Keloid and Hypertrophic Scar Post-Excision Recurrence
Keloid and Hypertrophic Scar Post-Excision Recurrence
Article
Alya Mutiara Azzahra1, David Sontani Perdanakusuma2,4*), Diah Mira Indramaya3,4 , Iswinarno Doso
Saputro2,4
ABSTRACT
Introduction : Abnormal scar recurrence can occur and often be greater than pre-excision because the recurrence
rate is giving a high percentage. Data about keloid and hypertrophic scar recurrence are rarely found in Indonesia.
Therefore, it is necessary to conduct research related to abnormal scar, aims to determine the incidence of abnormal
scar recurrence to support future research by giving valuable data.
Method : A retrospective descriptive study that evaluated post-excision abnormal scar patients from 2018 to 2020
using medical records.
Result : The sixteen cases had varied by age with the highest number of presentations in the late adolescence (17-
25 years) (31%). Comparison of male (56%) and female (44%) patients were 1.28:1. The distribution of patients with
recurrence of abnormal scars based on the type of abnormal scar found that 11 patients (69%) had keloids and the
rest had hypertrophic scars with a total of 5 patients (31%) with predominantly ear (38%). Strategies of therapy
most commonly excision only (50%), followed by excision with steroid injection combination (31%).
Conclusion: This exemplifies recurrence case in post-excision abnormal scar. Our findings indicate that there are
differences in surgical strategy, such as wound closure techniques. Most of them were found with keloid scars and
the incidence of recurrence was 11 cases and 5 cases experienced more than 1 recurrence. Furthermore, combination
therapy, such as steroid injection, which is the most commonly used therapy after excision in this case, did not
appear to prevent recurrence.
Latar Belakang: Kekambuhan bekas luka abnormal dapat terjadi dan seringkali lebih besar dari pra-eksisi karena
tingginya tingkat kekambuhan. Data tentang keloid dan kekambuhan skar hipertrofi masih jarang ditemukan di
Indonesia. Oleh karena itu, perlu dilakukan penelitian terkait skar abnormal, bertujuan untuk menentukan
kejadian kekambuhan skar abnormal untuk mendukung penelitian selanjutnya dengan memberikan data yang
berharga.
Metodologi: Sebuah studi deskriptif retrospektif yang mengevaluasi pasien bekas luka abnormal pasca eksisi dari
tahun 2018 hingga 2020 menggunakan rekam medis.
Hasil: Enam belas kasus bervariasi berdasarkan usia dengan jumlah presentasi tertinggi pada remaja akhir (17-25
tahun) (31%). Perbandingan pasien laki-laki (56%) dan perempuan (44%) adalah 1,28:1. Distribusi pasien dengan
kekambuhan skar abnormal berdasarkan jenis skar abnormal didapatkan 11 pasien (69%) mengalami keloid dan
sisanya mengalami skar hipertrofik dengan total 5 pasien (31%) dengan area predominan telinga (38%). Strategi
terapi yang paling banyak adalah eksisi saja (50%) dan diikuti eksisi dengan injeksi steroid kombinasi (31%).
Kesimpulan: Studi ini mencontohkan kasus kekambuhan pada bekas luka abnormal pascaeksisi. Temuan kami
menunjukkan bahwa ada perbedaan dalam strategi bedah, seperti teknik penutupan luka. Sebagian besar
ditemukan bekas luka keloid dan kejadian kekambuhan sebanyak 11 kasus dan 5 kasus mengalami kekambuhan
lebih dari 1 kali. Selanjutnya, terapi kombinasi, seperti injeksi steroid, yang merupakan terapi yang paling umum
digunakan setelah eksisi, tidak mencegah kekambuhan dalam kasus ini.
Kata Kunci: Keloid; Cicatrix, Hipertrofik; Kambuh; Bekas luka; Revisi Bekas Luka
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Keloid and hypertrophic scar post-excision recurrence… Jurnal Plastik Rekonstruksi, Vol. 9, No. 2, 2022
Most patients were in the late adolescent age (17- between 2018 and 2020 were more likely to
25 years) (31%). The lowest number in this study develop keloid abnormal scar formation.
was in the age range of children (6-11 years) with
1 patient (6%). From the data studied, it was Table 2. Distribution of abnormal scar recurrence
found that children aged 6 years was the patients based on type of scar
youngest and adults aged 70 years was the oldest. Frequency Percentage
Abnormal Scar Type
(n) (%)
Table 1. Demographics of abnormal scar recurrence Hypertrophic scar 5 31
patients by age Keloid 11 69
Total 16 100
Frequency Percentage
Age Distributions
(n) (%)
Toddler (0-5 years) 0 0 Table 3 showed that the ear had the most
Children (6-11 years) 1 6 recurrence of abnormal scarring, with a total of
Early teens (12-16 years) 4 25 six patients (38%) of the sixteen patients studied,
Late adolescence (17-25 5 31 and the least was one case on the arm, abdomen,
years) and palm, respectively (6%).
Early adulthood (26-35 0 0 Table 4 showed that 11 of 16 patients had
years) abnormal scar recurrence after undergoing
Late adulthood (36-45 years) 2 13 excisional therapy, and 5 of 16 patients had
Early elderly (46-55 years) 1 6 abnormal scar re-recurrence with 1 of 5 patients
Late elderly (56-65 years) 2 13 having at most 5 (five) recurrences after abnormal
Seniors (>65 years) 1 6 scar revision with a general surgeon in the
Total 16 100
previous hospital and at the same scar site.
Figure 1 depicted the gender distribution of Table 3. Distribution of abnormal scar locations in
abnormal keloid scars and hypertrophic scars in abnormal scar recurrence patients
this study mostly male patients with a slight
Location Frequency (n) Percentage (%)
difference between male (9 patients) and female
(7 patients) with a ratio of 1.28:1. Face 4 25
Ear 6 38
Chest 3 19
Arm 1 6
Abdomen 1 6
Palm 1 6
Total 16 100
12 of the 16 patients underwent abnormal scar adolescence, and the average number of
excision procedures with a plastic surgeon at the patients aged 30 years was consistent with
Plastic, Reconstructive, and Aesthetic Surgery, previous research, namely the highest
Dr. Soetomo General Hospital polyclinic with the prevalence was in patients under the age of 30
remaining two of the four other patients years.(2)(7) Adolescent skin is still relatively
undergoing excision with a general surgeon at tense and has higher collagen synthesis than
the previous hospital and the final two patients elderly.(7) The adolescent age range is included
undergoing excision with no surgeon in the productive age range (15-65 years),
information at the previous hospital.
indicating that patients in this age range are
more likely to be curious, try new things,
Table 5. Abnormal scar recurrence based on treatment
group participate in activities, and work optimally.
According to the case, most of the patients in
Frequency Percentage this study developed abnormal scars as a result
Treatment Group
(n) (%)
of burns caused by work accidents, ear
Excision only 8 50 piercing, or traffic accidents. The skin has a
Excision + Steroid 5 31 high level of elasticity in the adolescent age
Excision + Injection 2 13 range, which will affect the high tension, which
(nonspecific) is also one of the causes of abnormal scars.
Excision + Steroid + 5-FU 1 6 Keloids were found more frequently than
Injection + Laser hypertrophic scars in the results of this study,
Total 16 100 with 11 patients out of a total of 16 cases. The
5-FU = 5-Fluorouracil
incidence of hypertrophic scars after surgery is
around 39-68%,(2) whereas keloids can reach
DISCUSSION 40-100%.(4) Keloids have a high recurrence rate
after attempted excision and are more difficult
Based on data collected in the Plastic
to treat than hypertrophic scars,(8) so they will
Surgery Outpatient Unit at Dr. Soetomo
be encountered frequently due to their very
General Hospital in Surabaya, Indonesia,
high recurrence rate and low therapeutic
between 2018 and 2020, male patients had
efficacy. One of the factors that contribute to
more abnormal scars in this study, despite a
the recurrence of abnormal scars is the
slight difference between male and female
abnormal location of the scar, which includes
patients with a ratio of 1.28:1. Male patients
the ear and chest area.(2)(9)
presented with abnormal scarring due to ear
The most typical places for keloids to
piercing, burns, work accidents, motorcycle
appear are on the chest, face, and ears.
accidents, or trauma to the face, according to
Meanwhile, the arms, palms, and abdomen
the causes of abnormal scarring in the sixteen
were the least affected. There is more collagen
cases. Meanwhile, female patients are more
and extracellular matrix (ECM) at the keloid
likely to have abnormal scarring as a result of
predilection site. Fibroblasts migrate by
ear piercing and cosmetic needs. The findings
adhering to the ECM and then descending and
of female and male are not significantly
reorienting it. During the fibroblast
different.(2)(5)
proliferation phase, skin defects will start
The structure of the skin differs between
appearing in the form of immature scars. At
male and female, as does the collagen
this stage, the cell components are dominated
thickness, which is more predominant in
by fibroblasts, which will proliferate and
male.(6) This can support the percentage of
synthesize collagen. A high concentration of
male who are more prone to abnormal scarring
collagen in the keloid predilection area can
than female. The abnormal scar formation
change the behaviour of fibroblasts,
process is based on an abnormal process of
establishing the foundation for keloid
collagen formation in the skin, which causes
formation and growth.
collagen dysregulation, that further eventually
In this study, cases were chosen based on
leads to scarring.
previous surgical excision of the keloid, so that
In accordance to the research results, the
all cases of the patient had undergone surgery.
highest number of patients were in late
This study discovered 11 patients who had one abnormal scarring was in the ear, chest, and face.
recurrence and 5 patients who had re- Data from this study had keloids rather than
recurrences. There were 4 cases underwent hypertrophic scars, with 11 recurrence incidents
revision scar surgery at the previous hospital and 5 cases with multiple recurrences out of a
before being referred to a plastic surgery unit total of 16 cases, and TAC was the most
at Dr. Soetomo General Hospital, and two of commonly used therapy after excision in this
them contained information if they had case. Data from this study suggest that there are
undergone surgery with a general surgeon differences between excision with a general
surgeon and a plastic surgeon related to the
with three recurrences and five recurrences,
surgical strategy, wound closure techniques, and
respectively, which were the highest rates of
surgical instruments. Future research will
recurrence of abnormal scars. This could be
investigate into the role of abnormal scar scores,
due to the operator's lack of attention to detail such as the Vancouver Scar Scale, in determining
in technical aspects of the surgical procedure, whether the therapy is effective. It would be
such as technique and instrument selection, plausible since it would be easier to assess what
because it may contributed to the recurrence of to intervene under certain patients with different
abnormal scarring and simple excision risk factors.
procedure can stimulate additional collagen
synthesis.(10)
Excision with corticosteroid injection was ACKNOWLEDGEMENT
the most preferred therapy in this study, aside The authors would like to thank the Director of Dr.
from excision alone. Triamcinolone acetonide Soetomo General Hospital and Department of Plastic
(TAC), a corticosteroid, is thought to suppress Reconstructive and Aesthetic Surgery Dr. Soetomo
General Hospital for supporting this research.
inflammation, degeneration, and collagen
production. Despite the easy of use and high
tolerance level of TAC injection, it still has a
Correspondence regarding this article should be
recurrence rate of 9-50%.(10) In this study, one addressed to:
patient received multiple therapies, including David Sontani Perdanakusuma. Department of Plastic,
TAC injection with a combination of 5- Reconstructive, and Aesthetic Surgery, Faculty of Medicine,
fluorouracil (FU) injection and Er:YAG laser. Universitas Airlangga, Surabaya, Indonesia
TAC and 5-FU injections increase the potency E-Mail: [email protected]
of corticosteroids in TAC injections, and the
combination of laser and corticosteroids
reduces recurrence rate to 16-74%.(2) In this REFERENCES
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