Histology and Vascular Architecture Study of Keloid Tissue to Outline the Possible Terminology of Keloid Skin Flaps.
Flap
Keloid
Subepidermal vascular network
Vascular density
Journal
Aesthetic plastic surgery
ISSN: 1432-5241
Titre abrégé: Aesthetic Plast Surg
Pays: United States
ID NLM: 7701756
Informations de publication
Date de publication:
04 2022
04 2022
Historique:
received:
12
09
2021
accepted:
04
01
2022
pubmed:
17
2
2022
medline:
14
5
2022
entrez:
16
2
2022
Statut:
ppublish
Résumé
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. 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. 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. 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." 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 .
Sections du résumé
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 .
Identifiants
pubmed: 35169912
doi: 10.1007/s00266-022-02775-0
pii: 10.1007/s00266-022-02775-0
doi:
Types de publication
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
985-994Informations de copyright
© 2022. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.
Références
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
doi: 10.1007/s00403-014-1491-5
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
pubmed: 17711533
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: 17447978
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
doi: 10.3346/jkms.2012.27.10.1248
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
doi: 10.1097/GOX.0000000000000357
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
doi: 10.1111/j.1524-4725.1976.tb00211.x
Salasche SJ, Grabski WJ (1983) Keloids of the earlobes: a surgical technique. J Dermatol Surg Oncol 9(7):552–556
doi: 10.1111/j.1524-4725.1983.tb00853.x
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
doi: 10.1097/00000637-200102000-00008
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
doi: 10.1097/PRS.0000000000000962
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
doi: 10.1067/moe.2000.101611
Adams BB, Gloster HM (2002) Surgical pearl: excision with suprakeloidal flap and radiation therapy for keloids. J Am Acad Dermatol 47(2):307–309
doi: 10.1067/mjd.2002.118349
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
doi: 10.1097/01.PRS.0000117199.47891.4F
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
doi: 10.1111/dsu.12262
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
doi: 10.1111/j.1524-4725.2012.02455.x
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
doi: 10.1007/s00266-017-0949-1
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
doi: 10.1111/bjd.14844
Lee JY, Yang CC, Chao SC, Wong TW (2004) Histopathological differential diagnosis of keloid and hypertrophic scar. Am J Dermatopathol 26(5):379–384
doi: 10.1097/00000372-200410000-00006
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
doi: 10.1080/02844310410029552
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
doi: 10.1002/lsm.22470
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
doi: 10.1056/NEJM199101033240101
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
doi: 10.1007/BF00666038
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)
doi: 10.1111/bjd.18219
pubmed: 31206605
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
doi: 10.1097/DSS.0000000000000176
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
doi: 10.3892/mmr.2014.2827
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
doi: 10.1159/000075030
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
doi: 10.3109/2000656X.2010.532923
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
doi: 10.1007/s00403-016-1703-2
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
doi: 10.1007/s00403-018-1873-1
Kischer CW, Thies AC, Chvapil M (1982) Perivascular myofibroblasts and microvascular occlusion in hypertrophic scars and keloids. Hum Pathol 13(9):819–824
doi: 10.1016/S0046-8177(82)80078-6
Lametschwandtner A, Staindl O (1990) Angioarchitecture of keloids. A scanning electron microscopy study of a corrosion specimen. HNO 38(6):202–207
pubmed: 1696250
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
doi: 10.1078/0344-0338-00447
Bux S, Madaree A (2010) Keloids show regional distribution of proliferative and degenerate connective tissue elements. Cells Tissues Organs 191(3):213–234
doi: 10.1159/000231899
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
doi: 10.1016/j.mvr.2010.05.012
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
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)
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
doi: 10.1631/jzus.B1800132
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
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)
doi: 10.1016/j.jss.2015.06.038
pubmed: 26216750
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
doi: 10.1089/wound.2016.0707