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A postoperative skin lesion

1.  What is this post operative skin lesion?
2.  How could you manage it?

This post-operative skin lesion is a keloid scar. They present as a thickened, raised skin-coloured lesions at the site of surgery or trauma.   It is important differentiate keloid from hypertrophic scars. Both are elevated due to deposition of excess collagen within the dermis.  Keloid scars grow progressively and behave like tumours invading the surrounding normal skin. Hypertrophic scars are confined to the area of tissue damage. Hypertrophic scar usually regress with time whereas keloid scars usually do not.

Keloids are seen more often in patients of West African and Asian origin. Within these population groups some people are more susceptible than others but no common genetic defect has been identified. They can occur at any age but are more common in adolescence and early adulthood. Both sexes are equally affected. They almost always occur after injury or surgery. 'Spontaneous' keloids have been described but these are more likely to arise from trivial injury that has been forgotten by the patient. The extent of keloid formation is invariably out of proportion to the degree of tissue damage. Disfiguring lesions can occur after apparently minor trauma. They are more common on the skin of the presternal area, neck, ears and proximal limbs. The incidence is reduced in scars placed along lines of election (Langer's lines).

During normal wound healing, from three days to three weeks, a period of proliferation occurs during which collagen deposition exceeds collagen lysis. There then follows a period of equilibrium before a late phase of remodeling occurs. During this later phase collagen lysis exceeds collagen deposition and scar thins. The strength of the scar is maximal at four to six weeks. Remodelling is complete by one year. In keloid scar formation this ordered sequence is deranged with collagen deposition far exceeding lysis.

No treatment of keloids has been shown to be uniformly effective. Surgery is unfortunately associated with a high risk of recurrence. It may be of use in keloids that occur as a result of post-operative wound infection or from poorly placed incisions. If further surgery is contemplated post-operative pressure from elastic compression garments may help to prevent recurrence. Physiotherapy may be a useful adjunct as also may be topical silicone gel sheets. These have been shown to be particularly useful in post-burn hypertrophic scars. Cryotherapy, laser and both external beam and intra-lesional radiotherapy have been used. The use radiotherapy is controversial as it does induce regression of keloid scars but concerns exist that it may induce skin tumours.

The most extensively used drug treatment is topical or intra-lesional injection of the long-acting steroid, triamcinolone. Steroids reduce collagen synthesis by decreasing mRNA production and shifting collagen metabolism in favour of lysis. Whilst reducing the extent of keloid scarring complications including skin atrophy, hypopigmentation and telangiectasia are not uncommon. Interferon-gamma has recently been used with encouraging results.

Keloid scar

Recent Papers

Ahn S T,  Monafo W W,  Mustoe T A.  Topical silicone gel for the prevention and treatment of hypertrophic scar.  Arch Surg 1991;  126:  499-504.

Mustoe T A,  Cooter R D,  Gold  M H et al.  International clinical recommendations on scar management.  Plast Reconstr Surg 2002;  110:  560-571

O'Sullivan S T, O'Connor T P, O'Shaughnessy M. Aetiology and management of hypertrophic scars. Ann R Coll Surg 1996; 78: 168-175.

Poston J.  The use of silicon gel sheeting in the management of hypertrophic and keloid scars.  J Wound Care 2000;  9:  6-10.

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