Origin and treatment of keloid scars

Some of the most horrific scars that are the bane of existence for cosmetic plastic surgeons are keloid scars, and their treatment is, at best, difficult.
In fact, any time a plastic surgeon puts knife to skin, at the back of his or her mind is the thought of the outcome of the scar. The success of the surgery is important, of course, but the type of scarring can immensely help or detract from the cosmetic surgical result.
Types of scars
There are a number of different types of scarring that can occur as a result of healing after surgery:
  1. A normal, thin scar
  2. An atrophic or wide and spread scar
  3. A hypertrophic or thick scar within the boundary of the initial incision
  4. A keloid scar

The keloid scar

This type of scar is one where there is an abnormal growth of a hard and thick scar outside of the line of the initial incision or skin trauma. The surgeon may have made a straight line incision, but the scar grows outside of this line and extends onto the surrounding skin in lobulated masses.

Causes of keloids

The cause of keloid scars is unknown; like all scars, the thought is that there is a relationship to tension that incites abnormal growth of the fibroblasts, which lay down the collagen that forms the scars. Studies have shown that the type of collagen in the keloid scarv is different from normal scar collagen. Something just goes wrong.
Darker skin types and keloids
Keloids can occur in any one. Though more common in darker-skinned patients, they can occur in any skin type. And just because you have a great scar on your back does not mean you won’t get a keloid on your chest!

Sebaceous glands and keloids

There are some areas of the body that are more prone to getting keloid scars. These areas also happen to be areas with higher sebaceous gland density. Sebaceous glands are the bigger oil-producing glands that grow as we go through puberty and are responsible for our body odor as well as lubrication of the skin. They are typically found under the armpits, between the legs, around the ears and between and under the breasts, among other places.

Treatment of keloids

The first thing I tell my patients with keloids is “you have a 50% chance that the treatment will work and a 50% chance that the keloid will come back and be even worse than before.” That is usually enough to scare away all but the most serious patients.

When the keloid is an obvious embarrassment that cannot be hidden, the plastic surgeon has no choice but to attempt a cure. Look at my patient below.

Keloid scar of the ear

Keloid scar treated by excision, injection and silicone cream

A common area for keloids is the earlobe, specially after piercings for earrings. In this case, the initial trauma was a cut that led to this humongous keloid. The patient complained of pain and itching as well. Treatment of the keloid can involve one or all of these modalities:
  • Excision – cutting it out
  • Pressure therapy – helps mold the collagen fibers
  • Silicone gel therapy – flattens scar through unknown mechanism
  • Injection with steroids – reduces scar’s inflammatory response and scar formation.
  • Injection with 5-Flurouracil – reduces the rate of fibroblast cell division and hence scar formation
  • Radiation therapy – kills the fibroblasts—and everything else around them

The patient shown here was treated via excision of the keloid, injection of steroids and 5-FU, as well as a silicone cream treatment. So far so good.

Morad Tavallali, M.D., FACS

Cosmetic Plastic Surgeon