Advertisement

Surgery and Radiation Therapy for Keloids and Hypertrophic Scars

  • Rei OgawaEmail author
Chapter

Abstract

Over the past 10 years, our understanding of the pathogenesis of pathological scars, including keloids and hypertrophic scars, has increased markedly. Consequently, keloids and hypertrophic scars are now regarded as treatable diseases. However, the available therapeutic approaches still require improvement. Surgery and radiation therapy should play more prominent roles in current therapeutic strategies for pathological scars. Due to fear of recurrence after keloid resection (which often led to even worse scars), plastic surgeons and dermatologists have been fearful about actively treating keloids. However, there is substantial evidence now that surgery followed by radiation therapy can successfully manage keloids and hypertrophic scars with low levels of recurrence. The development of a standard international algorithm for treating pathological scars on the basis of this evidence is warranted. This chapter discusses the reasons for this. Optimal surgical and radiotherapy treatment protocols and the possible side effects of radiotherapy are also discussed.

Keywords

Scar revision Keloid surgery Core excision Radiation therapy Radiotherapy Brachytherapy β-Ray Electron beam Superficial X-ray 

References

  1. 1.
    Huang C, Murphy GF, Akaishi S, Ogawa R. Keloids and hypertrophic scars: update and future directions. Plast Reconstr Surg Glob Open. 2013;1(4):e25.PubMedPubMedCentralCrossRefGoogle Scholar
  2. 2.
    Ogawa R. Keloid and hypertrophic scars are the result of chronic inflammation in the reticular dermis. Int J Mol Sci. 2017;18(3):E606.CrossRefGoogle Scholar
  3. 3.
    Ogawa R, Akaishi S, Kuribayashi S, Miyashita T. Keloids and hypertrophic scars can now be cured completely: recent progress in our understanding of the pathogenesis of keloids and hypertrophic scars and the most promising current therapeutic strategy. J Nippon Med Sch. 2016;83(2):46–53.PubMedCrossRefPubMedCentralGoogle Scholar
  4. 4.
    Ogawa R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125(2):557–68.PubMedCrossRefPubMedCentralGoogle Scholar
  5. 5.
    Ogawa R, Akaishi S. Endothelial dysfunction may play a key role in keloid and hypertrophic scar pathogenesis—keloids and hypertrophic scars may be vascular disorders. Med Hypotheses. 2016;96:51–60.CrossRefGoogle Scholar
  6. 6.
    Ogawa R. Mechanobiology of scarring. Wound Repair Regen. 2011;19(Suppl 1):s2–9.CrossRefGoogle Scholar
  7. 7.
    Mandy SH. The practical use of Z-plasty. J Dermatol Surg. 1975;1(4):57–60.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    Ogawa R, Akaishi S, Huang C, Dohi T, Aoki M, Omori Y, Koike S, Kobe K, Akimoto M, Hyakusoku H. Clinical applications of basic research that shows reducing skin tension could prevent and treat abnormal scarring: the importance of fascial/subcutaneous tensile reduction sutures and flap surgery for keloid and hypertrophic scar reconstruction. J Nihon Med Sch. 2011;78(2):68–76.CrossRefGoogle Scholar
  9. 9.
    Yoshino Y, Kubomura K, Ueda H, Tsuge T, Ogawa R. Extension of flaps associated with burn scar reconstruction: a key difference between island and skin-pedicled flaps. Burns. 2018;44:683–91.PubMedCrossRefPubMedCentralGoogle Scholar
  10. 10.
    Jacobsson F. The treatment of keloids at Radium-hemmet, 1921–1941. Acta Radiol. 1948;29(3):251–67.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Levy DS, Salter MM, Roth RE. Postoperative irradiation in the prevention of keloids. AJR Am J Roentgenol. 1976;127(3):509–10.PubMedCrossRefPubMedCentralGoogle Scholar
  12. 12.
    Enhamre A, Hammar H. Keloids with excision and postoperative X-ray irradiation. Dermatologica. 1983;167(2):90–3.PubMedCrossRefPubMedCentralGoogle Scholar
  13. 13.
    Borok TL, Bray M, Sinclair I, Plafker J, LaBirth L, Rollins C. Role of ionizing irradiation for 393 keloids. Int J Radiat Oncol Biol Phys. 1988;15(4):865–70.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    Kovalic JJ, Perez CA. Radiation therapy following keloidectomy: a 20-year experience. Int J Radiat Oncol Biol Phys. 1989;17(1):77–80.PubMedCrossRefPubMedCentralGoogle Scholar
  15. 15.
    Doornbos JF, Stoffel TJ, Hass AC, Hussey DH, Vigliotti AP, Wen BC, Zahra MK, Sundeen V. The role of kilovoltage irradiation in the treatment of keloids. Int J Radiat Oncol Biol Phys. 1990;18(4):833–9.PubMedCrossRefPubMedCentralGoogle Scholar
  16. 16.
    Chaudhry MR, Akhtar S, Duvalsaint F, Garner L, Lucente FE. Ear lobe keloids, surgical excision followed by radiation therapy: a 10-year experience. Ear Nose Throat J. 1994;73(10):779–81.PubMedCrossRefPubMedCentralGoogle Scholar
  17. 17.
    Norris JE. Superficial X-ray therapy in keloid management: a retrospective study of 24 cases and literature review. Plast Reconstr Surg. 1995;95(6):1051–5.PubMedCrossRefPubMedCentralGoogle Scholar
  18. 18.
    Sclafani AP, Gordon L, Chadha M, Romo T 3rd. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature. Dermatol Surg. 1996;22(6):569–74.PubMedCrossRefPubMedCentralGoogle Scholar
  19. 19.
    Ragoowansi R, Cornes PG, Glees JP, Powell BW, Moss AL. Ear-lobe keloids: treatment by a protocol of surgical excision and immediate postoperative adjuvant radiotherapy. Br J Plast Surg. 2001;54(6):504–8.PubMedCrossRefPubMedCentralGoogle Scholar
  20. 20.
    Malaker K, Vijayraghavan K, Hodson I, Al Yafi T. Retrospective analysis of treatment of unresectable keloids with primary radiation over 25 years. Clin Oncol (R Coll Radiol). 2004;16(4):290–8.CrossRefGoogle Scholar
  21. 21.
    Klumpar DI, Murray JC, Anscher M. Keloids treated with excision followed by radiation therapy. J Am Acad Dermatol. 1994;31(2 Pt 1):225–31.PubMedCrossRefPubMedCentralGoogle Scholar
  22. 22.
    Caccialanza M, Piccinno R, Schiera A. Postoperative radiotherapy of keloids: a twenty-year experience. Eur J Dermatol. 2002;12(1):58–62.PubMedPubMedCentralGoogle Scholar
  23. 23.
    Speranza G, Sultanem K, Muanza T. Descriptive study of patients receiving excision and radiotherapy for keloids. Int J Radiat Oncol Biol Phys. 2008;71(5):1465–9.PubMedCrossRefPubMedCentralGoogle Scholar
  24. 24.
    Lo TC, Seckel BR, Salzman FA, Wright KA. Single-dose electron beam irradiation in treatment and prevention of keloids and hypertrophic scars. Radiother Oncol. 1990;19(3):267–72.PubMedCrossRefPubMedCentralGoogle Scholar
  25. 25.
    Chen HC, Ou SY, Lai YL. Combined surgery and irradiation for treatment of hypertrophic scars and keloids. Zhonghua Yi Xue Za Zhi (Taipei). 1991;47(4):249–5.Google Scholar
  26. 26.
    Maarouf M, Schleicher U, Schmachtenberg A, Ammon J. Radiotherapy in the management of keloids. Clinical experience with electron beam irradiation and comparison with X-ray therapy. Strahlenther Onkol. 2002;178(6):330–5.PubMedCrossRefPubMedCentralGoogle Scholar
  27. 27.
    Bischof M, Krempien R, Debus J, Treiber M. Postoperative electron beam radiotherapy for keloids: objective findings and patient satisfaction in self-assessment. Int J Dermatol. 2007;46(9):971–5.PubMedCrossRefPubMedCentralGoogle Scholar
  28. 28.
    Ogawa R, Mitsuhashi K, Hyakusoku H, Miyashita T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg. 2003;111(2):547–53. discussion 554–5.PubMedPubMedCentralGoogle Scholar
  29. 29.
    Ogawa R, Miyashita T, Hyakusoku H, Akaishi S, Kuribayashi S, Tateno A. Postoperative radiation protocol for keloids and hypertrophic scars: statistical analysis of 370 sites followed for over 18 months. Ann Plast Surg. 2007;59(6):688–91.PubMedCrossRefPubMedCentralGoogle Scholar
  30. 30.
    Vivante H, Salgueiro MJ, Ughetti R, Nicolini J, Zubillaga M. 32P-patch contact brachyradiotherapy in the management of recalcitrant keloids and hypertrophic scars. Indian J Dermatol Venereol Leprol. 2007;73(5):336–9.PubMedCrossRefPubMedCentralGoogle Scholar
  31. 31.
    Supe SS, Supe SJ, Rao SM, Deka AC, Deka BC. Treatment of keloids by 90Sr-90Y beta-rays. Strahlenther Onkol. 1991;167(7):397–402.PubMedPubMedCentralGoogle Scholar
  32. 32.
    Fraunholz IB, Gerstenhauer A, Böttcher HD. Results of postoperative (90)Sr radiotherapy of keloids in view of patients’ subjective assessment. Strahlenther Onkol. 2005;181(11):724–9.PubMedCrossRefPubMedCentralGoogle Scholar
  33. 33.
    Malaker K, Zaidi M, Franka MR. Treatment of earlobe keloids using the cobalt 60 teletherapy unit. Ann Plast Surg. 2004;52(6):602–4.PubMedCrossRefPubMedCentralGoogle Scholar
  34. 34.
    Malaker A, Ellis F, Paine CH. Keloid scars: a new method of treatment combining surgery with interstitial radiotherapy. Clin Radiol. 1976;27(2):179–83.PubMedCrossRefPubMedCentralGoogle Scholar
  35. 35.
    Escarmant P, Zimmermann S, Amar A, Ratoanina JL, Moris A, Azaloux H, Francois H, Gosserez O, Michel M, G’Baguidi R. The treatment of 783 keloid scars by iridium 192 interstitial irradiation after surgical excision. Int J Radiat Oncol Biol Phys. 1993;26(2):245–51.PubMedCrossRefPubMedCentralGoogle Scholar
  36. 36.
    Clavere P, Bedane C, Bonnetblanc JM, Bonnafoux-Clavere A, Rousseau J. Postoperative interstitial radiotherapy of keloids by iridium 192: a retrospective study of 46 treated scars. Dermatology. 1997;195(4):349–52.PubMedCrossRefPubMedCentralGoogle Scholar
  37. 37.
    Guix B, Henríquez I, Andrés A, Finestres F, Tello JI, Martínez A. Treatment of keloids by high-dose-rate brachytherapy: a seven-year study. Int J Radiat Oncol Biol Phys. 2001;50(1):167–72.PubMedCrossRefPubMedCentralGoogle Scholar
  38. 38.
    Garg MK, Weiss P, Sharma AK, Gorla GR, Jaggernauth W, Yaparpalvi R, Delrowe J, Beitler JJ. Adjuvant high dose rate brachytherapy (Ir-192) in the management of keloids which have recurred after surgical excision and external radiation. Radiother Oncol. 2004;73(2):233–6.PubMedCrossRefPubMedCentralGoogle Scholar
  39. 39.
    Narkwong L, Thirakhupt P. Postoperative radiotherapy with high dose rate iridium 192 mould for prevention of earlobe keloids. J Med Assoc Thai. 2006;89(4):428–33.PubMedPubMedCentralGoogle Scholar
  40. 40.
    Veen RE, Kal HB. Postoperative high-dose-rate brachytherapy in the prevention of keloids. Int J Radiat Oncol Biol Phys. 2007;69(4):1205–8.PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Kuribayashi S, Miyashita T, Ozawa Y, Iwano M, Ogawa R, Akaishi S, Dohi T, Hyakusoku H, Kumita S. Post-keloidectomy irradiation using high-dose-rate superficial brachytherapy. J Radiat Res. 2011;52(3):365–8.PubMedCrossRefPubMedCentralGoogle Scholar
  42. 42.
    Ogawa R, Huang C, Akaishi S, Dohi T, Sugimoto A, Kuribayashi S, Miyashita T, Hyakusoku H. Analysis of surgical treatments for earlobe keloids: analysis of 174 lesions in 145 patients. Plast Reconstr Surg. 2013;132(5):818e–25e.PubMedCrossRefPubMedCentralGoogle Scholar
  43. 43.
    Ogawa R, Akaishi S, Dohi T, Kuribayashi S, Miyashita T, Hyakusoku H. Analysis of the surgical treatments of 63 keloids on the cartilaginous part of the auricle: effectiveness of the core excision method. Plast Reconstr Surg. 2015;135(3):868–75.PubMedCrossRefPubMedCentralGoogle Scholar
  44. 44.
    Ogawa R, Ono S, Akaishi S, Dohi T, Iimura T, Nakao J. Reconstruction after anterior chest wall keloid resection using internal mammary artery perforator propeller flaps. Plast Reconstr Surg Glob Open. 2016;4(9):e1049.PubMedPubMedCentralCrossRefGoogle Scholar
  45. 45.
    Kal HB, Veen RE. Biologically effective doses of postoperative radiotherapy in the prevention of keloids. Dose-effect relationship. Strahlenther Onkol. 2005;181:717–23.PubMedCrossRefPubMedCentralGoogle Scholar
  46. 46.
    Preston DL, Ron E, Tokuoka S, Funamoto S, Nishi N, Soda M, Mabuchi K, Kodama K. Solid cancer incidence in atomic bomb survivors: 1958–1998. Radiat Res. 2007;168(1):1–64.PubMedCrossRefPubMedCentralGoogle Scholar
  47. 47.
    Ogawa R, Yoshitatsu S, Yoshida K, Miyashita T. Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis. Plast Reconstr Surg. 2009;124(4):1196–201.PubMedCrossRefPubMedCentralGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  1. 1.Department of Plastic, Reconstructive and Aesthetic SurgeryNippon Medical SchoolTokyoJapan

Personalised recommendations