Predictors of Keloid Recurrence Following Surgical Excision: Clinical, Surgical, and Molecular Determinants
Abstract
A narrative clinical practice review examining clinical, surgical and molecular determinants of keloid recurrence following surgical excision.
Keloids are benign fibroproliferative lesions resulting from abnormal wound healing. Unlike hypertrophic scars, they extend beyond the original injury and rarely regress without treatment. Surgical excision is commonly used for symptomatic or cosmetically unacceptable lesions; however, recurrence rates remain high (45–100%), necessitating structured perioperative strategies to reduce risk.
To synthesize current evidence on predictors of keloid recurrence after surgical excision and propose a risk-stratified framework for operative management.
A narrative review of contemporary literature examining clinical, surgical, and molecular predictors of recurrence was conducted.
Younger age, darker Fitzpatrick phototype, family history, and prior recurrence increase risk. Lesion size, chronicity, and location in high-tension areas further contribute to recurrence. Surgical technique significantly influences long-term outcomes. Although persistent profibrotic signaling drives keloid formation, clinically applicable molecular predictive biomarkers remain underdeveloped.
Keloid recurrence reflects persistence of a pathological wound microenvironment rather than surgical failure alone. Effective management requires a multifaceted, risk-based approach with ongoing follow-up.
High Recurrence After Excision Alone
Recurrence following surgical excision remains a major clinical challenge, with recurrence rates after excision alone reported as high as 45–100%.
Patient Factors Influence Risk
Younger age, darker Fitzpatrick phototype, positive family history and previous recurrence are important clinical predictors that can contribute to postoperative risk stratification.
A Major Predictor of Future Recurrence
A history of previous recurrence is identified as a particularly important predictor. Recurrent lesions may represent a more established profibrotic phenotype and should be approached as high-risk disease.
Mechanical Tension Matters
Presternal, shoulder and upper-back lesions are associated with increased risk because mechanical stress can sustain fibroblast activation through mechanotransduction.
Larger Lesions Carry Greater Risk
Lesion dimensions contribute to recurrence risk. The review’s proposed clinical framework identifies lesions greater than 5 cm as a higher-risk characteristic.
Tension-Reducing Closure Is Important
Closure under mechanical tension is an important modifiable surgical determinant. Layered closure, deep supporting sutures, adequate undermining and avoidance of excessively tight primary closure are emphasised.
Persistent Profibrotic Signalling
Keloid biology involves persistent fibroblast activation, abnormal extracellular-matrix deposition and profibrotic pathways including TGF-β/Smad signalling and related intracellular pathways.
Mechanical Forces Affect Fibroblast Activity
Mechanical tension can activate intracellular signalling and profibrotic gene expression, helping explain the association between high-tension anatomical sites and recurrence.
Excision Should Not Be Considered in Isolation
The review discusses postoperative corticosteroids, 5-fluorouracil, selective radiotherapy, silicone and pressure therapy, and laser-based approaches as potential components of multimodal management.
A Multimodal Perioperative Strategy
The authors propose matching the intensity of surgical and adjunctive management to the patient’s overall recurrence risk rather than relying on excision alone.
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Narrative Clinical Practice Review
The article integrates clinical observations, surgical principles and emerging biological knowledge to develop a practical framework for perioperative decision-making.
Narrative Review
Formal systematic-review methodology was not used. Accordingly, the review did not use a PRISMA flow diagram, formal quantitative risk-of-bias assessment or evidence grading system.
Patient & Lesion Risk Factors
Important factors discussed include younger age, darker Fitzpatrick phototype, family history, prior recurrence, anatomical location, lesion size, lesion chronicity and multiple lesions.
Mechanical Environment
The operative technique and mechanical environment of the healing wound are central considerations. Excessive closure tension may reactivate mechanotransductory profibrotic pathways.
Profibrotic Signalling
The review discusses persistent TGF-β/Smad signalling, JAK/STAT, PI3K/Akt/mTOR and MAPK pathways alongside resistance to apoptosis and abnormal extracellular-matrix deposition.
Not Yet Ready for Routine Prediction
Although molecular mechanisms of keloid formation are increasingly understood, clinically applicable predictive molecular biomarkers remain underdeveloped.
Proposed Clinical Model
The paper proposes a weighted clinical framework incorporating age, Fitzpatrick phototype, family history, prior recurrence, high-risk anatomical site, lesion size and multiple lesions.
Conceptual, Not Prospectively Validated
The proposed risk-stratification model is conceptual. It was not prospectively validated and its weights were not derived from pooled statistical modelling or a quantitative meta-analysis.
Multimodal Treatment
The article discusses corticosteroids, 5-fluorouracil, postoperative radiotherapy, silicone and pressure therapy, laser-based approaches and appropriate postoperative monitoring.
Equal Contributions
All authors contributed equally to the work.
Conflict of Interest & Funding
Conflict of Interest:
No conflict of interest.
Funding:
No funding received by the authors.
Editorial Timeline
CC BY 4.0
This article is published under the Creative Commons
Attribution 4.0 International licence.
DOI: 10.64573/torgj2602004
Volume 2 · Issue 1 · 2026
The Operating Room Global Journal (TORGJ).
ISSN 3105-3262.
Review Article.
DOI: 10.64573/torgj2602004.
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