Para-aortic lymph node dissection following neoadjuvant chemotherapy for type 4 or large type 3 gastric cancer with extensive lymph node metastasis.

BACKGROUND: D2 and para-aortic lymph node dissection (PAND) following neoadjuvant chemotherapy (NAC) are reportedly effective for gastric cancer (GC) with extensive lymph node metastasis (ELM), such as para-aortic nodal metastasis or bulky nodal metastasis, around the major perigastric arteries. However, type 4 and large type 3 tumors were excluded from previous studies, as they are considered special subtypes that easily spread to the peritoneum. Whether or not PAND contributes to the survival of type 4 or large type 3GC with ELM is thus unclear. METHODS: This study examined patients who underwent radical gastrectomy with D2 resection and PAND following NAC between 2002 and 2019. Patients were classified into the normal-type group and the type 4 or large type 3 group. The overall survival (OS) and prognostic factors were investigated. RESULTS: Forty-nine patients were examined and classified into the normal-type group (34 patients) and type 4 or large type 3 group (15 patients). The 5-year OS rates of the normal-type and type 4 or large type 3 groups were 55.5% and 26.7%, respectively. Type 4 or large type 3 tumors were an independent risk factor for a poor prognosis in the multivariate analysis (hazard ratio: 2.506, 95% confidence interval: 1.111-5.650, and p = 0.027). CONCLUSIONS: The prognosis of type 4 or large type 3 GC with ELM treated with radical gastrectomy with D2 and PAND after NAC was poor. Type 4 or large type 3 GC with ELM should be treated using a different strategy than the normal type with ELM.

Anatomical Analysis of the Superior Gluteal Artery in 100 Women for Superior Gluteal Artery Perforator Flap Breast Reconstruction.

Background: The superior gluteal artery (SGA) perforator (SGAP) flap is used more rarely for breast reconstruction with autologous tissue than other flaps because the SGA is often narrow, and the SGAP can be short. However, it provides ample fat, including in lean women. To improve its safety and utility, the preoperative SGA course in women who underwent autologous breast reconstruction was determined with three-dimensional computed tomography angiography. Methods: Consecutive deep inferior epigastric perforator, profunda artery perforator, and SGAP flap cases in 2019-2023 were identified. Frequencies of the following favorable preoperative SGA-anatomy variables were determined: branching of the main-SGA trunk on top/posterior of the greater sciatic foramen (designated M1/2), which allows access to a sufficiently wide SGA artery; superolateral perforating location of the superficial-SGA branch (SP3), which means the perforator is sufficiently long for uncomplicated flap placement; and nonbranching of the deep-SGA branch (D1/D2), which means this branch can used a venous and an arterial graft to extend an insufficiently long perforator. Results: A total of 100 cases of deep inferior epigastric perforator (n = 80), profunda artery perforator (n = 13), and SGAP flap-based breast reconstructions (n = 7) were identified. Out of 200 buttocks, 89%, 91.5%, and 62% had the favorable M1/2, SP3, and D1/D2 variables, respectively. An atypical descending branch feeding the lower buttocks (DES1/2) was observed in 34%. Conclusions: The branching position of the main-SGA trunk, perforating location of the SGAP, and the shape of the deep branch were classified in detail in 100 patients. By creating a surgical plan that understands the anatomy taking preoperative three-dimensional computed tomography angiography, the SGAP flap can accommodate many patterns, increasing the possibility of safe execution.

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.

KECORT Study: An International e-Delphi Study on the Treatment of KEloids Using Intralesional CORTicosteroids in Clinical Practice.

BACKGROUND: Intralesional corticosteroid administration (ICA) is a first-line keloid treatment. However, it faces significant variability in current clinical and scientific practice, which hinders comparability of treatment results. OBJECTIVES: The aim of the study was to reach consensus on different aspects of ICA using hypodermic needles in keloids among an international group of dermatologists and plastic surgeons specialized in keloid treatment to provide consensus-based clinical treatment recommendations for all physicians treating keloids. METHODS: The keloid expert panel of 12 dermatologists and 11 plastic surgeons rated 30 statements. Two online e-Delphi rounds were held, both with a response rate of 100%. Fifteen (65%) keloid experts participated in the final consensus meetings. Consensus was defined as ≥ 75% of the participants choosing agree or strongly agree on a 7-point Likert scale. RESULTS: Consensus was reached on treatment goals, indication for ICA, triamcinolone acetonide (TAC) 40 mg/mL as the preferred corticosteroid administered at a maximum of 80 mg per month and at intervals of 4 weeks, minimizing pain during ICA, the use of 1 mL syringes and 25 or 27 Gauge needles, blanching as endpoint of successful infiltration, caution of not injecting subcutaneously, and the option of making multiple passes in very firm keloids prior to infiltration. Consensus could not be reached on TAC dosing, methods of prior local anesthesia, and location of injection. CONCLUSIONS: This e-Delphi study provides important clinical treatment recommendations on essential aspects of ICA in keloids. By implementing these recommendations, uniformity of ICA in keloid treatment will increase and better treatment results may be achieved.

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.

Effective Treatment of an Aggressive Chest Wall Keloid in a Woman Using Deprodone Propionate Plaster without Surgery, Radiotherapy, or Injection.

Treatment with steroid tape is the standard of care for keloid and hypertrophic scars in Japan. In this article, we present a woman with an aggressive and progressive keloid of the anterior chest wall. At the time of presentation, the keloid had been present for 40 years, and was continuing to worsen and expand. Initially, it was believed that a multidisciplinary approach, including surgery and radiation, would be necessary to achieve an acceptable scar outcome. However, we successfully treated her keloid using only steroid tape (deprodone propionate plaster), and no other treatment modality. The case therefore supports the effectiveness of deprodone propionate plaster, and emphasizes its potential for wider future use. With the paucity of experience reported in the literature on steroid tape for scars, more reports are useful to inform plastic surgeons and dermatologists worldwide about this therapeutic option.

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.

Characteristics of Metachronous Remnant Gastric Cancer After Proximal Gastrectomy: A Retrospective Analysis.

PURPOSE: Despite annual endoscopy, patients with metachronous remnant gastric cancer (MRGC) following proximal gastrectomy (PG) are at times ineligible for endoscopic resection (ER). This study aimed to clarify the clinical risk factors for ER inapplicability. MATERIALS AND METHODS: We reviewed the records of 203 patients who underwent PG for cT1 gastric cancer between 2006 and 2015. The remnant stomach was categorized as a pseudofornix, corpus, or antrum. RESULTS: Thirty-two MRGCs were identified in the 29 patients. Twenty MRGCs were classified as ER (ER group, 62.5%), whereas 12 were not (non-ER group, 37.5%). MRGCs were located in the pseudo-fornix in 1, corpus in 5, and antrum in 14 in the ER group, and in the pseudo-fornix in 6, corpus in 4, and antrum in 2 in the non-ER group (P=0.019). Multivariate analysis revealed that the pseudo-fornix was an independent risk factor for non-ER (P=0.014). In the non-ER group, MRGCs at the pseudo-fornix (n=6) had more frequent undifferentiated-type histology (4/6 vs. 0/6), deeper (≥pT1b2; 6/6 vs. 2/6) and nodal metastasis (3/6 vs. 0/6) than non-pseudo-fornix lesions (n=6). We examined the visibility of the region developing MRGC on an annual follow-up endoscopy one year before MRGC detection. In seven lesions at the pseudofornix, visibility was only secured in two (28.6%) because of food residues. Of the 25 lesions in the non-pseudo-fornix, visibility was secured in 21 lesions (84%; P=0.010). CONCLUSIONS: Endoscopic visibility increases the chances of ER applicability. Special preparation is required to ensure the complete clearance of food residues in the pseudo-fornix.

Understanding the Mechanical Forces on the Sacrum Can Help Optimize Flap-based Pilonidal Sinus Reconstruction.

Background: Pilonidal sinus can be treated with excision and flap reconstruction, but treatment is often complicated by wound dehiscence, infection, and recurrence. Understanding the mechanical forces on the sacrococcygeal area during posture change could help guide optimal flap choice. Methods: Sixteen volunteers underwent measurements of skin-stretching, pressure, and shear stress on the sacrum when sitting relative to standing. Skin-stretching was measured by drawing a 4 × 4 cm square on the sacrum and measuring the vertical, horizontal, and diagonal axes. Pressure and shear stress was measured at six sacral points with a device. The data analysis highlighted the potential of the superior gluteal artery perforator (SGAP) flap for dissipating mechanical forces. Ten pilonidal sinus cases treated with SGAP flaps were retrospectively reviewed for 6-month outcomes. Results: Sitting is associated with high stretching tension in the horizontal direction [estimated marginal mean (95% confidence intervals) = 17.3% (15.4%-22.6%)]. The lower sacrum experienced the highest pressure [106.6 (96.6-116.5) mm Hg] and shear stress [11.6 (9.7-13.5) N] during sitting. The transposed SGAP flap was deemed to be optimal for releasing the horizontal tension and providing sufficient subcutaneous tissue for ameliorating pressure/shear stress during sitting. It also has high blood flow and can therefore be used with large lesions. Moreover, its donor site is above the high-pressure/stress lower sacrum. Retrospective analysis showed that no patients experienced complications. Conclusions: Sitting is associated with high mechanical forces on the sacrococcygeal skin. The transposed SGAP flap may ameliorate these forces and thereby reduce the risk of complications of pilonidal sinus reconstruction for large defects.

From Time to Timer in Wound Healing Through the Regeneration.

Hard-to-heal wounds are an important public health issue worldwide, with a significant impact on the quality of life of patients. It is estimated that approximately 1-2% of the global population suffers from difficult wounds, which can be caused by a variety of factors such as trauma, infections, chronic diseases like diabetes or obesity, or poor health conditions. Hard-to-heal wounds are often characterized by a slow and complicated healing process, which can lead to serious complications such as infections, pressure ulcers, scar tissue formation, and even amputations. These complications can have a significant impact on the mobility, autonomy, and quality of life of patients, leading to an increase in healthcare and social costs associated with wound care. The preparation of the wound bed is a key concept in the management of hard-to-heal wounds, with the aim of promoting an optimal environment for healing. The TIME (Tissue, Infection/Inflammation, Moisture, Edge) model is a systematic approach used to assess and manage wounds in a targeted and personalized way. The concept of TIMER, expanding the TIME model, further focuses on regenerative processes, paying particular attention to promoting tissue regeneration and wound healing in a more effective and comprehensive way. The new element introduced in the TIMER model is "Regeneration", which highlights the importance of activating and supporting tissue regeneration processes to promote complete and lasting wound healing. Regenerative therapies can include a wide range of approaches, including cellular therapies, growth factors, bioactive biomaterials, stem cell therapies, and growth factor therapies. These therapies aim to promote the formation of new healthy tissues, reduce inflammation, improve vascularization, and stimulate cellular proliferation to accelerate wound closure and prevent complications. Thanks to continuous progress in research and development of regenerative therapies, more and more patients suffering from difficult wounds can benefit from innovative and promising solutions to promote faster and more effective healing, improve quality of life, and reduce the risk of long-term complications.

A Case of Frostbite on Hands Due to Liquid Nitrogen.

This study examines a rare case of frostbite on the hands caused by liquid nitrogen, focusing on the scar maturation process. Frostbite is typically less prone to abnormal scarring compared to burns, and this report contrasts the differences in scar maturation between the two. A 31-year-old male hospital employee sustained first- to second-degree frostbite on his gloved hands from a 20-s exposure to liquid nitrogen while changing a cylinder. Conservative treatment was applied, and the patient was monitored for 9 months. The deeply affected area took 50 days to epithelialize but healed without hypertrophic scarring. A mild extension contracture was noted in the distal interphalangeal joint of the right index finger, but the skin remained supple and soft. Incidents of liquid nitrogen-induced frostbite are uncommon, with only 14 cases reported in PubMed previously. In frostbite, the wound healing involves a slow replacement of damaged connective tissue, which acts as an internal splint, reducing wound contraction. This contrasts with burns, where rapid connective tissue replacement occurs, often leading to significant wound contraction due to the presence of myofibroblasts in granulation tissue. In the presented case, the slow healing process and minimal wound contraction led to mature scarring without abnormalities, underlining a distinctive healing trajectory in frostbite injuries compared to burns.

Key nodal stations for predicting splenic hilar nodal metastasis in upper advanced gastric cancer without invasion of the greater curvature.

Background: Standard surgery for upper advanced gastric cancer without invasion of the greater curvature (UGC-GC) is spleen-preserving D2 total gastrectomy without dissection of the splenic-hilar nodes (#10). However, some patients with nodal metastasis to #10 survive more than 5 years due to nodal dissection of #10. If nodal metastasis to #10 is predictable based on the positivity of other nodes dissected by the current standard surgery without #10 nodal dissection, physicians may be able to consider #10 dissection. Methods: This study retrospectively reviewed data from the National Cancer Center Hospital in Japan between 2000 and 2012. We selected cases that met the following criteria: (1) D2 or more total gastrectomy with splenectomy, (2) UGC-GC, and (3) histological type is gastric adenocarcinoma. We performed univariate and multivariate analyses concerning lymph node stations associated with #10 metastasis. Results: A total of 366 patients were examined. A multivariate analysis revealed that #10 metastasis was associated with positivity of the nodes along the short gastric arteries (#4sa) and distal nodes along the splenic artery (#11d) (#4sa: p = 0.003, #11d: p = 0.016). When either key node was positive, the metastatic rate of #10 was 24.4%, and the therapeutic value index was 13.3. Conclusions: #4sa and #11d were key lymph nodes predicting #10 nodal metastasis in UGC-GC. When these key nodes are positive on computed tomography before surgery or according to a rapid pathological examination during surgery, dissection of #10 should be considered even if upper advanced tumors are not invading the greater curvature.

Head and Neck Reconstruction in Burn Patients.

Reconstruction of burns in the head and neck region is challenging. This is because it must achieve both functional reconstruction and esthetic reconstruction. Local flaps are best for minor defects, particularly in the case of deep burns, because they bear the correct texture and color. However, for large deep burn wounds, simple grafting or small local flaps will not produce satisfactory results. It is also crucial to assess the extent and depth of reconstruction that is needed throughout the face-neck-anterior chest region, and to make the choice between techniques such as Z-plasty, skin grafting, super-thin flaps, and free flaps.

Update on Hypertrophic Scar Management in Burn Patients.

Hypertrophic scars arise from burn injuries because of persistent inflammation in the reticular dermis. Several risk factors promote this chronic inflammation. One is tension on the burn wound/scar due to surrounding skin tightness and bodily movements. High estrogen levels and hypertension are also important systemic risk factors. Thus, to prevent burn wounds from developing into hypertrophic scars, it is important to focus on quickly resolving the reticular dermal inflammation. If conservative treatments are not effective and the hypertrophic scar transitions to scar contracture, surgical methods such as Z-plasty, full-thickness skin grafting, and local flaps are often used.

In the face and neck, keloid scar distribution is related to skin thickness and stiffness changes associated with movement.

Keloid scars tend to occur in high-tension sites due to mechanical stimuli that are involved in their development. To date, a detailed analysis of keloid distribution focused specifically on facial and neck areas has not been reported, and limited literature exists as to the related mechanical factors. To rectify this deficiency of knowledge, we first quantified the facial and neck keloid distribution observed clinically in 113 patients. Subsequently, we performed a rigorous investigation into the mechanical factors and their associated changes at these anatomic sites in healthy volunteers without a history of pathologic scarring. The association between keloid-predilection sites and sebaceous gland-dense and acne-prone sites was also examined. To assess skin stretch, thickness and stiffness, VECTRA, ultrasound and indentometer were utilised. Baseline skin stiffness and thickness were measured, as well as the magnitude of change in these values associated with facial expression and postural changes. Within the face and neck, keloids were most common near the mandibular angle (41.3%) and lateral submental (20.0%) regions. These areas of increased keloid incidence were not associated with areas more dense in sebaceous glands, nor linked consistently with acne-susceptible regions. Binomial logistic regression revealed that changes in skin stiffness and thickness related to postural changes significantly predicted keloid distribution. Skin stiffness and thickness changes related to prolonged mechanical forces (postural changes) are most pronounced at sites of high keloid predilection. This finding further elucidates the means by which skin stretch and tension are related to keloid development. As a more detailed analysis of mechanical forces on facial and neck skin, this study evaluates the nuances of multiple skin-mechanical properties, and their changes in a three-dimensional framework. Such factors may be critical to better understanding keloid progression and development in the face and neck.

The effects of systemic diseases, genetic disorders and lifestyle on keloids.

Keloid are a fibroproliferative disorder caused by abnormal healing of skin, specifically reticular dermis, when subjected to pathological or inflammatory scars demonstrating redness, elevation above the skin surface, extension beyond the original wound margins and resulting in an unappealing cosmetic appearance. The severity of keloids and risk of developing keloids scars are subjected to elevation by other contributing factors such as systemic diseases, general health conditions, genetic disorders, lifestyle and natural environment. In particular, recently, daily physical work interpreted into mechanical force as well as the interplay between mechanical factors such as stress, strain and stiffness have been reported to strongly modulate the cellular behaviour of keloid formation, affect their location and shape in keloids. Herein, we review the extensive literature on the effects of these factors on keloids and the contributing predisposing mechanisms. Early understanding of these participating factors and their effects in developing keloids may raise the patient awareness in preventing keloids incidence and controlling its severity. Moreover, further studies into their association with keloids as well as considering strategies to control such factors may help clinicians to prevent keloids and widen the therapeutic options.

Posterior Auricle Bilobed Cartilage-skin Flap for Reconstructing the Earlobe: A Case Report.

Because the auricle plays an important role in facial aesthetics, all earlobe operations must seek to limit postoperative ear deformity. This report describes the single-stage posterior-auricle bilobed cartilage-skin flap technique for reconstructing the earlobe. A 31-year-old man incurred a left earlobe deficiency due to a human bite. Earlobe reconstruction was conducted 102 days later. A bilobed flap was designed on the posterior-auricular skin. Both flaps were pedicled in the caudal posterior-auricular area. The first incision raised the upper lobe, which consisted of posterior-auricle skin and conchal cartilage. The skin was sutured to the auricle base so that it formed the anterior earlobe. The cartilage was then cut to separate and processed to the natural curve. The second incision elevated the second flap from the caudal posterior-auricular area. This was sutured to the first flap so that it formed the posterior earlobe. The donor sites were closed with simple sutures. The reconstructed earlobe had no obvious contracture after surgery. Most donor-site scarring was hidden behind the auricle. At 9 months postoperative, the patient was satisfied with the result. Our technique allows us to harvest cartilage from the same operative field, perform a single-stage reconstruction, and recreate a relatively large earlobe with good size and shape. The posterior auricle bilobed cartilage-skin flap technique is useful for earlobe reconstruction.

The Square-Plus Flap: A Modification to Release Long Postburn Scar Contractures.

The square flap method has been successful in releasing contracture bands at various body regions. However, the original square flap method alone may not be efficient in releasing long contracture bands. We, therefore, proposed an extended design to the traditional design, which is called the "square-plus flap." A 4-year-old girl presented with a postburn web-like contracture band over the right axilla. We marked a square flap technique at the center of the contracture band and then two additional Z-plasties were placed on both edges of the flap. After the release and securing of the square flap, the adjacent distal Z-plasty was then transposed and sutured in their new locations. We do not need to incise the proximal Z-plasty as we could achieve complete relaxation of the contracture band. This novel modification can be added to the plastic surgeon's armamentarium for releasing long postburn contracture bands involving distinct body regions.

Ear Keloid as an Unusual Complication of Prolonged Mask Use during the COVID-19 Pandemic.

The recent COVID-19 pandemic required many people to wear ear-loop face masks (ELFMs) for protracted periods, and ear injuries have been reported. Here, we report a rare case of a keloid on the right posterior ear that appeared to arise from prolonged ELFM use. A 76-year-old Japanese man presented with a 7.3 × 2.2 × 1.4-cm keloid running from the medial retroauricular sulcus to the posterior lobule. The lack of keloid history suggested the absence of genetic risk factors. The patient reported extensive mask-wearing habits that were augmented by the pandemic. The keloid developed from an ear injury. Although it healed well, it started thickening 2 months later. Because local mechanical forces (eg, pressure/friction) can promote keloid growth, the ELFM may have provoked the keloid. The patient disclosed a history of uncontrolled hypertension and diabetes mellitus, which associate with severe keloids. The whole keloid was removed via total excision, and the defect was closed primarily and subjected to 15Gy/2Fr radiotherapy. The patient was advised to use a different mask type. Twelve months later, the scar had healed without complications or recurrence and with good cosmetic outcomes. Thus, ELFMs can promote retroauricular keloid formation, possibly by imposing local pressure/friction. ELFMs may also raise local skin temperatures and humidity, thereby fostering infection, which can trigger keloids. Hypertension/diabetes may further elevate the risk of EFLM-induced keloid. Thus, an auricular keloid is an unusual complication of prolonged ELFM use. Combination therapy can have excellent outcomes. Patients with keloid risk factors should be advised to use face masks without ear loops.