Purpose: Keloid excision in severe and recurrent cases has been shown to be most effective when there is a reduction in wound tension and adjuvant therapies are employed. In large keloids, other reconstruction other than direct closure has been utilised to reduce wound tension. Often radiotherapy is used as an adjuvant therapy but traditionally radiotherapy is given post excision. In wounds that require skin grafting or local flaps, the planning and delivery of radiotherapy is difficult because of dressing impedance of the radiotherapy beams and concerns about graft survival. Methodology: We present two patients with large and symptomatic keloids that underwent preoperative radiotherapy, keloid excision and reconstruction with a dermal matrix followed by split skin graft. One patient presented with a pre-sternal chest keloid and another with a large right neck keloid. Both patients had undergone previous scar revisions with multiple rounds of steroid injection with minimal improvements. Patients received daily preoperative radiotherapy for the three days prior to excision of the keloid and were reconstructed with a synthetic dermal matrix and immediate split skin graft. Results: The synthetic dermal matrix integrated and skin graft healed well. We present our results demonstrating healed wounds and satisfactory aesthetic result. Conclusion: The case series supports the use of preradiotherapy for keloid management with the use of a dermal matrix and split skin grafting. This may be a promising treatment option for patients with large keloids that require excision and skin graft repair.