General Surgery · Year 3 · from General Surgery
Case 2: Keloid Formation Following Sternotomy
Patient Demographics
- Age: 42 years
- Sex: Female
- Occupation: Marketing executive
- Ethnicity: African American
Chief Complaint
"The scar from my heart surgery keeps growing and is painful."
History of Present Illness
The patient underwent mitral valve repair via median sternotomy 18 months ago for severe mitral regurgitation. The initial wound healed uneventfully, but over the past year, she has noticed progressive enlargement of the scar tissue, which now extends beyond the original incision line. The scar is raised, firm, and causes significant itching and occasional sharp pain. She is self-conscious about the appearance and has difficulty wearing low-cut clothing.
Past Medical History
- Mitral valve prolapse with severe regurgitation (repaired)
- Family history of keloid formation (mother and sister)
- Previous keloid formation after ear piercing (age 16)
Physical Examination
Scar Examination:
- Midline chest scar extending 15 cm from sternal notch to xiphoid
- Keloid formation extending 2-3 cm beyond original wound margins
- Firm, raised, nodular texture
- Hyperpigmented with erythematous areas
- Tender to palpation
- No signs of infection
Comparison to Hypertrophic Scar:
| Feature | This Patient (Keloid) | Hypertrophic Scar |
|---|---|---|
| Extends beyond wound | Yes (2-3 cm) | No |
| Spontaneous regression | Unlikely | Often improves 1-2 years |
| Recurrence after excision | High (>50%) | Lower |
| Risk factors | Darker skin, genetic | Wound tension, location |
Diagnosis
Keloid scar formation following median sternotomy
Treatment Options Discussed
1. Intralesional Corticosteroid Injection:
- First-line therapy
- Triamcinolone acetonide 10-40 mg/mL
- Monthly injections for 3-6 months
- Mechanism: Reduces collagen synthesis, increases collagenase activity
2. Silicone Gel Sheeting:
- Adjunctive therapy
- Worn 12-24 hours daily for 3-6 months
- Mechanism: Hydration, pressure, unknown factors
3. Pressure Therapy:
- Difficult to apply to sternotomy site
- Custom pressure garments available
4. Combination Therapy:
- Surgical excision + immediate intralesional steroids + radiation
- Reserved for refractory cases due to recurrence risk
Treatment Plan Initiated
- Intralesional triamcinolone 40 mg/mL monthly x 6 treatments
- Silicone gel sheeting 12 hours daily
- Reassessment at 6 months
Follow-up (6 months)
- 50% reduction in keloid height and firmness
- Itching and pain significantly improved
- Continued monthly injections recommended
- Patient satisfied with improvement
Teaching Points
- Keloids extend beyond original wound margins (key distinguishing feature)
- Genetic predisposition common, especially in darker-skinned individuals
- High recurrence rate (>50%) with surgical excision alone
- Multimodal treatment most effective
- Prevention in high-risk patients: avoid unnecessary surgery, use tension-free closures, early silicone therapy