Z-plasty and Postoperative Radiotherapy for Upper-arm Keloids: An Analysis of 38 Patients

Keloids are the result of prolonged and intense dermal inflammation that is driven by genetics, systemic factors such as high cytokine levels, and local factors such as infection and sustained mechanical loading.1–5 We showed previously that approximately 5% of all keloids develop on the upper arm.6 These keloids are largely driven by 2 etiological factors. First, the upper arm is the most common site of Bacillus Calmette–Guerin (BCG) vaccination; it is also prone to acne or folliculitis, which are well-known triggers of keloidogenesis.7 All of these triggers arouse an inflammatory response. Second, the upper arm is subject to considerable skin tension due to the frequent movements of the shoulder and elbow joints.6 These movements cyclically stretch the skin of the upper arm in the longitudinal direction. Arm growth during childhood also imparts continuous stretching tension. This mechanical tension on even a minor upper arm wound caused by vaccination or acne/folliculitis exacerbates and prolongs the reticular dermal inflammation in the wound.6,8,9 This scenario explains why highly mobile anatomical sites are in general prone to keloid formation.6,8 The resulting inability to progress through the first (inflammatory) phase of wound healing in a timely fashion is a well-known cause of keloidogenesis.1,8,9 The most widely used treatments for upper arm keloids are surgical excision with postoperative radiotherapy, steroid injection, sheeting, pressure therapy, and laser therapy.10–12 However, an established and widely used treatment strategy for these keloids is lacking. We have developed a combination treatment strategy for these keloids. To determine its effectiveness, we analyzed all small- to medium-sized upper-arm keloid cases that were treated with this strategy in our facility in 2013–2016. We show here that this approach is highly effective for these keloids.