Undergoing breast surgery, whether mastectomy or reconstruction, is a nerve-wracking experience for many women. You not only want to stay safe and avoid repeated procedures, you also want minimal scarring and a cosmetically appealing result. Unfortunately, for some African American women, getting cosmetically appealing results following a breast procedure is challenging. This is due to a higher rate of certain breast surgery complications: in particular, keloids and hypertrophic scarring.
These two healing problems are common among African American women and many other minorities. While they are still seen among Caucasian women, they are significantly less common occurrences, particularly in the case of keloids.
In many cases, women who are prone to keloids and hypertrophic scarring already know about it. This is because these healing problems can form after something as simple as acne or minor injuries.
What is Hypertrophic Scarring?
Hypertrophic scarring is found in all racial groups. They occur much more often than keloids and are formed from excess collagen. Most hypertrophic scars are simply unsightly or widened scars that appear to be slightly larger versions of a regular scar. Regular scars are very thin lines, almost like a pencil line. Hypertrophic scars, on the other hand, are wider and more akin to a line left by a pencil eraser. In most cases, once a hypertrophic scar reaches a certain size, it stabilizes and may actually get smaller over time.
Many women experience hypersensitivity around a hypertrophic scar. They have been associated with itchiness and even pain, particularly when the area is moved. Compared to the surrounding skin, hypertrophic scars are normally stiffer and raised. Further, they are often purple, red, or pink in color, making them stand out even further.
What are Keloids?
Some physicians have described keloids as hypertrophic scars on steroids. The reason for this is that keloids do not stay within a scar’s original boundaries. They also do not get smaller on their own. In many cases, keloids form shortly after an injury has healed. It is an overgrowth of skin and connective tissue and is typically very dense.
Although keloids can form anywhere on the body, they are most often seen along the shoulders, upper back, and upper chest areas. This makes them an extreme concern for women who are undergoing breast surgery and have a history of developing keloids. Similar to hypertrophic scars, keloids are associated with pain and itchiness. They are often discolored and are mounds of tissue that are elevated away from the skin. This has resulted in many physicians looking a keloids as benign tumors. Still, they are regarded as a cosmetic problem and do not ever become malignant.
Keloids are seen more often among individuals with darker skin colors. This means that African American women have a much higher risk of developing a keloid than Caucasian women do. Unlike hypertrophic scars, there is a genetic component to the development of keloids. Most women who are prone to developing them either have family members who have a history of keloids or have experienced a keloid themselves in the past.
Why do Keloids and Hypertrophic Scars Form?
When the body is healing, it goes through a somewhat complicated process of rebuilding the skin and tissue in the area that was cut. This process involves multiplying skin cells and connective tissue cells to repair any damage. The body also sends collagen to the wound area. As new collagen enters into the site, the old collagen is broken down. This process is what creates normal scars.
In the case of hypertrophic scars, the breakdown of old collagen does not occur. This creates an overgrowth of collagen in the area. As new collagen is sent in, the old collagen has nowhere to go and they start to build on top of one another. This ultimately forms a hypertrophic scar.
Keloids are formed by a similar process. However, instead of resulting from too much collagen, they result from too much connective tissue growth. Once the wound is filled in, the growth of skin and connective tissues is supposed to stop. Keloids form when connective tissue keeps growing. This is what causes them to be raised above the surface of the skin.
Treatment and Prevention
Although keloids and hypertrophic scars are a concern, you can treat and prevent them in most cases.
Many of the preferred methods of prevention for both keloids and hypertrophic scars involves changing how the wound is dressed.
Silicone sheeting has been particularly helpful in preventing and treating hypertrophic scars. It is a pain-free, non-invasive option that has minimal side effects. It is not known how silicone sheeting prevents such problems, but most physicians believe that it helps reduce the production of collagen by keeping the skin from getting too dehydrated. Most silicone sheeting is used for up to 12 weeks and must be left on the incision site for between 12 and 24 hours a day.
In addition to that, pressure dressings have been used to prevent and treat both of these problems. They have minimal side effects and may include such things as silicone gel and compression earrings. Steri strips may also help with preventing scar overgrowth. Further, using less tension to close up wounds and avoiding incisions in certain areas of the body may decrease your risk of developing a hypertrophic or keloid scar.
In terms of treatment, there is a wide range of possibilities. We won’t cover every single one here, but you can still get a good idea of what may be available to you.
Corticosteroids, particularly intralesional steroid injections, are the most common treatment for keloids and hypertrophic scars. Steroids reduce the production of collagen and protect against excessive scarring. In most cases, steroid injections are given every two to six weeks. While this often treats hypertrophic scars completely, keloids may only be reduced in size. Keloids may also recur after treatment.
Cryo- and radiotherapy
Radiotherapy has been used to treat keloid scars after surgery. As long as the surrounding tissue is properly protected, the risk of such a treatment are relatively low. Cryotherapy is effective in stopping the growth of early-stage keloids. It can be used by itself or with or treatments, such as intralesional steroids. However, cryotherapy does have the possible side effect of hypopigmentation.
Various laser treatments, such as carbon dioxide laser ablation and pulsed dye laser treatment, have been effectively used to treat keloids and hypertrophic scars. Most of the evidence for lasers success is associated with hypertrophic scars, but new research is being done on their effectiveness for keloids. Unfortunately, some lasers, particularly pulsed dye lasers, are less effective when treating these healing problems on dark skin.
Severe cases of keloids may require surgical treatment. However, it comes with the added risk of a high recurrence rate. In some cases, the recurring keloid may even be larger than the original one. To reduce this risk, most women may undergo x-ray therapy to prevent the regrowth of a new keloid once the original is removed.
Conclusion: Breast Surgery Complications, Healing Risks
While these healing risks are certainly a concern, you should not avoid getting the treatment or procedures you need just based on fear. If you are concerned about your risk of developing a keloid or hypertrophic scar, discuss it with your physician. Your physician may choose a slightly different path for your overall breast cancer treatment or breast reconstruction options that will still allow you to get back to normalcy with a smaller chance of developing either issue.