2017-18 HSC Section 4 Green Book

Plastic and Reconstructive Surgery • September 2014

± 0.2 cm; length, 5.5 ± 1 cm), illustrating an aver- age decrease of 56.7 percent ( p = 0.011). The scar tissue that remained was the result of skin widen- ing caused by postoperative radiation scar weak- ness and the high tension at the location of the excised keloids. Patient and Observer Scar Assessment Scale The scar evaluation using the Patient and Observer Scar Assessment Scale showed low scores according to both patients and the physi- cian on the keloids after treatment at long-term follow-up (the lower the score, the more the scar resembled normal skin). The physician scored an overall value of 16.71 ± 1.1, and the patient scored a slightly higher value of 19.69 ± 2.4 (0, normal scar; 60, worst scar). With respect to physical complaints, all seven parameters improved in the majority of the nonrecurring patients. On aver- age, pain decreased with 82.9 percent, pruritus decreased with 87.2 percent, movement restric- tion decreased with 90.5 percent, burning sensa- tion decreased with 83.2 percent, physical burden decreased with 79.2 percent, functional discom- fort decreased with 79.7 percent, and dysesthesia decreased with 77.2 percent (Fig. 3). Recurring scars showed less or no improvement. Eighty- six percent of all patients were satisfied with the treatment and 77 percent were satisfied with the cosmetic result; 88.6 percent would repeat the treatment if necessary. Complications and Adverse Events Complications included postoperative infec- tion (5.7 percent) requiring oral antibiotics. Problems with hypopigmentation and hyperpig- mentation were seen in six of 35 patients (21.4 percent) during follow-up. When subdividing this group into skin color, five of these patients had Fitzpatrick type V to VI skin (African American) and one patient had Fitzpatrick type III to IV skin (Mediterranean/Asian). No cases of radiation- induced wound dehiscence, dermatitis, neuritis, or cutaneous malignancy appeared. DISCUSSION This prospective study shows that keloid exci- sion followed by a 2 × 6-Gy high-dose-rate brachy- therapy schedule resulted in significant scar surface reduction, alleviated complaints of pain and itching, provided good cosmetic results, and yielded a low recurrence rate of 3.1 percent. Find- ing a successful treatment for recalcitrant keloids is of great importance, as keloids cause aesthetic

which received an external beam radiation ther- apy session of 6.6 Gy at day 2 instead of the 6-Gy high-dose-rate brachytherapy. The other did not receive any treatment at day 2. The third patient had a lower dose high-dose-rate brachytherapy during his second session, because of a technical problem. These three patients were not excluded from the study. Recurrence Of the patients that completed the radiation protocol, one recurring scar (3.1 percent) was seen at a mean follow-up of 33.6 months (range, 24 to 96 months). Of the three patients that did not complete the radiation protocol, two showed recurring scars (66.6 percent) (Fig. 2). Surface Area The average keloid surface area before treat- ment was 11.44 cm 2 (width, 2.2 ± 0.2 cm; length, 5.2 ± 0.8 cm). After treatment, at long-term follow up, the average surface area of the nonrecurring keloids had been reduced to 4.95 cm 2 (width, 0.9 Fig. 2. Patient flowchart. Between 2003 and 2009, 43 patients with 67 keloids were treated. In total, 28 of the initial 43 patients with 35 keloids participated in this study.

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