Dermal substitutes in keloid surgery: A systematic review and analysis of 116 lesions

Keloids are pathological scars characterized by excessive fibroproliferation and high recurrence rates after surgical excision. Dermal substitutes have been proposed as an adjunct to keloid surgery because they restore a stable dermal matrix, reduce mechanical tension, and may modulate fibroblast activity. However, their clinical effectiveness in preventing recurrence remains insufficiently defined. This study aimed to systematically review the available literature on the use of dermal substitutes following keloid excision.

A systematic review was conducted according to PRISMA guidelines. Medline, Embase, Web of Science were searched from inception to January, 2026. Eligible studies included clinical reports using a dermal substitute after complete keloid excision with at least 6 months of follow-up and explicit recurrence data. Case reports, case series, and conference abstracts with sufficient clinical detail were included. Extracted variables comprised patient characteristics, lesion features, substitute type, operative protocol, adjuvant therapy, follow-up, recurrence. Due to heterogeneity, a descriptive synthesis was performed.

Twenty studies were included, representing 109 patients and 116 keloid lesions. Most publications ware case series or case reports (Level IV-V evidence). Integra® was the most frequently used substitute, followed by Pelnac®, AlloDerm®, and Apligraf®. Reconstruction was most commonly performed using a two-stage approach with delayed split-thickness skin grafting. At 6 months, only one recurrence was reported among the studies providing early follow-up data. However, a recent larger retrospective cohort reported a recurrence rate of 28.8% after long-term follow-up. Adjuvant therapies such as radiotherapy, triamcinolone, and 5-fluorouracil were frequently combined with dermal substitute reconstruction.

Dermal substitutes appear to be a promising adjunct in the surgical management of keloids, providing favorable aesthetic outcomes and low early recurrence rates. However, recurrence remains possible over long-term follow-up, and the independent effect of dermal matrices remains difficult to isolate due to frequent use of multimodal treatment protocols. Prospective studies with standardized surgical techniques and long-term follow-up are needed to better define the role of dermal substitutes in keloid surgery.