A Keloid Edge Precut, Preradiotherapy Method in Large Keloid

Skin Graft Treatment

WENBO LI, MD, YOUBIN WANG, MD, XIAOJUN WANG, MD, AND ZHIFEI LIU, MD*

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.

A keloid is a benign growth caused by an

overabundance of collagen deposits. Surgical
excision is one of the major methods used for keloid
treatment. In patients with large keloids, the wound
is sometimes difficult to close after the keloid has
been removed, and skin grafts and skin flap trans-
plantations are often necessary,1,2 but skin flaps are
not available in all patients. Skin grafts are the only
remaining option for covering defects in some
patients.
Surgical excision without other adjuvant treatment
is less effective in keloid treatment. The recurrence
rate is reportedly between 45% and 100% in cases
treated with surgical excision alone.3 Combining
surgical excision with adjuvant radiotherapy can
provide satisfactory results without recurrence in
up to 97% of cases.4 Radiotherapy is most
effective when it is applied immediately, ideally on
the day of the surgical excision and no more than
2448 hours after surgery,3 but in patients receiv-
ing skin grafts, the application of radiotherapy
treatment within these time constraints is not
practical because of surgical bandage impedance
and concerns about graft survival. Therefore,
radiotherapy treatment is often postponed to
14 days after surgery (when the graft has sur-
vived). We designed the keloid edge precut,
preradiotherapy method to address the problems
of delayed radiotherapy.

*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.

Evaluation after Therapy

Surgical and Radiotherapy Methods
Two experienced nurses in our center evaluated the
Conventional Surgical and Radiotherapy scar at the surgical site during the follow-up period.
They were experienced in scar evaluation but had no
After intravenous general anesthesia was adminis-
awareness of the detailed treatment for each patient.
tered, the edge of the keloid was marked. The keloid
They took photographs of each patient at follow-up
mass and normal skin vicinity was infused with
and completed the evaluation at the same time. The
0.5% lidocaine (1:100,000 epinephrine). The keloid
scar was rated using the following guidelines:
mass was then excised along the mark. The size of

40:1:JANUARY 2014 53
 KELOID EDGE PRECUT PRERADIOTHERAPY METHOD
Ordinary scar: flat, pale in color, within the limits
of the operation incision; the patient may
experience an occasional tingling sensation at the
site of the scar.
Hypertrophic scar: protuberant, red or
purplish-red in color, within the range of the
operation incision; the patient often experiences
itching and aching.
Keloid scar: protuberant, red or purplish-red in
color, exceeds the range of the operation incision;
the patient often experiences significant itching
and aching.
The evaluator nurses graded the keloid therapy
results at follow-up as follows: cured, an ordinary
scar at the surgical site; partially cured, a hypertro-
phic scar in a part or the entirety of surgical site;
recurrence, a keloid scar in a part or the entirety of
the surgical site.
Patients aesthetic satisfaction was also recorded and
evaluated at the final visit. The questionnaires were
used to gather information about the opinions of
patients. The aesthetic results were graded as good,
acceptable, or poor. No detailed guidelines were
given to the patients when conducting these
satisfaction questionnaires.
The recurrence and aesthetic satisfaction rates were
recorded and compared. Data were analyzed using
SPSS 17.0 software (SPSS, Inc., Chicago, IL).
Recurrence and satisfaction rates of the two groups
were compared using the chi-square test.
Results
Twenty-nine patients were treated with conven-
tional surgery and radiotherapy. In these patients, 16
cases of keloid recurrence were observed (Table 1);
the recurrence rate was 55.2%, and the cure rate
(including cured and partially cured scars) was
44.8%. Recurrent keloids extended along the sur-
gical incisions, expanding beyond the incision range.
The keloid mass was hard and red or purplish- red in
color. The grafted skin was contracted, crimped, and
54 DERMATOLOGIC SURGERY
TABLE 1. Keloid Treatment Results According to
Treatment Method
Partially
Cured Cured Recurred
Treatment Method n (%) n (%) n (%)
Conventional, 2 (6.9) 11 (37.9) 16 (55.2)
n = 29
Precut, n = 24 11 (45.8) 9 (37.5) 4 (16.7)
dark in color (Figures 1 and 2). Fourteen (48.3%) of
the patients in this group were dissatisfied with the
aesthetic results (poor grade), 20.7% thought that
the aesthetic results were good, and 31.0% thought
the results were acceptable (Table 2).
Twenty-four patients were treated using the precut,
preradiotherapy method. Four of these (16.7%)
experienced keloid recurrence in the follow-up
period. The cure rate (including cured and partially
cured scars) was 83.3%. The recurrence rate in this
group was significantly lower than that in the
conventional method group (v2 = 6.73, p < .01)
(Table 1). The incision scar was flat, soft, and pale.
The grafted skin was also flat and pale. There was no
obvious graft contraction (Figures 3 and 4), and
only two (8.3%) of the patients in this group were
dissatisfied with the aesthetic results (poor). The
majority of patients rated the aesthetic results as
good (50.0%) or acceptable (41.7%) (Table 2).
There was also significant difference in the aesthetic
results between the two groups (v2 = 7.50, p < .01).
Discussion
Keloid formation and expansion is related to skin
tension. Keloids often occur in the anterior chest,
shoulder, scapular, and suprapubic regions,5 sites
that are constantly subjected to mechanical forces
from body movement. Ogawa thought that
mechanical forces may not only promote keloid
growth, but also be the primary trigger of their
generation.6 Therefore, reducing the mechanical
force on healing skin would help to prevent the
development and recurrence of keloids.7
 LI ET AL

Figure 1. Case 1 in the conventional surgical and radiotherapy method group.

Figure 2. Case 2 in the conventional surgical and radiotherapy method group.

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

Figure 3. Case 1 in the precut, preradiotherapy method group.

Figure 4. Case 2 in the precut, preradiotherapy method group.

40:1:JANUARY 2014 55
 KELOID EDGE PRECUT PRERADIOTHERAPY METHOD
grafts might be performed;2 tissue expansion can
also be used in some cases.8
Surgical therapy can be used to remove the keloid
mass and resurface the wound, but surgical excision
without any postsurgical treatment is not sufficient
to prevent keloid recurrence. The reported recur-
rence rate is between 45% and 100% in patients
treated with surgical therapy alone.3 Many types of
adjunctive therapies after keloid operations have
been reported, including radiation therapy,3 steroid
injection,9 imiquimod therapy,10 and pressure.11
Radiation therapy is the most effective of
these methods.3
The recommended radiation therapy procedure is to
radiate the surgical site within 24 or 48 hours after
the operation.3 The recommended radiation doses
(single or cumulative) and intervals between appli-
cations vary.3 It has been reported that radiotherapy
with a single 900-cGy dose is effective when applied
on postoperative day 1 or 7.12 Radiotherapy can
easily be applied if the wound is directly closed using
a tensile reduction suture, skin flap transference, or
tissue expansion, but radiotherapy cannot be applied
within 24 or 48 hours after surgery if the wound is
closed using a skin graft. The bolus dressing and
bandage will impede radiotherapy. Radiation injury
at this time will also negatively influence graft
survival. Radiotherapy is often postponed until
the suture is removed and the graft is determined to
have survived.
The effects of radiation on keloids are thought to be
mediated through the inhibition of neovascular buds
and proliferating fibroblasts, which results in less
collagen production.13 Failure to apply early-stage
radiotherapy leads to more neovascular formation
and fibroblast proliferation and increases the recur-
rence risk. To solve the problem of the inconve-
nience of early-stage radiotherapy in patients with
keloids treated with skin grafts, we rearranged the
order of the procedure. First, we precut the edge of
the keloid. The incision was made in the normal skin
near the keloid, deep into the subcutaneous layer.
56 DERMATOLOGIC SURGERY
The incision was then approximated with continu-
ous intradermal sutures after bipolar coagulation.
To prevent wound infection, the keloid was not
removed at that time. The tissue trauma and
systemic reaction that this procedure caused were
almost the same as those that conventional keloid
removal surgery causes. Radiotherapy was applied
approximately 24 hours after surgery. This treat-
ment procedure greatly suppressed neovascular for-
mation and fibroblast proliferation reaction around
the incision. The third step involved keloid removal
and skin graft procedures. This step was performed
on the day after radiotherapy. The skin graft was
typically harvested from the groin, and the groin
wound was closed directly. The second radiotherapy
treatment was the final step in the treatment
procedure. This procedure was usually performed
between postoperative days 10 and 14, at which
time the sutures were removed, and graft survival
was evaluated.
With the precut method, the sequence of the con-
ventional treatment procedure was rearranged to
enable early-stage radiotherapy. Our clinical data
demonstrated the good surgical and aesthetic results
of the treatment. The precut method achieved a lower
keloid recurrence rate than the conventional method.
The aesthetic satisfaction rate in the precut group
was also higher than that in the conventional group.
The clinical data have demonstrated the effective-
ness of early-stage radiotherapy, but the mechanism
of this effect remains unclear. Radiotherapy may
suppress the inflammatory reaction as well as
neovascular formation and fibroblast proliferation
to promote healing after keloid scar removal.
Conclusion
Early-stage radiotherapy is an important adjunctive
therapy for the prevention of postoperative keloid
recurrence. In patients treated with skin grafts,
early-stage radiotherapy is often hindered. With the
precut, preradiotherapy method, the conventional
treatment procedure was rearranged to permit

early-stage radiotherapy. A low recurrence rate and
satisfactory clinical results were achieved with this
method. Precut, preradiotherapy treatment may be a
promising choice for patients with large keloids that
require skin graft operations.
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Address correspondence and reprint requests to: Youbin
Wang, MD, Peking Union Medical College Hospital,
Beijing 100032, China, or e-mail: wy.benz@aliyun.com
40:1:JANUARY 2014 57