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Keloid Scar Removal Surgery: Are Your Keloids Suitable?

by Dr Wan Chee Kwang
September 12, 2022

Keloid scar removal surgery is notorious for failure. Modern surgical techniques and ancillary treatments can greatly improve the chances of successful keloid scar removal surgery. However, this does not take away from the fact that surgical removal of keloids is risky and may actually worsen the scarring.

Some keloid scars have a fantastic response to keloid scar removal surgery while others have a less optimal course. Selecting which keloids to operate on is therefore critical to successful surgical removal. This requires lots of experience treating keloids, and an in-depth understanding of keloids as well as plastic surgical principles.

From my experience with keloid scar removal treatment, paying close attention to the history and examination can help filter out which keloid scars will do great with surgery, and which ones are better treated with more conservative treatments such as keloid injections. Which factors may indicate that the keloid you have is suitable for surgery?

Keloids That Do Not Respond To Non-Surgical Keloid Scar Removal Treatment

Some keloids don't really respond to conservative treatment with lasers and injections. Numerous rounds of injections and laser treatments may result in little to no improvement in the size of the keloid. Many patients that have come to consult me have already tried multiple rounds of conservative treatment elsewhere with not much to show for it.

One of the reasons keloids don't respond to non-surgical keloid scar removal treatment may be due to the presence of a mature, dense core of built-up collagen. The older and thicker the keloid, the more likely that this core exists. Unfortunately, there is no surefire way to identify such keloids with certainty. A doctor experienced in treating keloids would usually be able to identify keloids likely to contain such a 'keloid core' with careful examination.

keloid core surgical picture
Keloid core (whitish tissue) visible during keloid scar removal surgery

How To Identify Keloids That May Have A Mature 'Core'

Some factors in the history and examination that would point to the possibility of the keloid not responding to non-invasive treatments include:

  • Older keloids - the longer the keloid has been there, the higher the chance that a keloid core has developed
  • More raised but less red - indicates the keloid is older / more mature but still has significant excess collagen
  • Harder/firmer/bulkier - the denser and larger keloids tend not to respond to non-surgical removal

It's best to try and identify keloids that might respond better to surgery so that we don't waste unnecessary time, money, and effort on painful injections or lasers with limited benefit.

Keloids That Will Likely Heal Well From Keloid Scar Removal Surgery

No matter how resistant your keloid is to conservative treatment, there's no point going for keloid scar removal surgery if it just grows back the same or even bigger. It is critical to assess if the keloid will heal well before deciding if it is suitable for surgery.

Size/shape of keloid

Keloids that cover a large surface area are difficult to treat surgically no matter what kind of surgery is done. In keloid extra-marginal excision surgery, stitching the large wound together directly would result in high wound tension. Hence, more complicated surgeries like flap surgeries are necessary to cover the skin defect. Even in newer types of surgery in which the surface skin flaps are preserved, a large surface area predisposes the center portions of the keloid to wound breakdown due to poorer blood supply. On the other hand, relatively large keloids that have a narrow base usually do well.

pedunculated keloid with narrow base
Keloids with a relatively narrow base tend to do well with keloid scar removal surgery

Depth of keloid

Removing keloids that occupy much of the thickness of the dermis results in loss of structural support to the skin. As a result, the wound tends to pull apart and is subject to a lot of tension from the surrounding intact skin. Of course, we can counteract this to a certain extent by plastic surgical techniques such as layered anti-tension sutures under the skin. Still, compared to a keloid scar that does not go that deep into the dermis, the chance of recurrence is higher.

set-back dermal suture, a type of tension relieving suturing technique
Tension relieving suture techniques such as set-back dermal suturing can be used to reduce wound tension during keloid scar removal surgery

Are Your Keloids Suitable For Keloid Scar Removal Surgery?

Surgery can work extremely well for some keloids. However, due to the recurrent nature of keloid scarring, a decision for surgery should not be taken lightly. Careful assessment and planning are mandatory to ensure the best outcome.

Hopefully, you've gained some knowledge about how to assess if your keloid is suitable for keloid scar removal surgery. Having said that, this is just a broad overview. It takes a lot of real-life experience to approach an accurate assessment. Even then, keloids are difficult to treat and may not respond exactly how we predict them to. While we cannot control everything, we can at least choose the keloids with the best chance of successful treatment and ensure that we do everything possible to improve those chances. If you are considering keloid scar removal surgery, do schedule a consultation with us to find out more before taking the next step!

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 surgery149(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 zasshi83(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. Lee, Y., Minn, K. W., Baek, R. M., & Hong, J. J. (2001). A new surgical treatment of keloid: keloid core excision. Annals of plastic surgery46(2), 135–140. https://doi.org/10.1097/00000637-200102000-00008
  5. El-Kamel, M. F., Selim, M. K., & Alghobary, M. F. (2016). Keloidectomy with core fillet flap and intralesional verapamil injection for recurrent earlobe keloids. Indian journal of dermatology, venereology and leprology82(6), 659–665. https://doi.org/10.4103/0378-6323.187084
  6. Kantor J. (2010). The set-back buried dermal suture: an alternative to the buried vertical mattress for layered wound closure. Journal of the American Academy of Dermatology62(2), 351–353. https://doi.org/10.1016/j.jaad.2009.05.049

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