Review Article
Keloid and Hypertrophic Scar
Gregory Grabowski, MD
Matthew J. Pacana, MD
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Elliot Chen, MD
From the Prisma Health-USC
Departments of Orthopaedic Surgery
and Plastic Surgery, Columbia, SC.
None of the following authors or any
immediate family member has
received anything of value from or has
stock or stock options held in a
commercial company or institution
related directly or indirectly to the
subject of this article: Dr. Grabowski,
Dr. Pacana, and Dr. Chen.
J Am Acad Orthop Surg 2020;28:
e408-e414
DOI: 10.5435/JAAOS-D-19-00690
Copyright 2020 by the American
Academy of Orthopaedic Surgeons.
e408
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Formation, Prevention, and
Management: Standard Review of
Abnormal Scarring in Orthopaedic
Surgery
Abstract
Keloid and hypertrophic scar formation after orthopaedic surgical
closure is a complex issue. The nature and location of procedures
maximize wound tension, leave foreign bodies, and diminish
dermal supply, all potentiating keloid formation. There is little
discussion regarding the pathophysiology and management of this
recurrent problem in orthopaedic literature. Keloid formation is a
fibroproliferative disorder resulting in extensive production of
extracellular matrix and collagen, but prevention and treatment is
poorly understood. Patient and surgical factors contributing to the
development of this condition are discussed. The treatments
include both medical and surgical therapies that work at a biologic
level and attempt to produce a cosmetic and complication-free
management strategy. Medical options that have been investigated
include combinations of intralesional steroid therapy, laser therapy,
and biologics. Preventive surgical closure and excision remain
mainstays of treatment. Radiation therapy has also been used in
refractory cases with mixed results. Despite medical therapies
and surgical excision aimed at treating the resulting scar,
recurrence rate is very high for all modalities that have been studied
to this point. Future work is being done to better understand the
pathophysiology leading to keloid and hypertrophic scar formation
in an effort to find preventive methods as compared to treatment
strategies.
O rthopaedic surgery by its na-
ture creates notable tissue
trauma, often under adverse con-
scars may arise, becoming a lifelong
reminder of the procedure. However,
even in high-risk patients, measures
ditions after injury. In addition, can be done to mitigate or even com-
subcutaneous implant, direct dermal pletely prevent a bad scar. This article
injury, retained foreign bodies, and will discuss the features of pathologic
incisions in high tension areas can be scars and how some of these afore-
necessary to achieve optimal repair. mentioned orthopaedic techniques can
Preserving function is of course the be modified to help prevent pathologic
primary concern, but this can be to scar formation. It will conclude with
the detriment of soft-tissue wound potential treatments and future direc-
healing. Keloids and hypertrophic tions to be taken.
Journal of the American Academy of Orthopaedic Surgeons

Table 1
Appearance and Pattern of Growth for Various Scar Types
Scar Type
Immature Scar Red, raised, irritating
Mature scar Light colored, flat
Hypertrophic scar Elevated, possibly painful, confined to surgical
incision or trauma
Keloid scar Elevated, pruritic, and painful
History and Epidemiology
Keloid scars are a pathologic process
initially described in 1806 by Alibert
who coined the term “cheloid.” Clini-
cians further studied this in the 1960s
and differentiated these from hyper-
trophic scars. To a surgeon, a scar
marks a process complete; for pa-
tients, however, a scar can be a
psychological burden and source of
distress. Keloids can occur at any
stage of life but are most common
between 10 and 30 years. Mean age
of diagnosis is 22.3 years for women
and 22.8 for men.1
There is a possible association with
hormone regulation; pregnancy and
puberty demonstrate higher inci-
dence with elevated androgen recep-
tor levels seen in keloid tissue. This
correlation, however, is not demon-
strated heavily in the literature.2 Ke-
loids are more common in black
and Hispanic races. Incidence in the
Caucasian cohort is ,1% according
to one study form the United King-
dom.3 Incidence in black and His-
panic cohorts varies from 4.5% to
16% in the literature.4
Genetics
Multiple studies have demonstrated
an autosomal dominant inheritance
pattern with incomplete penetrance
and variable expression.5 Nine up-
regulated genes have been identified
in keloid tissue.6 These genes, espe-
cially novel nuclear protein-1, likely
May 15, 2020, Vol 28, No 10
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Gregory Grabowski, MD, et al
Appearance Growth pattern
Continues to mature
Takes appearance of normal skin over time
Occurs weeks after insult, begins to flatten and
resolve after 6 mo up to 1 yr
Minimal changes seen for 3 mo, continues to grow
contribute either to keloid scar
formation.7
Figure 1
Biology
Scar formation is the normal end
result of the wound-healing process.
Oversimplified, wound healing starts
at the time of injury. A normal cas-
cade of vasodilation, removal of for-
eign bodies, and cell migration marks
the initial inflammatory phase. The Keloid scar on the anterior neck.
proliferative phase is marked by
deposition of collagen by fibroblasts.
Finally, this scar is organized in
fer on a histologic level. Although
the maturation phase, returning the
hypertrophic scars contain type III
skin tensile strength to 80% of nor-
collagen, keloids contained mixed
mal.8 Throughout the proliferative
bundles and type I and type III col-
and maturation phases, collagen is
lagen. Keloid scars have thicker col-
simultaneously deposited and bro-
lagen bundles in line with the
ken down, forming a dynamic equi-
epidermis and form acellular node-
librium of wound strength and
like structures with few central cells.
organization. The final scar ideally is
Collagen fibers in keloids are larger,
slightly hypopigmented, thin, and
thicker, and oriented in a random
supple.
position compared with their
By contrast, hypertrophic and keloid
hypertrophic counterparts with
scars are a form of abnormal wound
parallel fibers with a size similar to
healing. The tissue is a benign dermal
normal scars.9 Ultimately, the
fibroproliferative tumor that results in
underlying regulatory mechanisms
excessive net collagen deposition. In
responsible for this excessive repair
nonpathologic wound healing, the
are still under investigation.
inflammatory phase ceases when the
dermis closes and epithelialization is
finished. However, when cell-to-cell Assessment
signals are corrupted, this process
can tilt toward excessive net collagen Clinical characteristics separate hyper-
deposition. trophic and keloid scars from normal
It is important to make a distinc- scars. Both hypertrophic and keloid
tion between hypertrophic scars and scars are distinct entities from each
true keloids. The two scar types dif- other as well. Being able to identify
e409
Formation, Prevention, and Management
Figure 2
Hypertrophic scar on the sternum.
what type of scar is present in the clin-
ical setting allows for a more precise
treatment plan. The area most suscep-
tible to abnormal scarring within
orthopaedics is the neck. Although the
anterior chest is most common for
keloid formation, it is less applicable to
this current review. Other areas of
concern include the pretibial skin, the
posterior shoulder, and across joints.
Although ear keloids are most common
in the cohort as a whole, they are
a distinct entity that does not pre-
dict keloid formation in other body
areas. The patient’s own perception of
the cosmesis of their scar, pain, and
pruritus should all be considered in
management.
When assessing a postsurgical
wound, several factors must be con-
sidered. The Vancouver Scar Scale
is a validated tool for scar assessment
and assesses for pigmentation, vas-
e410
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
cularity, height, and pliability.10 It
can be a useful tool for progno-
sis and treatment requirement. Al-
though very specific in nature, its
utility is limited clinically. The Van-
couver Scar Scale focuses on burn
scars and is often more applicable in
the research setting. Table 1 above
demonstrates several clinical and
developmental features of the vari-
ous scar types.
Keloid are raised, itchy, and expand
past the original scar borders. Figure 1
below shows the typical pattern of a
keloid scar that has severely pro-
gressed. Unlike hypertrophic scars,
they often continue to worsen over
time. Their growth is most similar to
benign skin tumors with slow growth,
but recurrence is almost guaranteed
with excision alone.11
Hypertrophic scars are also patho-
logic in nature. They remain con-
tained to the wound boundaries and
grow abnormally thickened.8 They
are red, sometimes painful, and can
cause mild irritation to the skin. One
study states this discomfort results
from proinflammatory substance P
released from nerve endings after
the trauma or surgical insult.12 They
can form as a result of excess ten-
sion, demonstrating the importance
of a tension free closure. An exam-
ple of tensioned closure with a
characteristic hypertrophic scar
pattern can be seen above in Figure
2 on the sternum. They are more
common at flexion surfaces on the
extremities. They fade with time and
flatten over the year after the insult
to the dermis.
Prevention
There are prevention tactics that
all surgeon can apply to help to
prevent the formation of abnormal
scarring. Unfortunately, surgical
and medical techniques to remove
them after formation have variable
success.
Journal of the American Academy of Orthopaedic Surgeons
Patient Factors
A number of factors rely on the
patient involved and are not modifi-
able. Poor nutrition, diabetes, obe-
sity, and previous radiation exposure
all lead to tissue that is less likely to
heal normally. These processes pre-
dispose patients to morbid scars.
Medications also play a role to re-
sult in poor tissue healing. Cortico-
steroids and isotretinoin should be
recognized as medications that result
in wound complications.
Primary Prevention
(Surgical Technique)
The primary goals of scar avoidance
include atraumatic closure, minimi-
zation of tension, skin eversion, and
ideal apposition. Care must also be
taken to avoid tissue strangulation
with stitches that are too tight or closely
spaced. Atraumatic technique includes
fine instruments and minimizing touch
to the skin. Hooks should be used for
retraction when able to avoid crush
injuries. Grasping with forceps should
be done as little as possible on superfi-
cial tissue. Placement of incision should
be done between angiosomes if at all
possible. Angiosomes are the dermal
plexuses fed by the deeper vessels
supplying the skin. Placing incision
between these areas keeps loss of der-
mal vascularity to a minimum.
Tension plays a role in scar widening
leading to edge separation. Approxi-
mation with deep buried subdermal
stitches brings the dermal layers into
close proximity. A number of suture
techniques help prevent these goals.
High tension tissue can be approxi-
mated with a near far pulley stitch. In-
cisions should also be placed in lines of
natural tension (Langer lines) to con-
tinue to minimize tension. Scars will be
parallel to skin creases and also be hid-
den. This applies heavily to incisions
such as those done in anterior approach
cervical spine surgery and at the joints of
 Gregory Grabowski, MD, et al

Table 2
Primary Prevention Techniques for Abnormal Scarring
Technique Method Failure of Technique

Atraumatic closure Minimal grasping; use sharp, fine instrumentation Blunt retraction, excessive forcep usage
Minimize tension Well-spaced suture; avoid strangulation Loss of blood supply
Skin eversion Horizontal mattress sutures Poor placement / overgrowth
Apposition Skin edges touching before epidermal closure Tissue strangulation, wound degradation

extremities. In Table 2, these methods Figure 3

are outlined, as well as the con-
sequences of failing to follow these
principles.
Final epidermal closure should result
in skin eversion. Skin eversion applies
the same principles of approxima-
tion by placing the epidermis close to-
gether. This can be accomplished
through vertical mattress sutures.
Prompt removal of stitches should take
place as soon as the wound allows.
Alternative final layer closures include
subcuticular sutures or adhesive glues.
Nondegradable sutures such as poly-
propylene or nylon initiate less inflam-
matory responses compared with
absorbable and retained sutures such as
chromic gut or polyglactin. Resorbable
sutures should be avoided as they
increase the inflammatory response to
the area of the incision. Internal knots
also incite more inflammation and can
be secured externally by tape instead.
One additional method used in our
institution to prevent keloid forma-
tion is the early elimination of any
retained suture. Many orthopaedic
closures require approximation of the
fascial layers in deep exposure resulting
in retained suture which serves as a
foreign body and impetus for abnor-
mal scarring. Below, Figure 3 describes
one suturing technique to allow for
removal of deep suture after wound
healing. Fascial closure is done similar
to a horizontal mattress suture that
enters and exits through one side of
the incision followed by a superficial
Allgower-Donati technique to allow for
minimal disruption to the dermal blood
supply. Because keloids rarely develop
before 3 months after skin insult, it is
Closure technique. A, Deep fascial closure. B, Allgower-Donati technique. C,
Everted final closure with all suture removable after wound healing.
crucial to take out the suture as early as
the wound healing will allow.
In our institution, these techniques
have shown excellent results. Follow-
ing these principles can prevent keloid
scarring even in high-risk patients.
One such patient was a known keloid
former after laparoscopic abdominal
surgery as seen below in Figure 4.
The patient developed radiculopathy
that did not respond to nonsurgical
intervention and underwent anterior
neck surgery with assistance from
plastic surgery for closure. The above
techniques were used. All suture was
removed including deep fascial closure
as previously described along with in-
trasurgical corticosteroid injection.
The patient ultimately did not develop
keloids, and Figure 5, A and B below
demonstrates her minimal scarring at
the 1-year mark.
Adjunct Closure Tools
Closure techniques continue to
develop in the surgical literature.
Various taping methods have also
been used as adjunctive therapy.
These off-loading devices for scar
reduction are a demonstration for the
necessity of additional research into
the effectiveness of this therapy.
Taping can be done and have some
effectiveness up to 3 months after
closure of the incision.13 Paper tape
applied across the incision maintains
moisture, offloads incision tension,
and helps with camouflaging of the
scar.14
Silicone gel sheeting is another pro-
phylactic tool used approximately 24
hours after wound epithelialization in
the first 48 to 72 hours. Silicone
products may alter evaporative loss
and assist hydration of the epidermis.
After wound healing, water still evap-
orates more rapidly through scar tissue
and may take more than a year to
recover to preinjury levels.15 Silicone
elastomeric dressings have been shown
in two randomized trials to reduce
scarring after scar revision surgery.16
Recommendations exist for its use in
high-risk incision areas and patients. A

May 15, 2020, Vol 28, No 10 e411

Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Formation, Prevention, and Management
Figure 4
Abdominal keloids after minimally
invasive laparoscopic abdominal
surgery.
2006 Cochrane review found weak
evidence to support its use, but mul-
tiple randomized controlled trials have
demonstrated some value.17 These
randomized controlled trials demon-
strated faster hypertrophic scar mat-
uration and less pain and itching.18
Optimizing the environment of the
wound is also an important adjunct to
closure. In addition to paper tape
and silicone gel sheeting, compressive
dressings should be applied early if a
scar is beginning to demonstrate ele-
vation. Motion should be minimized
for incision made at joints. Early
motion is vital in many orthopaedic
surgeries and should be prioritized for
function. When able, splinting in the
first 2 weeks of wound healing can
limit the risk of abnormal scarring. An
alternative to continuous immobili-
zation is to limit splinting to night time
only with removable splints.
Vitamin E, oils, lotions, and onion
extract have also been studied, but no
evidence exists in the literature for
their benefit. Other strategies include
massage, hydrotherapy, and ultraso-
nography, but more studies are needed
to demonstrate any efficacy.19,20
Secondary Prevention
(Medical Treatment)
Multiple techniques can be used after
surgery. For patients who are known
e412
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
to form hypertrophic or keloid scars,
plans should be made before surgery to
use adjunctive therapies to minimize
formation of these scars. Methods
include intralesional corticosteroid
injection, silicone gel sheeting, com-
pressive dressings, and laser therapy.
Above, Table 3 outlines the modalities
that have been used with varying
levels of success. Although hypertro-
phic scars show good results with
some of the discussed methods below,
keloid scars have very few successful
treatment modalities. Discussing the
likely recurrence preoperatively is vital.
When therapy must be undertaken, the
risk of growth or recurrence must be
discussed. The mainstays of treatment
are monitoring scar development or
excision followed by adjuvant therapy.
Intralesional corticosteroid injection
has an unknown mechanism that has
been studied extensively in the litera-
ture. It is believed to suppress the
mechanism of fibroblast proliferation
and local inflammatory cytokines.
Increasing collagenase production re-
sults in the degeneration of the disor-
ganized collagen bundles.21 Some
evidence supports response rates of
80%.22 However, another study
showed intraoperative and postoper-
ative intralesional steroid therapy after
excision has been shown to reduce
recurrence rates to below 50%.23
This should be done very early in scar
development as effectiveness decreases
as the keloid matures. Triamcinolone at
concentrations of 10 to 40 mg/mL is
attempted. Injection is done into the
lesion itself every 2 to 6 weeks until
resolution or until side effects force the
cessation of treatment. Injection itself
can be painful due to the dense collagen
at the site. Local side effects include skin
atrophy, pigmentation changes, and
pain. These occur in over half of pa-
tients undergoing this treatment; how-
ever, systemic steroid effects are rare,
and pigmentation concerns are typically
transient.24 Steroid injection in the
operating should be considered very
carefully as it can slow wound healing
Journal of the American Academy of Orthopaedic Surgeons
and the inflammatory response leading
to nonhealing wounds. However, in
high-risk patients who are known to
form keloids, its use can be considered.
Laser therapy has also been used,
often within the setting of the der-
matologic clinic. The mechanism is
also unclear, but several studies
hypothesize that it ablates disulfide
bonds within the proliferating colla-
gen fiber formation. Most studies
have not been powered to effective
demonstrate its efficacy or provide
adequate follow-up when it is used.
High-energy pulsed CO2 lasers are
an area of future investigation in the
treatment of scars.25 Larger studies
are needed to demonstrate the utility
of these laser therapies.
Radiation therapy after excision has
been shown to reduce recurrence ac-
cording to multiples studies.26,27 The
mechanism by which radiation ther-
apy works is proposed to be direct
fibroblast damage resulting in de-
struction of the collagen structure. By
increasing the apoptotic rate of fibro-
blasts, the cell cohort is returned to a
state of equilibrium.28 Typically doses
of 10 to 20 Gy are used immediately
postoperatively. As an adjunct to
surgery, recurrence rates have been
reported from 1% to 35% in older
literature. Newer studies have shown
that recurrence can still remain as high
as 72% and malignant transformation
can result. It should be reserved for
those with scars resistant to all other
modalities.29
Cryotherapy is being used as a
medical treatment to discuss the vol-
ume of abnormal scarring. One study
examined scar volume 1 year after
treatment noting 63% reduction in
volume, as well as increased aesthetic
appearance rated by physician and
patient and a 24% recurrence rate of
keloid formation.30
In summary, no single modality has
proven effective for keloid scars.
For hypertrophic scars, some of the
described interventions show good to
excellent results. For keloids, the most

effective approach casts a wide net
using several different treatment
options over time with a focus on
prevention and early management
when recognized. The larger and
more mature the scar for both vari-
eties, the greater the chance of fail-
ure in treatment and increase in
morbidity.
Tertiary Prevention
(Surgical Management)
After a keloid or hypertrophic scar
develops, patients often desire scar
revision. Timing of medical and sur-
gical intervention should be carefully
considered given the timing of scar
development for both hypertrophic
and keloid scars discussed earlier.
Patients often seek scar revision for
physical disfigurement and psycho-
logical burden for scars in particu-
larly visible locations. This burden
often falls to the dermatologist and the
plastic surgeon. However, a discus-
sion of these techniques can be infor-
mative to the orthopaedic surgeon and
guide management before and after
surgery. When poor surgical tech-
nique is used, re-excision can be an
effective treatment using appropriate
surgical skills. Re-excision and pri-
mary closure with adjuvant therapy
(ie, steroids and radiation) can at times
give a more optimal end result. Sur-
gical excision alone, however, has
high recurrence rates of 40% to
100%.3
Timing of revision should be when
scars are not new and heavily vas-
cularized. Scars should also be at
their most mobile and soft and not
late into the maturation process. In
general, this should take place based
on clinical examination. Hypertro-
phic scars often demonstrate reso-
lution up to 1 year from surgical
intervention or trauma and should
be monitored carefully. Operation
should be avoided before the 1-year
mark. Keloid scars do not begin
May 15, 2020, Vol 28, No 10
Copyright © the American Academy of Orthopaedic Surgeons. Unauthorized reproduction of this article is prohibited.
Gregory Grabowski, MD, et al
Figure 5
A, Anterior cervical approach scar at 1 year in known keloid former. B, Lateral
view.
Table 3
Secondary Prevention Modalities
Medical Treatment Success Rate
Corticosteroid .50% recurrence reduction
Laser therapy Anecdotal success
Radiation therapy 1%-35% occurrence reduction
Cryotherapy 63% volume reduction
to present until approximately
3 months after the inciting event, and
Developing New Treatment
their excision should be avoided in Strategies
the early stages after surgery or
Recent studies are examining the
trauma.
effectiveness of antitumor and im-
Basic tenets include avoidance of
munomodulation for treatment of
complex scar revision. Techniques
these scars. 5-fluorouracil TGF-B
such as Z-plasty and deeper excision
modulation, and interferons have
will only multiply the problem. Sim-
been used in preclinical studies of scar
ple excision with minimal disruption
biology. All three of these agents act
to deeper tissues should be followed
in the collagen formation pathway
closely. Suture after scar revision
and seek to inhibit its formation or
should be removed as early as possi-
increase its degradation.31,32 Data
ble. Monofilament suture incites a
are limited but may be a future
lower inflammatory response and is
direction for the efficacious treat-
preferred. Retained suture should be
ment of hypertrophic and keloid
avoided even when closing deeper
scarring.
layers.
Postoperative care is also impor-
tant to direct wound healing as much Conclusions
as possible. Glucose control should
be as strict as possible. Smoking Although existing strategies for the
cessation is vital for protection of the management of hypertrophic scars
neovascularization of the wound. and keloids are similar, the histologic
Activity precautions should be taken differences between the two scars
to prevent undue stress on the suggest therapeutic approaches that
wound. identify these types may be effective.
e413
Formation, Prevention, and Management
Presently, there is no single best ther-
apy. Multimodal therapy has been the
most common practice among plastic
and dermatologic surgeon in the pre-
sent. Although the burden of keloid
formation may not lie entirely on the
orthopaedic surgeon doing elective
surgery, there are important factors
that should be considered to minimize
this risk. There is also a responsibil-
ity to appropriately assess scars and
determine the next steps that need to
be taken. This may include eventual
referral to a plastic surgeon or der-
matologist for treatment.
Summary
• Keloid and hypertrophic scars
are two examples of abnormal
scarring that can present after
orthopaedic surgery or trauma.
• Clinical assessment is key to
identify the type of scar present.
• Prevention techniques are para-
mount when a patient who is
known to scar undergoes surgery.
• Secondary and tertiary treat-
ment can be necessary and often
will require the assistance of a
plastic surgery or dermatology
colleague.
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References printed in bold type are
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