Flap Reconstruction for Facial Keloid in an Area Previously Affected by Herpes Zoster: A Case Report

Reconstrucción con colgajo para queloide facial en zona previamente afectada por Herpes Zóster: reporte de caso

Introduction: The development of keloids following herpes zoster (HZ) infection is a rare occurrence. As a result, the management of such cases remains poorly described, particularly in tropical countries with high rates of herpes zoster infection. Surgical flap procedures are one of the treatment options for keloid management. These techniques involve the use of local, regional, distant, or free flaps to achieve appropriate wound closure after keloid excision.

Case presentation: A 4-year-old girl was brought by her guardian to a plastic surgery clinic in Purwokerto, Indonesia, with multiple keloid scars on the left side of her face. One year earlier, she had developed HZ in the facial region, initially presenting as a sore under the nose. The infection progressed, leading to unilateral facial weakness and hearing loss. After receiving dermatological care, the lesions healed; however, they left residual keloid scars. Surgical management consisted of partial keloid excision with reconstruction using a nasolabial pedicled flap, elevated in the subcutaneous plane while preserving perforators of the angular artery. A controlled resection of the fibrotic core and tension-free flap inset were performed, and subcutaneous sutures were avoided to reduce recurrence risk. Postoperative evolution showed stable vascularity, adequate contour restoration, and improved esthetic integration.

Conclusion: Keloids caused by infectious diseases, particularly HZ, are rare. This case report presents a surgical approach for managing keloids that develop in previously untreated, damaged skin. Treating facial keloids can be particularly challenging; therefore, further research is required to clarify the mechanisms of keloid formation in this context and to establish optimal treatment strategies.

Introducción. La formación de queloides como secuela de una infección por herpes zóster (HZ) es una complicación infrecuente. Debido a su baja incidencia, el consenso sobre su abordaje terapéutico es limitado, particularmente en localización facial, donde los objetivos funcionales y estéticos representan un desafío reconstructivo. El uso de colgajos (locales, regionales, a distancia o libres) constituye una alternativa quirúrgica que permite lograr un cierre adecuado de la herida tras la escisión del queloide y optimizar el resultado estético.

Presentación del caso. Niña de 4 años de edad, quien fue llevada a consulta de cirugía plástica en una institución de salud de Purwokerto, Indonesia, por múltiples cicatrices queloides en el lado izquierdo de la cara desarrolladas tras un episodio previo clínicamente compatible con HZ facial. Según el relato del cuidador, la sintomatología inicial incluyó lesión vesicular dolorosa bajo la nariz, que progresó y produjo debilidad facial unilateral y pérdida auditiva, síntomas compatibles con neuropatía del nervio facial secundaria a HZ. Tras recibir manejo dermatológico, las lesiones cicatrizaron, pero dejaron cicatrices queloides residuales. Se realizó un abordaje quirúrgico mediante la escisión parcial del queloide con reconstrucción mediante un colgajo nasolabial pediculado, elevado en el plano subcutáneo, preservando las perforantes de la arteria angular. El cierre se efectuó sin tensión y se evitaron las suturas subcutáneas para reducir el riesgo de recurrencia. La evolución posoperatoria fue satisfactoria, con adecuada vascularidad, restauración del contorno e integración estética favorable.

Conclusión. Los queloides faciales posteriores a lesiones compatibles con HZ son poco frecuentes y representan un reto terapéutico. El manejo de queloides faciales puede ser particularmente complejo, en especial en climas cálidos, donde las temperaturas elevadas pueden dificultar la recuperación posoperatoria y los procedimientos quirúrgicos basados en colgajos. Este reporte destaca la viabilidad de la reconstrucción con colgajos pediculados en piel previamente comprometida.

Case report

Flap Reconstruction for Managing a Facial Keloid in a Site of Previous Herpes Zoster Infection: A Case Report

Gembong Satria Mahardhika1 Ahmad Fawzy Mas’ud2†

1 Universitas Jenderal Soedirman - Faculty of Medicine - Purwokerto, Central Java - Indonesia.

2 Universitas Jenderal Soedirman - Faculty of Medicine - Department of Surgery - Division of Plastic Surgery - Purwokerto, Central Java - Indonesia.

†The author passed away prior to the publication of this work.

Open access

Received: 20/06/25

Accepted: 17/02/2026

Corresponding author: Gembong Satria Mahardhika. Faculty of Medicine, Universitas Jenderal Soedirman. Purwokerto, Central Java. Indonesia. Email: mahardhika.gembong@gmail.com.

Keywords: Nasolabial Fold; Plastic Surgery Procedures; Keloid; Cicatrix, Hypertrophic; Herpes Zoster

Palabras clave: Surco Nasolabial; Procedimientos de Cirugía Plástica; Queloide; Cicatriz Hipertrófica; Herpes Zóster

How to cite: Mahardhika GS, Mas’ud AF. Flap Reconstruction for Managing a Facial Keloid in a Site of Previous Herpes Zoster Infection: A Case Report. Case reports. 2026;12:e120358. English. doi: https://doi.org/10.15446/cr.v12.120358

Cómo citar: Mahardhika GS, Mas’ud AF. Reconstrucción con colgajo para queloide facial en zona previamente afectada por herpes zóster: reporte de caso. Case reports. 2026;12:e120358. doi: https://doi.org/10.15446/cr.v12.120358

Copyright: ©2025 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium, as long as the original author and source are credited.

Abstract

Introduction: Keloid development following herpes zoster (HZ) infection is a rare occurrence. As a result, the management of such cases remains poorly documented, particularly in tropical countries with high HZ infection rates. Surgical flap reconstruction is a viable therapeutic option, involving the use of local, regional, distant, or free flaps to achieve appropriate wound closure after keloid excision.

Case presentation: A 4-year-old girl was brought by her guardian to a plastic surgery clinic in Purwokerto, Indonesia, due to the presence of multiple keloid scars on the left side of her face. One year earlier, she contracted HZ in the facial region, which initially manifested as a sore under the nose and then progressed to unilateral facial paralysis and hearing loss. Although the primary lesions resolved following dermatological intervention, they resulted in residual keloid scarring. Surgical management consisted of partial keloid excision with reconstruction using a nasolabial pedicled flap elevated in the subcutaneous plane, while preserving the angular artery perforators. Following controlled resection of the fibrotic core, a tension-free flap inset was achieved. Subcutaneous sutures were avoided to reduce recurrence risk. Postoperative follow-up showed stable vascularity, adequate contour restoration, and improved esthetic integration.

Conclusion: Keloids caused by infectious diseases, particularly HZ, are rare. This case report describes a surgical approach for managing keloids that develop in previously untreated, damaged skin. Given the complexity of facial keloid management, further research is required to elucidate the mechanisms of keloid formation in this context and to establish optimal treatment strategies.

Resumen

Introducción. La aparición de queloides tras una infección por herpes zóster (HZ) es poco frecuente. Debido a su baja incidencia, el tratamiento de estos casos sigue estando poco documentado, especialmente en países tropicales con altas tasas de infección por HZ. La implementación de reconstrucción quirúrgica con colgajos es una opción terapéutica viable, ya que permite utilizar colgajos locales, regionales, a distancia o libres para lograr un cierre adecuado de la herida tras la extirpación del queloide.

Presentación del caso. Una niña de 4 años fue llevada por su tutor a una clínica de cirugía plástica en Purwokerto, Indonesia, debido a la presencia de múltiples cicatrices queloides en el lado izquierdo de la cara. Un año antes, ella contrajo HZ en la zona facial, lo que inicialmente se manifestó como una lesión vesicular dolorosa debajo de la nariz, pero posteriormente progresó a parálisis facial unilateral y pérdida de audición. A pesar de que las lesiones primarias se resolvieron tras la instauración de un tratamiento dermatológico, varias cicatrices queloides residuales se formaron en la zona de la infección. El tratamiento quirúrgico consistió en la extirpación parcial del queloide, seguido de reconstrucción mediante un colgajo pediculado siguiendo el pliegue del surco nasolabial y elevado en el plano subcutáneo, al tiempo que se preservaban las arterias perforantes angulares. Tras la resección controlada del núcleo fibrótico, se logró un injerto de colgajo sin tensión y sin suturas subcutáneas para reducir el riesgo de recidiva. En el seguimiento postoperatorio se observó una vascularización estable, una restauración adecuada del contorno y una mejor integración estética.

Conclusión. Los queloides causados por enfermedades infecciosas, en particular el HZ, son poco frecuentes. Este caso clínico describe un enfoque quirúrgico para el tratamiento de los queloides que se desarrollan en piel dañada y no tratada previamente. Dada la complejidad del tratamiento de los queloides faciales, es necesario continuar investigando los mecanismos de formación de los mismos en este contexto y establecer estrategias de tratamiento óptimas.

Introduction

Keloids are abnormal scars that develop as a result of prior skin trauma or inflammation (1-3). These lesions are typically firm and rubbery, often protruding above the skin surface with a narrow base. While keloids can develop in various anatomical regions, the most frequently involved sites include the deltoid, presternal region, upper back, and ears. In contrast, the eyelids, genitalia, palms, and soles are considered atypical locations Furthermore, increased mechanical tension within a wound can also contribute to the development of keloids (1,2).

Keloids have been rarely reported in areas previously affected by herpes zoster, a condition resulting from the reactivation of the Varicella-zoster virus (VZV), which remains latent in sensory nerve ganglia following primary varicella (chickenpox) infection (3). Keloid formation occurs when fibroblasts continue making collagen beyond the boundaries of the original wound, resulting in excessive tissue growth. The occurrence of keloids secondary to HZ is uncommon, and the precise underlying mechanism is yet unknown (3). Previous studies indicate that keloid scar development is more prevalent in individuals of African, Asian, and, to a lesser extent, Latin American or Mediterranean descent, suggesting a correlation with darker skin pigmentation (3).

Wolf’s isotopic reaction (WIR) refers to the emergence of a novel, unrelated cutaneous condition at the location of a previously resolved dermatological lesion, typically after HZ infection. HZ, resulting from the reactivation of the VZV, is the most documented antecedent for WIR, with a variety of secondary dermatoses, including granulomatous responses, lichen planus, and neoplasms, appearing at the site of resolution (4). Among uncommon cases, WIR may manifest as atypical scar formation, such as keloids, especially in persons susceptible to irregular wound healing. Although infrequent, keloid formation in the facial area secondary to HZ has been reported, suggesting that inflammatory and immunological changes after VZV infection may interfere with normal dermal repair processes and lead to excessive collagen accumulation (4).

Reconstructive flap techniques have been well-documented for the management of facial keloids. This approach utilizes adjacent tissue to restore skin and soft tissues defects resulting from malignancy or other trauma. These procedures are classified as either local or free flaps, depending on whether the tissue remains pedicled to its original blood supply or requires microvascular reanastomosis. Local flaps are frequently preferred in facial reconstruction due to their superior color and texture match, as well as a reduced risk of scar contracture, which can compromise facial appearance (6).

Flap-based procedures have also been used in the management of facial keloids. With this technique, the keloid mass is partially resected, while the overlying skin—including keloid tissue when viable—is preserved as a skin flap to repair the defect with minimal wound closure tension (6). The present case report discusses the application of this flap-based approach for the treatment of keloids secondary to HZ infection.

Case presentation

A 4-year-old girl, accompanied by her guardian, presented to a plastic surgery clinic in 2023, in the city of Purwokerto, Indonesia, for the evaluation of multiple keloid scars on the left side of her face. According to the guardian’s report, the patient had experienced a facial herpes zoster–like episode approximately one year earlier, but, due to a lack of formal medical records, it was not possible to verify prior varicella infection, vaccination status, or immunological evaluation. The initial lesion reportedly presented as a small subnasal sore and progressed to a vesicular eruption involving the left side of the face (Figure 1). While no medical records or confirmatory diagnostic tests were available, the guardian described transient facial weakness and hearing loss during the acute phase, raising clinical suspicion of a possible—but unconfirmed—Ramsay Hunt syndrome.

Sixty days after symptom onset, the patient was evaluated by a dermatologist in an outpatient setting. According to the guardian, the patient received systemic antiviral therapy and topical treatment. However, no intralesional corticosteroids, pressure therapy, laser therapy, or silicone-based scar modulation were administered at that stage. Following complete epithelialization (the lesions showed progressive improvement and eventually healed after 3 months, leaving residual facial keloids), no additional dermatologic scar-directed therapy was initiated prior to the plastic surgery referral. Therefore, the keloid developed and remained untreated for approximately 9 months before surgical consultation.

Figure 1. Cutaneous manifestations during acute HZ infection. Hyperpigmented plaques are observed, accompanied by ulcerations and necrotic areas.

Source: Primary patient data.

Upon consultation with the plastic surgery service, a surgical plan was defined, and keloid excision was scheduled to take place 1 week after the initial evaluation.

Intraoperatively, the keloid was excised after careful delineation of its anatomical margins. Following the surgical design, a nasolabial pedicled skin flap was elevated via dissection in the subdermal plane, ensuring the preservation of the angular artery perforators and the dominant vascular pedicle supplying the nasolabial region. The fibrotic core was partially resected, preserving sufficient dermal and subdermal tissue to maintain the integrity of the vascular plexus. The resection was carried out under direct visualization with meticulous hemostasis using bipolar electrocautery.

The resulting defect was repaired by advancing the pedicled flap, achieving a tension-free closure. Subcutaneous sutures were intentionally avoided to minimize the risk of keloid recurrence; wound approximation was achieved with precise dermal sutures and proper edge alignment. The skin was closed with 6-0 nylon interrupted sutures. Figure 2 illustrates the surgical design and excision technique, while Figure 3 shows the immediate and late postoperative outcomes.

Figure 2. Preoperative assessment. The round dashed line delineates the keloid excision area, while the linear markings inferior to the lesion indicate the flap design.

Source: Image obtained while conducting the study.

Figure 3. Postoperative image of the patient showing the excised keloid and the resulting linear incision, strategically positioned to conceal the surgical site.

Source: Image obtained while conducting the study.

The patient tolerated the procedure well, without intraoperative complications. She was monitored overnight for flap viability; the flap remained well-perfused, with no evidence of venous congestion or hematoma formation, with only mild edema being observed. She was discharged on postoperative day 3 with instructions for daily gentle wound cleansing with saline, application of a thin layer of topical antibiotic ointment, and a short prophylactic course of oral antibiotics. Analgesia was managed with NSAIDs as needed, and antihistamines were prescribed to reduce pruritus. The guardian was advised to ensure the patient avoided tension across the operative site for 7–10 days, limited sun exposure, and initiated silicone gel or silicone sheeting therapy once epithelialization was complete.

Follow-up appointments were scheduled for postoperative days 3, 7, and 14, followed by monthly visits for three months. At each visit, the flap remained viable with no signs of infection, dehiscence, or vascular compromise. Sutures were removed between postoperative days 7 and 10. Long-term follow-up at 1, 3, and 6 months demonstrated a favorable outcome, with stable flap contour, good color match, no evidence of keloid recurrence, and high patient and guardian satisfaction with both functional and aesthetic outcomes.

Discussion

Keloid formation following a HZ infection is uncommon and has been documented primarily in case reports and reviews addressing WIR (4,5). Proposed mechanisms include local neuroimmunological and fibroproliferative alterations, but they remain hypotheses without causal confirmation (4). Nevertheless, this case may represent a potential example of WIR occurring in a post-herpetic location, particularly in cosmetically sensitive regions such as the face. This interpretation remains speculative and should be approached with caution, as current literature has yet to establish a definitive mechanistic association.

Flap reconstruction is a specialized approach in the management of keloids and is described as an effective strategy in selected cases (7,8). Advanced techniques, such as the keloid fillet flap, are recognized for adhering to the “5 As and one B” surgical principles, namely, asepsis, atraumatic method, absence of raw surface, avoidance of tension, accurate (exact) approximation of wound edges, and bleeding control, which are essential for minimizing the risk of recurrence (7). However, although these techniques demonstrate favorable outcomes in specific scenarios, the surgical approach implemented in the present case differed substantially in both purpose and design.

A study by Liu et al. (8), involving a case series of 45 patients with facial keloids treated between January 2013 and January 2016, demonstrated that flap-based reconstruction can yield aesthetically favorable outcomes following the excision of underlying fibrotic tissue. Their technique involved elevating the keloid skin on pedicles and using it to resurface the defect. While effective in specific facial regions, this method was unsuitable for the current case, as the keloid skin was not preserved for resurfacing, necessitating a different reconstructive strategy based on lesion characteristics and local anatomy. In the present case, a nasolabial pedicled flap was selected due to its predictable vascularity, superior color and texture match, and reliable mobility within the perinasal and medial cheek region.

According to Rao and Shende (6), an absorbable suspension suture may be employed to restore the natural concavity of the nasofacial sulcus, although this is not standardized in all cases. Furthermore, while several adjuvant therapies—including intralesional corticosteroids, pressure therapy, imiquimod, interferon alfa-2b injections, laser therapy, and radiotherapy—are recognized for preventing recurrence following surgical excision (7,8), no such adjuvant treatments were administered in the present case.

The nasolabial flap procedure considers various parameters, including the anatomical characteristics of the area affected by the keloid. The medial paranasal cheek is vascularized by the angular artery and its associated perforators, while the central cheek region receives its blood supply from the perforating branches of the internal maxillary artery and the transverse facial branches of the superficial temporal artery. A nasolabial flap may be elevated as either an axial-pattern, based on a specific named artery, or a random-pattern flap, which relies primarily on the subdermal and dermal plexuses for vascularity. In both instances, the appropriate dissection plane is situated within the subcutaneous adipose layer (9).

Dermal substitutes, such as acellular dermal matrices (e.g., AlloDerm®), the Integra® Dermal Regeneration Template, and other bilayer dermal scaffolds, have been described as useful adjuncts in scar reconstruction, especially in cases with significant dermal deficiency or large defects. These materials may promote dermal regeneration and assist in tension modulation; however, their role in reducing keloid recurrence has not been sufficiently established in the literature (10,11).

In the present case, the use of a dermal substitute was not indicated for several reasons: adequate adjacent tissue was available, allowing for reconstruction with a well-vascularized nasolabial pedicled flap that provided sufficient dermal thickness; reliable perfusion; and optimal color and texture match. Furthermore, the defect size following intralesional excision was moderate and could be closed without excessive tension. The pediatric setting and resource limitations were additional practical considerations. Given these factors, reconstruction with autologous vascularized local tissue was deemed the most appropriate course of action. In pediatric facial reconstruction, local flaps are frequently preferred when feasible due to their reliable integration, low infection risk, and the avoidance of foreign biomaterials.

The lack of documented virologic confirmation or immunologic evaluation limits any causal inference between the presumed HZ episode and the subsequent keloid formation. Therefore, the temporal association observed in this case should be interpreted with caution, as the reconstructive strategy was determined primarily considering the clinical characteristics of the mature scar.

This case illustrates the rare occurrence of facial keloids following HZ infection and highlights the potential application of nasolabial flap reconstruction for optimal aesthetic outcomes. Given the limited evidence regarding the pathophysiology of keloid formation associated with HZ infection, the proposed mechanisms remain speculative. Nevertheless, surgical management using well-planned flap techniques, combined with vigilant postoperative care, may provide effective functional and cosmetic outcomes.

Conclusion

Keloid development is driven by an excessive production of collagen during the wound-healing process, resulting in fibrotic tissue that extends beyond the initial wound boundaries. Keloids are a known complication of skin trauma, but their occurrence following infectious disorders—specifically Herpes Zoster (HZ)—is rare.

This case report details a surgical approach involving a nasolabial flap for the management of facial keloids following HZ infection. Although the procedure yielded favorable outcomes, further research is required to clarify the underlying mechanisms of keloid formation in this context of viral infections and to establish standardized, evidence-based treatment protocols.

Ethical considerations

This case report was conducted in accordance with the ethical standards of both the institutional and the national research committees, adhering to the Declaration of Helsinki and its subsequent amendments. Informed written consent was obtained from the patient’s legal guardian for the publication of this case report and the accompanying clinical pictures. All identifying information has been anonymized to ensure patient confidentiality.

Conflicts of interest

None stated by the authors.

Funding

None stated by the authors.

Acknowledgments

The authors would like to express their sincere gratitude to the Division of Plastic Surgery, Department of Surgery, Universitas Jenderal Soedirman, for their institutional support and the resources provided for this case. Special recognition is extended to the surgical team and the patient for their cooperation throughout the management and follow-up process.

References

1.McGinty S, Siddiqui WJ. Keloid. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2026 Feb 24]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507899/.

2.Betarbet U, Blalock TW. Keloids: A Review of Etiology, Prevention, and Treatment.
J Clin Aesthet Dermatol. 2020;13(2):33-43.

3.Wang J, Shen H. Keloids After Herpes Zoster: Report of Wolf’s Isotopic Phenomenon and Literature Review. Clin Cosmet Investig Dermatol. 2023;16:2129-33. https://doi.org/qsp8.

4.Sinha P, Madakshira M, Lekshmipriya K, Sharma J. Wolf’s isotopic response seen as a rare occurrence of pityriasis lichenoides et varioliformis acuta (PLEVA) lesions over healed
lesions of tinea corporis. Indian Dermatol Online J. 2022;13(5):660-2. https://doi.org/qsp9.

5.Corral-Forteza M, Pérez-Muñoz N, Fernández-Figueras MT. Postherpetic
Pseudolymphomatous Angiosarcoma Concealed Within Milia en Plaque: Expanding the Spectrum of Wolf Isotopic Response with a Literature Review. Dermatopathology (Basel). 2025;12(2):9.
https://doi.org/qsqb.

6.Rao JK, Shende KS. Overview of Local Flaps of the Face for Reconstruction of Cutaneous
Malignancies: Single Institutional Experience of Seventy Cases. J Cutan Aesthet Surg. 2016;9(4):220-5. https://doi.org/f9npnw.

7.Cerejeira D, Bonito F, António AM, Goulão J. A 7-year Experience with Keloid Fillet Flap and Adjuvant Intralesional Corticosteroids. J Cutan Aesthet Surg. 2021;14(2):172-6. https://doi.org/qsqc.

8.Liu S, Liang W, Song K, Wang Y. Keloid Skin Flap Retention and Resurfacing in Facial Keloid Treatment. Aesthetic Plast Surg. 2018;42(1):304-9. https://doi.org/gcxdng.

9.Abdelmofeed AM, Salama RS. Different modalities of nasolabial flaps in
nasal-defect reconstruction: clinical experience in 40 cases and review of literature.
The Egyptian Journal of Surgery. 2021;40(4):1192-204.

10.Fuenmayor P, Huaman G, Maita K, Schwemmer K, Soliman W, Abdelmoneim S, et al. Skin Substitutes: Filling the Gap in the Reconstructive Algorithm. Trauma Care. 2024;4(2):148-66. https://doi.org/hbj2km.

11.Schiestl CM, Moiemen N, Duhamel P, Jones I, Zamparelli M, López-Gutiérrez JC, et al. Use of Integra® Dermal Regeneration Template Bilayer in Burn Reconstruction: Narrative Review, Expert Opinion, Tips and Tricks. Eur Burn J. 2025;18;6(3):45. https://doi.org/qsqd.