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BACKGROUND Keloids are scars that extend beyond the borders of the original wound. They are difficult to
cure because of their high recurrence rate, particularly in large keloids that require skin grafts. This article
describes a study to compare the effectiveness of a new technique, a combination precut, preradiotherapy
method, with the conventional surgical method of keloid skin graft treatment.
METHODS Fifty-three patients with chest wall keloids were treated from April 2005 to June 2011. Twenty-
nine patients were treated with conventional surgery and radiotherapy. Keloids were removed from these
patients, and their wounds were closed with skin grafts. If the grafts survived well, radiotherapy was applied,
and the sutures were removed. Twenty-four patients were treated using the novel precut, preradiotherapy
method. An incision was made down to the subcutaneous layer around the edge of the keloid, and
radiotherapy was applied on the following day. Then the keloid was removed, and the wound was closed
using a skin graft. Radiotherapy was applied for the second time when the graft was found to have survived.
Patients underwent follow-up examinations 6 and 12 months after surgery. The scar at the operation site and
aesthetic satisfaction were recorded and compared.
RESULTS The recurrence rate was 55.2% in the conventional group and 16.7% in the precut group, a
significant difference (v2 = 6.73, p < .01). There was a significant difference in aesthetic satisfaction between
the two groups, with 48.3% in the conventional group rating their satisfaction as poor versus 8.3% in the
precut group (v2 = 7.50, p < .01).
CONCLUSION The precut, preradiotherapy strategy may be a promising treatment option for patients with
large keloids that require excision and skin graft repair.
Wenbo Li and Youbin Wang contributed equally to this article.
*All authors are affiliated with Department of Plastic Surgery, Peking Union Medical College Hospital, Peking, China
2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.
ISSN: 1076-0512 Dermatol Surg 2014;40:5257 DOI: 10.1111/dsu.12374
52
LI ET AL
Patients and Methods the wound was measured, and an intermediate split-
thickness skin graft was harvested from the groin.
Patient Group
After step-by-step bipolar coagulation, the wound
Fifty-three patients with chest wall keloids were was covered with the skin graft and a bolus pressure
treated in our center from April 2005 to June 2011. dressing. The dressing was removed between post-
Mean keloid size was approximately 5.4 by 9.8 cm. operative days 10 and 14. Radiotherapy was used
The wounds in these patients could not be directly for the first time after the dressing was removed and
closed after keloid excision, and skin grafts were again 7 days later (900 cGy each time). Radiother-
required. The patients were randomly divided into apy was applied at the groin on days 1 and 7 after
two groups based on the month during which the the graft harvest operation (900 cGy each time).
operation was performed. Patients whose operations
were performed in January, March, May, July, Precut, Preradiotherapy Method
September, and November were placed in the
Anesthesia was administered, and a mark method
conventional method group. Patients whose opera-
similar to that of the conventional method was used.
tions were performed in alternating months were
After the keloid edge and normal peripheral skin
placed in the precut, preradiotherapy group. There
were infused with 0.5% lidocaine (1:100,000 epi-
were 29 patients (19 male, 10 female, mean age
nephrine), an incision was made along the mark
23 5) in the conventional group. Mean keloid size
deep into the subcutaneous fat. After bipolar coag-
was 5.6 by 9.3 cm. They were treated using
ulation, the incision was approximated using a
conventional surgery and radiotherapy. There were
continuous intradermal suture. The surgical site was
24 patients (13 male, 11 female, mean age 21 6)
covered with surgical dressing, and radiotherapy
in the precut, preradiotherapy group. Mean keloid
was performed within 24 hours (900 cGy). The
size was 5.2 by 10.3 cm. They were treated using
patient received a second operation the following
our novel precut, preradiotherapy method.
day. After administration of anesthesia, the sutures
were removed, and the keloid mass was excised. The
All patients with chest wall keloids in this study had
size of the wound was measured, and an interme-
no history of smoking or autoimmune disease. There
diate split-thickness skin graft was harvested from
was no significant difference in mean size of keloid
the groin. After hemostasis, the wound was covered
and wound between the two groups. Patients
with the skin graft and a bolus pressure dressing.
received follow-up examinations from two experi-
The dressing was removed between postoperative
enced nurses in our center 6 and 12 months after
days 10 and 14, and the second round of
surgery. The Institutional Review Board of Peking
radiotherapy was performed (900 cGy). Radiother-
Union Medical College Hospital approved the
apy at the groin was performed as for the
experimental protocols, and all patients had
conventional method.
previously provided informed consent.
40:1:JANUARY 2014 53
KELOID EDGE PRECUT PRERADIOTHERAPY METHOD
Discussion
Results
Keloid formation and expansion is related to skin
Twenty-nine patients were treated with conven- tension. Keloids often occur in the anterior chest,
tional surgery and radiotherapy. In these patients, 16 shoulder, scapular, and suprapubic regions,5 sites
cases of keloid recurrence were observed (Table 1); that are constantly subjected to mechanical forces
the recurrence rate was 55.2%, and the cure rate from body movement. Ogawa thought that
(including cured and partially cured scars) was mechanical forces may not only promote keloid
44.8%. Recurrent keloids extended along the sur- growth, but also be the primary trigger of their
gical incisions, expanding beyond the incision range. generation.6 Therefore, reducing the mechanical
The keloid mass was hard and red or purplish- red in force on healing skin would help to prevent the
color. The grafted skin was contracted, crimped, and development and recurrence of keloids.7
54 DERMATOLOGIC SURGERY
LI ET AL
Many methods have been used to reduce the closed directly. Tensile reduction sutures are often
mechanical force on wounds. In cases of small used to reduce wound tension.6 In patients with
keloids, the wound edge after keloid removal can be larger keloids, the wound often cannot be closed
directly, and a skin flap must be used to distribute
TABLE 2. Aesthetic Results According to Treatment the wound tension,7 but a skin flap is not always
Method
available. In patients with large keloids, a local skin
Treatment Good Acceptable Poor
flap cannot provide sufficient skin coverage.
Method n (%) n (%) n (%)
Furthermore, some patients refuse to accept a skin
Conventional, 6 (20.7) 9 (31.0) 14 (48.3)
flap procedure because it requires additional inci-
n = 29
Precut, n = 24 12 (50.0) 10 (41.7) 2 (8.3) sions at the same surgical site. In these cases, skin
40:1:JANUARY 2014 55
KELOID EDGE PRECUT PRERADIOTHERAPY METHOD
grafts might be performed;2 tissue expansion can The incision was then approximated with continu-
also be used in some cases.8 ous intradermal sutures after bipolar coagulation.
To prevent wound infection, the keloid was not
Surgical therapy can be used to remove the keloid removed at that time. The tissue trauma and
mass and resurface the wound, but surgical excision systemic reaction that this procedure caused were
without any postsurgical treatment is not sufficient almost the same as those that conventional keloid
to prevent keloid recurrence. The reported recur- removal surgery causes. Radiotherapy was applied
rence rate is between 45% and 100% in patients approximately 24 hours after surgery. This treat-
treated with surgical therapy alone.3 Many types of ment procedure greatly suppressed neovascular for-
adjunctive therapies after keloid operations have mation and fibroblast proliferation reaction around
been reported, including radiation therapy,3 steroid the incision. The third step involved keloid removal
injection,9 imiquimod therapy,10 and pressure.11 and skin graft procedures. This step was performed
Radiation therapy is the most effective of on the day after radiotherapy. The skin graft was
these methods.3 typically harvested from the groin, and the groin
wound was closed directly. The second radiotherapy
The recommended radiation therapy procedure is to treatment was the final step in the treatment
radiate the surgical site within 24 or 48 hours after procedure. This procedure was usually performed
the operation.3 The recommended radiation doses between postoperative days 10 and 14, at which
(single or cumulative) and intervals between appli- time the sutures were removed, and graft survival
cations vary.3 It has been reported that radiotherapy was evaluated.
with a single 900-cGy dose is effective when applied
on postoperative day 1 or 7.12 Radiotherapy can With the precut method, the sequence of the con-
easily be applied if the wound is directly closed using ventional treatment procedure was rearranged to
a tensile reduction suture, skin flap transference, or enable early-stage radiotherapy. Our clinical data
tissue expansion, but radiotherapy cannot be applied demonstrated the good surgical and aesthetic results
within 24 or 48 hours after surgery if the wound is of the treatment. The precut method achieved a lower
closed using a skin graft. The bolus dressing and keloid recurrence rate than the conventional method.
bandage will impede radiotherapy. Radiation injury The aesthetic satisfaction rate in the precut group
at this time will also negatively influence graft was also higher than that in the conventional group.
survival. Radiotherapy is often postponed until
the suture is removed and the graft is determined to The clinical data have demonstrated the effective-
have survived. ness of early-stage radiotherapy, but the mechanism
of this effect remains unclear. Radiotherapy may
The effects of radiation on keloids are thought to be suppress the inflammatory reaction as well as
mediated through the inhibition of neovascular buds neovascular formation and fibroblast proliferation
and proliferating fibroblasts, which results in less to promote healing after keloid scar removal.
collagen production.13 Failure to apply early-stage
radiotherapy leads to more neovascular formation
Conclusion
and fibroblast proliferation and increases the recur-
rence risk. To solve the problem of the inconve- Early-stage radiotherapy is an important adjunctive
nience of early-stage radiotherapy in patients with therapy for the prevention of postoperative keloid
keloids treated with skin grafts, we rearranged the recurrence. In patients treated with skin grafts,
order of the procedure. First, we precut the edge of early-stage radiotherapy is often hindered. With the
the keloid. The incision was made in the normal skin precut, preradiotherapy method, the conventional
near the keloid, deep into the subcutaneous layer. treatment procedure was rearranged to permit
56 DERMATOLOGIC SURGERY
LI ET AL
early-stage radiotherapy. A low recurrence rate and keloid and hypertrophic scar reconstruction. J Nippon Med Sch.
2011;78(2):6876.
satisfactory clinical results were achieved with this
7. Aoki M, Akaishi S, Ono S, Iwakiri I, et al. Usefulness and
method. Precut, preradiotherapy treatment may be a problems of flap surgery for keloids. Scar Management
promising choice for patients with large keloids that 2010;4:10811.
require skin graft operations. 8. Roeder JA, White SK. Tissue expansion for the treatment of
keloids. Plast Surg Nurs. 1990;10(3):1147.
40:1:JANUARY 2014 57