3 0 pds 2

All keloids were extralesionally excised above the deeper fascia under local anesthesia. Subcutaneous undermining was widely performed to reduce mechanical force on the dermis of the wound edge. Wound edges were shifted in opposite directions along the major axis to form an S-shape (Fig. 1). Dog-ear collection was not required. The incision was closed by applying deep fascial sutures using 3-0 PDS II (Ethicon, Inc., Somerville, N.J.), subcutaneous sutures using 3-0 or 4-0 PDS II (Ethicon, Inc.), and superficial sutures using 6-0 nylon.
Postoperative external beam radiation therapy was started within 6 hours after surgery at a dose of 20 Gy applied in 4 fractions.^{4 (link),5 (link)} After the sutures were removed, all wounds were covered with silicone-gel sheeting fixed with tape. Postoperative follow-up was performed approximately every 1–2 months. No intralesional corticosteroid injection or oral administration of tranilast was performed. Corticosteroid tape (Eclar Plaster, Hisamitsu, Tokyo, Japan) was applied in cases of postoperative recurrence. Scoring was performed using the Manchester Scar Scale before surgery and at the final examination.^{9 (link)} All procedures were performed in Okayama Saiseikai General Hospital between December 2014 and January 2016.

Figure 1 shows the design of the standard square flap, which is composed of a square advancement flap with 2 triangular transposition flaps. The angles of the triangular flaps are 45 and 90 degrees (designated as the α and β angles, respectively). After subcutaneous injection of local anesthesia with adrenaline diluted in normal saline (1:200,000), the whole thickness of the skin was incised with a No. 15 blade along the line marks. This was followed by incision of the subcutaneous tissue. Before skin closure, it was necessary to perform electrocautery and subcutaneous dissection as standard procedures. The incision was then closed by applying subcutaneous/superficial fascial sutures with 3-0 PDS II (Ethicon, Tokyo), dermal sutures with 4-0 PDS II (Ethicon), and finally, superficial sutures with 6-0 Ethilon (Ethicon). All patients were treated with taping fixation for the first 3 months after surgery; this treatment was initiated immediately after the sutures were removed.