Wide spread scars, hypertrophic scars, and keloids.

Patients with a wide scar may complain of having a "keloid," yet have a hypertrophic or a wide spread scar. The plastic surgeon should make the appropriate clinical diagnosis, because therapy varies depending on the condition present. A wide spread scar is best treated with excision and closure. A buried dermal flap may help to prevent recurrence, which is nevertheless likely to some degree. A hypertrophic scar can be distinguished from a keloid on clinical grounds. Although both may be red, nodular, and itchy, the keloid overgrows the original wound boundary and is much more likely to recur after surgical excision. Nonsurgical treatment of hypertrophic scars and keloids is similar, using repeated intralesional injections of Kenalog 40 mg per cc and sustained pressure on the lesion when possible. Surgical treatment differs for hypertrophic scars or keloids. Scar excision and closure, and selective Z-plasty, may be used in hypertrophic scars. In keloids, aggressive surgery is usually avoided, unless the lesion has a narrow pedicle. Surgery of keloids should be accompanied by intra- and postoperative Kenalog-40 injections, and on occasion by sustained pressure. Very large keloids may be resistant to medical management, and too aggressive for surgery owing to a high likelihood of recurrence. These difficult lesions serve as the impetus for continued biochemical and tissue culture research, seeking a biochemical means of control keloids.