Keloid scar is a manifestation of abnormal wound healing in predisposed individuals. Many treatment modalities have been tried with varying degrees of success. Radiotherapy is one such modality that is widely recognised. We present a case report and literature review based on a patient who developed unilateral keloid scarring following bilateral breast reduction surgery. Some 4 years previously, she had undergone breast conserving surgery followed by adjuvant radiotherapy for breast cancer. After her breast reduction surgery, she developed keloid scarring on the non-irradiated breast only. This case highlights a possible 'preventative' effect of radiotherapy in keloid formation

AP Kelly

B Berman

C Metayer

Dibyesh Banerjee

EE Peacock

FA Mettler

Haresh Devalia

JE Norris

JO Oluwasanmi

Lucy Mansfield

N Botwood

Neda Minakaran

P Omo-Dare

R De Bearman

R Ragoowansi

SJ Stegman

TL Borok

W Yasui

English

PubMed

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BioMed Central
International Seminars in Surgical 
Oncology
ssOpen AcceCase report
A case of unilateral keloid after bilateral breast reduction
Haresh Devalia*, Lucy Mansfield†, Neda Minakaran† and Dibyesh Banerjee†
Address: St George's Hospital, Blackshaw Road, London, SW17 0QT, UK
Email: Haresh Devalia* - hareshdevalia@doctors.org.uk; Lucy Mansfield - lucymansfield@hotmail.com; 
Neda Minakaran - neda.minakaran@doctors.org.uk; Dibyesh Banerjee - Dibyesh@aol.com
* Corresponding author    †Equal contributors
Abstract
Keloid scar is a manifestation of abnormal wound healing in predisposed individuals. Many
treatment modalities have been tried with varying degrees of success. Radiotherapy is one such
modality that is widely recognised. We present a case report and literature review based on a
patient who developed unilateral keloid scarring following bilateral breast reduction surgery. Some
4 years previously, she had undergone breast conserving surgery followed by adjuvant radiotherapy
for breast cancer. After her breast reduction surgery, she developed keloid scarring on the non-
irradiated breast only. This case highlights a possible 'preventative' effect of radiotherapy in keloid
formation.
Background
Keloid scars can be an unsightly complication of surgery
in predisposed individuals. Radiotherapy is a treatment
modality that is widely recognised. We present a patient
who received adjuvant radiotherapy to one breast for the
management of breast cancer. She then underwent bilat-
eral breast reduction surgery 4 years later and developed
keloid scarring in the non-irradiated breast only.
Case report
A 35-year old West Indian female was diagnosed with car-
cinoma in her left breast. She was treated by breast con-
serving surgery in 2001, followed by radiotherapy (50 Gy)
to the left breast. Histopathology confirmed a 21 mm,
grade 2, mucinous adenocarcinoma with no axillary
lymph node involvement.
In 2005, she underwent bilateral breast reduction for
relief of symptoms of macromastia. A few weeks post-
operatively the peri-areolar scar on the right breast started
becoming hypertrophic. Over the next few months it
continued to grow in all directions, despite topical sili-
cone gel treatment. Interestingly, the scar on the left breast
healed without any complications, most probably due to
the protective effect of prior radiotherapy. This case report
demonstrates the effect that radiotherapy had in prevent-
ing keloid formation.
Discussion
Keloid scars are abnormal wound responses in predis-
posed individuals. These fibrous growths result from a
connective tissue response to trauma, inflammation, sur-
gery, or burns. Classically they are described as healed
human skin that extends beyond the confines of the orig-
inal wound and are characterized by over abundant colla-
gen deposition [1]. Keloids occur in all races, with
preponderance in Africans [2]. Genetic predisposition
appears to be a major factor in the role of keloid develop-
ment (coupled with some form of skin trauma); however
the mode of inheritance remains to be elucidated [3].
Regional susceptibility to keloid scarring is also
Published: 24 February 2008
International Seminars in Surgical Oncology 2008, 5:3 doi:10.1186/1477-7800-5-3
Received: 17 December 2007
Accepted: 24 February 2008
This article is available from: http://www.issoonline.com/content/5/1/3
© 2008 Devalia et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 3
(page number not for citation purposes)
International Seminars in Surgical Oncology 2008, 5:3 http://www.issoonline.com/content/5/1/3recognized, with the presternal area, the back and the pos-
terior neck being the most common sites [4].
Skin or wound tension has also been implicated as a crit-
ical factor in the development of keloids [5]. Several
sources have been identified to be a cause of this tension.
With loss of tissue (such as with the surgical excision dem-
onstrated in this case) there will be an increased tension
when an attempt is made to close the wound. In addition,
underlying bony and cartilaginous skeleton will transmit
a constant tension to the overlying skin.
Keloid therapy is fraught with varying degrees of success.
The variety of treatments elucidates to the fact that few are
satisfactory. Surgery alone has been documented to lead
to recurrence rates of 45 to 100% [6]. Treatments that
have been tried with limited success over the years include
cryosurgery, laser destruction, hyaluronidase, nitrogen
mustard, methotrexate, steroid infiltration, retinoic acid,
zinc, colchine, anthistamines, tetrahyroxyquinone, com-
pression splints and dermabrasion. Many anecdotal
reports of therapeutic success have been demonstrated to
be untrue when investigated within the setting of rand-
omized clinical trials.
Radiotherapy was first introduced as a treatment for kel-
oid scars in 1906 [7]. Keloids remain the commonest type
of benign disease treated by radiotherapy [8]. This can be
attributed to the fact that these scars are particularly refrac-
tory to most other treatment modalities. Radiation can be
used as a monotherapy or combined with surgery to pre-
vent recurrence of keloids following excision. A combina-
tion of the two appears to be a superior approach to the
management. When used as a monotherapy, recurrence
rates of between 50 and 100% have been reported [9],
unless large doses are used. A retrospective analysis with
up to 5-year outcome data by Ragoowansi et al [10]
revealed that the majority of patients' keloids can be con-
trolled by a single operation with immediate adjuvant sin-
gle fraction radiotherapy. From a review of other previous
studies, reported recurrence rates at one year or more vary
from 53% [11] to 2% [9]. It is difficult to make meaning-
ful comparisons between these studies as there was such
variation between treatment schedules. Within the litera-
ture there is no consensus as to the optimal dosage, frac-
tionation or timing with respect to surgical procedures.
Radiotherapy doses have been given over the range of 2 to
62 Gy [12].
The risk of radiation-induced malignancy may result in
hesitation amongst doctors to recommend radiotherapy
for treatment of such a "benign" condition. It has been
shown in epidemiological studies that ionizing radiation
carries a risk of carcinogenesis [8]. In particular, an
increased incidence of breast cancer has been observed in
women given radiotherapy for post-partum mastitis [13].
Despite the potential risks, however, there are very few
reports in the literature of malignancies arising from the
treatment of keloids with radiotherapy. The few that are
reported are in patients irradiated at a young age, which
appears to be the greatest risk factor [14,15]. The total-
body radiation dose from a superficial low-voltage radio-
therapy technique is low, thus the main excess risk would
be anticipated to occur close to the treated site. As the risks
remain yet to be truly quantified, the physician must
clearly clarify this to the patient during the consent proce-
dure.
Conclusion
This case report demonstrates the effect radiotherapy had
in preventing keloid formation. Direct comparison can be
Photograph showing keloid scarring of right non-irradiated breast and absence of keloid scarring of lef irrad ate  breastFigure 1
Photograph showing keloid scarring of right non-irra-
diated breast and absence of keloid scarring of left 
irradiated breast.
Photograph of right breast keloid scarring following bilateral breast eductionFigure 2
Photograph of right breast keloid scarring following 
bilateral breast reduction.Page 2 of 3
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made between both irradiated and non-irradiated skin
within the same individual, thus eliminating many other
variables. Not only did the patient not develop keloid
scarring after her first operation to the breast, which was
treated by radiotherapy post-surgery, but that same breast
was also protected from keloid scarring 4 years later after
the bilateral breast reduction surgery.
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
HD: Concept, design, literature search, manuscript prepa-
ration. LM: Literature search, manuscript preparation.
NM: Literature search, manuscript preparation. DB: Con-
cept, manuscript editing, manuscript review.
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A case of unilateral keloid after bilateral breast reduction

Crossref

Bieley HC: Adjuvant therapies to surgical management of keloids. Dermatol Surg

Bieley HC: Keloids.

Cheloides des maqueuses. Ann Dermatol Syphilol (Paris)

Dermatol Clin

Genetic studies on keloid.

Glees JP: Treatment of keloids by surgical excision and immediate post-operative single-fraction radiotherapy. Plast Reconstr Surg

Glogan RG: Treatment of keloids.

I: Role of ionizing irradiation for 393 keloids.

Keloids in the African. Clin Plast Surg

Lowdell C: The risks of treating keloids with radiotherapy.

Superficial x-ray therapy in keloid management: A retrospective study of 24 cases and literature review. Plast Reconstr Surg

Travis LB: Second cancers among long-term survivors of Hodgkin's disease diagnosed in childhood and adolescence.

WC: Biologic basis for the treatment of keloids and hypertrophic scars.

WR: Breast neoplasms in women treated with x-rays for acute post-partum mastitis; a pilot study.

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A case of unilateral keloid after bilateral breast reduction

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