There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.

We studied the long-term outcome of injection of triamcinolone acetonide into keloid scars in Asian patients. Between 1985 and 2003, we treated 109 keloid scars in 94 patients by injecting 1 to 10?mg of triamcinolone acetonide depending on the size of the lesion at four week intervals. There was little morbidity. Thirty-one patients gave up treatment within 10 injections because of pain and lack of immediate improvement. Improvement in subjective symptoms was seen in 52 of the remaining 63 patients (82%). In objective symptoms, fair or better results were seen in 40 of 63 (63%), and good or better results in 25 of 63 (39%). The treatment method required 20-30 injections over three to five years. Although we did not achieve as good results as other authors, we think it was safer because we used a smaller dose of a steroid.

A major disadvantage of free radial forearm flaps is the conspicuous donor site. However, there have been few studies on donor scars. The authors evaluated the donor site in patients who underwent oral-floor reconstruction with a free radial forearm flap. The subjects were 23 patients (19 males and four females) who underwent reconstruction with a free radial forearm flap following resection of a malignant oral tumor, and were followed for 1 year or longer. The fasciocutaneous flap collection site was closed by full-thickness skin graft (FTSG) from the groin with tie-over dressing. All grafts took perfectly. At the scar at the donor site, five items (pigmentation, scar width, depression, wrist mobility, and sensory abnormalities) were evaluated. Depression and pigmentation were often observed, but patient dissatisfaction was slight. While their main postoperative concern was the oral reconstruction site, after about 1 year, the donor site became more important to patients. However, the results were good. A 100 percent take of the FTSG at the donor site should produce good results. Surgeons should pay adequate attention not only to the outcome at the reconstruction site, but also to the closure of the donor site.

We have treated keloids using a combination of surgical excision and postoperative irradiation. The objective of this study was to evaluate the results of our treatment over 12 years. From 1995 until 2006, we treated keloids using the aforementioned treatment. If we identified a sign of recurrence during the follow-up period, we started an intralesional injection of triamcinolone acetonide immediately. We selected 91 keloids for which we had more than 2 years of follow-up data for this study and assessed the results according to our original scale (Kyoto scar scale) based on objective and subjective symptoms. In all, 51 keloids (56.0%) were cured completely by a combination of surgical excision and postoperative irradiation without additional treatment, and finally 81 keloids (89.0%) showed good results with additional treatment. Keloids are a controllable condition when treated with combination therapy, involving surgical excision with postoperative irradiation and early conservative treatment after the detection of recurrence.

For vulvar reconstruction following radical vulvectomy in a 71-year-old woman with a large vulvar cancer, we applied the deep inferior epigastric perforator flap (DIEP flap), a typical perforator flap, which could be performed by utilizing an abdominal incision wound without producing another surgical scar and had less donor site morbidity because of a minimal sacrifice of muscles. The surgical procedures were less invasive and simple, and morphologically and functionally satisfactory results were obtained: no recurrence of cancer, a well-preserved vulvar morphology with less donor site scarring, and no functional disturbance such as dysuria and abdominal hernia. We consider that the DIEP flap is the first choice for vulvar reconstruction following radical vulvectomy. Even in radical vulvectomy without an abdominal incision wound, the DIEP flap with an anatomically reliable vascular pedicle can be an effective option.