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 Table of Contents  
Year : 2020  |  Volume : 15  |  Issue : 3  |  Page : 477-479

Postcesarean section keloid: Ultrasonography, color doppler, and elastography evaluation

Department of Radio Diagnosis, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University) ,Wardha, Maharashtra, India

Date of Submission23-Sep-2020
Date of Decision25-Sep-2020
Date of Acceptance30-Sep-2020
Date of Web Publication1-Feb-2021

Correspondence Address:
Dr. Suresh Phatak
Department of Radiodiagnosis, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 001, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdmimsu.jdmimsu_141_19

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Keloid is the overgrowth of scar tissue at the site of wound. We report a case of young female who presented with minimal discharge from previous cesarean section site. On ultrasonography, Doppler, and elastography are discussed.

Keywords: Doppler, elastography, keloid, ultrasonography

How to cite this article:
Gulve S, Phatak S, Lohchab B, Patwa P, Tapadia S. Postcesarean section keloid: Ultrasonography, color doppler, and elastography evaluation. J Datta Meghe Inst Med Sci Univ 2020;15:477-9

How to cite this URL:
Gulve S, Phatak S, Lohchab B, Patwa P, Tapadia S. Postcesarean section keloid: Ultrasonography, color doppler, and elastography evaluation. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Feb 28];15:477-9. Available from: http://www.journaldmims.com/text.asp?2020/15/3/477/308544

  Introduction Top

Keloid is the formation of a type of scar which is composed mainly of collagen. It is due to the overgrowth of granulation tissue at the site of a scar. It is a benign and not contagious condition. It was first described by Egyptian surgeons around 1700 BC. Baron Jean-Louis Alibert identified the keloid as an entity in 1806.[1]

  Case Report Top

We present a case of a 32-year-old female who presented with minimal discharge and pruritus at the previous cesarean section scar since 1 month. Cesarean section was done 10 years back. On examination, the scar was brown to black with firm and rubbery consistency. The lesion was extending beyond the original wound site. The lesion was approximately measuring 30 mm × 11 mm [Figure 1]. The patient underwent the ultrasonography of the wound site, which revealed heterogeneously hypoechoic lesion approximately measuring 28.2 mm × 10.5 mm in cutaneous plane [Figure 2]. There is also evidence of hyperechoic dermal calcifications giving posterior acoustic shadowing. On color Doppler sonography, there was evidence of palisading blood vessels [Figure 3]. The strain elastography was also done for the same lesion which showed mostly hard colors (predominantly blue) Tsukuba score-5 and strain ratio of 54 suggestive of hard and stiff tissue [Figure 4]. Based on these findings, the diagnosis of keloid was made.
Figure 1: Keloid formation at the site of previous cesarean section scar

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Figure 2: Heterogeneously hypoechoic lesion in a cutaneous plane with multiple superficial calcifications giving posterior acoustic shadow

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Figure 3: Color Doppler sonography showing the palisading blood vessels suggesting the active lesion

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Figure 4: Elastography of the lesion revealing hard colors (predominantly blue color) and strain ratio of 54 suggesting the possibility of the stiff lesion

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  Discussion Top

Keloid is the formation of a type of scar at the previous site of trauma. It represents the pathological healing process. The patient has symptoms of cosmetic disfigurements, itching, pain, and inflammation.[2],[3] On ultrasonography, keloids appears as heterogeneously hypoechoic dermal thickening with or without laminar patters with or without extension to the deeper layers of skin.[3],[4] Ultrasonography also shows multiple small calcifications in dermis with posterior acoustic shadowing.[3]

Color Doppler sonography shows palisading blood vessels. Color Doppler ultrasound helps in tracking the activity of keloid. The presence of blood vessel in keloid suggest activity and growth in keloid.[4] The absence of color flow in Doppler suggests inactive keloid.[3]

Tsukuba scoring system of elastography differentiates benign and malignant masses. A score 1 indicates even strain for the entire hypoechoic lesion (i.e., the entire lesion was evenly shaded in green). A score 2 means strain in most of the hypoechoic lesion, with some areas of no strain (i.e., the hypoechoic lesion had a mosaic pattern of green and blue). A score 3 implies that strain at the periphery of the hypoechoic lesion, with sparing of the center of the lesion (i.e., the peripheral part of lesion was green, and the central part was blue). A score of 4 shows no strain in the entire hypoechoic lesion (i.e., the entire lesion was blue, but its surrounding area was not included. A score of 5 indicated no strain in the entire hypoechoic lesion or in the surrounding area (i.e., both the entire hypoechoic lesion and its surrounding area were blue). In strain patterns, score 1, 2, and 3 emphasized benign features, whereas masses with scores of 4 and 5 were considered as malignant.[5]

Strain ratio measurement is the semi-quantitative method developed to access the lesion. The average strain of the lesion can be calculated by selecting the region of interest encompassing the lesion. As the stiffness increases the strain ratio increases.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15]

  Conclusion Top

There is increasing role of ultrasonography in the in the evaluation of the dermal lesions. Ultrasonography is the noninvasive technique for the assessment of the keloid. Color Doppler and elastography help in tracking activity and stiffness of keloid.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. p. 1499. ISBN 978-1-4160-2999-1.  Back to cited text no. 1
Fraccalvieri M, Sarno A, Gasperini S, Zingarelli E, Fava R, Salomone M, et al. Can single use negative pressure wound therapy be an alternative method to manage keloid scarring? A preliminary report of a clinical and ultrasound/colour-power-doppler study. Int Wound J 2013;10:340-4.  Back to cited text no. 2
Lobos N, Wortsman X, Valenzuela F, Alonso F. Color doppler ultrasound assessment of activity in keloids. Dermatol Surg 2017;43:817-25.  Back to cited text no. 3
Wortsman X. Atlas of Dermatologic Ultrasound Springer International Publishing AG: Part of Springer Nature; 2018  Back to cited text no. 4
Itoh A, Ueno E, Tohno E, Kamma H, Takahashi H, Shiina T, et al. Breast disease: Clinical application of US elastography for diagnosis. Radiology 2006;239:341-50.  Back to cited text no. 5
Zhi H, Xiao XY, Yang HY, Wen YL, Ou B, Luo BM, et al. Semi-quantitating stiffness of breast solid lesions in ultrasonic elastography. Acad Radiol 2008;15:1347-53.  Back to cited text no. 6
Aya R, Yamawaki S, Muneuchi G, Naitoh M, Suzuki S. Ultrasound elastography to evaluate keloids. Plast Reconstr Surg Glob Open 2014;2:e106.  Back to cited text no. 7
Elrefaie AM, Salem RM, Faheem MH. High-resolution ultrasound for keloids and hypertrophic scar assessment. Lasers Med Sci 2020;35:379-85.  Back to cited text no. 8
Daga S, Phatak S. Rhabdomyosarcoma of the Forearm: USG, Doppler, Elastography, and Magnetic Resonance Imaging with Pathological Correlation. J Datta Meghe Inst Med Sci Univ 2019;14:261-4. Available from: https://doi.org/10.4103/jdmimsu.jdmimsu_85_19. [Last accessed on 2019 Dec 09].  Back to cited text no. 9
Sadavarte TP, Bansal NO, Banode P, Padmawar M. Role of High Resolution ultrasonography and Color Doppler in Evaluating and Distinguishing the Type of Inguinal hernia. Int J Cur Res Rev 2020;12: 135-40. Available from: https://doi.org/10.31782/IJCRR.2020.135140. [Last accessed on 2019 Dec 09].  Back to cited text no. 10
Mishra A, Inamdar S. Deep Venous Thrombosis in Pregnancy. J SAFOG 2020;12:56-8. Available from: https://doi.org/10.5005/jp-journals-10006-1759.  Back to cited text no. 11
Sharma S, Tembhare A, Inamdar S, Agarwal HD. Impact of Diabetic Ketoacidosis in Pregnancy. J SAFOG 2020;12:113-15. Available from: https://doi.org/10.5005/jp-journals-10006-1761. [Last accessed on 2019 Dec 09].  Back to cited text no. 12
Agarwal HD, Tayade S, Dhurve K. Living with Discordance: Pregnancy in Hiv-Discordant Couple. J SAFOG 2020;12:108-10. Available from: https://doi.org/10.5005/jp-journals-10006-1762. [Last accessed on 2019 Dec 09].  Back to cited text no. 13
Choudhary A, Rani S, Kundi G, Jaiswal A. Study of Fetomaternal Outcome in Premature Rupture of Membranes in Pregnancy More than 34 Weeks. Int J Res Pharm Sci 2020;11:6136-43. Available from: https://doi.org/10.26452/ijrps.v11i4.3287. [Last accessed on 2019 Dec 09].  Back to cited text no. 14
Dawood FS, Kittikraisak W, Patel A, Hunt DR, Suntarattiwong P, Wesley MG, et al. Incidence of Influenza during Pregnancy and Association with Pregnancy and Perinatal Outcomes in Three Middle-Income Countries: A Multisite Prospective Longitudinal Cohort Study. The Lancet Infect Dis 2020. Available from: https://doi.org/10.1016/S1473-3099(20)30592-2. [Last accessed on 2019 Dec 09].  Back to cited text no. 15


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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