Skip to main content

Advertisement

SpringerLink
Log in

Histology and Vascular Architecture Study of Keloid Tissue to Outline the Possible Terminology of Keloid Skin Flaps

  • Original Article
  • Special Topic
  • Published:
Aesthetic Plastic Surgery Aims and scope Submit manuscript

Abstract

Background

Using the keloid “epidermis” to cover a wound is widely used during treatment for keloids. Many flap terminologies have been used in literature. However, the definition of the flap is not well established. Here, we refined the definition of the flap and associated terminology and explored the survival mechanism of the ‘flap’ through histological analysis and blood supply studying.

Methods

Histology and vascular study of keloid was carried out with keloid and its surrounding normal skin tissue which were collected from keloid patients following keloid resection operations. The histological structures and thicknesses of epidermal and subepidermal of the keloids were analyzed and measured using hematoxylin & eosin (H&E) staining. Vascular density and blood perfusion in the subepidermal layer of keloids (KDS) were analyzed using CD31 immunohistochemical staining and a laser speckle contrast imaging system (LSCI), respectively. The vascular network in KDS was visualized by CD31 immunofluorescence staining and three-dimensional reconstruction.

Results

29 pieces of keloid and its surrounding normal skin tissue sample from ten patients were collected. Keloid samples were about 2 cm wide and 5 cm long. The normal skin samples were about 2 to 3 mm in width. The thickness of epidermal layer of keloids was (136.4 ± 35.3) μm, and the thickness of epidermal layer of surrounding normal skin was (78.8 ± 13.9) μm. There was statistical thickness difference between the two layers, t(20) = 7.469, P < 0.001. The total thickness of keloid epidermal and subepidermal layers was 391.4 ± 2.3 μm. The vascular density (13.9 ± 3.4/field) and blood flow perfusion (132.7 ± 31.3) PU in KDS were greater than that of surrounding normal skin (7.8 ± 2.3/field, 73.9 ± 17.9 PU), P < 0.001. Horizontally distributed vessels with several vertical branches were observed in 3D vascular network reconstruction.

Conclusion

The epidermal layer of keloid is thicker than that of surrounding normal skin. There is a vascular network structure under it. The vessels mainly locate at a depth of about 150 to 400 μm from the surface of keloid epidermis, randomly distribute and run parallel to the epidermis. Based on these characteristics which may ensure an adequate blood supply, we propose the concept of a “keloid subepidermal vascular network flap.”

Level of Evidence V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8
Fig. 9
Fig. 10

Similar content being viewed by others

References

  1. Sun LM, Wang KH, Lee YC (2014) Keloid incidence in Asian people and its comorbidity with other fibrosis-related diseases: a nationwide population-based study. Arch Dermatol Res 306(9):803–808

    Article  Google Scholar 

  2. Walker SL, Shah M, Hubbard VG, Pradhan HM, Ghimire M (2008) Skin disease is common in rural Nepal: results of a point prevalence study. Br J Dermatol 158(2):334–338

    CAS  PubMed  Google Scholar 

  3. Yang YC, Cheng YW, Lai CS, Chen W (2007) Prevalence of childhood acne, ephelides, warts, atopic dermatitis, psoriasis, alopecia areata and keloid in Kaohsiung County, Taiwan: a community-based clinical survey. J Eur Acad Dermatol Venereol 21(5):643–649

    PubMed  Google Scholar 

  4. Bae JM, Ha B, Lee H, Park CK, Kim HJ, Park YM (2012) Prevalence of common skin diseases and their associated factors among military personnel in Korea: a cross-sectional study. J Korean Med Sci 27(10):1248–1254

    Article  Google Scholar 

  5. van Leeuwen MC, Stokmans SC, Bulstra AE et al (2015) Surgical Excision with adjuvant irradiation for treatment of keloid scars: a systematic review. Plast Reconstruct Surg Glob Open 3(7):e440

    Article  Google Scholar 

  6. Apfelberg DB, Maser MR, Lash H (1976) The use of epidermis over a keloid as an autograft after resection of the keloid. J Dermatol Surg 2(5):409–411

    Article  CAS  Google Scholar 

  7. Salasche SJ, Grabski WJ (1983) Keloids of the earlobes: a surgical technique. J Dermatol Surg Oncol 9(7):552–556

    Article  CAS  Google Scholar 

  8. Lee Y, Minn KW, Baek RM, Hong JJ (2001) A new surgical treatment of keloid: keloid core excision. Ann Plast Surg 46(2):135–140

    Article  CAS  Google Scholar 

  9. Ogawa R, Akaishi S, Dohi T, Kuribayashi S, Miyashita T, Hyakusoku H (2015) Analysis of the surgical treatments of 63 keloids on the cartilaginous part of the auricle: effectiveness of the core excision method. Plast Reconstr Surg 135(3):868–875

    Article  CAS  Google Scholar 

  10. Ziccardi VB, Lamphier J (2000) Use of keloid skin as an autograft for earlobe reconstruction after excision. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 89(6):674–675

    Article  CAS  Google Scholar 

  11. Adams BB, Gloster HM (2002) Surgical pearl: excision with suprakeloidal flap and radiation therapy for keloids. J Am Acad Dermatol 47(2):307–309

    Article  Google Scholar 

  12. Kim DY, Kim ES, Eo SR, Kim KS, Lee SY, Cho BH (2004) A surgical approach for earlobe keloid: keloid fillet flap. Plast Reconstr Surg 113(6):1668–1674

    Article  Google Scholar 

  13. Al Aradi IK, Alawadhi SA, Alkhawaja FA, Alaradi I (2013) Earlobe keloids: a pilot study of the efficacy of keloidectomy with core fillet flap and adjuvant intralesional corticosteroids. Dermatol Surg 39(10):1514–1519

    Article  CAS  Google Scholar 

  14. Qi Z, Liang W, Wang Y et al (2012) “X”-shaped incision and keloid skin-flap resurfacing: a new surgical method for auricle keloid excision and reconstruction. Dermatol Surg 38(8):1378–1382

    Article  CAS  Google Scholar 

  15. Liu S, Liang W, Song K, Wang Y (2018) Keloid skin flap retention and resurfacing in facial keloid treatment. Aesthetic Plast Surg 42(1):304–309

    Article  Google Scholar 

  16. Limandjaja GC, van den Broek LJ, Waaijman T, van Veen HA, Everts V, Monstrey S, Scheper RJ, Niessen FB, Gibbs S (2017) Increased epidermal thickness and abnormal epidermal differentiation in keloid scars. Br J Dermatol 176(1):116–126

    Article  CAS  Google Scholar 

  17. Lee JY, Yang CC, Chao SC, Wong TW (2004) Histopathological differential diagnosis of keloid and hypertrophic scar. Am J Dermatopathol 26(5):379–384

    Article  Google Scholar 

  18. Ueda K, Yasuda Y, Furuya E, Oba S (2004) Inadequate blood supply persists in keloids. Scand J Plast Reconstruct Surg Hand Surg 38(5):267–271

    Article  Google Scholar 

  19. Liu Q, Wang X, Jia Y, Long X, Yu N, Wang Y, Chen B (2016) Increased blood flow in keloids and adjacent skin revealed by laser speckle contrast imaging. Lasers Surg Med 48(4):360–364

    Article  Google Scholar 

  20. Weidner N, Semple JP, Welch WR, Folkman J (1991) Tumor angiogenesis and metastasis-correlation in invasive breast carcinoma. N Engl J Med 324(1):1–8

    Article  CAS  Google Scholar 

  21. Weidner N (1995) Current pathologic methods for measuring intratumoral microvessel density within breast carcinoma and other solid tumors. Breast Cancer Res Treat 36(2):169–180

    Article  CAS  Google Scholar 

  22. Limandjaja GC, Belien JM, Scheper RJ, Niessen FB, Gibbs S (2020) Hypertrophic and keloid scars fail to progress from the CD34(-) /alpha-smooth muscle actin (alpha-SMA)(+) immature scar phenotype and show gradient differences in alpha-SMA and p16 expression. Br J Dermatol 182(4):974–986. https://doi.org/10.1111/bjd.18219 (Epub 2019 Sep 4)

    Article  CAS  PubMed  Google Scholar 

  23. Chong Y, Park TH, Seo S, Chang CH (2015) Histomorphometric analysis of collagen architecture of auricular keloids in an Asian population. Dermatol Surg 41(3):415–422

    Article  CAS  Google Scholar 

  24. Zhang Z, Nie F, Chen X, Qin Z, Kang C, Chen B, Ma J, Pan B, Ma Y (2015) Upregulated periostin promotes angiogenesis in keloids through activation of the ERK 1/2 and focal adhesion kinase pathways, as well as the upregulated expression of VEGF and angiopoietin1. Mol Med Rep 11(2):857–864

    Article  CAS  Google Scholar 

  25. Le AD, Zhang Q, Wu Y, Messadi DV, Akhondzadeh A, Nguyen AL, Aghaloo TL, Kelly AP, Bertolami CN (2004) Elevated vascular endothelial growth factor in keloids: relevance to tissue fibrosis. Cells Tissues Organs 176(1–3):87–94

    Article  CAS  Google Scholar 

  26. Kurokawa N, Ueda K, Tsuji M (2010) Study of microvascular structure in keloid and hypertrophic scars: density of microvessels and the efficacy of three-dimensional vascular imaging. J Plast Surg Hand Surg 44(6):272–277

    Article  Google Scholar 

  27. Suttho D, Mankhetkorn S, Binda D, Pazart L, Humbert P, Rolin G (2017) 3D modeling of keloid scars in vitro by cell and tissue engineering. Arch Dermatol Res 309(1):55–62

    Article  CAS  Google Scholar 

  28. Limandjaja GC, van den Broek LJ, Waaijman T, Breetveld M, Monstrey S, Scheper RJ, Niessen FB, Gibbs S (2018) Reconstructed human keloid models show heterogeneity within keloid scars. Arch Dermatol Res 310(10):815–826

    Article  CAS  Google Scholar 

  29. Kischer CW, Thies AC, Chvapil M (1982) Perivascular myofibroblasts and microvascular occlusion in hypertrophic scars and keloids. Hum Pathol 13(9):819–824

    Article  CAS  Google Scholar 

  30. Lametschwandtner A, Staindl O (1990) Angioarchitecture of keloids. A scanning electron microscopy study of a corrosion specimen. HNO 38(6):202–207

    CAS  PubMed  Google Scholar 

  31. Amadeu T, Braune A, Mandarim-de-Lacerda C, Porto LC, Desmouliere A, Costa A (2003) Vascularization pattern in hypertrophic scars and keloids: a stereological analysis. Pathol Res Pract 199(7):469–473

    Article  Google Scholar 

  32. Bux S, Madaree A (2010) Keloids show regional distribution of proliferative and degenerate connective tissue elements. Cells Tissues Organs 191(3):213–234

    Article  Google Scholar 

  33. Roustit M, Millet C, Blaise S, Dufournet B, Cracowski JL (2010) Excellent reproducibility of laser speckle contrast imaging to assess skin microvascular reactivity. Microvasc Res 80(3):505–511

    Article  CAS  Google Scholar 

  34. Arima J, Huang C, Rosner B, Akaishi S, Ogawa R (2015) Hypertension: a systemic key to understanding local keloid severity. Wound Rep Regen 23(2):213–221. https://doi.org/10.1111/wrr.12277

  35. Jiao H, Zhang T, Fan J, Xiao R (2017) The superficial dermis may initiate keloid formation: histological analysis of the keloid dermis at different depths. Front Physiol 8:885. https://doi.org/10.3389/fphys.2017.00885 (eCollection 2017)

  36. Song KX, Liu S, Zhang MZ, Liu H, Dong XH, Hao Y, Liu YF, Wang YB (2018) Hyperbaric oxygen therapy improves the effect of keloid surgery and radiotherapy by reducing the recurrence rate. J Zhejiang Univ Sci B 19(11):853–862

    Article  CAS  Google Scholar 

  37. Zhang M, Liu S, Guan E, Liu H, Dong X, Hao Y, Zhang X, Zhao P, Liu X, Pan S, Wang Y, Wang X, Liu Y (2018) Hyperbaric oxygen therapy can ameliorate the EMT phenomenon in keloid tissue. Medicine 97(29):e129

    Article  Google Scholar 

  38. Xiao YD, Liu YQ, Li JL, Ma XM, Wang YB, Liu YF, Zhang MZ, Zhao PX, Xie F, Deng ZX (2015) Hyperbaric oxygen preconditioning inhibits skin flap apoptosis in a rat ischemiae-reperfusion model. J Surg Res 199(2):732–739. https://doi.org/10.1016/j.jss.2015.06.038 (Epub 2015 Jun 23)

    Article  CAS  PubMed  Google Scholar 

  39. Francis A, Baynosa RC (2017) Hyperbaric oxygen therapy for the compromised graft or flap. Adv Wound Care 6(1):23–32. https://doi.org/10.1089/wound.2016.0707

    Article  Google Scholar 

Download references

Acknowledgement

This project was supported by the 2019 Grant of Research and Application of Clinical Diagnosis and Treatment Technology in Beijing from Beijing Science and Technology Commission.

Funding

2019 Grant of research and application of clinical diagnosis and treatment technology in Beijing from Beijing science and technology commission [Grant Number: Z191100006619009].

Author information

Authors and Affiliations

  1. Department of Plastic Surgery, Peking Union Medical College Hospital, No. 41 Damucang Hutong, Xicheng District, Beijing, China

    Kexin Song & Youbin Wang

  2. Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China

    Yue Teng, Yan Hao, Hao Liu, Mengjie Shan & Qiao Chen

Authors
  1. Yue Teng
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Yan Hao
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Hao Liu
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Mengjie Shan
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Qiao Chen
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Kexin Song
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Youbin Wang
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Youbin Wang.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Below is the link to the electronic supplementary material.

Supplementary file1 (MP4 9152 KB)

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Teng, Y., Hao, Y., Liu, H. et al. Histology and Vascular Architecture Study of Keloid Tissue to Outline the Possible Terminology of Keloid Skin Flaps. Aesth Plast Surg 46, 985–994 (2022). https://doi.org/10.1007/s00266-022-02775-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00266-022-02775-0

Keywords

Search

Navigation