Keloid Scar Excision

What is a keloid excision?

A keloid scar is a thick raised scar. It can occur wherever you have a skin injury, but usually forms on earlobes, shoulders, cheeks or the chest. If you are prone to developing keloid scars, you may develop them in multiple areas. A keloid scar is different from a hypertrophic scar. In a hypertrophic scar, the scar stays within the bounds of the original wound and can fade over time without treatment.

Keloid scar treatment is possible, but even with treatment, it can last for years or recur.

Symptoms

A keloid scar may form within months to years of sustaining the injury. Signs and symptoms may include:

  • Thick, irregular scarring, typically on the earlobes, shoulders, cheeks or middle chest.
  • Shiny, hairless, lumpy, raised skin.
  • Varied sizes, depending on the dimensions of the original injury and when the keloid scar stops growing.
  • Varied textures, from soft to firm and rubbery.
  • Reddish, brown or purplish colour, depending on your skin tone.
  • Itchiness.
  • Discomfort and restrictive.

Causes

A keloid scar may form within months to years of sustaining the injury. Signs and symptoms may include:

Experts do not completely understand what causes keloid scars, but most agree it is likely a dysfunction of the wound-healing process. Collagen is a protein found throughout the body and is key to wound healing. However, when the body produces too much of it, keloid scars can form.

Keloid growth may be triggered by any sort of skin injury – an insect bite, acne, an injection, body piercing, burns, hair removal, and even minor scratches and bumps. Sometimes keloid scars form for no obvious reason.

Risk factors

Risk factors for keloid scars include:

  • Having brown or black skin. Keloid scars are most common in people with these skin colours. The reason for this predisposition is unknown.
  • Having a personal or family history of keloid scars and can run in families, indicating that the tendency might be inherited. If you have had one keloid scar, you are at risk of developing more.
  • You are more likely to develop a keloid scar if you are between the ages of 20 and 30.

One, or a combination of various approaches, might be best for your situation. Even after successful flattening or removal, keloid scars can grow back, sometimes bigger than before; or you may develop new ones.

Wound care: For newer keloid scars, the initial treatment option might be compression dressings made from elastic fabric or other materials. This technique is also employed after surgical removal of keloid scars. The objective is to minimise or prevent scarring by applying pressure to the wound during the healing process. These dressings need to be worn for 12 to 24 hours a day for 4 to 6 months to be effective. This method is effective but can be quite uncomfortable.

Corticosteroid cream: A prescription strength corticosteroid cream can help ease itchiness.

Injected medicine: If you have a smaller keloid scar, your doctor might try reducing its thickness by injecting it with cortisone or other steroids. Monthly injections may be required, for a period of up to 6 months, before the scar flattens.

Possible side effects of corticosteroid injections are skin thinning, spider veins and a permanent change in skin colour (hypopigmentation or hyperpigmentation).

Freezing the scar: Small keloid scars may be reduced or removed by freezing them with liquid nitrogen (cryotherapy). Repeat treatments could be required. Possible side effects of cryotherapy are blistering, pain and loss of skin colour (hypopigmentation).

Laser treatment: Larger keloid scars can be flattened by pulsed-dye laser sessions. This method has also been useful in easing itchiness and causing keloid scars to fade. Pulsed-dye laser therapy is delivered over several sessions in 4-to-8-week intervals. Possible side effects (more common in people with a darker skin tone), include hypopigmentation or hyperpigmentation, blistering and crusting.

Radiation therapy: Low-level x-ray radiation (alone or after surgical removal of a keloid scar) can help shrink or minimize the scar tissue and repeat treatments are sometimes required. Possible side effects of radiation therapy are skin complications and, in the long term, cancer.

Surgical removal: If your keloid scar has not responded to other therapies, it can be surgically removed in combination with other methods. Surgery alone has a recurrence rate of 45% to 100%.

Surgical removal of keloid scars is not essential, and you could choose to avoid surgery and accept your current appearance or to resume steroid injections.

The operation can be performed under local anaesthetic injection (you are awake, but the area is numb) or general anaesthetic (you will be fully unconscious). It is commonly performed under local anaesthetic in a treatment room. The area is numbed with an injection, and the procedure takes 40 minutes to perform.

Intralesional excision involves removing the keloid scar within its existing boundaries to prevent enlarging the scar. The remaining rim of keloid scar would be treated with steroid injections 2 weeks after removal of the lesion. You may need to have repeat steroid injections every 6 weeks to flatten it completely.

I also recommend the incision is closed with dissolvable sutures, if in the trunk and limbs. Alternatively, non-dissolvable sutures are used on facial keloid scars, which require removal after a period of 5 days.

Complications are infrequent and usually minor. However, all surgery has risk, and it is important that you are aware of the possible complications.

All the risks will be discussed in detail with you at your consultation. However, if you have further questions or concerns, please do not hesitate to discuss them with me.

Decisions about surgery should never be rushed.

These risks can be divided into the risks specific to the surgery and the risks of anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

  • Unintended intraoperative awareness, which is very rare.
  • Dizziness and nausea.
  • Sore throat.
  • Damage to teeth or mouth.
  • Nerve injury due to body positioning.
  • Allergic reaction or anaphylaxis.
  • Malignant hyperthermia, which is a rare life-threatening condition.

Scars: The aim of surgery is to reduce the size of the keloid scar to allow steroid injections to flatten the remaining keloid. However, there is a risk that the keloid will return and it could potentially be worse than before surgery.

Bruising and swelling: This is very common and may take approximately 2 weeks to resolve.

Haematoma: This can happen if a bleed occurs under the skin, allowing a large blood clot to form. If a haematoma develops, it is likely to do so within 4 to 6 hours post-surgery. Any increase in swelling or pain should be reported immediately so that treatment can be given. Sometimes patients need to have this collection of blood removed with another short operation.

Infection: This is rare, but you may require antibiotics if there are any concerns.

Numbness, reduced sensation or oversensitivity: These can occur around the scar. They are usually temporary, but occasionally the changes can remain to some degree.

Wound healing problems: These healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, resulting in skin loss. People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Dog-ears: These are soft tissue prominences where the scar stops. In most cases these settle over the course of 3 months. A small local anaesthetic procedure may be required to remove any excess that remains.

Recurrence: Even when a lesion is completely excised, it is possible that it could recur, or a new one can grow in the area.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and move to your lungs. If the blood clot is large enough it could prove fatal. In order to reduce any risks of this, we give you special stockings to wear in bed and a blood thinning injection if you are not mobile.

All of the risks outlined above will be discussed in detail at your consultation with me. However, if you have further questions or concerns, please do not hesitate to ask. Decisions about cosmetic surgery should never be rushed.

The anaesthetist will go through these risks in more detail prior to your surgery.

Depending on the area of your surgery, your incisions are closed with either dissolvable or non-absorbable sutures.

Dissolvable sutures under the skin do not require removal whereas the non-absorbable sutures will need to be taken out after 5 days. You normally have a waterproof dressing to enable you to shower.

Before you leave the clinic, you will be given a follow up appointment to see the nurses at one week post-operatively to check your incisions and an appointment to see me in Clinic 2 weeks’ time.

Scar advice
Once the dressings are removed, I recommend that you massage the incisions, using small circular motions at least twice a day for 5 minutes. You can use any moisturising cream of your choice and apply firm pressure until it blanches.

The scars will also benefit from silicone scar gel (ScarAway® or Kelo-Cote®) twice a day, which will soften and fade them, as well as applying sunblock for 12 months to provide sun protection.

The ScarAway® can be purchased from Healthcare Pharmacy at Governors Square in Grand Cayman.

Recovery times vary from one person to another, but most patients return to work the next day, and I recommend that you avoid swimming and strenuous activities for 1 to 2 weeks.

For self-funding patients, surgical fees are a combination of the hospital costs, the surgeon and anaesthetic fees and any consumables. I do not charge an additional fee for post-op appointments. The fee is based on the surgical time rather than procedure. This means that the costs are calculated fairly, and complex patients may have higher costs than routine patients. You will be given a quotation for surgery within 48 hours of your consultation.

Some insurance companies will cover keloid scar excision, but it depends on your policy coverage. Most patients contribute towards the surgery in the form of a copay, which is normally 20% of the total cost of the procedure.