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A New Surgical Treatment of Keloid: Keloid

Core Excision

Article in Annals of Plastic Surgery March 2001

DOI: 10.1097/00000637-200102000-00008 Source: PubMed

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Seoul National University
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Keloids and hypertrophic scars result from excessive collagen
deposition, the cause of which is not yet known. Unlike hypertro-
phic scars, keloids frequently persist at the site of injury, often
recur after excision and always overgrow the boundaries of the
original wound. There have been many trials to control keloids,
but most of them have been unsuccessful. The authors propose a
new surgical technique to treat keloids and name it keloid core
extirpation. They excise the inner fibrous core from the keloid and
cover the defect with a keloid rind flap, which is arterialized by the
subcapsular vascular plexus. The authors treated 24 keloids of
the ear, trunk, face, and genitalia with keloid core excision. Four
cases of partial rind flap congestion or necrosis occurred. Those
patients who healed primarily after surgery showed no evidence of
keloid recurrence as long as they were followed. The authors have
found the keloid core extirpation technique to be excellent in
preventing keloid recurrence, with no adjuvant therapy after
surgery.
Lee Y, Minn K, Rong-Min Baek, Hong JJ. A new surgical treatment of
keloid: keloid core excision. Ann Plast Surg 2001;46:135140
From the *Department of Plastic and Reconstructive Surgery, College of
Medicine, Seoul National University; and Inje University Medical Center,
Seoul, Korea.
Received Dec 20, 1999, and in revised form Sep 6, 2000. Accepted for
publication Sep 6, 2000.
Address correspondence and reprint requests to Dr Lee, Department of
Plastic Surgery, Seoul National University Hospital, 28 Yongon-Dong
Chongno-Gu, Seoul, 110-744, Korea.
Keloids and hypertrophic scars are benign fibrous
growths that usually occur after trauma in predis-
posed individuals. Alibert1 first clearly described
surface overhealing and proposed the word che-
loide in 1817 to differentiate keloids from cancer-
ous overgrowths. The term is derived from the
Greek word chele, which means the claw of a
crustacean. Keloids extend beyond the confines
of the original wound and tend to recur after
excision.2
The incidence of keloid formation is difficult to
assess, ranging from 4.5% to 16% in black and
Hispanic populations,3,4 and is higher during
times of physiological hyperactivity of the pitu-
Copyright 2001 by Lippincott Williams & Wilkins, Inc.
A New Surgical Treatment of
Keloid: Keloid Core Excision
Yoonho Lee, MD*
Kyung-Won Minn, MD*
Rong-Min Baek, MD
Jin Joo Hong, MD*
itary, such as puberty and pregnancy.5 Keloids
are seen more commonly between the ages of 10
and 30,6 and tend to run more in families than
hypertrophic scarring.7 Wounds in the presternal
and deltoid regions, wounds that cross skin ten-
sion lines, wound closed under tension, and
wounds in thicker skin have a greater tendency to
heal with an abnormal scar. Some locations al-
most never develop abnormal scars, such as the
genitalia, the eyelid, the palm of the hand, and
the sole of the feet.8
Despite the disfigurement and symptoms like
pain or pruritus from keloids, the literature offers
little consensus about appropriate therapy. Ke-
loids that are resistant to nonsurgical treatment
modalities such as corticosteroid injection, pres-
sure therapy, or silicon gel sheeting should be
considered for surgical excision. According to a
review of the literature, surgical excision alone
leads to recurrence rates that range from 45% to
100%.9
When surgery is combined with intralesional
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
other therapies, has been associated with recur-
rence rates of less than 10%.11 Various lasers
have been used in the treatment of keloids with
great variability in the recurrence rate, but in
general they result in recurrence rates similar to
conventional surgery.12 Interferon--2b injected
after keloid excision demonstrated an 8% recur-
rence rate in a small series of patients.13 We
developed a new surgical technique to treat ke-
loids, for which adjuvant therapy to prevent
keloid recurrence is unnecessary.
Our treatment consists of excising the fibrous
core of the keloid, which leaves a shell or rind of
the keloid attached to the normal skin as a flap
135
Annals of Plastic Surgery Volume 46 / Number 2 / February 2001
and a rim of scar as a splint. We then resurface
the defect with a keloid rind flap that is well
nourished by the subcapsular vascular plexus.
Patients and Methods
Patients
Twenty-one Korean patients with 24 keloids re-
sistant to pressure therapy and repeated intrale-
sional steroid injection underwent keloid core
extirpation surgery at Seoul National University
Hospital between June 1987 to October 1995
(Table). The keloids varied in size from 1 1.5 to
5 6 cm.
Patient age ranged from 13 to 40 years (mean
age, 24.9 years). The patient group consisted of
11 women and 10 men. The ear (N 14) was
the most common location of the keloid fol-
lowed by the trunk (N 4), face (N 4), and
genitalia (N 2). In contrast to the general
belief that the genitals are immune to keloid
reaction, there was a case of keloid of the
labium major after excision of a redundant left
labium majora, and a case of keloid of the
prepuce after circumcision.
Operative Procedure
We prefer to use local anesthesia. An incision is
made approximately halfway around the keloid1
mm within the keloid edge. The keloid rind flap,
which consists of epidermis and thin dermis over-
lying the keloid, is raised from the fibrous keloid
core. It is mandatory to include the subcapsular
vascular plexus underneath the flap(Fig 1). This
flap is easily separated from the keloid core with
the scalpel, especially when the local anesthetic
agent is administered between the flap and the
keloid core. It is important to keep the base of the
flap as wide as possible to prevent flap congestion.
After raising the flap completely, the fibrous keloid
core is extirpated through the avascular cicatricial
plane, leaving a thin margin of scar tissue in the
normal tissue. After trimming the redundant keloid
rind flap, defects are resurfaced with the flap. All
wounds are closed with one layer of 6-0 black silk
without tension, and a tie-over dressing is applied
to prevent hematoma formation and to release
tension.
If the circulation of the flap shows marked
136
congestion, the patient is placed in the hyper-
baric oxygen chamber at 2.4 atm three times a day
for 3 to 5 days. No adjuvant therapy to prevent
keloid recurrence was necessary after surgery.
Results
Follow-up ranged from 6 months to 12 years
(mean follow-up, 20 months). Both surgeon and
patient estimated the results (Figs 35). Twelve
patients (62.5%) were highly satisfied with their
result, and were rated as good by the surgeon.
Four patients (17.7%) showed general satisfac-
tion but wanted aesthetic refinement of the re-
sults, and those patients were rated as fair by the
surgeon. Two patients (8.3%) showed no evi-
dence of recurrence after surgery, but disliked the
result because of the discoloration and irregular-
ity of the scar surface. These patients were rated
as poor by the surgeon.
Partial recurrence of the keloid occurred in 3
patients (12.5%). Two recurrences occurred after
partial flap necrosis, which occurred postopera-
tively. One patient with a chin keloid showed
recurrence of the keloid 3 months after surgery
probably because of poor hematoma control. Sim-
ple flap congestion did not affect the final result
when managed immediately with hyperbaric ox-
ygen therapy.
Keloids of the ear and genitalia yielded a high
satisfaction rate partly because of their concealed
location. That is, removal of the mass itself was a
relief to most of the patients. Meanwhile, core
extirpation of keloids of the face and trunk pro-
duced less aesthetically pleasing reactions, de-
spite the elimination of the keloid. Poor color and
texture match of the flap with surrounding skin
contributed to the poor final score.
Discussion
The etiology of keloids is not yet fully known.
This is due, in part, to the lack of a reliable in
vivo experimental model, because abnormal scar
formation is a unique phenomenon that occurs in
humans. However, a variety of genetic and envi-
ronmental causes have been implicated in the
pathogenesis of abnormal scars such as keloids
 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
mass with overabundant extracellular matrix.
Glycoproteins and water are both increased nota-
bly in the extracellular matrix of keloids and
hypertrophic scars.15 There is also an excessive
accumulation of collagen from increased collagen
synthesis or decreased collagen degradation.16,17
The rate of collagen synthesis in keloids is
markedly elevated, although it usually dimin-
ishes after 2 to 3 years.18 21 Although the concen-
tration of collagenase is increased in keloids,
tissue -globulins such as -2 macroglobulin and
alpha-1 antitrypsin inhibit collagenase function
and are found in increased amounts.22,23 Al-
though emerging knowledge has influenced dra-
matically the way we think of abnormal scar
formation, very little of this basic research has
translated into clinical wound management.
A variety of keloid treatment options has been
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

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
small keloids, pressure therapy plus surgerys-
teroid combination for moderately large scars, and
combination surgery and postoperative radiother-
apy for very large, resistant scars. Although surgical
excision combined with radiotherapy has demon-
strated fairly successful results in treating resistant
keloids, many surgeons are still reluctant to use
ionizing radiation in the treatment of benign
disease.
Several modifications in surgical technique have
been proposed to achieve successful closure of the
wound with minimal tension after keloid excision.
However, a skin graft or local flap needs a donor
site and leaves unnecessary scars. On histological
analysis, we determined that the subcapsular vas-
cular plexus offers a rich blood supply to the
capsular rind flap. During the immediate postoper-
ative period, wound tension can be reduced using a
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
lesion, keloid recurrence was prevented, with no
adjuvant therapy.
The limitation of this technique lies in the size
Lee et al: Keloid Core Excision
of the keloid. We experienced two cases of partial
necrosis and two cases of temporary flap conges-
tion, all of which occurred in large keloids. Be-
cause, especially in large keloids, the base of the
flap is narrower than the width of the flap, necro-
sis of the distal end of the flap can be anticipated,
and a cautious design is mandatory. We have
used hyperbaric oxygen therapy for cases of flap
congestion, and have salvaged more than 50% of
the compromised flap.
The rind flap, which is nourished via the sub-
capsular vascular plexus, survived well enough
to maintain tension-free status to prevent recur-
rence of keloid. The keloid core extirpation tech-
nique, which consists of excising the keloid core
and resurfacing the defect using its own keloid
rind flap, has demonstrated excellent results in
preventing keloid recurrence, without requiring
adjuvant therapy.
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