Where should the new incision be made to completely excise the intramuscular hemangioma in a patient with a pre-existing keloid scar?

Incision Placement for Intramuscular Hemangioma Excision in the Deltoid with Pre-existing Keloid Scar

The new incision should be made directly through the existing keloid scar whenever anatomically feasible, as this avoids creating an additional scar in a patient with proven keloid-forming tendency and allows complete excision of both the keloid and underlying hemangioma through a single incision.

Rationale for Incision Through Existing Scar

• Patients with keloid history are at high risk for forming new keloids at any fresh incision site, making it critical to minimize the number of new incisions 1, 2
• The existing oblique scar over the deltoid provides direct access to the intramuscular hemangioma, as these lesions typically arise within the muscle belly where the previous excision occurred 1, 3
• Excising through the keloid allows simultaneous removal of both pathologies (the keloid scar tissue and the underlying hemangioma), addressing two problems with one surgical intervention 1, 2

Surgical Approach Considerations

When the Keloid Scar Provides Adequate Access

• If the 10-15cm oblique keloid scar overlies the hemangioma location, incise directly through it to access the deltoid muscle 1, 2
• Wide excision is the treatment of choice for intramuscular hemangiomas to prevent local recurrence, which occurs in approximately 9% of cases (1 of 11 patients in one series) 1
• The infiltrative nature of intramuscular hemangiomas requires complete excision with clear margins, as incomplete removal leads to recurrence 1, 2, 4

When the Keloid Scar Does Not Provide Adequate Access

• If the hemangioma extends beyond the keloid scar boundaries, extend the incision along the existing scar axis (following the oblique orientation) rather than creating a perpendicular or separate incision 1, 2
• Avoid creating new incisions parallel to the existing keloid, as this creates multiple scars in a keloid-former 1
• Consider preoperative MRI to precisely map the hemangioma extent and determine if the existing scar provides sufficient access, as MRI is the best imaging modality for these lesions 1, 5

Critical Technical Points

Muscle-Splitting Technique

• Split the deltoid muscle fibers along their natural orientation rather than cutting across them to minimize functional impairment 5
• Intramuscular hemangiomas have infiltrative borders that blend with surrounding muscle, requiring careful dissection to achieve complete excision while preserving muscle function 1, 2, 4

Avoiding Additional Scarring

• Do not place incisions in "cosmetically favorable" locations or along relaxed skin tension lines in this keloid-forming patient, as any new incision will likely form another keloid 1, 2
• The principle of minimizing scar length does not apply here—the priority is minimizing the number of scars, not their length 1

Common Pitfalls to Avoid

• Do not attempt a separate "cosmetically optimal" incision thinking you can improve the appearance—you will simply create two keloids instead of one 1, 2
• Do not perform incomplete excision to minimize the incision size, as intramuscular hemangiomas have a significant recurrence rate with subtotal excision 1, 2
• Do not assume the lesion is superficial—intramuscular hemangiomas are deep-seated and require adequate exposure for complete removal 1, 3, 2
• Obtain preoperative biopsy confirmation if not already done, as these lesions can masquerade as malignant soft tissue tumors on imaging 2

Postoperative Considerations

• Long-term follow-up is essential, as recurrence can occur years after excision (mean follow-up in one series was 3 years 4 months, range 1-9 years) 1
• Consider adjunctive keloid management strategies for the incision site, such as pressure therapy, silicone sheeting, or intralesional corticosteroids, though these are beyond the scope of the surgical approach 1