Is keloid surgery risky?

Keloids are raised, thickened scars that grow beyond the boundaries of the original wound. They can be itchy or painful and often cause cosmetic concerns. Doctors now know that keloids are not just “too much scar.” They are more active than normal scars, with scar cells that grow more and die less, and they are often affected by tension on the skin. This complex nature makes planning effective surgery for scars & keloids much more challenging than treating ordinary wounds.

Surgery for scars & keloids, such as intralesional excision, involves removing the scar tissue while trying to preserve surrounding skin. However, this technique has shown mixed results due to the potential of leaving behind active scar tissue. In older studies, when keloids were only cut out and no extra treatment was added, recurrence rates as high as 45–100% were reported for some patients.

When surgery was combined with radiotherapy afterwards, the chance of recurrence dropped significantly—in some cases to single digits—though it still didn’t go down to zero. Because of this, most experts see surgery for scars & keloids not as a “simple fix,” but as one part of a bigger treatment plan that usually needs other therapies around it.

Intralesional excision means removing the central part of the keloid. The idea is to cut away the bulk without disturbing surrounding areas. When performing surgery for scars & keloids using this method, different surgeons have tried versions like:

• leaving a thin rim of keloid tissue around the edges,

• sometimes avoiding cutting into the deepest layer of the skin,

• sometimes thinning the keloid flap and closing it under less tension. A review of published cases found that, even when intralesional excision was combined with steroid injections or radiotherapy, the median recurrence rate was about 25%. In one study where intralesional surgery was used alone, almost half of the keloids came back. Newer lab studies suggest that the outer rim left behind may contain active scar cells, explaining the regrowth.

Many patients hope that removing only part of the keloid might be safer. However, research indicates:

• Only a small number of studies actually tested intralesional excision.

• Overall, recurrence remained common after intralesional surgery, especially without other treatments. In one larger analysis, keloids treated with complete removal (extralesional excision) plus radiotherapy had much lower recurrence rates. Because of this, current evidence regarding surgery for scars & keloids slightly favors complete excision with good margins plus adjuvant therapy over partial removal.

Recurrence: There’s a significant chance that keloids will return after surgery, especially if not combined with other treatments.
Even in studies where surgery was followed by steroid injections, some groups still had recurrence rates of around 20–30% or more.

Skin Changes: Surgery can cause changes in skin pigment, leading to areas that are lighter or darker than the surrounding skin.
In one study on head and neck keloids treated with intralesional excision plus steroid injections, almost all patients developed some hypopigmentation (lighter skin) around the treated area.

Other possible issues: wound opening (dehiscence), infection, and thickened scars around the stitches, although these are less common when surgery and aftercare are done carefully.

Adjuvant Therapy: Using treatments like steroids or radiotherapy after surgery can help lower the chance of the keloid returning.
The best evidence so far supports combination therapy, especially complete removal plus radiotherapy, in selected patients and body areas.

Proper Surgical Techniques: Ensuring complete removal of the keloid and surrounding tissue can reduce recurrence.
Surgeons also try to reduce tension on the wound (for example, with deep stitches or special incision designs), because high tension is thought to be an important trigger for keloid growth.

For very bulky, stiff keloids, some doctors still use intralesional excision mainly as a “debulking” step to make the scar smaller so that steroid injections and other treatments are easier and less painful. This approach can be helpful, but current evidence suggests it does not fully solve the recurrence problem on its own.