Is Keloid Scar Removal Surgery Worthless?

Keloid scar removal treatment is a long and frustrating process. Many patients have undergone multiple painful steroid injections that may have only reduced the size of the keloid but not flattened it completely. Others may notice only a temporary improvement or even no change at all. While there are constant developments with newer and more effective injectable treatments for keloid removal in Singapore, the costs add up and improvements are usually gradual.

Faced with such a reality, patients seeking keloid scar treatment in Singapore often find it tempting to undergo keloid surgery to 'just cut away the keloid'. After all, it seems logical that physically removing the keloid gets rid of the problematic area, allowing everything to go back to normal.

Unfortunately, the facts are cruel. No matter how nice the area looks after keloid scar removal surgery, studies show that up to 100% of keloid scars recur. Many patients that have come to consult me for keloid scar removal treatment have been to other medical aesthetics doctors, dermatologists, and even plastic surgeons. These patients were told that keloid scar removal surgery is not a viable option for their keloid. Given these statistics, this certainly seems the case.

Is keloid scar removal surgery really worthless? To answer this question, we need to understand why keloids recur after surgery, when surgery is a good option and how to make surgery work for you.

Why do keloids recur after keloid scar removal surgery?

Keloids result from an abnormal skin healing response. After an injury, an excessive inflammatory reaction results in excessive collagen deposition. The key to understanding why keloids recur after surgery is to realize that the abnormal healing process extends to the entire body. Even if the keloid is physically gone, the normal-looking skin is still more prone to keloids.

Furthermore, most doctors are still using relatively outdated keloid scar removal surgery techniques. These older methods, (even if they involve lasers) result in large raw surfaces that take a long time to heal or excessive tension on the wound. Such keloid scar removal surgeries provoke a lot of inflammation during recovery, stimulating keloid activity and regrowth. Hence the bad reputation of keloid removal surgery and its high recurrence rate.

When is keloid scar removal surgery a good option?

Despite its drawbacks, keloid scar removal surgery has advantages, particularly in large or longstanding keloids. Such keloids may have accumulated a dense fibrous core comprised of built-up collagen. These mature areas are relatively metabolically inactive with minimal blood flow. Thus, the keloid may respond poorly or not at all to non-surgical interventions. Clinically, this would manifest as a stubborn refusal to reduce in size despite multiple rounds of treatments such as steroid injections.

By removing the keloid mass through surgery, patients can see a much more rapid and complete improvement in the appearance of the keloid. Keloid scar removal surgery directly removes the excessive collagen and abnormal scar tissue thus treating even resistant and recalcitrant keloids.

While surgery may cost more upfront than injections or lasers, the keloid scar removal treatment course may actually cost less overall. It may take many rounds of injections to reach the same level of keloid removal that surgery can provide, which could add up to significantly more than the price of keloid scar removal surgery.

Selecting the right keloids to operate on is also key to getting good results.

How to make keloid scar removal surgery work?

In my experience, keloid scar removal surgery can actually work very well, sometimes much better than non-surgical treatments like injections or lasers. However, for keloid scar removal surgery to work, careful attention must be paid to the following

• healing from the surgery
• pressure/tension on the keloid
• suppression of keloid growth

Healing from keloid scar removal surgery

As keloids result from an overactive healing response, the less healing that needs to take place as a result of keloid scar removal surgery, the better. Older surgical techniques such as surgical shave excision (even when done with a laser) result in large raw wounds that take a long time to heal. This extensive and prolonged healing process triggers a lot of inflammation that is basically an invitation for the keloid to grow back.

Some clinics and hospitals in Singapore are still actively using these methods. I've seen multiple patients who've had their keloids grow back repeatedly (sometimes bigger) after keloid scar removal surgeries using such older techniques.

Even with newer methods with dramatically faster recovery, care has to be taken during surgery to limit the amount of healing that needs to take place. Over-zealous or radical removal of keloid scar tissue can affect the blood supply to the area, resulting in wound breakdown and a lengthy healing period that increases the risk of keloid regrowth. Sometimes less is more and it's a fine line between removing just enough keloid tissue that practically makes the keloid disappear and trying too hard to strip out all the keloid tissue in the area causing more problems.

Growth factors can also be considered during the healing phase immediately after keloid scar removal surgery. They speed up wound healing and exert an anti-inflammatory effect.

Pressure/tension

Tension is a strong stimulus for keloid growth. Wound tension and stretching provoke inflammation and thus hypertrophic scarring. Any keloid scar removal surgery should take wound tension into account. For example, extramarginal excision is very attractive to both patients and surgeons. It removes the entire keloid and some of the surrounding skin. After extramarginal excision, there is no longer any visible keloid scar. To close the resultant wound, the surgeon stretches the surrounding skin inwards and stitches the edges together. This does not produce a large wound that takes a long time to heal. However, the natural tendency is for the surrounding skin to pull back outwards. This produces tension on the wound line, stimulating excessive inflammation that may lead to keloid regrowth.

Indeed, I've seen many patients that had their keloids regrow after extramarginal excision, sometimes even larger than before. Extramarginal excision can work well but only in a very select group of keloids. Tension relieving measures such as subdermal/fascial sutures, and steristrips can reduce the tension on the wound. Even then, the risk of recurrence is elevated compared to newer methods of keloid scar removal surgery.

Conversely, immobilization and pressure on the wound help to prevent keloid regrowth after surgery. Examples include magnetic pressure earrings, pressure garments, and external mechanical support using tapes, sheets, and/or garments. Such measures need to be prolonged and sustained until the keloid is mature and inactive. Keloid scar treatment using neurotoxins can relax the wound edges, reducing dynamic muscle tension. This blocks some of the signals telling the keloid to regrow.

Suppression of keloid growth

It is absolutely essential to suppress the activity of the keloid before, during, and after surgery. No matter how precise and minimalist the surgery is, there will be some inflammation during healing that may trigger keloid recurrence. Lasers, injections, keloid scar removal creams, and even oral medications help to reduce the inflammatory reaction from the skin.

While most of the inflammation peaks after surgery and tapers off subsequently, we should not relax too early and stop the suppressive treatments. This is a common mistake and one of the top reasons why a keloid grows back after surgery. The keloid may look like it is much better or even completely gone after the surgery. Don't be fooled! The abnormal keloidal healing response remains. It is necessary to suppress this until inflammation from the keloid scar removal surgery subsides and the keloid is dormant. When in doubt, it is better to continue suppressing the keloid's growth for longer until we are sure that it is no longer active.

My take on keloid scar removal surgery

Contrary to what many patients may have been told, keloid scar removal surgery is not pointless. In fact, it can often produce faster, better, and more complete keloid removal in the right hands. The truth is that, like many medical aesthetics treatments, your doctor's experience, skill, and judgment are key to the results.

Surgery is an important tool in our treatment arsenal for keloid removal. As you've probably already surmised, many subtle details need to be handled properly for keloid scar removal surgery to succeed. Doing surgery haphazardly without paying attention to these important factors may indeed be worthless and might as well not be attempted. If you have any questions, please feel free to drop by for a consultation!

References

1. Ogawa R. (2022). The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago. Plastic and reconstructive surgery, 149(1), 79e–94e. https://doi.org/10.1097/PRS.0000000000008667
2. Ogawa, R., Akaishi, S., Kuribayashi, S., & Miyashita, T. (2016). Keloids and Hypertrophic Scars Can Now Be Cured Completely: Recent Progress in Our Understanding of the Pathogenesis of Keloids and Hypertrophic Scars and the Most Promising Current Therapeutic Strategy. Journal of Nippon Medical School = Nippon Ika Daigaku zasshi, 83(2), 46–53. https://doi.org/10.1272/jnms.83.46
3. Wang, L. Z., Ding, J. P., Yang, M. Y., & Chen, B. (2014). Forty-five cases of chest keloids treated with subcutaneous super-tension-reduction suture combined with postoperative electron-beam irradiation. Dermatologic surgery : official publication for American Society for Dermatologic Surgery [et al.], 40(12), 1378–1384. https://doi.org/10.1097/DSS.0000000000000163
4. Gurung, K. , Tan, Q. , Xu, Y. and Duan, B. (2020) Botulinum Toxin Type A and Its Possible Mechanisms on Wound Healing. Modern Plastic Surgery, 10, 38-55. https://doi.org/10.4236/mps.2020.103006
5. Sanders, K. W., Gage-White, L., & Stucker, F. J. (2005). Topical mitomycin C in the prevention of keloid scar recurrence. Archives of facial plastic surgery, 7(3), 172–175. https://doi.org/10.1001/archfaci.7.3.172