Keloids Surgical

management
Dr Tanmayee
Dept of Plastic Surgery
CMCH
 Abnormal proliferation of scar tissue that forms at the site of
cutaneous injury that grows beyond the original scar margins.
Benign dermal fibroproliferative tumors with no malignant
potential.
The term keloid, meaning "crab claw," was first coined by Alibert in
1806, in an attempt to illustrate the way the lesions expand
laterally from the original scar into normal tissue.
 Keloids are found only in humans and occur in 5-15% of wounds.
They tend to affect both sexes equally, although more common in
premenopausal women and more severe in susceptible women
during pregnancy.
15 times higher in pigmented/dark individuals.
The average age at onset is 10-30 years.
 Genetic associations for the development of abnormal scars have
been found for HLA-B14, HLA-B21, HLA-BW16, HLA-BW35, HLA-
DR5, HLA-DQW3, and blood group A.
Spectrum of
wound healing
 TGF- is a cytokine implicated in the pathogenesis of keloids. It is
produced and released by platelets, fibroblasts, endothelial,
epithelial, and inflammatory cells such as macrophages and
lymphocytes after skin injury and participates in the regulatory
process of cell proliferation and tissue repair.
Pathogenesis Low levels of the inmmune-response modifiers, interferon alpha
and gamma (IFN-, IFN-) IFN-2b achieves its antifibrotic
properties by normalizing collagen, glycosaminoglicans, and
collagenase synthesis and activity.
Current research targets these pathogenetic mechanisms
 Four histologic features that are consistently found in keloid
specimens that are deemed pathognomonic for their diagnosis.
1) the presence of keloidal hyalinized collagen
2) a tonguelike advancing edge underneath normal-appearing
epidermis and papillary dermis
3) horizontal cellular fibrous bands in the upper reticular dermis
4) prominent fascia like fibrous bands.
 Grow beyond margins
Height more than 4 mm
Do not regress
Characteristics Recurrence
 Local therapy.
Approach to Excision.

management Post excisional treatments.

 Intralesional injection of : Corticosteroids, 5-FU, Bleomycin
Pressure application
Local Silicon sheets
therapies. Botox
 Intralesional triamcinolone

Intralesional cortisone improves keloids by inhibiting alpha 2-

macroglobulin, which inhibits collagenase in keloids. An increase
in collagenase then increases collagen degradation
Triamcinolone has been found to inhibit transforming growth
factor (TGF)-1 expression and to induce apoptosis in fibroblasts
The papillary dermis is the target because that is where
collagenase is produced
Given pre and postoperatively 1 week after sutures are removed
50-100% response rates
Local dermal atrophy, hypopigmentation, suppression of axis
 5-Fluorouracil Therapy

Intralesional 5-fluorouracil ( 5-FU is an antimetabolite that blocks

DNA synthesis by blocking thymidylate synthetase) decreases
collagen synthesis in proliferating fibroblasts.
Better results are achieved when used in combination with
triamcinolone.
The standard dosage is 5-FU 50 mg/mL, 0.9 mL, and 0.1 mL of
triamcinolone acetonide 10 mg/mL. Lesions are injected 1 to 3
times a week for 10 to 12 weeks.
 The combination of 5-fluorouracil (5-FU) and triamcinolone seems
to be superior to intralesional steroid therapy alone in the
treatment of keloids; an average reduction in 92% of the lesion
size has been reported for this combination therapy compared to
73% for steroid therapy alone

-Davison SP, Dayan JH, Clemens MW, et al. Efficacy of intralesional 5-fluorouracil and
triamcinolone in the treatment of keloids. Aesthet Surg J. 2009;29:4046.
 Intralesional Interferon

Interferon alpha and gamma inhibit type I and III collagen

synthesis. Other potential mechanisms of action include reduced
production of transforming growth factor beta and increased
levels of collagenase activity.

1 million units of interferon alpha-2b per linear centimeter in the

postoperative site immediately after surgery and 1 to 2 weeks
later.
Better outcomes in combination therapies.
 Imiquimod Therapy

Imiquimod is a topical therapeutic agent that acts as an immune-

response modulator by inducing interferon-, tumor necrosis
factor-, and interleukin-1, -6, and -8.
5% cream applied daily starting immediately till 8 weeks
Patients with large excisions, wounds under tension, or wounds
closed with flaps or grafts are advised not to use imiquimod for 4
to 6 weeks after excision because the postoperative site may splay
or dehisce.
50% patients develop hyperpigmentation
 Altered kinetics of collagenase and resulting scar formation due to
an increase in skin surface temperature of approximately 1.7C
Silicone based Increases tissue hydration by decreasing water evaporation in the
products stratum corneum; restoring epithelial fluid homeostasis.Hydration
mechnism is unique to silicone as compared to other occlusive
dressings.
 Verapamil is a phenylalkylamine calcium channel blocker
antiarrhythmic agent that alters fibroblast shape (from bipolar to
spherical), induces procollagenase expression, inhibits the
synthesis/secretion of extracellular matrix molecules, including
collagen, glycosaminoglycans, and fibronectin, and increases
collagenase
Can reduce the incidence of keloid recurrence after surgical
excision and topical silicone application

-Lawrence WT. Treatment of earlobe keloids with surgery plus adjuvant intralesional
verapamil and pressure earrings. Ann Plast Surg. 1996;37:167169.
 Simple surgical excision has high chance of recurrence..

Types if intralesional excision : Core excision with suprakeloidal

flap , subtotal , intramarginal
Intra marginal excision with suprakeloidal flap
 Low dose fractionated radiotherapy post surgery :most effective
5-FU and Triamcinolone injection post surgery.
Post operative triple keloid therapy combining surgery, corticosteroids, and
adjuvant silicone sheeting has been shown to be even more effective, with
only a 12.5 percent recurrence rate after 13 months
Time* Treatment Regimen
0 Injection 1: Intralesional triamcinolone acetonide, 40 mg/mL
1 month Injection 2: Same as injection 1
1 month Injection 3: Same as injection 1
1 month Surgical excision
Injection 4: Triamcinolone acetonide, 10 mg/mL, intraoperatively

57 days Suture removal

Apply silicone gel sheeting

13 weeks Injection 5: Triamcinolone acetonide, 10 mg/mL, to 3 parts

Apply topical 5% imiquimod cream twice weekly

46 weeks Injection 6: Same as injection 5

Begin tapering silicone gel sheeting

46 weeks Injection 7: Same as injection 5

4 weeks to 9 months Continue injections as needed to prevent recurrence
Consider silicone gel sheeting at signs of recurrence

Source: Modified from Brissett AE, Sherris DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg
2001;17(4):263272.
 Recommended dosages range from 10 to 20 Gy with timing of
administration within 2 days after surgery.
Doses are tailored for the anatomic site, with higher dosages
reserved for sites exposed to greater skin tension (ie, chest wall,
shoulder, scapula).
In 2007 Ogawa and colleagues recommended radiation protocols
depending on anatomic site:
(1) anterior chest wall, shoulder-scapular region, suprapubic
region, 20 Gy in 4 fractions over 4 days;
(2) ear lobe, 10 Gy in 2 fractions over 2 days; and
(3) for other sites, 15 Gy in 3 fractions over 3 days
 BTX injections into the musculature adjacent to the wound (15 IU
of BTX-A, Allergan) resulted in enhanced wound healing and less
noticeable scars. (2006, Gassner et al)
Interleukin 10
Ongoing Mitomycin C
research Tamoxifen Citrate
Methotrexate
Retinoids
Tacrolimus