Surgical Removal of Cyst Yields Unsightly Result

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This is a classic case of keloid formation—a real problem since no good, permanent solution exists. In one form or another, this otherwise attractive woman will likely bear this lesion the rest of her life.

Not all excessive scars are keloids. When scarring is excessive, but the outline of the original wound can still be seen, the result is usually termed hypertrophic scarring. By definition, a true keloid, by its thickness, shape, and width, totally obscures the original insult and, unlike a hypertrophic scar, does not spontaneously involute. Viewed as a continuum, there is normal scarring, inappropriate scarring, and severe inappropriate scarring. Unlike the first two, the latter is almost always symptomatic (burning) and does not spontaneously resolve.

Two things could have alerted the surgeon to the possibility that a keloid would form: (1) location, since the chest, shoulders, ear lobes, and neck are especially prone to inappropriate scarring, and (2) skin type, because in general, the darker the skin is, the greater the tendency to form inappropriate scars. While keloids are commonly a postoperative complication, they are also not infrequently triggered by acne, cysts, or even chickenpox. Other high-tension areas prone to keloids are knees and ankles.

The best thing, obviously, would have been for the patient to avoid having the surgery. An alternative to surgical removal of her cyst might have been intralesional injection with triamcinolone solution (5 mg/cc). While this would have been unlikely to produce a cure, it almost certainly would have shrunk the cyst for months at a time.

When surgery in a high-risk area is necessary (eg, in the case of a skin cancer), the surgical margins can be injected with triamcinolone (2.5 mg/cc) at the time of suture removal and again a month postoperative, which will reduce but not eliminate the risk for keloid formation. Low-tension closure (making generous use of undermining and deep sutures to reduce tension on surface sutures) and proper wound care by the patient can help too.

Surgical removal of a keloid in such a location, in a high-risk patient, is an option. However, such procedures are usually left for the plastic surgeon to deal with. Weapons that can be brought to bear on these difficult lesions include excision, intralesional steroid injection, cryotherapy, ionizing radiation, and laser surgery.

This particular patient chose to have us inject her keloid with 1.5 cc of triamcinolone (20 mg/cc), using a 10-cc syringe and 30-gauge needle. (This was made from stock triamcinolone, which comes in a 40 mg/cc strength, mixed half-and-half with lidocaine 1%.) Had her keloid been so dense as to make injection impossible (which happens fairly often), I would have treated it with liquid nitrogen first (approximately 5 seconds), waited five minutes while the keloid softened, then injected it.

• The tendency to form keloids is in large part a function of location and skin type.
• Skin on chests, shoulders, earlobes, and necks is especially prone to keloid formation.
• The darker the patient’s skin, the greater the chance for keloid formation.
• The decision to perform elective surgery should be informed by a full review of the risks involved, including that for keloid formation.
• Alternatives to excision of cysts in high-risk areas include intralesional steroid injection (using their tendency to cause atrophy to advantage), cryotherapy, or benign neglect.
• Once a keloid has formed, no perfect remedy exists. However, several options can be considered: intralesional injection, excision followed by steroid injection of the wound margins, or referral to plastic surgery.
• Viewed as a continuum, scarring can either be normal, excessive (eg, hypertrophic scarring), or lesional (eg keloid). The latter totally obscures the original insult, fails to spontaneously involute, and is often symptomatic (burning).

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