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. 2019 May 16;7(5):e2215.
doi: 10.1097/GOX.0000000000002215. eCollection 2019 May.

Innovative Surgical Approaches and Selection Criteria of Large Acne Keloidalis Nuchae Lesions

Sanusi Umar  1   2   3 , Consuelo V David  3 , Jason R Castillo  3 , Jenna Queller  3 , Sophia Sandhu  3
Affiliations
Free PMC article

Innovative Surgical Approaches and Selection Criteria of Large Acne Keloidalis Nuchae Lesions

Sanusi Umar et al. Plast Reconstr Surg Glob Open. .
Free PMC article

Abstract

Background: Acne keloidalis nuchae is a debilitating condition mainly affecting the occipital region or nape of the neck. Surgical approaches are limited in aesthetic outcomes. Three innovative surgical approaches based on selection criteria are presented for enhanced and more predictable wound healing and posterior hairline cosmesis.

Methods: "Bat excision" and secondary intention healing are shown for 2 of 37 representative patients and confined to the area between the occipital protuberance superiorly and posterior hairline inferiorly. Lesions with ≤3 cm vertical width were required to be in the lower one-half portion of this zone. The same procedure was aided by the use of tension sutures for lesions with >3 cm vertical width area within the defined zone. It was also suitable for breaches of the 2 horizontal lines defined above but generally located in the nuchal area. Debridement of premature epithelizing granulation tissue is shown in 2 additional patients.

Results: Use of these procedures with debridement in selected patients allowed fine control over the hairline shape and resulted in narrower scars. The mean maximum sagittal width of excised lesions was 5.4 cm. Excised lesion width ≥6.5 cm was highly predictive of >2.5 cm wide scar (P = 0.001).

Conclusion: Innovative procedures based on selection criteria can extend the approach of acne keloidalis nuchae excision with secondary intention healing to better control the final hairline shape and minimize scarring.

Figures

Fig. 1.
Fig. 1.
Anatomical landmarks. Side and back views of the head showing anatomical landmarks and posterior scale, with indication for bat excision alone (A) and bat excision and tension suturing (B).
Fig. 2.
Fig. 2.
Examples of Bat excision and SIH procedure. A, Patient 1, a Hispanic man, age 59 years, with a ≤3 cm vertical width acne keloidalis nuchae lesion in the lower half of the area between the posterior hairline and occipital protuberance showing the outline for a planned bat excision. B, Patient 1, after bat excision, the wound assumes the shape of a bat in a spread-eagled posture. C, Patient 1, 8 weeks postoperative.
Fig. 3.
Fig. 3.
Examples of Bat excision and SIH with the aid of tension sutures. A, Patient 2, an African American man, age 44 years, with acne keloidalis nuchae tumors whose spread breaches the level of the occipital protuberance superiorly and the posterior hairline inferiorly. B, Patient 2, after bat excision, the wound assumes a shape of a bat in a spread-eagled posture. C, Patient 4, a Hispanic male, age 40 years, immediately after aggressive debridement of granulation tissue and wound margin epithelial tissue followed by application of horizontal mattress tension sutures exteriorized on both sides and padded by folded gauzes soaked in povidone-iodine solution. The wound edges are brought to within 1–1.5 cm of each other. D, Patient 2, after the application of tension sutures to bring the superior wound margins into the concave fold of the nuchal area. A half-buried horizontal mattress with exteriorization of the sutures is performed in an area 1–2 cm superior to the wound edges. Wound edges are approximated to within 2–3 cm of each other. E, Patient 4. 15 weeks after bat excision of acne keloidalis nuchae and tension suturing, which had been prematurely removed after 1 week, showing an open wound that has ceased to contract any further in the prior 4 weeks. The noncontracting wound shows marked epithelization especially in the lateral margins. In this state of wound healing, the myofibril activity has ceased and the wound width and size are set to define the final scar dimensions. F, Patient 2, 14 months postoperative.
Fig. 4.
Fig. 4.
Example of debridement of maturing granulation tissue and neoepithelium without tension suturing. A, Patient 3, a Hispanic man age 22, 4 weeks after acne keloidalis nuchae oval excision showing a 2-cm-wide granulated wound with premature epithelization in wound margins at 4 weeks after oval excision (not bat excision). B, Patient 3, immediately after debridement of granulation tissue and wound margin epithelial tissue. C, Patient 3, at 8 weeks showing that a cosmetically pleasing scar line holds.
Fig. 5.
Fig. 5.
Example of delayed stretched scar A, Patient 4, 4 weeks after debridement of mature granulation and neoepithelial tissue and SIH assisted by tension sutures. The wound shows an ideal M-shaped scar and posterior hairline. B, Patient 4, 16 months after the debridement of mature granulation and neoepithelial tissue and SIH assisted by tension sutures. The wound shows a mildly stretched M-shaped scar and posterior hairline with a maximum vertical width of nearly 2 cm as well as suture track marks.
Fig. 6.
Fig. 6.
Example of an unacceptable scar shape. Reprinted with permission from Arch Facial Plast Surg 1999;1:308–311; Copyright © 2000 American Medical Association.
Fig. 7.
Fig. 7.
Example of post- operative hypertrophic scarring. Patient 2, showing formation of an M wave–shaped hypertrophic scar at 6 months after bat excision and SIH assisted by tension sutures.
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