BACKGROUND: Keloids represent a challenging problem. Surgical excision remains the definitive treatment for immediate lesion debulking, but recurrence rates are reported to be 45 to 100 percent. The authors present a staged reconstructive approach using a dermal regeneration substrate and epidermal grafting to minimize recurrence and donor-site morbidity. METHODS: Keloids were completely excised down to normal subcutaneous tissue or perichondrium. A bilaminar dermal regeneration matrix was approximated to the entire wound, with the silicone lamina oriented superficially. Reconstruction was delayed for at least 21 days to allow for neodermal ingrowth. The silicone lamina was then removed, and an epidermal skin graft was harvested from the thigh and secured to the neodermis with nonocclusive dressing. Reconstructed defects and donor sites were assessed for recurrence of keloids and scar appearance. RESULTS: Five patients underwent treatment; two had keloids involving the superior helix of the ear (average area, 2.6 cm), two had keloids involving the chest (average area, 28 cm), and one had a keloid in the pubic region (area, 10 cm). All had failed at least one previous treatment with direct excision and steroid injections. Mean follow-up was 48.8 weeks (range, 38 to 60 weeks). Average time to complete wound epithelialization was 5.5 weeks. There were no infections or cellulitis. All reconstructed defects were aesthetically acceptable and remained flat without significant widening. There were no long-term complaints of pruritus or pain and there was no evidence of donor-site scarring. CONCLUSIONS: Epidermal grafting provides significant advantages when used with a dermal regeneration matrix. This approach obviates reliance on skin creep and flap undermining to achieve primary closure. Exclusion of dermis and significant extracellular matrix components limits contracture, further facilitating tension-free wound healing. Scarring response within the donor site and graft is also minimized. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.
BACKGROUND: Keloids represent a challenging problem. Surgical excision remains the definitive treatment for immediate lesion debulking, but recurrence rates are reported to be 45 to 100 percent. The authors present a staged reconstructive approach using a dermal regeneration substrate and epidermal grafting to minimize recurrence and donor-site morbidity. METHODS: Keloids were completely excised down to normal subcutaneous tissue or perichondrium. A bilaminar dermal regeneration matrix was approximated to the entire wound, with the silicone lamina oriented superficially. Reconstruction was delayed for at least 21 days to allow for neodermal ingrowth. The silicone lamina was then removed, and an epidermal skin graft was harvested from the thigh and secured to the neodermis with nonocclusive dressing. Reconstructed defects and donor sites were assessed for recurrence of keloids and scar appearance. RESULTS: Five patients underwent treatment; two had keloids involving the superior helix of the ear (average area, 2.6 cm), two had keloids involving the chest (average area, 28 cm), and one had a keloid in the pubic region (area, 10 cm). All had failed at least one previous treatment with direct excision and steroid injections. Mean follow-up was 48.8 weeks (range, 38 to 60 weeks). Average time to complete wound epithelialization was 5.5 weeks. There were no infections or cellulitis. All reconstructed defects were aesthetically acceptable and remained flat without significant widening. There were no long-term complaints of pruritus or pain and there was no evidence of donor-site scarring. CONCLUSIONS: Epidermal grafting provides significant advantages when used with a dermal regeneration matrix. This approach obviates reliance on skin creep and flap undermining to achieve primary closure. Exclusion of dermis and significant extracellular matrix components limits contracture, further facilitating tension-free wound healing. Scarring response within the donor site and graft is also minimized. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.