The prevention and treatment of keloid scars has been a major challenge in aesthetic plastic surgery. Since some important aspects of its pathogenesis are still unclear, there are many treatment methods but none of them are very effective, mainly because of the difficulty in controlling its high recurrence rate. Studies at home and abroad have shown that no single treatment can effectively control the recurrence rate, and that only comprehensive treatment is expected to achieve a breakthrough and significant results in the treatment of keloid scars.
Diagnostic criteria for keloid scars
1. The skin damage exceeds the original damage and invades the surrounding normal skin
2. The duration of the disease exceeds 9 months without signs of spontaneous regression.
3. Previous surgical excision and recurrence
Any one or more of the above can confirm the diagnosis
Points criteria of scar severity classification
Color: red or bright red with capillary dilatation 3 points
Light red, disappearing after pressure is counted as 2 points Not red.
1 point for some grayness. 0 points for normal skin color.
Scar height: 3 points for 8 mm or more; 2 points for 4-8 mm
1 point for 11-4mm. Flat or slightly depressed scores 0.
Hardness: 3 points for hardness like cartilage. Hardness like rubber scores 2 points.
1 point for slightly soft. Soft like normal skin scores 0.
Itch: 3 points for intense or persistent with scratch marks.
Frequent but not too intense, tolerable score of 2.
1 point for sometimes itchy. 0 points for no itching.
Tenderness: 3 points for very strong “pain allergy”.
Allergic pain of moderate intensity is scored as 2.
Sometimes, 1 point. None, 0 points.
According to the above criteria, a total score of 10 or more is considered severe; 6-10 is moderate; 1-5 is mild.
Criteria for the efficacy of keloid
Cure: disappearance of pain and itching, complete softening and flattening of the scar, soft to the touch without hard nodules, and no recurrence for at least 12 months after completion of treatment. Or 12 months after surgery without recurrence.
Significant effect: disappearance or significant reduction of pain and itching, softening and flattening of 60-70% of the scar or conversion of the severity of the keloid from severe to moderate or mild according to the aforementioned points criteria, or conversion of moderate to mild without reversal at 12 months follow-up, or mild scar formation after surgery (according to the aforementioned points criteria) at 12 months follow-up without change.
Ineffective: The symptoms and signs such as pain, itching, color, etc. are reduced or not changed, the texture and size of the scar are not changed or changed very little, or the standard of cure or efficacy was achieved, but the scar recurred 12 months after the course of treatment or within 12 months after surgical excision.
Treatment methods
1.Injection-based comprehensive therapy-surgery with compression therapy, topical medicine, physiotherapy, etc.
The first step is to inject trimethoprim and other drugs into the scar parenchyma with our high hydraulic scar injector. Injections are given once a week for a course of 3 to 7 times depending on the size of the scar. In between injections, the scar is coated with scar removal cream and then sealed with “silicone film” on the surface of the scar to allow the drug to fully function and to avoid staining clothing. After the injections, this method can be used to continue to apply the medication for 1 to 2 months. To consolidate the therapeutic effect.
1) Indication: keloid occurs on exposed parts of the body such as face and earlobes and the patient has cosmetic requirements
2) Method: 1 to 2 weeks before the surgery, the drug is injected 1 to 2 times around and at the base of the scar, and then the scar is excised in its entirety and the subcutaneous tissue and dermis are sutured separately in alignment with 5-0 silk thread. Instead of suturing the epidermal layer of the skin, the “silicone film” is cut to a suitable size according to the length of the incision and pasted to the skin on both sides of the incision in a direction perpendicular to the incision, and the elasticity of the film pulls the two sides of the incision together neatly without tension, thus effectively preventing scar formation during the healing process of the incision. In addition, Ansulto itself is a sterile dressing, which can effectively isolate bacterial contamination.
If the tension on both sides of the incision is high, Band-Aid or skin stretching tape (no-sew tape) can be used to reduce the tension.
In the third week after surgery, a small amount of medication will be injected into the incision, and “silicone film” will be used to continue to reduce tension and seal the medication in the incision to prevent the widening of the incision and scar growth.
2.Surgery-based comprehensive treatment – surgery with drug injection or radiotherapy before and after surgery
Proliferative scar usually matures after 6 months-2 years, becomes soft and flat, and the congestion subsides. Therefore: this kind of scar is best treated after 6 months or 1 year, after the scar has softened and stabilized before surgery, for better results. However, in areas that affect function, one should not wait, but should promptly excise the scar, loosen the surrounding tissue and perform a skin slice or flap repair. Eyelid scar contracture can lead to ectropion of the eye and face; the conjunctival membrane is exposed, leaving the cornea unprotected, and if not corrected for a long time, chronic conjunctivitis, hypertrophy of the lid and conjunctiva, corneal ulceration, self-plaque, and in severe cases, blindness. In addition, if the hand is burned or traumatized, a proliferative scar is formed after the wound heals, which often cannot maintain normal function: especially the scar on the back of the hand. The contracture can pull the metacarpophalangeal joint into dorsiflexion and even cause joint dislocation, which should be treated early.
The basic surgical methods of scar surgery
1.Keloid scar excision with direct suture
2.Keloid scar excision “Z” shaping
3. scar excision with five flaps
4. skin grafting
5. Soft tissue skin expansion
Principles of treatment for various kinds of scars
(1) Superficial linear scar: Most of them do not need treatment. If it occurs on the face and is detrimental to the appearance, surgical excision can be carefully considered. If the area is small, the scar can be excised and sutured in the direction of the skin line. If the scar is staggered at right angles to the dermatoglyphic pattern, Z-plasty should be applied to repair the scar, otherwise the long-term effect is poor. If the area is small, excision should be performed in stages according to the above principles. The scar is first excised in the central part of the scar or on the side of the scar, free, pulled together and sutured: the second or multiple excisions are performed after 2-6 months. Free skin grafting is not recommended for this type of scar to avoid affecting the efficacy of the treatment.
(2) depressed scar: for simple depressed scar, the thin epithelium on the scar can be excised, the subcutaneous tissue on both sides of the scar can be subconsciously separated, and the two sides can be pulled together and sutured layer by layer on top of the preserved scar (Figure 9-18), or the fat flap can be transferred to fill the depression near the traumatic margin (Figure 9-29), but in order not to affect the appearance. Local application of a flap to cover an extensive depressed scar is ideal, and in cases where no flap can be transferred locally or to adjacent tissues, a distant flap can be used depending on the situation. For depressions caused by trapped bone defects, cartilage, bone and medical silicone rubber can be used for filling.
(3) Atrophic scar: usually no treatment is needed. If the scar is located on the face, if the area is small and in an appropriate place, it can be excised and sutured in stages or repaired by local flap transfer. These scars often form chronic ulcers due to abrasions, which should be excised together with the basal scar and repaired with flaps or free flaps to prevent late malignant transformation.
(4) Contracture scar: For large contracture scar, the scar should be partially or completely excised, and medium-thickness or full-thickness skin grafting should be performed, and flap repair can be used if necessary. In general, for mild contracture and not deep scar, medium-thickness skin grafting is more suitable. If the contracture is severe, the scar is close to the deep tissue, and adheres to tendons, blood vessels, nerves or bones, flap transfer is more appropriate.
Complete release of the contracture is the key step in surgical treatment. Inflatable tourniquets are appropriate for surgery of extremity sites to reduce
bleeding and clear surgical field. The release begins with an incision perpendicular to the longitudinal axis of the contracture and follows the stratification of scar and normal tissue.
The dissection is performed gradually at the level of the scar and normal tissue until the contracture is completely released. Sometimes, tendon lengthening, arthrotomy, and ligament excision are also required to achieve the contracture.
In order to achieve full release, it is necessary to perform auxiliary procedures such as tendon lengthening, arthrotomy, and joint ligament removal. During the release, appropriate external force can be applied; however, violent
However, do not use violent pulling to force the joint to reset, in order to avoid lacerations or fractures of soft tissues such as nerves and blood vessels. If the joint cannot be repositioned, postoperative traction, arthroplasty, or fusion table surgery can be performed according to the situation.
(5) Deep scar contracture: Trauma that enters deep into the body, such as stab wounds or shrapnel wounds, can often form a large number of scars in deep tissues, which not only adhere to the surrounding nerves and muscles, but also often cause reflex pain and muscle dysfunction due to contracture traction of the surrounding tissues. Two points should be noted when dealing with this kind of scar: ① The location, extent and depth of the scar are often difficult to determine before surgery, and must be explored clearly during surgery. In case of adhesions with important organs and difficult radical surgery, a thorough preoperative study should be done to carefully design the surgical plan and select the surgical approach for safety; ② Tissue filling should be tried: the cavity created after scar excision is usually filled with fatty tissue graft with tip for better efficacy.
(6) Proliferative scar: surgical treatment is only used when there is functional impairment or morphological change. The principle of surgery is to excise the fatty scar, fully loosen it, correct the deformity, and repair the wound with skin slice or flap. For cases with extensive scar area and lack of skin source, only the scar can be excised or partially excised. Only the contracture is sought to be loosened, and the defect is repaired with skin flaps. The residual hyperplastic scar can gradually soften on its own due to the disappearance of tension.
(7) Surgical Treatment of the Keloid
There is no ideal treatment for keloids. After surgical excision, the keloid is very prone to recurrence and the lesion is enlarged compared to the preoperative one. Therefore, excision and suturing alone are considered contraindicated. Radiation therapy to the operative area after surgery can help prevent recurrence, so radiation therapy should be planned before surgery is performed. Tension sutures should be avoided during surgery. If the wound is large or there is tension after suturing, it should be repaired by skin grafting. After the sutures are removed, radiation therapy is given. Surgical treatment is generally only applicable to cases with contracture deformity that hampers function, and should be considered carefully if the main purpose is to improve appearance. In addition to strict adherence to the principles of aseptic and noninvasive techniques, the donor area must also be treated with measures to prevent the formation of keloids.
Measures for formation
(8) Linear scar: If it affects the appearance or contracture causes functional impairment, it can be surgically removed. Surgical method: first excise the linear hyperplastic scar and apply Z-plasty staggered sutures to loosen the contracture and correct the deformity. If the scar is accompanied by significant protruding dotted scar on both sides, it can be repaired by using multiple W-plasty as shown in the figure.
(9) Webbed scar: Generally, Z-plasty can be used to correct the scar. The webbed crease is evenly dissected into two layers of equal thickness, and a pair or several pairs of mutually corresponding triangular flaps can be designed to release the contracture. If the flap is not enough to cover the entire wound, it is supplemented with free skin flap graft. Webbed scar is often thicker on one side than the other. Therefore, when designing a Z-shaped flap, the angle of the triangular flap on the side with more scar should be larger, and the tip should be wider and cut in the midline of the scar and peeled off in the loose tissue of the two scar layers. Do not favor one side. To ensure flap blood flow and prevent flap necrosis.
(10) Bridge-like (superfluous) scar: a few small simple bridges and superfluous skin can be excised and sutured. For most of the larger complex bridges and superfluous skin, the rolled-up skin should be cut and flattened to form a double-tipped or single-tipped flap to repair the scar after excision. Because of its good color and thickness, it can achieve better cosmetic results than simple excision and suturing.