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Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) xx, 1e3

CASE REPORT

Keloid formation after trigger finger release: A case


report
Kaoru Tada*, Seigo Suganuma, Takeshi Segawa, Naohiro Asada,
Hiroyuki Tsuchiya

Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, 13-1 Takaramachi,
Kanazawa 920-8641, Japan

Received 18 July 2012; accepted 21 October 2012

KEYWORDS Summary We report a case of keloid formation on the palm of the hand after trigger finger
Keloid; release.
Palm; A 58-year-old male with trigger finger of the right index, middle and ring fingers was treated
Trigger finger; with open release at a nearby hospital. Three months after this operation, a progressively
Skin graft; enlarging skin lesion formed at the surgical site. A diagnosis was made of keloid formation after
Radiation trigger finger release, and keloid excision with full thickness skin graft and postoperative radi-
ation therapy was done. One year postoperatively, the patient was asymptomatic and had not
experienced a recurrence.
This is a first report about keloid formation on the palm after trigger finger release. Our
patient had a good outcome with keloid excision, full thickness skin graft and postoperative
radiation therapy.
ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by
Elsevier Ltd. All rights reserved.

Keloids are formed as the result of an abnormal skin keloid formation on the palm of the hand after trigger
response after trauma or surgery. They are common on the finger release.
anterior chest, shoulder and periauricular region, but
extremely rare on the palm of the hand. We report a case of
Case report

Our patient was a 58-year-old male with trigger finger of


* Corresponding author. Tel.: þ81 76 265 2374; fax: þ81 76 234 the right index, middle and ring fingers without any family
4261. history. He underwent operation with Brunner’s incision for
E-mail address: tdkr@med.kanazawa-u.ac.jp (K. Tada). release and synovectomy at a nearby hospital. There was

1748-6815/$ - see front matter ª 2012 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.bjps.2012.10.014

Please cite this article in press as: Tada K, et al., Keloid formation after trigger finger release: A case report, Journal of Plastic,
Reconstructive & Aesthetic Surgery (2012), http://dx.doi.org/10.1016/j.bjps.2012.10.014
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2 K. Tada et al.

no wound dehiscence or infection after operation. Three


months after this operation, a progressively enlarging skin
lesion formed at the surgical site. The protruding skin lesion
extended around the base of the middle and ring fingers
and was irregularly shaped with clear boundaries. It was
haemorrhagic and severely tender (Figure 1). We made the
diagnosis of keloid formation after trigger finger release
and planned for keloid excision with full-thickness skin
graft and postoperative radiation therapy.
We made a skin incision, never crossing skin creases at
right angles, and excised the keloid along with some
subcutaneous fatty tissue. The soft-tissue defect was
covered with a full-thickness skin graft, harvested from the
groin, and a tie-over dressing was applied (Figure 2).
Histopathological examination showed dense deposits
of eosinophilic collagen fibres and confirmed the diagnosis
of keloid. The tie-over dressing was removed after 10
days, and compression therapy was applied until 3 weeks
postoperatively. After confirmation of complete survival
of the skin graft, the patient commenced radiation
therapy with a total dose 20 Gy in five fractions. One year
after operation, though the proximal interphalangeal (PIP)
joints of his middle and ring fingers could actively flex
only 60 due to adhesion of flexor tendons, the patient
was asymptomatic and had no recurrence of keloid
formation (Figure 3).

Figure 2 The soft tissue defect was covered with a full-


thickness skin graft, and a tie-over dressing was applied.

Discussion

Keloid formation on the palm of the hand is very rare.


Although there have been some reports of keloid formation
on the finger after surgery for syndactyly, there have only
been two reported cases of palmar keloid formation due to
other aetiologies. Tsekoulas et al. reported the case of
a white male with bilateral Dupuytren’s contracture, who
developed a keloid following palmar fasciectomy.1 This
case was treated with keloid excision and full-thickness
skin graft, without recurrence by 1 year postoperatively.
Britto et al. reported the case of a white male in whom
keloids of the wrist and the palm caused severe functional
problems of the hand and the wrist over a 10-year period.2
Our report is the first to present keloid formation on the
palm after trigger finger release.
Several treatments for keloids, including corticosteroid
injections, local pressure therapy, radiation therapy and
keloid excision, have been reported. We decided on keloid
excision for our patient because he had severe pain, and
conservative therapy had failed. We knew that keloid
excision might leave a large skin defect that could not be
sutured primarily. Although there are few reports of keloid
excision with full-thickness skin grafting, Brown reported
Figure 1 Keloid formation on the palm of the right hand. good results for this treatment in 10 cases of auricular

Please cite this article in press as: Tada K, et al., Keloid formation after trigger finger release: A case report, Journal of Plastic,
Reconstructive & Aesthetic Surgery (2012), http://dx.doi.org/10.1016/j.bjps.2012.10.014
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Keloid formation after trigger finger release 3

we administered radiation according to the latter protocol.


The interval between excision and radiation treatment
remains controversial. Mizuno et al. reported that radiation
should be initiated 48e72 h after excision, as fibroblasts are
sensitive to radiation in this period.8 Although there are
many opinions recommending relatively early irradiation,
we performed radiation 3 weeks postoperatively in order to
ensure survival of the skin graft.
There are limited previous reports regarding palmar
keloid formation, making the decision regarding a treat-
ment plan difficult. In our patient, keloid excision with full-
thickness skin graft, followed by postoperative radiation,
had good results and there has been no recurrence.

Conflict of interest statement

There are no conflicts of interest or funding in relation to


this report.
Informed consent for this report was obtained from the
patient and the research was done following the code of
ethical conduct of our hospital.

Figure 3 One year after operation, the patient had no References


recurrence of keloid formation.
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formation. Br J Plast Surg 1999;52:593e4.
2. Britto JA, Elliot D. Aggressive keloid scarring of the Caucasian
keloids,3 and we decided on this technique for our patient.
wrist and palm. Br J Plast Surg 2001;54:461e2.
The sole of the foot is generally preferred as a donor site
3. Brown NA, Ortega FR. The role of full-thickness skin grafting and
for palmar grafts, as its skin shares the same characteristics steroid injection in the treatment of auricular keloids. Ann Plast
as the skin of the palm. We chose to harvest the skin graft Surg 2010;64:637e8.
from the groin, however, because we were concerned 4. Ogawa R, Yoshitatsu S, Yoshida K, Miyashita T. Is radiation
about the possibility of keloid formation at the donor site. therapy for keloids acceptable? The risk of radiation-induced
One of the main complications of keloid excision is carcinogenesis. Plast Reconstr Surg 2009;124:1196e201.
recurrence. Though several therapeutic methods including 5. Flickinger JC. A radiobiological analysis of multicenter data for
continuous pressure, steroid injections and silicone gel postoperative keloid radiotherapy. Int J Radiat Oncol Biol Phys
seem unsatisfactory for preventing keloid recurrence, 2011;79:1164e70.
postoperative radiation therapy has become common in 6. Ogawa R. The most current algorithms for the treatment and
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recent years.4,5 Standard protocols for radiation therapy
Surg 2010;125:557e68.
for this purpose, however, have not yet been established. 7. Sakamoto T, Oya N, Shibuya K, Nagata Y, Hiraoka M. Dos-
Ogawa et al. reported that radiation therapy should involve eeresponse relationship and dose optimization in radiotherapy
the application of 10e20 Gy delivered as 5 Gy per fraction.6 of postoperative keloids. Radiother Oncol 2009;91:271e6.
Meanwhile, Sakamoto et al. reported that 20 Gy delivered 8. Mizuno H, Hyakusoku H. Suture method for the keloids. PEPARS
as 4 Gy per fraction had lower morbidity.7 For our patient, 2007;14:81e5 [article in Japanese].

Please cite this article in press as: Tada K, et al., Keloid formation after trigger finger release: A case report, Journal of Plastic,
Reconstructive
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