tissue -globulins such as -2 macroglobulin and
Glycoproteins and water are both increased nota- alpha-1 antitrypsin inhibit collagenase function
bly in the extracellular matrix of keloids and and are found in increased amounts.22,23 Al-
hypertrophic scars.15 There is also an excessive though emerging knowledge has influenced dra-
accumulation of collagen from increased collagen matically the way we think of abnormal scar
synthesis or decreased collagen degradation.16,17 formation, very little of this basic research has
The rate of collagen synthesis in keloids is translated into clinical wound management.
markedly elevated, although it usually dimin- A variety of keloid treatment options has been
ishes after 2 to 3 years.18 21 Although the concen- proposed and practiced with limited success.
137
Annals of Plastic Surgery Volume 46 / Number 2 / February 2001
Fig 2. (A) Preoperative keloid at the posterior surface of the auricle. (B) The keloid rind flap has been elevated from
the keloid core. (C) Postoperative result 5 months after core extirpation.
Fig 3. (A) A keloid at the anterior surface of the auricle. (B) Postoperative result 3 years after core extirpation.
The options include surgery, irradiation, pres- and tranilast. However, as a single modality,
sure, silicon gel sheeting, laser, and pharmaco- none of them shows satisfactory results in terms
logical agents such as corticosteroid, vitamin A, of cosmetic and symptomatic aspects.
-amino-propionitrile, asiaticoside, zinc oxide, In a large review of the literature, Friedman24
138
Lee et al: Keloid Core Excision
Fig 4. (A) A keloid of the labium major after trauma. (B) Postoperative result 2 years after core extirpation.
Fig 5. (A) Keloid of the shoulder. (B) Postoperative result 6 months after core extirpation. (C) Postoperative result 12
years after core extirpation. There has been no recurrence.
proposed surgical excision and corticosteroids for of the keloid. We experienced two cases of partial
small keloids, pressure therapy plus surgerys- necrosis and two cases of temporary flap conges-
teroid combination for moderately large scars, and tion, all of which occurred in large keloids. Be-
combination surgery and postoperative radiother- cause, especially in large keloids, the base of the
apy for very large, resistant scars. Although surgical flap is narrower than the width of the flap, necro-
excision combined with radiotherapy has demon- sis of the distal end of the flap can be anticipated,
strated fairly successful results in treating resistant and a cautious design is mandatory. We have
keloids, many surgeons are still reluctant to use used hyperbaric oxygen therapy for cases of flap
ionizing radiation in the treatment of benign congestion, and have salvaged more than 50% of
disease. the compromised flap.
Several modifications in surgical technique have The rind flap, which is nourished via the sub-
been proposed to achieve successful closure of the capsular vascular plexus, survived well enough
wound with minimal tension after keloid excision. to maintain tension-free status to prevent recur-
However, a skin graft or local flap needs a donor rence of keloid. The keloid core extirpation tech-
site and leaves unnecessary scars. On histological nique, which consists of excising the keloid core
analysis, we determined that the subcapsular vas- and resurfacing the defect using its own keloid
cular plexus offers a rich blood supply to the rind flap, has demonstrated excellent results in
capsular rind flap. During the immediate postoper- preventing keloid recurrence, without requiring
ative period, wound tension can be reduced using a
adjuvant therapy.
tie-over dressing. Furthermore, because the rind
flap serves as a splint and decreases the transmis-
sion of tensile forces to the central area of the
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Annals of Plastic Surgery Volume 46 / Number 2 / February 2001
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