title: Surgical Excision with Adjuvant Irradiation for Treatment of Keloid Scars: A Systematic Review.
abstract: BACKGROUND
  Excision followed by adjuvant irradiation is considered safe and most efficacious for treatment of keloid scars. Recently, different authors published successful treatment protocols and recommended the following: (1) the use of high-dose-rate brachytherapy instead of low-dose-rate brachytherapy or external radiation; (2) a short-time interval between operation and irradiation; (3) single fraction instead of multifraction irradiation; and (4) a minimum of 12- to 24-month follow-up post treatment.
  
  
  METHODS
  This study evaluates the above recommendations with a systematic review of the English-language literature, based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. Both PubMed and EMBASE were searched. Studies were graded according to the American Society of Plastic Surgeons Rating Levels of Evidence.
  
  
  RESULTS
  Thirty-three studies were selected. Six studies were graded as level of evidence type II studies and 27 as type III. High-dose-rate brachytherapy showed lower recurrence rates compared with low-dose-rate brachytherapy and external radiation. A short-time (<7 hours) interval between scar excision and irradiation results in a lower recurrence rate compared with long-time intervals (>24 hours). Single-fraction irradiation showed promising results in terms of recurrence rate and patient convenience. Finally, scar recurrences were seen between 2 and 36 months, with a mean of 15 months.
  
  
  CONCLUSIONS
  Based on this systematic review of the literature, the evidence confirms the recommendations stated by authors in the recent years. However, due to the lack of high-quality randomized studies, the quality of this evidence is limited. More randomized studies will generate stronger recommendations.
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Michiel C E
authors: MC
authors: van Leeuwen
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Suzanne C
authors: SC
authors: Stokmans
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Anne Eva J
authors: AE
authors: Bulstra
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Otto W M
authors: OW
authors: Meijer
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Martijn W
authors: MW
authors: Heymans
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Johannes C F
authors: JC
authors: Ket
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Marco J P F
authors: MJ
authors: Ritt
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Paul A M
authors: PA
authors: van Leeuwen
authors: Department of Plastic, Reconstructive, and Hand Surgery, VU University Medical Center, Amsterdam, The Netherlands; Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands; Department of Epidemiology and Biostatistics, VU University Medical Center, Amsterdam, The Netherlands; Medical Library, VU University, Amsterdam, The Netherlands; and Department of Surgery, VU University Medical Center, Amsterdam, The Netherlands.
authors: Frank B
authors: FB
authors: Niessen