Surgical and Non-Surgical Management of Hypertrophic Scars and Keloids in Plastic Surgery: A Contemporary Narrative Review

Abstract

Hypertrophic scars and keloids are fibroproliferative disorders of wound healing that remain among the most challenging conditions in plastic and reconstructive surgery. Although both entities share excessive extracellular matrix deposition, fibroblast activation, inflammation, and cosmetic burden, they differ in clinical behavior, recurrence risk, and therapeutic response. Hypertrophic scars usually remain confined to the original wound boundaries and may partially regress over time, whereas keloids extend beyond the initial injury and frequently recur after monotherapy. Contemporary management has shifted from isolated interventions toward multimodal, individualized treatment plans that integrate prevention, scar maturation control, tension reduction, silicone-based therapy, intralesional pharmacologic agents, laser-based modalities, microneedling, radiotherapy, and carefully selected surgical excision. This narrative review synthesizes recent evidence on surgical and non-surgical strategies for hypertrophic scars and keloids, emphasizing practical decision-making in plastic surgery. Particular attention is given to patient selection, anatomical location, scar phenotype, skin phototype, pediatric considerations, recurrence prevention, and combination therapy. The available evidence supports a stepwise approach in which early diagnosis, risk stratification, mechanical offloading, and conservative therapy are prioritized, while invasive modalities are reserved for symptomatic, functionally limiting, refractory, or cosmetically severe lesions. Despite advances in laser-assisted drug delivery, botulinum toxin, 5-fluorouracil, verapamil, bleomycin, and adjuvant radiotherapy, no single therapy is universally effective. A tailored, longitudinal, multimodal strategy remains the most rational framework for improving symptoms, function, appearance, and patient satisfaction.