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.

Histological analysis of hyalinised keloidal collagen formation in earlobe keloids over time: collagen hyalinisation starts in the perivascular area.

Keloids grow and do not regress. They are characterised histologically by hyalinised keloidal collagen (HKC). HKC amounts vary, and the mechanism by which they form is unclear. To clarify how HKCs form and whether their formation associates with specific clinical features, we studied the histological findings of earlobe keloids and compared them with respective clinical features. A total of 50 earlobe keloids from 43 patients were used for histological analysis of keloid size (mm2 ), HKC area (mm2 ) and HKC area ratio (%). As a result, keloid durations ranged from 3 months to >13 years. Early-stage keloids exhibited little HKC and a tendency for the HKCs to locate in perivascular regions. In later-stage keloids, the HKCs were extremely interconnected and formed a thick bitten donut-shaped region. HKC area ratios correlated positively with keloid duration (r2 = 0·58, P<0·05). HKC area ratios and keloid durations did not correlate with keloid sizes. These patterns of HKC formation and growth may explain why local therapies, which effectively remove fibroblasts and accumulated collagen but not HKCs, are ineffective in older keloids. Keloids should be promptly treated after diagnosis, and older keloids with extensive HKCs may require surgical excision followed by radiotherapy.

The microsecond 1064 nm Nd:YAG laser as an adjunct to improving surgical scars following Mohs micrographic surgery.

BACKGROUND: Scarring following skin surgery is an unavoidable certainty. Scars resulting from Mohs Micrographic Surgery (MMS) can cause both cosmetic and functional problems. Various lasers have been used to treat scars, but the role of the microsecond pulsed 1064 nanometer neodymium-doped yttrium aluminum garnet (1064 nm Nd:YAG) in treating surgical scars is not well-defined. OBJECTIVE: We aim to examine the clinical application of the 1064 nm Nd:YAG laser in improving surgical scars. METHODS: Ten patients who were unhappy with cosmetic or functional outcomes of their surgical scars following MMS were treated with 1-3 sessions of the 1064 nm Nd:YAG laser to improve their scars. Therapy completion was determined by patient satisfaction with the appearance of their scars and/or resolution of any contractures that formed following surgery. RESULTS: All ten patients were pleased with the improved appearance of their scars. Four patients saw complete resolution of an ectropion or eclabium that formed secondary to scar contractures from MMS. The side effects of laser treatments were limited to 1-2 hours of erythema, and there were no incidences of adverse effects or recurrence of contractures. CONCLUSION: Our clinical experience with the 1064 nm Nd:YAG laser provides promising data on improving appearance of and functionality from post-surgical scars.

Hypertension: a systemic key to understanding local keloid severity.

This study assessed whether hypertension, a circulating factor, influences local keloid severity. This retrospective cross-sectional study involved 304 consecutive patients (13-78 years old) with keloids who were surgically treated in our hospital between January 2011 and August 2013. Their blood pressure (BP), age and gender, and the size and number of their keloids before surgery were recorded. Ordinal logistic regression analyses showed that BP associated significantly with both keloid size and number (all p < 0.0001). Age also associated with keloid size (p < 0.0001). However, a Goodness-of-fit chi-square test showed that the prevalence of hypertension was not higher among keloid patients than in the general Japanese population. This study provides epidemiological evidence for the possibility that primary hypertension may aggravate keloids. We propose that the skin, along with the heart and liver, is a target organ of hypertension. The observations of this study, which require validation with large-scale prospective interventional trials, suggest that keloid patients should be screened for hypertension and that antihypertensive treatments may be of prophylactic and therapeutic value for skin fibrosis.

Loss of keratinocyte focal adhesion kinase stimulates dermal proteolysis through upregulation of MMP9 in wound healing.

OBJECTIVE: To investigate how epithelial mechanotransduction pathways impact wound repair. BACKGROUND: Mechanical forces are increasingly recognized to influence tissue repair, but their role in chronic wound pathophysiology remains unknown. Studies have shown that chronic wounds exhibit high levels of matrix metalloproteinase 9 (MMP9), a key proteolytic enzyme that regulates wound remodeling. We hypothesized that epithelial mechanosensory pathways regulated by keratinocyte-specific focal adhesion kinase (FAK) control dermal remodeling via MMP9. METHODS: A standard wound model was applied to keratinocyte-specific FAK knockout (KO) and control mice. Rates of wound healing were measured and tissue was obtained for histologic and molecular analyses. Transcriptional and immunoblot assays were used to assess the activation of FAK, intracellular kinases, and MMP9 in vitro. A cell suspension model was designed to validate the importance of FAK mechanosensing, p38, and MMP9 secretion in human cells. Biomechanical testing was utilized to evaluate matrix tensile properties in FAK KO and control wounds. RESULTS: Wound healing in FAK KO mice was significantly delayed compared with controls (closure at 15 days compared with 20 days, P = 0.0003). FAK KO wounds demonstrated decreased dermal thickness and collagen density. FAK KO keratinocytes exhibited overactive p38 and MMP9 signaling in vitro, findings recapitulated in human keratinocytes via the deactivation of FAK in the cell suspension model. Functionally, FAK KO wounds were significantly weaker and more brittle than control wounds, results consistent with the histologic and molecular analyses. CONCLUSIONS: Keratinocyte FAK is highly responsive to mechanical cues and may play a critical role in matrix remodeling via regulation of p38 and MMP9. These findings suggest that aberrant epithelial mechanosensory pathways may contribute to pathologic dermal proteolysis and wound chronicity.

Efficacy of a high FFP:PRBC transfusion ratio on the survival of severely injured patients: a retrospective study in a single tertiary emergency center in Japan.

PURPOSE: Recent studies have shown increased survival benefits when a high fresh frozen plasma (FFP) to packed red blood cell (PRBC) ratio is used during trauma resuscitation. However, some reports have raised questions about the effect of higher FFP:PRBC transfusion ratios. The aim of this study was to examine the efficacy of high FFP:PRBC ratios in injured patients with regard to survival and morbidity in a single tertiary emergency center in Japan. METHODS: This study examined severe trauma patients who received 10 or more PRBC units during the first 24 h of admission. We examined the relationship between the FFP:PRBC ratios during the first 6 h and the patient outcome. RESULTS: The severity was similar among all groups. The mortality rate was 44.4% in the high (>1:1.5), 16.7% in the middle (1:1.5-1:2) and 33.3% in the low (<1:2) F:P ratio groups. Only one patient in the high group developed sepsis, and none of the patients developed ARDS. CONCLUSIONS: The current results indicate that the FFP:PRBC ratios during the first 6 h after admission might not affect the mortality or morbidity. However, differences between trauma care systems in Japan and other countries, along with other study limitations, necessitate that a subsequent prospective multicenter study be undertaken before any definitive conclusions can be made.

Are keloid and hypertrophic scar different forms of the same disorder? A fibroproliferative skin disorder hypothesis based on keloid findings.

Hypertrophic scars (HSs) and keloids are commonly seen as two different diseases by both clinicians and pathologists. However, as supported by histological evidence showing they share increased numbers of fibroblasts and accumulate collagen products, HS and keloid might be different forms of the same pathological entity, rather than separate conditions. To test this hypothesis, keloids from patients who underwent scar excisions (n = 20) in Nippon Medical School from 2005 to 2010 were examined histologically. The proportion and distribution of cellular and matrix collagen components were evaluated at the centre and periphery of each sample. In keloid samples, coexistence of hyalinised collagen, which is the most important pathognomonic characteristic of a keloid and dermal nodules that are considered to be characteristic of HS, was found. Moreover, hyalinised fibres appeared to initiate from the corner of the dermal nodules. Key features of inflammation such as microvessels, fibroblasts and inflammatory cells all decreased gradually from the periphery to the centre of keloids, indicative of reduced inflammation in the centre. Thus, we hypothesise that HS and keloid can be considered as successive stages of the same fibroproliferative skin disorder, with differing degrees of inflammation that might be affected by genetic predisposition.

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.

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.

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.

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.

The relationship between skin stretching/contraction and pathologic scarring: the important role of mechanical forces in keloid generation.

Keloids tend to occur on highly mobile sites with high tension. This study was designed to determine whether body surface areas exposed to large strain during normal activities correlate with areas that show high rates of keloid generation after wounding. Eight adult Japanese volunteers were enrolled to study the skin stretching/contraction rates of nine different body sites. Skin stretching/contraction was measured by marking eight points on each region and measuring the change in location of the marked points after typical movements. The distribution of 1,500 keloids on 483 Japanese patients was mapped. The parietal region and anterior lower leg were associated with the least stretching/contraction, while the suprapubic region had the highest stretching/contraction rate. With regard to keloid distribution, there were 733 on the anterior chest region (48.9%) and 403 on the scapular regions (26.9%). No keloids were reported on the scalp or anterior lower leg. Because these sites are rarely subjected to skin stretching/contraction, it appears that mechanical force is an important trigger that drives keloid generation even in patients who are genetically predisposed to keloids. Thus, mechanotransduction studies are useful for developing clinical approaches that reduce the skin tension around wounds or scars for the prevention and treatment of not only keloids but also hypertrophic scars.

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.

Visual and pathologic analyses of keloid growth patterns.

Keloids grow and spread not only vertically but also horizontally, although hypertrophic scars do not grow beyond the boundaries of the original injury. Clinically, we have encountered keloids with regular and irregular (untypical) shapes. As the characteristics of the irregular growth patterns of keloids have not been studied yet, we analyzed the irregular growth of keloids both visually and pathologically.A total of 220 keloid specimens, each from a different patient, were surgically removed and used in this study. Through visual analysis, the preoperative shapes of these 220 keloids were classified into those with a regular shape (R group) and those with an irregular shape (IR group). Moreover, we distinguished between cases that had received keloidectomy previously and those that had not. We also determined whether the keloids were recurrent keloids or not. In both the R and IR groups, keloid specimens were studied histologically to examine for infection.In the R group, there were 156 cases (70.9%; 55 males and 101 females with a mean age of 33.68 years). Three patients (1.9%) had infection and 2 patients (1.3%) had undergone keloidectomy previously. In the IR group, there were 64 cases (29.1%; 24 males and 40 females with a mean age of 45.27 years). Thirty patients (46.9%) had infection and 24 patients (37.5%) had undergone keloidectomy previously. Statistically, the rates of infection and keloidectomy were significantly different between the R group and the IR group.Severe infection or operative history may be the cause of irregularly shaped keloids. Thus, in the absence of significant infection or a surgical history, the shape of keloids may be determined uniquely by skin tension.

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.

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.