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Keloids: When Excision Is the Better Part of Valor

Marsh, Daniel J. M.R.C.S.; Pacifico, Marc D. M.R.C.S.; Gault, David T. F.R.C.S.

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Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 214e-215e
doi: 10.1097/01.prs.0000305379.97906.68
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Sir:

Keloid scars continue to present a thorn in the plastic surgeon’s side. Until the underlying biological mechanisms are better understood, it seems that no treatment will be able to satisfactorily overcome all problems. We are left with a limited armory of suboptimal solutions that include pressure therapy, silicone gel sheets, intralesional steroid injection, excision, carbon dioxide laser ablation, and radiotherapy.1 These treatments suffice for most patients with a small number of keloids of reasonable size, but there are other patients with a large number of massively overgrown scars for whom permanent control of the problem is not possible. We have therefore adopted an alternative philosophy to deal with selected patients for whom the uphill battle to conquer the keloids can never be won. One patient in particular illustrates this approach.

The patient was a 27-year-old woman of Afro-Caribbean origin who first presented when she was 11 years old with a single keloid scar on her right upper ear after having been scratched by her neighbor’s dog. Subsequently she developed multiple keloid scars at a variety of sites, mostly as a result of very minor trauma. Between treatments, the original ear keloid continued to increase in size. Over the 16 years that she has been under our care, she has undergone every treatment available to us, including silicone gel sheeting, intralesional steroid injection, surgical excision (with or without flap reconstruction) and steroid injection into the wound, pressure therapy, carbon dioxide laser treatment, and excision with postoperative radiotherapy. At one recent operation, 168 g of keloid tissue was excised. Furthermore, various experimental therapies have been used, including intraoperative use of collagenase.

Three years ago, having accepted that none of the treatments produced any better results in her than another, we accepted a manner of defeat. We now admit her on an annual basis and perform intralesional scar excisions under general anesthesia. In so doing, we do not recruit any virgin skin into the surgical wound and aim purely to debulk the scars so that she is able to continue with as normal a life as possible. She remains free of massive disfiguring scars for 8 to 9 months before recurrence inevitably sets in. She accepts this approach and finds it preferable to any other she has previously undergone, and these repeated scar-free periods are beneficial to an attractive young girl, allowing her to lead a semblance of a normal life for a period. This technique is demonstrated in Figures 1 and 2.

Fig. 1.
Fig. 1.:
Preoperative view before intralesional debulking.
Fig. 2.
Fig. 2.:
Postoperative view after intralesional debulking.

We now use the philosophy of regular intralesional debulking surgery in such patients with aggressive, almost malignant keloid scars. After all, for the foreseeable future, there is no prospect of beating them, but at least we can lose honorably.

Daniel J. Marsh, M.R.C.S.

Marc D. Pacifico, M.R.C.S.

David T. Gault, F.R.C.S.

Mount Vernon Hospital

London, England

REFERENCE

1. Mustoe, T. A., Cooter, R. D., Gold, M. H., et al. International clinical recommendations on scar management. Plast. Reconstr. Surg. 110: 560, 2002.

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