Investigation of the Optimal Age in Months for Initiation of Conservative Treatment for Congenital Auricular Deformities.

Background: The effectiveness of conservative treatment for congenital auricular deformities depends primarily on the plasticity of the auricular cartilage. However, the effect remains uncertain due to various confounding factors such as differences in the characteristics of the deformity and timing of treatment initiation. In this study, we investigated the optimal timing for initiation of conservative treatment. Methods: We investigated the age at treatment initiation and surgical avoidance rate among 158 children with congenital auricular deformities who were treated with corrective devices at our hospital. In addition, we conducted and analyzed questionnaires containing items assessing treatment satisfaction and characteristics. Results: Surgical avoidance rates decreased markedly among those starting treatment after 5 months of age, and satisfaction was significantly higher in the surgical avoidance group. Multivariate analysis showed that the only factor affecting the treatment effect was the age at treatment initiation. Conclusions: This study suggests that the initiation of conservative treatment with corrective devices within 5 months of age for congenital auricular deformities may lead to avoidance of surgery and increased satisfaction. However, we should not judge the indication for conservative treatment solely based on age in months. Bearing in mind the effectiveness of initiating treatment within the first 5 months of age, we should initiate treatment at the earliest appropriate age with consideration of the individual patient's type and severity of deformity and cartilage elasticity.

Algorithm-based Management of Infantile Hemangiomas: Reducing Sequelae and Surgical Interventions.

Background: In Japan, oral propranolol (PPL) and pulsed dye laser are available for infantile hemangioma (IH) treatment without patient cost-sharing. However, no standardized algorithm exists to guide treatment selection that balances efficacy, potential side effects, and aesthetic risks. This study presents a comprehensive approach utilizing a treatment algorithm and aesthetic risk scoring system. Methods: This retrospective study analyzed outcomes from 156 patients with IHs. Oral PPL was used in IH patients with functional issues, whereas the rest underwent an aesthetic risk assessment that categorized them into low-, moderate-, or high-risk groups to guide treatment choices. Final treatment decisions depended on parental preference. The outcomes of algorithm-compliant and noncompliant patients were compared statistically. Results: The risk score's interrater reliability was 0.973 (95% confidence interval 0.933-0.992), with a mean intrarater reliability of 0.968 ± 0.027 and a mean evaluation time of 14.1 ± 5.0 seconds per case. Among the 156 patients, 88% pursued the algorithm-recommended treatment, whereas 12% opted for different approaches. Algorithm-compliant patients experienced significantly fewer sequelae than did noncompliant patients (5% versus 33%, P < 0.001). Compared with noncompliant patients, algorithm-compliant patients tended to require shorter treatment durations (17.9 versus 25.4 mo, P = 0.08) and fewer laser sessions (5.8 versus 7.2, P = 0.30), with a younger age at resolution (21.3 versus 29.0 mo, P = 0.08). Conclusions: Aesthetic concerns can be crucial for patients with IHs. This study introduces a comprehensive IH management algorithm to reduce the sequelae requiring surgical interventions and improve patients' quality of life.

Development of Postsurgical Pyoderma Gangrenosum with New Keloid after Keloid Resection.

ABSTRACT: Keloids are a dermal fibroproliferative disorder and can arise from trauma, acne, vaccination, and herpes zoster. Pyoderma gangrenosum (PG) is a painful ulcerative skin disorder that is associated with neutrophilic dysfunction. However, the pathophysiologies of keloids and PG are not fully understood. The authors encountered an unusual case of a 24-year-old woman who presented with an anterior chest keloid that bore an ulcer. The keloid was resected along with the ulcer, and histology revealed the ulcer to be a neutrophilic PG ulcer. A year after surgery, another ulcer developed in the scar. The ulcer met the PARACELSUS criteria of a postsurgical PG ulcer. After treatment with systemic prednisone and adalimumab for 250 days, the ulcer re-epithelialized. However, relapsed keloids were then observed at the PG site. Corticosteroid taping may be the safest therapy for patients with a history of PG. Conversely, if there is suspicion that a patient is prone to keloid development, diagnostic biopsies and surgical management of PG ulcers should be avoided or conducted with care.

High-frequency Power Doppler Ultrasonography in Predicting Burn Depth: A Preliminary Case Report.

Accurate burn depth assessment is essential to decide an appropriate surgical procedure. However, most cases of burn depth are diagnosed with subjective judgment by an experienced plastic surgeon. There is a need for a simple, noninvasive, and accurate diagnostic method. Here, the authors present two burn cases in which burn depth was predicted using high-frequency power Doppler ultrasonography. In case 1, the patient showed partial deep burn area prediagnosed by clinical inspection in dorsal area. However, pulsatile microcirculation was detected in the deep dermal layer using high-frequency power Doppler ultrasonography, and we rediagnosed it as deep dermal burn. Tangential excision was performed to debride necrotic tissue, preventing excessive removal of viable dermal tissue. In case 2, the patient showed anterior chest burn covered eschar. Pulsatile microcirculation was detected in the dermis using high-frequency power Doppler ultrasonography. The authors diagnosed the area as superficial dermal burn and opted for conservative treatment. Dermal microvascular damage is a more sensitive indicator of tissue injury. Hence, the burn depth can be assessed using dermal microcirculation. To the best of the authors' knowledge, there are no reports on the evaluation of blood flow in burn wounds using high-frequency power Doppler ultrasonography. In this case report, the authors introduce the possibility of using high-frequency ultrasonography to assess burn depth.

168 Cases of aneurysmal dermatofibroma and 29 cases of hemosiderotic dermatofibroma: A clinicopathologic study.

OBJECTIVES: Aneurysmal dermatofibroma (ADF) and hemosiderotic dermatofibroma (HDF) are rare variants of dermatofibroma (DF) characterized by distinct histologic features. While HDF is traditionally considered a precursor to ADF, supporting evidence is limited, and the etiology remains unclear. A retrospective analysis of 2128 DF cases (2016-2019) was conducted to investigate the clinicopathologic characteristics of ADF, HDF, and other DFs. METHODS: Histopathologically diagnosed DF cases were examined for ADF and HDF. Univariate analyses were performed to compare clinicopathologic features. RESULTS: Among the cases, 168 (7.9%) were ADF and 29 (1.4%) were HDF. Aneurysmal dermatofibroma and HDF shared several common characteristics, including lower occurrence in females, larger size, and increased cellularity (all P < .0001). Notably, 29% of ADFs lacked hemosiderin deposition. Aneurysmal dermatofibroma primarily manifested on exposed areas (face and forearm, both P < .001). In contrast, 41% of HDFs occurred on the lower leg (P = .018), and all lower leg HDFs exhibited signs of venous stasis, distinguishing them from other HDFs (P < .0001). CONCLUSIONS: Our findings indicate a potential close relationship between ADF and HDF. Contrary to conventional beliefs, we also presented the possibility of ADF progressing into HDFs. Physical trauma may induce ADF, and HDFs may emerge from ADFs in conjunction with venous stasis in the lower extremities.

Utilizing 3D Printing for the Surgical Management of Orbital Floor Fractures.

We present a technique for treating orbital floor fractures using three-dimensional (3D) printing technology and a preoperative template based on the mirror image of the unaffected orbit. Our patient, a 56-year-old man, experienced persistent diplopia in the upward direction and left enophthalmos after previous open reduction internal fixation surgery. To address these complications, we used a simulation of the ideal orbital floor from computed tomography images and used a 3D printer to create a template. Subsequently, an absorbable plate was molded intraoperatively based on this template. Notably, the plate fit seamlessly into the fracture site without requiring any adjustment, reducing the operation time. Postoperative computed tomography scans confirmed successful reduction, improved visual function, and the absence of complications. Our method offers a precise and efficient approach to reconstructing fractured orbital floors. By leveraging 3D printing technology and preoperative templates, surgeons can enhance postoperative outcomes and minimize patient burden. Further investigations are warranted to assess the long-term effectiveness and cost-effectiveness of this technique. Our findings highlight the potential of this approach to improve treatment strategies for patients with orbital floor fractures.

Lumbar Sympathetic Ganglion Block Facilitates Wound Healing in a Rat Ischemic Hindquarter Model.

Lumbar sympathetic nerve block (LSNB) improves blood flow in the lower limbs and relieves pain involving the sympathetic afferents. This study examines the use of LSNB, but there are no reports of its use for the purpose of wound healing. Therefore, the authors planned the following study. Methods: An ischemic limb ulcer was created on both lower limbs using a rat model (N = 18). The rats were divided into three groups, namely, A, B, and C. Group A received LSNB on one side (N = 6). Group B was sprayed with basic fibroblast growth factor preparation (trafermin/fiblast) on one side (N = 6). Group C was used as a control (N = 6). Lower limb temperature and the ulcer area were measured over time in each group. Furthermore, the correlation between the ulcer temperature and the ulcer area reduction rate was analyzed. Results: Group A had higher skin temperature on the LSNB-treated side than on the nontreated side (P = 0.0022 < 0.05). Regarding the correlation between the average temperature and the ulcer area reduction rate, the correlation coefficient was as high as 0.691 in group A. Conclusions: In the LSNB group, the skin temperature increased and the ulcer area decreased significantly. Conventionally, LSNB has been used for pain relief purposes, although the authors consider that it will be useful in the treatment of ischemic ulcers and that it is a potential treatment option for future chronic limb ischemia/chronic limb-threatening ischemia cases.

Keloidal dermatofibroma: Clinicopathological comparison of 52 cases with a series of 2077 other dermatofibromas.

Dermatofibroma is a common benign skin lesion with a contested etiology: some believe it is a neoplasm while others propose minor injuries initiate it. Many dermatofibroma variants have been described, including keloidal dermatofibroma, which is unusual by bearing keloidal collagen. Keloidal dermatofibroma was first described in 1998 and only 15 cases have been reported. Since keloids are driven by skin injuries, the existence of keloidal dermatofibroma has been suggested to support the injury hypothesis of dermatofibroma etiology. To better understand keloidal dermatofibroma characteristics and gain clues regarding dermatofibroma etiology, consecutive keloidal dermatofibroma cases (n = 52) and dermatofibroma without keloidal collagen (n = 2077) that were histopathologically diagnosed in 2016-2019 were identified from the records of a Japanese dermatopathology laboratory and compared in terms of demographic, clinical, and histopathological characteristics by univariate analyses. Compared to other dermatofibromas, keloidal dermatofibromas occurred more frequently on the forearm and hand (P < 0.0001 and 0.0019), especially the wrist dorsum, and in the superficial skin layer (P < 0.0001). Keloidal dermatofibromas also demonstrated more cellularity and hemorrhage (both P < 0.0001). Correlation analyses between keloidal collagen amount and keloidal dermatofibroma size (a proxy of time-since-onset) did not support the notion that keloidal collagen deposition and keloidal dermatofibroma formation are triggered simultaneously. Recent injury, as indicated by fresh hemorrhage, was equally common in putatively older and younger keloidal dermatofibromas. Thus, keloidal collagen in keloidal dermatofibromas could be due to injury to preexisting dermatofibromas, which suggests that the keloidal dermatofibroma entity does not prove the injury hypothesis. Commonalities between keloids and keloidal dermatofibromas suggest a link between genetics, provocative events that induce myofibroblast differentiation, and keloidal collagen production.

Objective Odor Assessment in Patients with Osmidrosis.

No standards for the assessment of axillary odor intensity and the effects of therapy for osmidrosis have been established. This study presents an objective method for assessing odor severity in patients with osmidrosis and investigates the volatile odorants and skin flora. Methods: The odor intensity was measured pre- and postoperatively using an industrial odor sensor in 79 patients with osmidrosis. Cultures of the axillary skin were obtained during skin flap surgery. Volatile odorants of the patients were assessed using an odor-sensor gas chromatograph mass spectrometer, and samples collected from clothing worn by the patients before and after surgery. The skin pH of the axilla was measured before and after surgery. The locations of odorants and bacteria in the skin were observed using electron microscopy. Results: The mean patient age was 28.8 years, and the male-to-female ratio was 4:3. The odor significantly decreased from 52.6 preoperatively to 20.5 postoperatively (P < 0.001). The bacterial flora on the skin included mostly Staphylococcus. Multiple causative substances (volatile proteins) were identified on gas chromatography. The mean preoperative axillary skin pH was 6.21, which was significantly different than that of patients without osmidrosis (5.92; P < 0.01). Conclusions: An odor sensor accurately assesses odor intensity in patients with osmidrosis. The neutralization of axillary pH may promote the production of odorants by creating the optimal pH for bacterial growth. Odor sensor and pH values can be used pre- and postoperatively as objective assessment measurements for patients with osmidrosis.

Hemodynamics and Vascular Histology of Keloid Tissues and Anatomy of Nearby Blood Vessels.

Keloids are red' invasive scars that are driven by chronic inflammation in the reticular dermis. The role of blood vessels in keloid behavior remains poorly understood. In the present study with 32 keloid patients, we examined the hemodynamics of keloid tissue, the anatomy of the blood vessels feeding and draining the keloids, and the vascular histology of keloids. Methods: Ten patients with large anterior chest keloids underwent near-infrared spectroscopy, which measured regional saturation of oxygen and total hemoglobin index in the keloid and surrounding skin. Another 10 patients with large chest keloids and three healthy volunteers underwent multidetector-low computed tomography. The extirpated chest keloids of 12 patients were subjected to histology with optical, CD31 immunohistochemical, and electron microscopy. Results: All keloids had a low regional saturation of oxygen and a high total hemoglobin index, which is indicative of blood congestion. Multidetector-low computed tomography revealed dilation of the arteries and veins that were respectively feeding and draining the keloid leading edge. Hematoxylin-eosin staining and CD31 immunohistochemisty revealed considerable neovascularization in the keloid leading edge but not in the center. Electron microscopy showed that the lumens of many vessels in the keloid center appeared to be occluded or narrowed. Conclusions: Keloids seem to be congested because of increased neovascularization and arterial inflow at the leading edge and blocked outflow due to vascular destruction in the center. The surrounding veins seem to expand in response to this congested state. Methods that improve the blood circulation in keloids may be effective therapies.

Preoperative Flap Surgery Simulation for a Case of Cryptotia Using a 3D Printer.

Cryptotia is a congenital auricular deformity. Common methods of surgical reconstruction involve creating an auricular temporal groove using local flaps and/or a skin graft. However, it can be difficult to determine which method is most suited to the unique 3-dimensional (3D) structure of each cryptotic ear. Here, we showed that creating 3D ear models of a cryptotic ear with a 3D camera and printer and using these models to simulate surgery with two different flap methods (cat's-ear and square) allowed selection of a reconstruction method that led to good outcomes after the actual surgery. The patient was a 7-year-old girl with left cryptotia. A 3D camera was used to acquire 3D data for the ear. After structural analysis, a home 3D printer was used to print the data into 3D ear models using an elastic material. These models exhibited good plasticity. After subjecting the models to simulated cat's-ear and square flap surgeries, the cat's-ear flap method was considered to better reproduce the healthy side of the ear compared with the square flap method for this particular case. Ear morphology during and after the actual surgery closely resembled the model-ear morphology during and after the simulated cat's-ear flap surgery. We successfully created a full-scale 3D model with good plasticity using a 3D camera and 3D printer. This allowed easy, noninvasive preoperative evaluation and identification of the most suitable operation for the specific case, facilitating easier, more successful surgery.

The Latest Strategy for Keloid and Hypertrophic Scar Prevention and Treatment: The Nippon Medical School (NMS) Protocol.

In 2006, we established a scar/keloid-specialized unit in the Department of Plastic, Reconstructive, and Aesthetic Surgery at Nippon Medical School (NMS) in Tokyo, Japan. In the ensuing 15 years, we treated approximately 2,000 new scar/keloid patients annually. This extensive experience has greatly improved the efficacy of the treatments we offer. Therefore, we discuss here the latest NMS protocol for preventing and treating keloids and hypertrophic scars. While this protocol was optimized for Japanese patients, our experience with a growing body of non-Japanese patients suggests that it is also effective in other ethnicities. The extensive evidence-based experience underlying the NMS protocol suggests that it may be suitable as the foundation of a standard international prevention/treatment algorithm for pathological scars.

Combination Therapy Composed of Surgery, Postoperative Radiotherapy, and Wound Self-management for Umbilical Keloids.

BACKGROUND: A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection. METHODS: All consecutive patients with umbilical keloids that developed from endoscopic surgical scars and underwent minimal-margin keloid excision followed by umbilicoplasty with a flap if needed, tension-reduction suturing, and postoperative radiotherapy in 2013-2017 in the keloid/scar-specialized clinic at the Department of Plastic, Reconstructive and Aesthetic Surgery of Nippon Medical School. The postsurgical radiotherapy regimen was 15 Gy administered in 2 fractions over 2 consecutive days. Radiotherapy was followed by tension-reducing wound self-management with silicone tape or, if needed, steroid plaster. The primary study focus was keloid recurrence during the 24-month follow-up period. Recurrence was defined as the growth of stiff red lesions in even small areas of the scar that was refractory to 2-6 months of steroid-plaster therapy. RESULTS: The case series consisted of 34 patients with 34 lesions. Three lesions (8.8%) recurred. One recurrence was successfully treated by concomitant steroid plaster/injection. The other 2 cases were resistant to steroid injection and underwent reoperation without radiotherapy followed by 6 months of steroid-plaster therapy. None of the 3 cases recurred within 2 years of steroid plaster/injection completion or reoperation. CONCLUSION: Umbilical keloids can be successfully treated by customized treatment plans that involve appropriate surgical modalities (including umbilicoplasty, if required), postoperative radiotherapy (15 Gy/2 fractions/2 days), and wound/scar self-management with silicone tape and steroid plaster.

Direct Delivery of Apatite Nanoparticle-Encapsulated siRNA Targeting TIMP-1 for Intractable Abnormal Scars.

Hypertrophic scars (HSs) and keloids are histologically characterized by excessive extracellular matrix (ECM) deposition. ECM deposition depends on the balance between matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteases (TIMPs). TIMP-1 has been linked to ECM degradation and is therefore a promising therapeutic strategy. In this study, we generated super carbonate apatite (sCA) nanoparticle-encapsulated TIMP-1 small interfering RNA (siRNA) (siTIMP1) preparations and examined the effect of local injections on mouse HSs and on ex vivo-cultured keloids. The sCA-siTIMP1 injections significantly reduced scar formation, scar cross-sectional areas, collagen densities, and collagen types I and III levels in the lesions. None of the mice died or exhibited abnormal endpoints. Apatite accumulation was not detected in the other organs. In an ex vivo keloid tissue culture system, sCA-siTIMP1 injections reduced the thickness and complexity of collagen bundles. Our results showed that topical sCA-siTIMP1 injections during mechanical stress-induced HS development reduced scar size. When keloids were injected three times with sCA-siTIMP1 during 6 days, keloidal collagen levels decreased substantially. Accordingly, sCA-siRNA delivery may be an effective approach for keloid treatment, and further investigations are needed to enable its practical use.

Gene Expression Profile of Isolated Dermal Vascular Endothelial Cells in Keloids.

Wound healing is a complex biological process, and imbalances of various substances in the wound environment may prolong healing and lead to excessive scarring. Keloid is abnormal proliferation of scar tissue beyond the original wound margins with excessive deposition of extracellular matrix (ECM) and chronic inflammation. Despite numerous previous research efforts, the pathogenesis of keloid remains unknown. Vascular endothelial cells (VECs) are a major type of inductive cell in inflammation and fibrosis. Despite several studies on vascular morphology in keloid formation, there has been no functional analysis of the role of VECs. In the present study, we isolated living VECs from keloid tissues and investigated gene expression patterns using microarray analysis. We obtained 5 keloid tissue samples and 6 normal skin samples from patients without keloid. Immediately after excision, tissue samples were gently minced and living cells were isolated. Magnetic-activated cell sorting of VECs was performed by negative selection of fibroblasts and CD45+ cells and by positive selection of CD31+cells. After RNA extraction, gene expression analysis was performed to compare VECs isolated from keloid tissue (KVECs) with VECs from normal skin (NVECs). After cell isolation, the percentage of CD31+ cells as measured by flow cytometry ranged from 81.8%-98.6%. Principal component analysis was used to identify distinct molecular phenotypes in KVECs versus NVECs and these were divided into two subgroups. In total, 15 genes were upregulated, and 3 genes were downregulated in KVECs compared with NVECs using the t-test (< 0.05). Quantitative RT-PCR and immunohistochemistry showed 16-fold and 11-fold overexpression of SERPINA3 and LAMC2, respectively. SERPINA3 encodes the serine protease inhibitor, α1-antichymotripsin. Laminin γ2-Chain (LAMC2) is a subunit of laminin-5 that induces retraction of vascular endothelial cells and enhances vascular permeability. This is the first report of VEC isolation and gene expression analysis in keloid tissue. Our data suggest that SERPINA3 and LAMC2 upregulation in KVECs may contribute to the development of fibrosis and prolonged inflammation in keloid. Further functional investigation of these genes will help clarify the mechanisms of abnormal scar tissue proliferation.

Geometric modeling and a retrospective cohort study on the usefulness of fascial tensile reductions in severe keloid surgery.

BACKGROUND: Severe keloids are currently treated with surgical resection followed by radiation. Radiotherapy is essential for preventing recurrences. Fascia tensile reduction suturing may also prevent recurrence. We asked whether superficial fascia tensile reduction with or without deep fascia tensile reduction reduced skin mechanical tension and yielded good outcomes. METHODS: Geometric modeling on 3-dimensional anatomic shapes assessed the effect of superficial fascia tensile reduction with or without deep fascia tensile reduction on skin tension. A retrospective cohort study was performed on patients with severe anterior-chest keloids with Japan Scar Workshop-scar scale classification score ≥ 16 who underwent resection plus fascia tensile reduction plus radiotherapy between 2011 and 2016 and were followed for >18 months. Patient characteristics and 18-month postoperative outcomes were examined. Postoperative outcome was defined as rates of keloid disappearance, improvement, and obvious recurrence. RESULTS: Maximal mechanical forces placed on the dermis by dermal sutures, dermal sutures plus superficial fascia tensile reduction, and dermal sutures plus superficial fascia tensile reduction plus deep fascia tensile reduction were 4,700, 573, and 697 Pa, respectively. Adding deep fascia tensile reduction to superficial fascia tensile reduction decreased the force on the superficial fascia. Of 77 cohort patients, 27 and 50 underwent superficial fascia tensile reduction and superficial fascia tensile reduction plus deep fascia tensile reduction, respectively. Superficial fascia tensile reduction plus deep fascia tensile reduction patients underwent complete excision more often (60.0% vs 37.0%, P = .046). The groups did not differ in 18-month surgical outcome, including recurrence rate (P = .670). CONCLUSION: Our 2003 study showed that in anterior-chest keloids, resection plus non-fascial suturing plus radiotherapy led to a 43.1% recurrence. Thus, fascia tensile reduction suturing helps reduce anterior-chest keloid recurrence to ∼5.2%. Superficial fascia tensile reduction plus deep fascia tensile reduction is suitable for relatively large keloids that require total resection. Deep fascia tensile reduction may facilitate superficial fascia tensile reduction but may only be useful when it is technically difficult to achieve reduction with superficial fascia tensile reduction alone.

Combination of 1,064-nm Neodymium-doped Yttrium Aluminum Garnet Laser and Steroid Tape Decreases the Total Treatment Time of Hypertrophic Scars: An Analysis of 40 Cases of Cesarean-Section Scars.

BACKGROUND: The 1,064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser (Cutera, Inc., Brisbane, CA) and steroid tape (fludroxycortide tape) have been used to treat keloids and hypertrophic scars. OBJECTIVE: To evaluate the efficacy of contact-mode 1,064-nm Nd:YAG laser therapy and steroid tape for hypertrophic cesarean-section scars versus conservative therapy (steroid tape only). MATERIALS AND METHODS: A medical record review identified 40 consecutive Japanese patients who had hypertrophic scars (total Japan Scar Workshop Scar Scale [JSS] 2015 evaluation scores of 9 to 12) for more than 1 year after a vertical cesarean section and who were treated at our scar-specialist clinic from July 2015 to December 2017. All 40 patients continued treatment until the total JSS score dropped below 3. Recurrence was defined as a ≥1-point increase in the total JSW score 6 months after achieving a total JSS score <3. RESULTS: The patients had a mean age of 34.2 years. The test (n = 25) and control (n = 15) groups took on average 16.9 and 24.3 months to achieve a total JSS score <3, respectively (p < .01). In the following 6 months, none of the scars recurred. CONCLUSION: Nd:YAG laser treatment effectively decreased the total treatment time of hypertrophic cesarean-section scars. An algorithm for treating mild and severe hypertrophic cesarean-section scars is proposed.

Surgical excision and postoperative radiotherapy for keloids.

Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%-80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (ß-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / ß ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.

The Interplay of Mechanical Stress, Strain, and Stiffness at the Keloid Periphery Correlates with Increased Caveolin-1/ROCK Signaling and Scar Progression.

BACKGROUND: Fibroproliferative disorders result in excessive scar formation, are associated with high morbidity, and cost billions of dollars every year. Of these, keloid disease presents a particularly challenging clinical problem because the cutaneous scars progress beyond the original site of injury. Altered mechanotransduction has been implicated in keloid development, but the mechanisms governing scar progression into the surrounding tissue remain unknown. The role of mechanotransduction in keloids is further complicated by the differential mechanical properties of keloids and the surrounding skin. METHODS: The authors used human mechanical testing, finite element modeling, and immunohistologic analyses of human specimens to clarify the complex interplay of mechanical stress, strain, and stiffness in keloid scar progression. RESULTS: Changes in human position (i.e., standing, sitting, and supine) are correlated to dynamic changes in local stress/strain distribution, particularly in regions with a predilection for keloids. Keloids are composed of stiff tissue, which displays a fibrotic phenotype with relatively low proliferation. In contrast, the soft skin surrounding keloids is exposed to high mechanical strain that correlates with increased expression of the caveolin-1/rho signaling via rho kinase mechanotransduction pathway and elevated inflammation and proliferation, which may lead to keloid progression. CONCLUSIONS: The authors conclude that changes in human position are strongly correlated with mechanical loading of the predilection sites, which leads to increased mechanical strain in the peripheral tissue surrounding keloids. Furthermore, increased mechanical strain in the peripheral tissue, which is the site of keloid progression, was correlated with aberrant expression of caveolin-1/ROCK signaling pathway. These findings suggest a novel mechanism for keloid progression.