Yong ZHANG,Xuwen TANG,Yang LIU,Dongyun YANG

ABSTRACT Keloids are fibroproliferative disorders that can result from cutaneous injuries to the reticular dermis.Recurrence rates as high as 100% have been reported following surgical excision alone.Consequently,a variety of post-surgical techniques have been employed to prevent keloid recurrence,including the use of radiation.Although numerous studies have shown that post-excisional X-rays,electron beams,lasers,and brachytherapy can reduce the rate of keloid recurrence,numerous inconsistencies,including a wide range of definitions for keloid recurrence,render it difficult to compare the outcomes.The treatment of severe keloids in children is much more challenging,and there have been few previous reports.It is generally believed that children with keloids should be treated with nonsurgical treatment such as hormone injections and radiotherapy.For severe keloids,these methods require a long treatment period,and their efficacy is not ideal.Moreover,the side effects of the treatment can affect children’s health.If keloid scars are not effectively treated,they will often seriously affect the physical and mental health of children.The purpose of this review is to discuss case studies of children with severe keloids who were only treated with surgery and their postoperative recovery.In this case,the deep-embedded circular mattress suture technique (LBD,the looped,broad,and deep buried suturing technique) was used in the scar resection.After 18 months of follow-up,the surgical scar was evaluated using the Vancouver Scar Scale (VSS).The scar was stable and did not recur.The child was satisfied.This case shows that it is completely feasible to treat severe keloids with surgery alone,as long as the tension is reduced during the operation to prevent surgical scar hyperplasia.

KEY WORDS Keloid;Child;Scar resection;Surgery;LBD suturing technique;Recurrence

INTRODUCTION

Keloid,a benign dermal fibroproliferative disorder of wound healing,is a common condition.The earliest reference to keloids in the literature was that of a 9-month-old girl with bilateral earlobe keloids after ear piercing[1].Due to their rarity in children,there are few studies on keloids in children.The treatment of severe keloids in children is challenging because,in principle,minors should not receive hormone injections or radiotherapy[2-4].However,it is generally believed that keloids require comprehensive treatment,especially radiotherapy.Surgical treatment alone has a high risk of relapse,and the recurrence rate reported in the literature has been 100%[5].However,severe keloids often seriously affect the physical and mental health of children and may even cause autism[6].Is it impossible to treat keloids that have affected the physical and mental health of children by surgery alone? The purpose of this study was to clarify the feasibility of surgical treatment for keloids in children.

CASE PRESENTATION

A 5-year-old girl developed a keloid on her chest for nearly two years after surgery for congenital heart disease.The mean size of the lesions,recorded as the largest diameter of the lesion,measured 2.9 cm (range,0.4-2.9 cm).Keloid hyperplasia was so serious that the outline of the keloid could be seen even when the child was wearing clothes (Fig.1).Due to this,the child has become withdrawn and is reluctant to play with other children.The parents of this child strongly requested surgical treatment.

Fig.1 Keloid on the chest

After fully communicating the risks of the operation and possible postoperative complications with the parents,we performed a keloid resection on July 26,2019.The operation adopted multi-level hypertension reduction sutures,including the LBD suturing technique[7](Fig.2).After the operation,the patient was required to apply scar stickers and reduction stickers for more than one year.

Fig.2 (A) Preoperative design.(B) Before suture.(C) After internal suture.(D) After external suture.

This case was unique.The keloid on the chest was highly proliferative.The child became introverted and did not communicate with others.If the operation was not per-formed,her mental health might have been severely affected.However,the treatment of keloids in minors neither advocates radiotherapy nor injection of scar needles.Surgical treatment alone has a high relapse risk,and there is not a particularly effective way to deal with it.Therefore,when the parents took the child to seek medical treatment,they were rejected by my colleagues,including my predecessors.

Fig.3 (A) 3 months after surgery.(B) 5 months after surgery.(C) 11 months after surgery.(D) 18 months after surgery.

The surgical scar was assessed preoperatively and at 3,5,11,and 18 months postoperatively according to the VSS.The evaluator used four sets of parameters (flexibility,thickness,blood vessel,and pigmentation) to evaluate and score the scar according to the VSS.The scale has a total score of 15 points.The higher the score,the more severe the scar.In this case,the preoperative score was 14.05 (Fig.2A);the postoperative score at 3,5,11,and 18 months was 3.56,4.15,4.22,and 3.60,respectively(Fig.3A-3D) Therefore,we concluded that there was no hyperplasia of the surgical scar.

Pathological scars mainly include hypertrophic scars and keloids.In addition to the differences in morphology and histopathology between these two pathological scar types,there are also obvious differences in treatment.At present,there is no ideal standard for the differential diagnosis of keloids and hypertrophic scars[8-9].The main method used to distinguish keloids and hypertrophic scars is histopathology combined with clinical symptoms.However,both histopathology and clinical symptoms have a high misdiagnosis rate in the distinction between the two scar types.In view of this,histopathological identification was not performed in this case.The differential diagnosis of keloids and hyperplastic scars was made based on the patient’s clinical symptoms.

The patient’s scar tissue appeared within 1 year after surgery for congenital heart disease.The clinical feature was that the mass was higher than the normal skin,with the highest point at approximately 1.2 cm and the lowest point at approximately 0.3 cm.The scar had extended far beyond the original surgical incision,especially at the upper end of the scar.The scar had continued to grow.The texture of the scar was hard,and the elasticity was poor.The child complained of itching and slight pain localized at the scar.The pink atrophic epidermis can be seen on the surface,and the dense blood vessels in the scar tissue can be observed with the naked eye.The scar,located in the anterior sternal area,is where keloids are likely to occur.The scar had a clear boundary from the surrounding normal skin and no contracture.After the scar appeared,there was no sign of degeneration,but it continued to grow,especially in the upper part of the scar.Based on the above clinical symptoms,we preliminarily determined that the patient had a keloid.

To overcome the shortcomings of existing tension reduction methods,we have begun to apply a new tension reduction suture technique,the LBD tension reduction suture technology,in our medical institutions since 2017.The idea of LBD reduced tension suture technology originated from the horizontal mattress sutures that reduced tension in general surgery[10].The external suture in the horizontal mattress suture was replaced with a built-in suture,and the suture was partially passed through the dermis.This not only retains the original horizontal mattress-like tension reduction effect but also avoids skin damage and secondary scar formation caused by external sutures.The use of absorbable sutures greatly prolongs the indwelling time[11],so it can more effectively and significantly reduce the tension of the incision,reduce the wound surface,and improve the long-term effect of scars.Since the invention of the reduced tension suture technology,it has been widely used in clinical operations at the author’s medical institution.It is widely promoted as a cosmetic suture technique,and many colleagues have mastered the surgical method,which greatly reduces the degree of scar hyperplasia after clinical operations.

We took up the case after due consideration of the risks and benefits.We have had many successful cases of treating keloids with surgery alone.Additionally,this keloid had already affected the child’s social life.To date,the child has been followed up for one and a half years after surgery.During this period,she had not been injected with drugs,treated with lasers,or received radiotherapy.She had no signs of hyperplasia recurrence.When the child came to the hospital for review,I found that the child had grown taller.The parents reported happily that the child became more outgoing and confident after the operation.

DISCUSSION

Keloid is the most stubborn scar type[12-13].In general,surgery alone is not recommended but is not absolutely effective.Currently,keloids are recognized as pathological scars without definitive treatment options.Its pathophysiology has been extensively studied.However,no conclusive cause has been determined.There is no consensus on the treatment of keloids.An increasing number of studies have reported the efficacy of multimodal therapy in keloid treatment[14-15],including surgery,radiotherapy,triamcinolone acetonide (TAC) injection,CO2laser therapy,cryotherapy,pressure,and other treatment methods.Multiple studies have shown that monotherapy is often unsuccessful in achieving keloid remission[16-17].Corticosteroid injections have been used for years,either alone or in combination with other treatments.They work by inhibiting the inflammatory process,collagen synthesis,and fibroblast proliferation during the wound remodeling process but the recurrence rate can be as high as 50%[17].Numerous studies have demonstrated that topical silicone and pressure garments can reduce scar thickness[18-19],although the clinical significance of this remains questionable.A randomized controlled trial comparing TAC injections with either CO2laser therapy or cryotherapy in 101 keloids demonstrated a ＞ 50%improvement in both groups,with no significant difference between them,showing that both combinations are effective in the treatment of keloids[20].Surgical treatment alone has a high relapse risk,and the recurrence rate reported in the literature is 100%[5].However,the current criteria for determining scar recurrence are not uniform[5].The use of comprehensive treatment alone or in combination is still associated with a high probability of postoperative recurrence.These studies demonstrate the need for more than one approach in the treatment of keloids and the necessity of regular follow-up visits to reassess the need for additional treatment.

The onset of keloids is reported to be most common in the second decade of life[21-22].The occurrence of keloids in this age group suggests hormonal etiopathogenesis,whereas its rarity in younger individuals is believed to be a result of immature immunologic responses[23].The earliest onset of keloids documented in the literature is that of a 9-month-old girl with bilateral earlobe keloids after ear piercing[1].Perhaps because of their rarity in children,there are few studies on keloids in children.In a retrospective review of all children under the age of 19 years with non-burn-related keloids between 2008 and 2014,Afieharo et al.found that patients who received multimodal treatment had a higher recurrence rate,which was consistent with previous reports[23].They also demonstrated a relationship between keloid size and the risk of recurrence.In some studies,keloids on the trunk and extremities and those managed with multimodal treatment have been associated with recurrence[24].In contrast,others have found no relationship between the treatment outcome and keloid location,duration of the keloid,or etiology[25-26].

Our child had a scar on the chest (length:8 cm;maximum width:2.9 cm) that we treated with surgery alone.In this case,the scar hyperplasia was serious,and the scar size was large.The outline of the scar can be seen even when the child was wearing clothes,and the child became inferior.Patients with keloids often present with psychological morbidity related to negative self-image symptoms and body dysmorphic disease[27].Taking this into consideration,we finally chose surgery.Many factors affect the quality of healing of the incision.Among all the factors,current research agrees that the size of the tension around the postoperative incision is the most important factor affecting the healing of the incision and the formation of postoperative scars.To overcome the shortcomings of existing tension reduction methods,we applied a new LBD decompression suture technique during the operation,that is,the deep-buried circular mattress suture technique.This technology not only retains the original horizontal mattress-like tension reduction effect but also avoids skin damage and secondary scar formation caused by external sutures.It can absorb the use of sutures and greatly extend the indwelling time.Therefore,it can reduce the tension of the incision more effectively,reduce the wound surface,and improve the long-term effect of scars[7].

Although most studies have reported that surgical resection combined with postoperative radiotherapy,intralesional injection of triamcinolone acetonide,carbon dioxide fractional laser,pulsed dye laser,silicone therapy,or other forms of pressure multimodal therapy are common methods to prevent scar hyperplasia.To eliminate keloids as soon as possible and to alleviate adverse effects on the children’s psychological well-being,we believe that surgery alone is the best choice.We have had many successful cases of managing keloids with surgery alone.In this case,we tried surgery alone without other treatments.This case has been followed up for one and a half years after the operation,the scar is basically stable,and there is no sign of recurrence.This shows that tension plays a very important and even decisive role in the occurrence of keloids.Keloids are rare during childhood.In this case,we have demonstrated that surgical treatment alone can effectively prevent postoperative scar recurrence.

ETHICS DECLARATIONS

Ethics Approval and Consent to Participate

The need for ethical approval was waived as it is a case report.The parents of the participant provided written informed consent before study enrollment.

Consent for Publication

All the authors have consented to the publication of this article.

Competing Interests

The authors declare no conflicts of interest.The authors state that the views expressed in the submitted article are their own and not the official position of the institution of funder.