Keloids are an overgrowth of scar tissue that forms after a skin injury, resulting in a raised and often discolored lesion that extends beyond the original wound’s boundaries. This abnormal healing response is characterized by the excessive production of collagen, creating a dense, firm mass that does not regress naturally. Surgical excision is a method used to remove this excess tissue, but treating keloids through surgery is complex. The incision creates a new wound, which can trigger a recurrence, with rates reported to be as high as 45% to 100% when surgery is used alone. Therefore, the procedure is almost always followed by additional therapies designed to suppress the body’s overzealous healing process.
Assessment and Candidacy for Excision
Determining if surgical excision is the right approach begins with a thorough assessment of the scar’s characteristics and the patient’s medical history. It is important to distinguish a keloid from a hypertrophic scar, as their behavior and treatment responses differ significantly. A hypertrophic scar remains confined to the original injury site and may naturally regress, while a keloid characteristically grows outside the wound margins into surrounding healthy skin. Excision is generally reserved for keloids that are large, mature, or have caused significant physical discomfort, such as pain or restricted movement. Surgical removal is typically considered when non-surgical options have failed to produce a satisfactory result or are deemed unlikely to be effective for the size of the lesion.
The Surgical Excision Process
The surgical removal of a keloid is an outpatient procedure usually performed under local anesthesia. The surgeon carefully excises the keloid, aiming to remove the abnormal tissue while minimizing trauma to the surrounding healthy skin, often using a scalpel or laser. A common technique is intralesional excision, where the bulk of the keloid is removed while leaving a small rim of tissue at the incision edges, avoiding cutting into the adjacent healthy skin. The method of closing the wound is paramount to reducing recurrence risk. To minimize mechanical tension, the surgeon may use deep, tension-reducing sutures beneath the skin’s surface, or for very large keloids, advanced plastic surgery techniques like skin grafts or local flaps may be necessary.
Strategies to Prevent Keloid Regrowth
The high recurrence rate associated with excision alone necessitates the immediate and sustained use of adjunctive therapies to suppress the body’s healing response. These preventative strategies are often initiated during the surgery or within hours of its completion for maximum effect. Combining excision with these modalities can significantly reduce the recurrence rate from the 45–100% range down to approximately 10–30% or even lower.
Intra-operative and Immediate Post-operative Therapies
One common immediate intervention is the injection of corticosteroids, such as triamcinolone acetonide, directly into the wound edges after the keloid is removed and the wound is closed. These injections reduce inflammation and suppress the fibroblasts responsible for producing excess collagen. This therapy is often repeated at regular intervals over several months following the surgery to maintain the suppressive effect. Another agent used is 5-Fluorouracil, an anti-metabolite drug that inhibits the rapid proliferation of scar tissue cells, administered via injection directly into the scar tissue to curb the overproduction of scar material.
Post-operative Therapies
Post-operative radiation therapy is considered one of the most effective adjunctive treatments, with the best results achieved when treatment begins within 24 to 48 hours of the excision. Low-dose radiation, often delivered through superficial external beam or brachytherapy, works by disrupting the cell cycle of fibroblasts, preventing them from multiplying and generating new collagen. This approach has been shown to achieve control rates of about 85% to 90% at one year.
Mechanical pressure is another long-term strategy, typically applied through custom-fitted pressure garments or earrings for keloids on the earlobe. The constant, firm pressure is thought to reduce blood flow and oxygen to the wound, which helps to flatten the forming scar and inhibit collagen synthesis. Patients may be instructed to wear these pressure devices for many months to achieve the desired result.
Silicone sheeting or gels are applied to the surgical site once the initial wound has healed. These products create a moist, occlusive environment that is believed to hydrate the outermost layer of the skin. This hydration helps regulate the production of collagen and soften the scar over time.
Immediate Recovery and Follow-Up Monitoring
The immediate recovery phase focuses on meticulous wound care to ensure the incision heals cleanly and minimize any inflammatory triggers. Patients must keep the surgical site clean and dry, following instructions for dressing changes and the application of any prescribed topical ointments. Patients must avoid strenuous activities and anything that might place tension or stress on the newly closed wound for at least two weeks. Protecting the healing area from direct sun exposure is also necessary, as ultraviolet rays can cause hyperpigmentation. Follow-up appointments are scheduled frequently to evaluate the wound’s healing progress and remove any non-dissolvable sutures, with long-term monitoring continuing for many months to allow for the early detection of recurrence.