Akira Sugamata

Kazuki Shimada

Keiichi Goya

Naoki Yoshizawa

吉沢 直樹

呉屋 圭一

島田 和樹

菅又 章

Tokyo Medical University Institutional Repository / 東京医科大学学術情報リポジトリ

─ ─360
（　　）
Treatment for protruding keloids in the pubic area with everting suture 
and multiple Z-plasty
Akira SUGAMATA, Naoki YOSHIZAWA, Keiichi GOYA, Kazuki SHIMADA
Department of Plastic and Reconstructive Surgery, Tokyo Medical University Hachioji Medical Center, Tokyo, Japan
1
fascia via a marginal skin incision of the stem of the 
keloid. Along the edges of the wounds, the skin and the 
subcutaneous fat tissue were formed into undermined 
flaps of about 3 cm in width. Dermal stitches with 4-0 
nylon threads were inserted at 1-1.5 cm from both inci-
sional margins and the suture threads were tied firmly to 
evert the flaps. Multiple Z-plasty was applied to the 
closed longitudinal wound ; each side of the triangular 
flaps had a length of approximately 7-10 mm. After 
each flap was put in place, dermis suturing was per-
formed with 6-0 polydioxanone thread and the surface 
skin closed with 6-0 nylon thread (Fig. 1).
Patients
Case 1
　A 55-year-old woman, who had undergone an opera-
tion for a uterine myoma 3 years previously, showed 
development of a keloid in the lowest region of the inci-
sional scar since after abscess formation caused by suture 
materials. The size of the keloid was 4×3×3 cm. The 
keloid was resected and the new wound was closed with 
everted margins with multiple Z-plasty. The everted 
J. Tokyo Med. Univ., 70（3）: 360-364, 2012
Introduction
　Although the pubic area has one of the highest rates of 
keloid scar formation in adults, only a few studies have 
reported valid means of treating keloids affecting this 
area1-4). Keloids formed on previous operative scars in 
the pubic area often form large protruding tumors that 
sometimes resist conservative therapies such as pressure 
tape bandages and intraregional steroid injections2-4).　
Therefore it is appropriate to use treatments that include 
surgical excision and prevention of recurrence. We 
have resected primary large protruded keloids in the 
pubic area using the operative technique of Imai5).　
These patients were followed up with postoperative ther-
apeutic strategies such as steroid injection and meshed 
paper tape pressure bandages. This paper examines the 
clinical results of 4 adult patients who were followed for 
more than 2 years.
Surgical technique
　During surgery, keloid scarring and subcutaneous fat 
tissue were both resected to the superficial abdominal 
Case reports
Received April 24, 2012, Accepted June 11, 2012
Key words : Keloid, Multiple Z-plasty, Pubic area, Meshed paper tape bandage
Corresponding author : Akira Sugamata MD, Department of Plastic and Reconstructive Surgery, Tokyo Medical University Hachioji 
Medical Center, 1163 Tatemachi, Hachioji City, Tokyo 193-0998, Japan
TEL : +81-426-65-5611　FAX : +81-426-65-1796　E-mail : sugamata@tokyo-med.ac.jp
Abstract
　　The pubic area has one of the highest rates of keloid scar formation in adults. Large protruding keloids in 
this area sometimes resist conservative therapies. We have resected primary keloids in the pubic area in 4 
patients using our operative technique which included extremely everted wound suture with deep dermal stitches, 
and multiple Z-plasty. The associated postoperative therapies includes : regional steroid injection 5-6 times in 3 
patients, and a meshed paper tape bandage was used continuously in all patients for 2-4 years until the surgical 
scars matured completely. None of the patients showed keloid recurrence following surgical correction.
A. SUGAMATA, et al : Treatment for protruding keloids in the pubic area with everting suture and multiple Z-plasty ─ ─361July, 2012
（　　）2
suture wounds were maintained for about 2 months after 
the surgery and subsequently flattened. A meshed paper 
tape bandage was continued from 10 days after the sur-
gery following removal of the suture materials to the last 
clinical examination 2 years later. There was no recur-
rence of the keloid (Fig. 2)
Case 2 
　A 42-year-old woman had undergone a cesarean sec-
tion 8 years previously. She had experienced recurrent 
folliculitis on her operation scar and showed develop-
ment of a large keloid in the lowest portion of the scar 
over a period of 1 year following surgery. The size of 
the keloid was 10×6×1 cm. The keloid was resected 
and the wound closed with crossed sutures with everted 
margins and multiple Z-plasty. The everted suture 
wounds were maintained for about 1.5 months after the 
surgery. During the follow up period, when the surgical 
scars became hard and reddish, corticosteroid (0.1 ml tri-
amcinolone acetate) was injected into the hard scar 
regionally at 3, 4, 7, 10, 12 and 15 months after the sur-
gery. A meshed paper tape bandage was continued from 
10 days after the surgery to the last clinical examination 
2 years later. There was no recurrence of the keloid 
(Fig. 3).
Case 3
　 A 39-year-old man had undergone an operation for a 
left inguinal hernia when he was 1 year old. From 4 
years prior to presenting at our clinic he had suffered 
several infections in the scar and a protruding keloid on 
the most infected inside region of the old scar gradually 
appeared. The size of the keloid was 5×4×3 cm. The 
keloid was resected and the wound was closed with 
everted margins with multiple Z-plasty. The everted 
suture wounds were maintained for about 1 month after 
the surgery. A meshed paper tape bandage was contin-
ued from 7 days after the surgery up to the last clinical 
examination 4 years later. When the surgical scars 
became hard, corticosteroid (0.1 ml triamcinolone ace-
tate) was injected into the hard scar regionally at 1, 3, 4, 
5 and 6 months after the surgery. Four years after the 
surgery for the keloid the scar had widened to 6 mm, 
however there was no recurrence of the keloid (Fig. 4).
Case 4
　A 34-year-old woman had undergone a cesarean sec-
tion 8 years prior to consulting us. She had recurrent 
abscesses in the entire scar due to the original suture 
materials as well as epidermal cysts. She had gradually 
developed a large keloid on the scar from the cesarean 
section. The size of the keloid was 17×6×1 cm. The 
keloid was resected and the wound was closed with 
everted margins with multiple Z-plasty. The everted 
suture wounds were maintained for about 2 months after 
the surgery. A meshed paper tape bandage has been 
continued to the present time. When the surgical scars 
became hard, corticosteroid (0.1 ml triamcinolone ace-
tate) was injected into the hard scar regionally at 3, 6, 10, 
16 20 and 24 months after the surgery. Four years after 
the surgery, the partial regions of the scar had widened to 
3 mm, however there was no recurrence of the keloid 
(Fig. 5).
Discussion
　The tension of the skin in the pubic area is not as 
marked as the frontal chest area and around the shoulder 
region4). Therefore, especially in adults, the greatest 
cause of pubic keloid formation in the primary scars is 
more likely due to recurrent inflammation from hair fol-
liculitis, infected epidermal inclusion cysts and abscesses 
Fig. 1　Keloid scarring and subcutaneous fat tissue were both 
resected to the superficial abdominal fascia via a marginal 
skin incision of the stem of the keloid. (A) Along the 
edges of the wounds, the skin and the subcutaneous fat 
tissue were formed into undermined flaps of about 3 cm 
in width.　Dermal stitches with 4-0 nylon threads were 
inserted at 1-1.5 cm from both incisional margins, and 
the suture threads were tied firmly to evert the flaps. (B)　
Multiple Z-plasty was applied to the closed longitudinal 
wound. (C)
THE JOURNAL OF TOKYO MEDICAL UNIVERSITY─ ─ Vol. 70　No. 3362
（　　）3
caused by suture materials, rather than anatomical ten-
sion of the skin. Our 4 patients also showed develop-
ment of regional keloid formation subsequent to infec-
tions in the primary operation scars.
　Our former co-worker, Imai5), reported a unique surgi-
cal method for hypertrophic scars in the chest, shoulder 
and abdomen, which included everted wound sutures 
with extremely deep dermal stitches and multiple 
Z-plasty. Recently, Okuda6) reported this operation 
method was also useful for hypertrophic scars in the 
extremities. However, there have been no reports that 
describe application of this technique to true keloid scar 
formation. We had applied this technique to protruding 
keloids in the pubic area.
　Imai5) described that deep dermal stitches reduced the 
skin tension in the wound for 1 month after surgery, and 
multiple Z-plasty of the suture wound also dispersed skin 
tension in the wound for a longer period. In the series 
of surgeries we reported here, the everted wounds were 
maintained for about 1-2 months, which was slightly 
longer than in Imai’s work. This is probably due to the 
tension of the skin in the pubic area being lower than in 
the chest or shoulder regions.
　To prevent the recurrence of keloids, associated post-
operative therapies were very important. A pressure 
bandage to the wound scar is the most basic associated 
therapy to prevent recurrence of keloids, and it eliminates 
skin tension to the wound scar and protects scars against 
external stimulation7-9). We used a meshed paper tape 
bandage (Nichiban No. 50) that, according to our mea-
surement, can produce a higher interface pressure 
(9 mmHg) than a general micropore tape (5 mmHg).　
When the wound scars became hard and reddish during 
the follow up period, we locally injected corticosteroid 
(0.1 ml triamcinolone acetate) into the scars10). A course 
of 6 injections was used in 2 patients and 5 injections in 
1 patient. After steroid injections, hard scars became 
soft and flat again. No serious complications (such as 
Fig. 2　A 55-year-old woman complained of a keloid in the lowest region of the incisional scar following an operation for a uterine 
myoma. (A) The keloid was resected and the new wound was closed with everted margins with multiple Z-plasty. (B) Two 
years after surgery, there was no recurrence of the keloid. (C)
Fig. 3　A 42-year-old woman showed a large keloid in the surgical scar following a cesarean section. (A) The keloid was resected 
and the wound closed with crossed sutures with everted margins and multiple Z-plasty. (B) Two years after surgery, there 
was no recurrence of the keloid. (C)
Fig. 4　A 39-year-old man complained of a keloid that had 
appeared on the old scar of an inguinal hernia correction. 
(A) Four years after the surgery for the keloid. The 
scar had widened however there was no recurrence of the 
keloid. (B)
Fig. 5　A 34-year-old woman showed a keloid on the scar of a 
cesarean section carried out 1 year before. (A) Four 
years after the surgery. There was no recurrence of the 
keloid, and application of a meshed tape bandage is being 
continued. (B)
A. SUGAMATA, et al : Treatment for protruding keloids in the pubic area with everting suture and multiple Z-plasty ─ ─363July, 2012
（　　）4
hematoma or necrosis of the wound margins) were seen 
in any patient. There were no patients who experienced 
recurrence of keloids, even though in 2 cases the wound 
scars increased to 3-6 mm in widths ; however none of 
the patients were concerned with these outcomes.
　Iida and Watanabe2) reported their operative method 
for hypertrophic scars in the pubic area, which involved 
using a rhomboid flap with multiple Z-plasty. However, 
in their technique, a flap without hair was inserted into 
the hair area and it seemed unnatural. The simple suture 
method described in this paper seems to have a more nat-
ural appearance. When keloids are removed from the 
pubic area, the underlying fat tissue should be preserved 
as much as possible to alleviate tension on the pubic 
bone, so our operative technique is also more useful for 
this purpose than skin grafts.
　Positive results were observed with our treatment 
methods, however, more specific and sufficient follow up 
is necessary because infection of scar and keloids might 
recur several years after treatment.
Conflict of interest statement : The authors have no 
conflicts of interest.
References
 1)　Bayat A, Arscott G, Ollier WER, Ferguson MWJ, Mc 
Grouther DA : Description of site-specific morphol-
ogy of keloid phenotypes in an Afrocaribbean popula-
tion. Br J Plast Surg 57 : 122-133, 2004
 2)　Iida N, Watanabe A : Rhomboid flap with multiple 
Z-plasty for treatment of hypertrophic scar on the 
pubic area. J Plastic Reconstr Aesthet Surg 64 :  
818-821, 2011
 3)　Hyakusoku H, Ogawa R : The small-wave incision 
for long keloids. Plast Reconstr Surg 111 : 964-
965, 2003
 4)　Lin SD, Chou CK, Yang CC, Lai CS : Management 
of hypertrophic scars on the pubic area with an iliac 
flap. Burns 17 : 220-224, 1991
 5)　Imai S : Operation for hypertrophic scar and keloid.　
Operation 38 : 285-295, 1984 [Japanese]
 6)　Okuda R : Study of surgical treatment for hypertro-
phic scar/scar of limbs, cosmetic study and long-term 
follow up. J Jap Plast Reconstr Surg 31 : 789-795, 
2011 [Japanese]
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term paper tape application. Plastic Reconstr Surg 
96 : 1715-1718, 1995
 8)　Daya M : Abnormal scar modulation with the use of 
micropore tape. Eur J Plast Surg 34 : 45-51, 2011
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DJ, Rudd M : A randomized, controlled trial to deter-
mine the efficacy of paper tape in preventing hyper-
trophic scar formation in surgical incision that tra-
verses Langer’s skin tension lines. Plast Reconstr 
Surg 116 : 1648-1656, 2005
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THE JOURNAL OF TOKYO MEDICAL UNIVERSITY─ ─ Vol. 70　No. 3364
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外反縫合とZ形成術による陰部ケロイドの治療
菅　又　　　章　　　吉　沢　直　樹　　　呉　屋　圭　一
島　田　和　樹
東京医科大学八王子医療センター形成外科
　陰部に生じるケロイドは、皮膚の緊張などの解剖学的な要因よりも毛嚢炎やアテローマ感染、縫合糸膿瘍などの
反復する炎症に起因することが多い。この部位のケロイドは、歩行による反復刺激を受けやすく、しばしば腫瘤型
の形態をとり、圧迫やステロイド注射などの保存的治療に抵抗する。われわれは、陰部の腫瘤型ケロイドに対しては、
ピアスケロイドの治療と同様に、腫瘤を一期的に切除して、再発を防止するという治療法を選択してきた。手術に
当たっては、深い真皮縫合による皮膚縁の eversionと Z-plastyを組み合わせ、術後はメッシュテープによる長期に
わたる創縁への張力の減退と刺激防止を行っている。また、瘢痕の発赤、硬化が生じた場合は、ステロイドの反復
注入を行う。この手術法の結果は、極めて良好であり、この論文では 4症例の臨床経過を提示してわれわれの手技
を解説する。
〈キーワード〉　ケロイド、陰部ケロイド、Z-plasty、真皮縫合、メッシュテープ
5


Treatment for protruding keloids in the pubic area with everting suture and multiple Z-plasty

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Treatment for protruding keloids in the pubic area with everting suture and multiple Z-plasty

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