Intralesional Cryosurgery for the Treatment of Hypertrophic Scars and Keloids

  • Yaron Har-Shai
  • Lior Har-Shai


This chapter is aimed to describe in a comprehensive way the novel cryoneedle which is inserted into the hypertrophic scars and keloid (HSK). It is connected to a canister of liquid nitrogen, which causes the cryoprobe to freeze, thereby freezing the HSK from the inside out.

Following the cryotreatment, the histomorphometric analysis demonstrated rejuvenation of the treated scars. The collagen bundles became more compact. A clear distinct transition zone separated the treated from the unaffected area. The surface thermal history showed a slow cooling and thawing rates, and less pronounced end temperature, which is “friendly” to the melanocytes; thus, only minimal hypopigmentation was evident. A significant long hold time was documented. This allows time for solute effects, ice crystal formation, and recrystallization, which enhances and increases the rate of cell death. This long hold time, which is unique for the cryosurgery technology, might explain the superior clinical results which have been obtained.

An average of 51% of scar volume reduction was achieved following a single cryotreatment: for ear HSK, 67% reduction, and for the upper back and shoulders, 60%. Significant alleviation of objective and subjective clinical symptoms was achieved. During the follow-up period there was no worsening or infection of the HSK and only minimal hypopigmentation.

A pain control protocol has been applied which involved oral pain relief tablets and translesional local anesthesia. This protocol significantly reduced pain severity during the cryosurgery treatment to tolerable levels (VAS ≤ 3 cm).

The intralesional cryosurgery treatment is an evidence-based effective and safe technology, simple to operate which can be applied as an office procedure, is cost-effective, and possesses a short learning curve.


Intralesional cryosurgery Cryoneedle probe Keloid Hypertrophic scar Liquid nitrogen Equipment Pain control regimen Histomorphometric analysis 


  1. 1.
    Butler PD, Longaker MT, Yang GP. Current progress in keloid research and treatment. J Am Coll Surg. 2008;206:731–41.CrossRefGoogle Scholar
  2. 2.
    Zouboulis CC, Orfanos CE. Kryochirurgische Behandlung Von Hypertropten Narben Und Keloiden. Hautarzt. 1990;41:683–8.PubMedGoogle Scholar
  3. 3.
    Zouboulis CC, Zouridaki E, Rosenberger A, Dalkowski A. Current developments and uses of cryosurgery in the treatment of keloids and hypertrophic scars. Wound Repair Regen. 2002;10:98–102.PubMedCrossRefGoogle Scholar
  4. 4.
    Zouboulis CC, Blume V, Buttner P, Orfanos CE. Outcomes of cryosurgery in keloids and hypertrophic scars. A prospective consecutive trial of case series. Arch Dermatol. 1993;129:1146–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Zouboulis CC, Orfanos CE. Cryosurgical treatment. In: Harahap M, editor. Surgical techniques for cutaneous scar revision. New York: Marcel Delcker, Inc.; 2000. p. 185–234.Google Scholar
  6. 6.
    Weshahy AH. Intralesional cryosurgery, a new technique using cryoneedles. J Dermatol Surg Oncol. 1993;19:123–6.PubMedCrossRefGoogle Scholar
  7. 7.
    Zouboulis CC. Principles of cutaneous cryosurgery: an update. Dermatology. 1999;198:111–7.PubMedCrossRefGoogle Scholar
  8. 8.
    Zouboulis CC, Rosenberger AD, Forster T, Beller G, Kratzsch M, Felsenberg D. Modification of a device and its application for intralesional cryosurgery of old recalcitrant keloids. Arch Dermatol. 2004;140:1293–4.PubMedCrossRefGoogle Scholar
  9. 9.
    Gupta S, Kumar B. Intralesional cryosurgery using lumbar puncture and/or hypodermic needles for large, bulky, recalcitrant keloids. Int J Dermatol. 2001;40:349–53.PubMedCrossRefGoogle Scholar
  10. 10.
    Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg. 2003;111:1841–52.PubMedCrossRefGoogle Scholar
  11. 11.
    Har-Shai Y, Dujovny E, Rohde E, Zouboulis CC. Effect of skin surface temperature on skin pigmentation during contact and intralesional cryosurgery of keloids. J Eur Acad Dermatol Venereol. 2007;21:191–8. Erratum in: J Eur Acad Dermatol Venereol. 21:292, 2007.Google Scholar
  12. 12.
    Har-Shai Y, Brown W, Labbê D, Dompmartin A, Goldine I, Gil T, Mettanes I, Pallua N. Intralesional cryosurgery for the treatment of hypertrophic scars and keloid following aesthetic surgery: the results of a prospective observational study. Int J Low Extrem Wounds. 2008;6:169.CrossRefGoogle Scholar
  13. 13.
    Fikrle T, Pizinger K. Cryosurgery in the treatment of earlobe keloids: report of seven cases. Dermatol Surg. 2005;31:1728–31.PubMedGoogle Scholar
  14. 14.
    Mirmovich O, Gil T, Goldin I, Lavi I, Mettanes I, Har-Shai Y. Pain evaluation and control during and following the treatment of hypertrophic scars and keloids by contact and intralesional cryosurgery—a preliminary study. J Eur Acad Dermatol Venereol. 2012;26:440–7.PubMedCrossRefGoogle Scholar
  15. 15.
    Har-Shai Y, Zouboulis CC. Intralesional cryosurgery for the treatment of hypertrophic scars and keloids. Chapter 86. In: Abramovich W, Graham G, Har-Shai Y, Strumia R, editors. Dermatological cryosurgery and cryotherapy. London: Springer; 2016. p. 453–74.CrossRefGoogle Scholar
  16. 16.
    Har-Shai L, Pallua N, Grasys I, Metanes I, Har-Shai Y. Intralesional excision combined with intralesional cryosurgery for the treatment of oversized and therapy-resistant keloids of the neck and ears. Eur J Plast Surg. 2018;41:233–8.CrossRefGoogle Scholar
  17. 17.
    Stromps JP, Dunda S, Eppstein RJ, Babic D, Har-Shai Y, Pallua N. Intralesional cryosurgery combined with topical silicone gel sheeting for the treatment of refractory keloids. Dermatol Surg. 2014;40:996–1003.PubMedCrossRefGoogle Scholar
  18. 18.
    Chopinaud M, Pham A-D, Labbe D, Verneuil L, Gourio C, Benateau H, Dompmartin A. Intralesional cryosurgery to treat keloid scars: results from a retrospective study. Dermatology. 2014;229:263–70.PubMedCrossRefGoogle Scholar
  19. 19.
    O’boyle CP, Shayan-Arani H, Hamada MW. Intralesional cryotherapy for hypertrophic scars and keloids: a review. Scars Burns Heal. 2017;3:1–9.Google Scholar
  20. 20.
    Gorney M. Medical malpractice and plastic surgery: the carrier’s point of view, Chapter 5. In: Goldwyn RM, Cohen MN, editors. The unfavorable results in plastic surgery: avoidance and treatment. Philadelphia, PA: Lippincott Williams & Wilkins; 2001. p. 38–43.Google Scholar
  21. 21.
    Gorney M. Recognition of the patient unsuitable for aesthetic surgery. Aesthetic Surg. 2007;27:626–7.CrossRefGoogle Scholar
  22. 22.
    Har-Shai Y. Special indications and contraindications. Chapter 54. In: Abramovich W, Graham G, Har-Shai Y, Strumia R, editors. Dermatological cryosurgery and cryotherapy. London: Springer; 2016. p. 265–8.CrossRefGoogle Scholar
  23. 23.
    Grimes PE, Hunt SG. Considerations for cosmetic surgery in the black population. Clin Plast Surg. 1993;20:27–34.PubMedGoogle Scholar
  24. 24.
    Baust JG, Gage AA. The molecular basis of cryosurgery. BJU Int. 2005;95:1187–91.PubMedCrossRefGoogle Scholar
  25. 25.
    Massalha L, Shitzer A. Freezing by flat, circular surface cryoprobe of a tissue phantom with an embedded cylindric heat source simulating a blood vessel. J Biomech Eng. 2004;126:736–44.PubMedCrossRefGoogle Scholar
  26. 26.
    Dalkowski A, Schuppan D, Orfanos CE, Zouboulis CC. Increased expression of tenascin-C by keloids in vivo and in vitro. Br J Dermatol. 1999;141:50–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Dalkowski A, Fimmel S, Beutler C, Zouboulis CC. Cryotherapy modifies synthetic activity and differentiation of keloidal fibroblasts in vitro. Exp Dermatol. 2003;12:673–81.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2020

Authors and Affiliations

  • Yaron Har-Shai
    • 1
    • 2
  • Lior Har-Shai
    • 1
    • 2
  1. 1.The Unit of Plastic Surgery, Carmel Medical Center, The Bruce Rappaport Faculty of MedicineTechnion Israel of TechnologyHaifaIsrael
  2. 2.The Department of Plastic and Reconstructive SurgeryRabin Medical CenterPetach TikvaIsrael

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