Abstract
Keloid scars pose a surgical challenge in the region of the head and neck. We present a rare case of a large infected and recurrent neck keloid that failed multiple prior reconstructive attempts. Ultimately, the tissue was resected and the surgical bed was repaired with a lateral arm microvascular free flap. This repair emphasizes the need for adequate coverage of the defect while maintaining neck mobility, ease of swallowing, and cosmesis. This is the second report in the literature of free tissue transfer as treatment for a large keloid scar, and the first to show the feasibility of early post operative low dose irradiation of the surgical bed.
1
Introduction
Keloids are benign growths of fibrous scar tissue that extend beyond the boundaries of the original cutaneous insult. Most commonly, they arise due to trauma, surgical incisions, infections, or burns. Rarely, they may grow spontaneously or from idiopathic causes. Keloids are differentiated from hypertrophic scars by their ability to locally invade adjacent skin and normal dermal elements. We present a case of an enlarging anterior neck keloid that had become infected and required complex surgical reconstruction and post-operative radiation to effectively control recurrence.
2
Case reports
An otherwise healthy 76-year-old woman was referred for a large disfiguring mass over her lower neck. She carried a previous diagnosis of keloid and had undergone several years of topical and intralesional therapy as well as multiple failed surgical resections. These interventions led to progressive enlargement and further scarring of the mass. The patient also had multiple secondary infections of the lesion, likely confounded by habitual scratching of the mass.
On physical examination, a large 8 × 8 × 2.5 cm epidermal mass with punctuate areas of purulent drainage in the midline of the lower neck was noted. There was moderate limitation of her neck mobility with tenderness to palpation diffusely along the keloid ( Fig. 1 ). Computed tomography (CT) with contrast demonstrated an abnormal, multi-lobulated mass along the anterior skin of the cricoid that extended to the thoracic inlet, which appeared more pronounced in size when compared to a study from two years prior. The patient was counseled on the risk of recurrence, but elected for surgical excision and reconstruction.
In the operating room, an incision was made around the large keloid mass and dissection was carried to the level of the platysma. A separate incision was made along the ride side of the neck to mobilize the strap musculature and expose the superior thyroid vasculature. A free myocutaneous left lateral arm flap with a 6 × 7 cm skin paddle was then harvested. Arterial and venous anastomoses of the free flap were performed from the posterior collateral radial artery to the superior thyroid artery with two venae comitantes joined to the superior thyroid veins. The flap was then sutured into position, a fully perforated suction drain was placed, and the skin was closed using absorbable sutures ( Fig. 2 A, B ). Pathologic analysis of the resected mass demonstrated a keloid with multiple epidermal cysts.
On the second postoperative day, the patient was started on adjuvant radiation therapy. In total she received 1300 rads over four sessions to the neck. She was then discharged home with silicone dressings to the arm for a two-month period in an effort to reduce the possibility of keloid formation at the lateral arm donor site.
The patient continued to heal well over her subsequent visits. At 18-month follow up, there were no signs of reformation of the keloid to either the donor or recipient site. She regained good mobility of her neck and demonstrated excellent signs of healing, with the exception of a small area of skin breakdown due to the patient’s habitual scratching ( Fig. 3 A, B ).
2
Case reports
An otherwise healthy 76-year-old woman was referred for a large disfiguring mass over her lower neck. She carried a previous diagnosis of keloid and had undergone several years of topical and intralesional therapy as well as multiple failed surgical resections. These interventions led to progressive enlargement and further scarring of the mass. The patient also had multiple secondary infections of the lesion, likely confounded by habitual scratching of the mass.
On physical examination, a large 8 × 8 × 2.5 cm epidermal mass with punctuate areas of purulent drainage in the midline of the lower neck was noted. There was moderate limitation of her neck mobility with tenderness to palpation diffusely along the keloid ( Fig. 1 ). Computed tomography (CT) with contrast demonstrated an abnormal, multi-lobulated mass along the anterior skin of the cricoid that extended to the thoracic inlet, which appeared more pronounced in size when compared to a study from two years prior. The patient was counseled on the risk of recurrence, but elected for surgical excision and reconstruction.
