Is a surgical approach more effective in treating keloids?

Is Surgical Approach More Effective in Keloid Treatment?

Surgery alone for keloids is ineffective and should never be performed as monotherapy due to recurrence rates of 50-80%, but surgical excision combined with postoperative radiotherapy and adjuvant intralesional corticosteroids achieves recurrence rates below 10% and represents the most effective treatment for therapy-resistant keloids. 1

Surgical Monotherapy: High Failure Rates

• Surgical excision alone triggers a fibroproliferative response similar to the initial injury that created the keloid, resulting in recurrence rates of 50-80% 1
• The surgical trauma itself acts as a new insult to the skin, perpetuating the pathologic scarring process 2
• One prospective study of surgical excision combined with radiotherapy still showed a 71.9% recurrence rate after mean follow-up of 19 months, suggesting even combined approaches can fail 3

Optimal Multimodal Surgical Protocol

The most effective approach combines three elements: surgical excision, immediate postoperative radiotherapy, and adjuvant intralesional corticosteroid injections. 4, 1

Surgical Technique Considerations

• Complete excision of the keloid with removal of all scar tissue is required 2
• For facial keloids, tissue expansion prior to excision allows for tension-free closure and better cosmetic outcomes 2
• For auricular keloids, fillet flap excision (preserving the posterior skin while removing keloid tissue) combined with adjuvant steroids achieves 81.2% improvement with no recurrence at 35-month follow-up 5

Postoperative Radiotherapy Protocol (Body Site-Customized)

• High-recurrence sites (anterior chest): 18 Gy in 3 fractions over 3 days 1
• Low-recurrence sites (earlobes): 8 Gy in 1 fraction 1
• Other body sites: 15 Gy in 2 fractions over 2 days 1
• Electron beam (β-ray) irradiation is superior to other radiotherapy modalities due to excellent dose distribution and safety profile 1
• Maximum biologically effective dose (BED) is 30 Gy; exceeding this provides no additional benefit and increases side effects 1

Adjuvant Intralesional Therapy

• Intralesional triamcinolone acetonide injections should begin at the first sign of recurrence during follow-up 4
• For facial keloids, combine 5-fluorouracil with triamcinolone injections after excision 2
• For auricular keloids, administer intralesional steroids at the end of the first postoperative week, then at 4-week intervals until lesions are soft and flat 5

Treatment Outcomes with Multimodal Approach

• 56% of keloids achieve complete cure with surgical excision plus postoperative radiotherapy alone, without additional treatment 4
• 89% of keloids show good results when early conservative treatment (intralesional steroids) is added at first sign of recurrence 4
• Overall recurrence rate drops below 10% when body site-customized surgical and radiotherapy protocols are employed 1
• Patient satisfaction reaches 81.8% rating their results as excellent with the fillet flap plus steroid approach for auricular keloids 5

Critical Pitfalls to Avoid

• Never perform surgical excision alone - this guarantees recurrence in 50-80% of cases 1
• Radiotherapy should be reserved as part of multimodal therapy for therapy-resistant keloids, not as first-line treatment 3
• Begin intralesional steroid injections immediately at first sign of recurrence rather than waiting for full keloid reformation 4
• Customize radiotherapy dose based on anatomic location rather than using uniform protocols for all body sites 1

When Surgery Is Indicated

Surgery should be considered for:

• Therapy-resistant keloids that have failed conservative management 3
• Keloids causing functional impairment 6
• Keloids with significant psychosocial impact and stigma 6
• Large or giant keloids where non-surgical options are inadequate 6