Journal Logo


Postoperative Radiation Therapy for Keloid

Ogawa, Rei M.D., Ph.D.; Miyashita, Tsuguhiro M.D., Ph.D.; Hyakusoku, Hiko M.D., Ph.D.

Author Information
Plastic and Reconstructive Surgery: April 2008 - Volume 121 - Issue 4 - p 1513
doi: 10.1097/01.prs.0000305366.28504.b4
  • Free


We would like to make critical comments on an article by van de Kar and colleagues entitled “The Results of Surgical Excision and Adjuvant Irradiation for Therapy-Resistant Keloids” (Plast. Reconstr. Surg. 119: 2248, 2007).

First, they used “Gy” as the scale of radiation absorption dose in the abstract, body, and Table 4 of their article. This is a clear mistake. They must have meant “cGy” (centigray). If they meant 1200 cGy, this means 12 Gy. Second, they indicated that “superficial 250-kV electron beam irradiation was used.” If 250 kV were correct, an electron beam would be impossible. They must have used x-rays. From these basic errors, we consider that no competent radiation oncologist participated in the radiation therapies. Moreover, it is doubtful that appropriate irradiation was performed on the appropriate area.

Third, they cited our article1 and commented that “some authors did not even report their minimum follow-up period.” However, in the article they cited, we indicated that “only cases that were followed for more than 18 months were selected for this study.” In fact, the median follow-up period was 24 months (range, 18 to 128 months) in our article.1

Fourth, they claimed that “some authors did not describe whether or not they performed histologic tissue analysis.” However, we clearly stated that “pathological discrimination of hypertrophic scars from keloids is difficult except for typical keloids.”1 In our experience, the history of the keloid and the clinical findings are much more important factors when it comes to distinguishing keloids from hypertrophic scars. If they insist on the importance of a histological examination, they must cite some articles2,3 that describe the pathological differences between keloid and hypertrophic scars.

Fifth, 18 of 21 patients (85.7 percent) in their study were of the black race. It is considered that keloid prevalence is five to 15 times higher in African-Americans than in Caucasians.4 Logically, therefore, their conclusions should be limited to people of the black race, admitting that appropriate radiation therapy was administered. However, they did not even describe the differences in prevalence or recurrence rates by race. Moreover, the number of patients by keloid site was too small. Recurrence rate by keloid site is a very useful indicator, as we have indicated previously.1 In our facility, keloids of Asian people are treated with dose protocols that are customized for each site: (1) 20 Gy in four fractions over 4 days for the anterior chest wall, scapular region, and suprapubic region, (2) 10 Gy in two fractions over 2 days for the earlobes, and (3) 15 Gy in three fractions over 3 days for other sites.

In conclusion, they should reconsider the cause of the abnormally high recurrence rates in their results. In addition, they should review and discuss whether or not their prescription and delineation of the target volume were appropriate. We think they should cast an eye on our facility, where we have tried to calculate the absorbed dose, even in irregular and complicated irradiation fields, on a case-by-case basis. Moreover, we have used a self-management program for postoperative patient care.

Rei Ogawa, M.D., Ph.D.

Tsuguhiro Miyashita, M.D., Ph.D.

Hiko Hyakusoku, M.D., Ph.D.

Department of Plastic and Reconstructive Surgery

Nippon Medical School

Tokyo, Japan


1. Ogawa, R., Mitsuhashi, K., Hyakusoku, H., and Miyashita, T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: Retrospective study of 147 cases followed for more than 18 months. Plast. Reconstr. Surg. 111: 547, 2003.
2. Ehrlich, H. P., Desmouliere, A., Diegelmann, R., et al. Morphological and immunochemical differences between keloid and hypertrophic scar. Am. J. Pathol. 145: 105, 1994.
3. Lee, J. Y., Yang, C. C., Chao, S. C., et al. Histopathological differential diagnosis of keloid and hypertrophic scar. Am. J. Dermatopathol. 26: 379, 2004.
4. Slemp, A. E., and Kirschner, R. E. Keloids and scars: A review of keloids and scars, their pathogenesis, risk factors, and management. Curr. Opin. Pediatr. 18: 396, 2006.

Section Description

Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.

Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS' enkwell, at

We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.

The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

©2008American Society of Plastic Surgeons