I read with great interest the article by Chen et al. titled “Lateral arm microvascular free tissue reconstruction of a large neck keloid.” The authors introduce their case of a large intractable neck keloid which was treated with surgical excision followed by lateral arm free flap.

We reported our successful treatment experience for the treatment foot keloids using complete surgical excision and full thickness skin grafting followed by four corticosteroid injections . We think that using free tissue transfer neglecting the basic step on the reconstructive ladder, skin grafting, might give patients more morbidities. In my opinion, closing defects with a free flap sacrificing distant tissue makes keloids vulnerable to recurrence. This also contributes to poor patient satisfaction due to significant donor site morbidity.

The most important consideration when treating keloids is to prevent keloid recurrence. It is generally accepted that keloids have a high propensity to recur after surgical excision as a monotherapy, with rates up to 80%–100% .

Even, keloids have high propensity to recur despite strict adjuvant therapy after surgery.

The authors adopt silicone gel sheeting as an adjuvant therapy for the treatment of keloids. Although silicone gel is known to increase temperature, hydration, and occlusion and affects collagenase kinetics, the application to the neck is rather bothersome and easily dislocated during neck extension/flexion.

Rather than using adjuvant silicone gel sheeting therapy, multiple corticosteroid injections can yield better outcomes in terms of less patient discomfort and early recurrence control with timely treatment.

However, we agree with Dr. Chen et al. in that free tissue transfer can be another option to decrease tension, substantially ceasing vicious cycle of keloid recurrence. In addition, to validate the authors’ surgical approach, a prospective multicenter study would be beneficial in establishing free tissue transfer as an option in comparable with skin grafting.