A MERI CAN JOUR NAL OF OTOLAR YNGOLOGY– H E A D A N D N E CK M EDI CI N E AN D S U RGE RY 3 5 (2 0 1 4 ) 8 2 9- 8 30
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Letters to the Editor Which is better option for the treatment of large neck keloids? Free tissue transfer versus skin grafting To the Editor: I read with great interest the article by Chen et al. [1] 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 [2]. 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% [3]. 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. REFERENCES
[1] Chen Y, Chhabra N, Liu YC, Zender CA. Lateral arm microvascular free tissue reconstruction of a large neck keloid. Am J Otolaryngol 2014;35:514–6. 0196-0709/© 2014 Elsevier Inc. All rights reserved.
[2] Park TH, Park JH, Chang CH. Clinical features and outcomes of foot keloids treated using complete surgical excision and full thickness skin grafting followed by corticosteroid injections. J Foot Ankle Res 2013;6:26. [3] Park TH, Park JH, Chang CH. Are auricular keloids and persistent hypertrophic scars resectable? The role of intrascar excision. Ann Plast Surg 2014;72:369.
Tae Hwan Park MD Buleun Health Care Center, Incheon, Republic of Korea Keloid Research Foundation, New York, United States Email address: [email protected]
http://dx.doi.org/10.1016/j.amjoto.2014.04.015
Response to “Which is better option for the treatment of large neck keloids? Free tissue transfer versus skin grafting.” To the Editor: I want to thank Dr. Park for his comments. Certainly other options exist in the management of keloids, but in this setting of a chronically infected keloid that had already had multiple procedures done by other physicians we felt free tissue might have some certain advantages. As Dr. Park had mentioned this patient's primary complaint was pain and tightness in the area of the chronically infected keloid. We did not feel that a skin graft would be ideal due to some of the known inherent limitations of skin grafting (contracture and susceptibility to infection). Local flaps were also considered but we didn't want to put any tension in the area of concern or make other incisions in the neck that would potentially worsen the patient's symptoms. Certainly as in all aspects of reconstructive surgery the reconstructive ladder should be considered and the simplest most effective method of reconstruction should be employed. In this case with the patient's prior procedures, chronic infection, close proximity to sternal wires and symptoms/findings of contracture we felt free tissue transfer offered enough benefits to warrant its use.
830
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y – H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 5 ( 2 0 14 ) 82 9 – 8 3 0
Yi-Chun Carol Liu MD⁎ Chad A. Zender MD Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA ⁎Corresponding author at: University Hospitals Case Medical Center, Department of Otolaryngology-Head and Neck Surgery
11100 Euclid Avenue, LKS 5045, Room 4535, Cleveland, OH 44106 Tel.: +1 216 844 8433; fax: +1 216 983 3180 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.amjoto.2014.06.012
Available online at www.sciencedirect.com
ScienceDirect www.elsevier.com/locate/amjoto
Letters to the Editor Which is better option for the treatment of large neck keloids? Free tissue transfer versus skin grafting To the Editor: I read with great interest the article by Chen et al. [1] 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 [2]. 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% [3]. 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. REFERENCES
[1] Chen Y, Chhabra N, Liu YC, Zender CA. Lateral arm microvascular free tissue reconstruction of a large neck keloid. Am J Otolaryngol 2014;35:514–6. 0196-0709/© 2014 Elsevier Inc. All rights reserved.
[2] Park TH, Park JH, Chang CH. Clinical features and outcomes of foot keloids treated using complete surgical excision and full thickness skin grafting followed by corticosteroid injections. J Foot Ankle Res 2013;6:26. [3] Park TH, Park JH, Chang CH. Are auricular keloids and persistent hypertrophic scars resectable? The role of intrascar excision. Ann Plast Surg 2014;72:369.
Tae Hwan Park MD Buleun Health Care Center, Incheon, Republic of Korea Keloid Research Foundation, New York, United States Email address: [email protected]
http://dx.doi.org/10.1016/j.amjoto.2014.04.015
Response to “Which is better option for the treatment of large neck keloids? Free tissue transfer versus skin grafting.” To the Editor: I want to thank Dr. Park for his comments. Certainly other options exist in the management of keloids, but in this setting of a chronically infected keloid that had already had multiple procedures done by other physicians we felt free tissue might have some certain advantages. As Dr. Park had mentioned this patient's primary complaint was pain and tightness in the area of the chronically infected keloid. We did not feel that a skin graft would be ideal due to some of the known inherent limitations of skin grafting (contracture and susceptibility to infection). Local flaps were also considered but we didn't want to put any tension in the area of concern or make other incisions in the neck that would potentially worsen the patient's symptoms. Certainly as in all aspects of reconstructive surgery the reconstructive ladder should be considered and the simplest most effective method of reconstruction should be employed. In this case with the patient's prior procedures, chronic infection, close proximity to sternal wires and symptoms/findings of contracture we felt free tissue transfer offered enough benefits to warrant its use.
830
AM ER IC AN JOUR NA L OF OTOLARY NG OLOG Y – H EA D A N D N E CK ME D I CI NE AN D SUR G E RY 3 5 ( 2 0 14 ) 82 9 – 8 3 0
Yi-Chun Carol Liu MD⁎ Chad A. Zender MD Ear, Nose, and Throat Institute, Case Western Reserve University, University Hospitals Case Medical Center, Cleveland, OH, USA ⁎Corresponding author at: University Hospitals Case Medical Center, Department of Otolaryngology-Head and Neck Surgery
11100 Euclid Avenue, LKS 5045, Room 4535, Cleveland, OH 44106 Tel.: +1 216 844 8433; fax: +1 216 983 3180 E-mail address: [email protected]
http://dx.doi.org/10.1016/j.amjoto.2014.06.012
