Analysis of the Surgical Treatments of 63 Keloids on the Cartilaginous Part of the Auricle: Effectiveness of the Core Excision Method

Efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids: A 13-year experience

BACKGROUND

Surgical excision combined with radiotherapy is considered an effective treatment for keloids, while the efficacy and safety of this regimen for huge keloids in patients who need reconstruction after excision is still unclear. Therefore, this study aimed to evaluate the efficacy and safety of surgical excision and reconstruction combined with radiotherapy for huge keloids in a single center with 13 years of experience.

METHODS

All consecutive patients with huge keloids who underwent surgical excision and reconstruction combined with radiotherapy were identified. Demographic information, prior interventions for keloids, parameters and complications, and recurrence rates were documented.

RESULTS

Twenty-one patients (10 males; mean age, 43.19 ± 18.15 years) were included, 14 patients reconstructed with z-plasties, 5 with skin grafts, and 2 with skin flaps. During a mean follow-up of 75 months, one patient developed local necrosis without the need for revision surgery and two patients developed temporary hyperpigmentation. Two patients with the z-plasties suffered partial keloids recurrence, which was healed with corticosteroid injection. No wound infection, hematoma, telangiectasia, or new keloids at donor sites were observed. The overall appearance of reconstructed defects was aesthetically acceptable.

CONCLUSION

Surgical excision and reconstruction combined with radiotherapy may be safe and effective for huge keloids.

A Working Classification and a Simple Effective Management Protocol for Ear Keloids

BACKGROUND

The unpredictable behavior of scars in the ear makes it a nightmare in planning the management protocol for ear keloids. To understand and classify the ear keloid, a simple working classification based on the anatomical location has been proposed. Low recurrence rate should be the primary determinant in choosing a management protocol. The scar control protocol includes complete excision of the keloid, taking care not to extend to normal skin which was followed by a round-the-clock 24×7 management protocol for 6 months to 1 year.

PATIENTS AND METHODS

This study presents a prospective analysis of 71 patients with 106 ear keloids who underwent surgery in our clinic between 2007 and 2022. The management included complete excision, postoperative adjuvant therapy in the form of self-managed scar stabilization with bi-digital, bi-dimensional, bi-directional massage and corticosteroid therapy if warranted. Complete keloid excision with primary reconstruction was followed up to 1 year, and recurrence rates were tracked during this period.

RESULTS

Of the 71 patients, 91.54% were women. All lesions (n = 106) were treated by complete excision. The average age was between 15 and 30 years. The overall recurrence rate was 5.6%.

CONCLUSION

With our classification and protocol, we were able to achieve a consistent recurrence free state in 94.4% of patients.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical Treatment for Chest "Lock" Keloid Using Autologous Split-Thickness Skin Grafting and Postoperative Radiotherapy

BACKGROUND

The treatment of chest "lock" keloids is challenging due to skin defects and a high recurrence rate.

OBJECTIVE

Evaluation of the effectiveness of autologous split-thickness skin graft with local radiotherapy for treating chest "lock" keloids.

METHODSAND MATERIALS

Fifty-seven patients with chest "lock" keloids were treated from July 2018 to September 2020. The skin defects were closed with an autologous split-thickness skin graft (STSG) and vacuum sealing drainage. The donor and the recipient sites received the first session of radiotherapy 72 hours postoperation for 3 consecutive days. Patients underwent follow-up examinations 12 months after surgery. The Patient and Observer Scar Assessment Scale (POSAS) was used to assess the treatment outcome.

RESULTS

Except for the complaints of pain, which did not improve in the patients' assessments (p = .368), POSAS improved significantly after treatment (p < .0001). The cure rate (including cured and partially cured scars) was 100%. No keloid recurrence was observed during the follow-up period.

CONCLUSION

The procedure of treating chest "lock" keloid by keloid debulking and autologous STSG followed by postoperational radiotherapy is a novel combined methodology for treating keloids.

Current advances in the selection of adjuvant radiotherapy regimens for keloid

Keloid is a common benign skin tumor in the outpatient department, and patients are often accompanied by itching and pain. Since the pathogenesis is unknown, the effect of single method treatment is unsatisfactory, and therefore the recurrence rate is high. Therefore, comprehensive treatment is mostly used in clinical treatment. Adjuvant radiotherapy is currently one of the most effective treatments for keloid. After long-term clinical practice, brachytherapy and electron beam radiotherapy has increasingly become the gold standard of treatment, because brachytherapy provides more focused radiation treatment to focal tissue to significantly reduce recurrence rate, and better preserve normal tissue. With the development of new radiotherapy techniques, more options for the treatment of keloid. Currently, adjuvant radiotherapy has been widely recognized, but there is no consensus on the optimal protocol for adjuvant radiotherapy for keloids. This review provides a review of published treatment options and new radiotherapy techniques for adjuvant radiotherapy of keloids and gives a comprehensive evaluation for clinical treatment.

Histology and Vascular Architecture Study of Keloid Tissue to Outline the Possible Terminology of Keloid Skin Flaps

BACKGROUND

Using the keloid "epidermis" to cover a wound is widely used during treatment for keloids. Many flap terminologies have been used in literature. However, the definition of the flap is not well established. Here, we refined the definition of the flap and associated terminology and explored the survival mechanism of the 'flap' through histological analysis and blood supply studying.

METHODS

Histology and vascular study of keloid was carried out with keloid and its surrounding normal skin tissue which were collected from keloid patients following keloid resection operations. The histological structures and thicknesses of epidermal and subepidermal of the keloids were analyzed and measured using hematoxylin & eosin (H&E) staining. Vascular density and blood perfusion in the subepidermal layer of keloids (KDS) were analyzed using CD31 immunohistochemical staining and a laser speckle contrast imaging system (LSCI), respectively. The vascular network in KDS was visualized by CD31 immunofluorescence staining and three-dimensional reconstruction.

RESULTS

29 pieces of keloid and its surrounding normal skin tissue sample from ten patients were collected. Keloid samples were about 2 cm wide and 5 cm long. The normal skin samples were about 2 to 3 mm in width. The thickness of epidermal layer of keloids was (136.4 ± 35.3) μm, and the thickness of epidermal layer of surrounding normal skin was (78.8 ± 13.9) μm. There was statistical thickness difference between the two layers, t(20) = 7.469, P < 0.001. The total thickness of keloid epidermal and subepidermal layers was 391.4 ± 2.3 μm. The vascular density (13.9 ± 3.4/field) and blood flow perfusion (132.7 ± 31.3) PU in KDS were greater than that of surrounding normal skin (7.8 ± 2.3/field, 73.9 ± 17.9 PU), P < 0.001. Horizontally distributed vessels with several vertical branches were observed in 3D vascular network reconstruction.

CONCLUSION

The epidermal layer of keloid is thicker than that of surrounding normal skin. There is a vascular network structure under it. The vessels mainly locate at a depth of about 150 to 400 μm from the surface of keloid epidermis, randomly distribute and run parallel to the epidermis. Based on these characteristics which may ensure an adequate blood supply, we propose the concept of a "keloid subepidermal vascular network flap."

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Optimizing surgical outcome of auricular keloid with a novel multimodal approach

Various treatments are available for auricular keloids, but none has an absolute advantage. A practical and safe therapy to optimize the surgical outcome for auricular keloids is needed. We adopted a multimodal treatment of surgical enucleation, core fillet flap reconstruction, intraoperative corticosteroid injection, and immediate postoperative radiotherapy. There were no routine intralesional corticosteroid injections during follow-up. Keloid recurrences, complications, and risk factors for recurrences were analyzed. The outcome was compared with other published literatures. 45 auricular keloids were included in this study. 85.7% were female with an average age of 27.1 ± 7.5 years, and averaged size was 1.8 × 1.2 ± 0.9 × 0.6 cm. 71.1% were located at ear helix with 28.9% at the ear lobe. Nine keloids were classified as Chang-Park classification type I, 30 for type II, two for type III, and four for IV. The average radiation dosage was 1578.6 cGy. The recurrence rate was 6.7% at an average 24.1-month follow-up. There were no complications of surgery, radiotherapy, and intralesional corticosteroid injection. Our recurrence rate was lower than those in mono-adjuvant therapies of intraoperative corticosteroid injection or radiotherapy. This one-session multimodal approach optimizes treating auricular keloids with a low recurrence rate and minimal post-radiation and long-term corticosteroid injection-related complications.

Adjuvant Radiotherapy for Keloids

Radiotherapy is one of the therapeutic methods for keloids, and the irradiation technique has innovated from superficial X-ray to brachytherapy after decades of clinical practice. At present, the application of adjuvant radiotherapy has been widely accepted by clinicians, while the consensus of optimal adjuvant radiotherapy strategies for keloids has not been reached. Factors such as radiation timing, dose, fractions, and lesion locations may be associated with the clinical outcomes of patients with keloids after radiotherapy while a comprehensive review is lacking. Herein, this review summarized the published literature of adjuvant radiotherapy for keloids involving mechanism, timing, dose, fractions, and complications, etc., which may facilitate clinical decision making.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The Most Current Algorithms for the Treatment and Prevention of Hypertrophic Scars and Keloids: A 2020 Update of the Algorithms Published 10 Years Ago

BACKGROUND

In 2010, this Journal published my comprehensive review of the literature on hypertrophic scars and keloids. In that article, I presented evidence-based algorithms for the prevention and treatment of these refractory pathologic scars. In the ensuing decade, substantial progress has been made in the field, including many new randomized controlled trials. To reflect this, I have updated my review.

METHODS

All studies were evaluated for methodologic quality. Baseline characteristics of patients were extracted along with the interventions and their outcomes. Systematic reviews, meta-analyses, and comprehensive reviews were included if available.

RESULTS

Risk factors that promote hypertrophic scar and keloid growth include local factors (tension on the wound/scar), systemic factors (e.g., hypertension), genetic factors (e.g., single-nucleotide polymorphisms), and lifestyle factors. Treatment of hypertrophic scars depends on scar contracture severity: if severe, surgery is the first choice. If not, conservative therapies are indicated. Keloid treatment depends on whether they are small and single or large and multiple. Small and single keloids can be treated radically by surgery with adjuvant therapy (e.g., radiotherapy) or multimodal conservative therapy. For large and multiple keloids, volume- and number-reducing surgery is a choice. Regardless of the treatment(s), patients should be followed up over the long term. Conservative therapies, including gel sheets, tape fixation, topical and injected external agents, oral agents, and makeup therapy, should be administered on a case-by-case basis.

CONCLUSIONS

Randomized controlled trials on pathologic scar management have increased markedly over the past decade. Although these studies suffer from various limitations, they have greatly improved hypertrophic scar and keloid management. Future high-quality trials are likely to improve the current hypertrophic scar and keloid treatment algorithms further.

Individualized surgery combined with radiotherapy and triamcinolone acetonide injection for the treatment of auricular keloids

Background

Although multiple methods have been proposed to treat auricular keloids, low curative effects and high recurrence rates are currently major clinical problems. Thereinto, surgery combined with radiotherapy and triamcinolone acetonide injection is considered to be the proper choice for comprehensive treatment of auricular keloids. This study aimed at evaluating the therapeutic effect of individualized surgery combined with radiotherapy for the treatment of auricular keloids.

Methods

From February 2014 to February 2017, 67 patients with 113 auricular keloids in total were enrolled in this study. According to specific conditions of lesions, the local tissue and patients’ individual wishes, different surgical methods were selected to analyze the scar excision and repairment of the defect. Within 24 h after the keloid was excised, 5 MeV electron beam irradiation by the linear accelerator was used by radiotherapy with a total dose of 20 Gy at interval of 1 day for 10 consecutive times. Triamcinolone acetonide was injected immediately after surgery, and per month afterward in the following three months.

Results

113 keloids in total were received treatment. The follow-up period was 24 months. Fourteen keloids (12.39%) showed subjective recurrence with a success rate of 87.61%. Wilcoxon matched-pairs rank-sum test was used to compare the differences of the 24-month postoperative VSS scores and the preoperative VSS scores. The VSS scores were as follows: 82 keloids (72.57%) scored less than 5 points (good result), 21 keloids (18.58%) scored 6 to 10 points (fair result), and only 10 keloids (8.85%) scored more than 10 points (bad result). The effective rate was 91.15%.

Conclusions

Individualized surgery combined with early postoperative radiotherapy and triamcinolone acetonide injection is an ideal treatment method to ensure good auricular appearance, low incidences of complications and recurrence based on effective treatment of auricular keloids.

What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis

Background:

Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids.

Methods:

We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality.

Results:

A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found.

Conclusions:

Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.

The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis

BACKGROUND

Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective.

OBJECTIVE

To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy).

MATERIALS AND METHODS

Systematic literature review and meta-analysis of combination treatment for keloids.

RESULTS

After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099).

CONCLUSION

Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.

Long-term outcomes and recurrence-free interval after the treatment of keloids with a standardized protocol

BACKGROUND

Recurrence rates of keloids have generally been reported at one time point. However, the longer the duration after treatment, the greater the likelihood that such lesions will recur. In this study, we analysed the time to recurrence during long-term follow-up.

MATERIAL AND METHODS

We retrospectively reviewed recurrence-free interval in 52 patients with keloid (age 8-79 years) who had been treated between June 2006 and January 2011 using a standardised protocol developed by our group.

RESULTS

Mean duration of follow-up was 37.5 (range, 7-120) months in patients with keloid. Kaplan-Meier survival curves revealed a statistically significant difference in recurrence-free interval between ear keloids and keloids excluding ear keloids. Recurrence rate for keloids was high in the first 2 years after treatment.

CONCLUSIONS

Kaplan-Meier analysis was useful for understanding the tendency of recurrence of keloids after treatment using a standardised protocol.

Combination Therapy Composed of Surgery, Postoperative Radiotherapy, and Wound Self-management for Umbilical Keloids

A universally accepted therapeutic strategy for umbilical keloids has not been determined. Our team has had considerable success with combination therapy composed of surgical excision followed by postoperative radiotherapy and steroid plaster/injection.

Toe Keloids Treated with Core Excision, Postoperative Radiotherapy, and Steroid Plaster

Although keloids are common on the joints, precordial areas, and abdomen, toe keloids are rare. The limited literature to date also suggests that they can be difficult to treat. We experienced the case of a 21-year-old woman with toe keloids on the first, second, and third toes that arose after ingrown-nail operations at another hospital. The second toe keloid was resected but recurred. Since subsequent conservative treatments were ineffective, the patient was referred to our hospital. The first visit revealed three large keloids: in particular, the keloid on the second toe had engulfed the entire circumference of the toe. Surgery with the core-excision method and postoperative radiotherapy were performed. After the sutures were removed, the scars were treated for 24 hours/day with steroid plaster until the induration disappeared. One and a half years after the operation, recurrence was not observed and the appearance of the toes had improved greatly. Thus, combination therapy composed of core excision, radiotherapy, and steroid plaster therapy is highly effective for toe keloids.

Direct Delivery of Apatite Nanoparticle-Encapsulated siRNA Targeting TIMP-1 for Intractable Abnormal Scars

Hypertrophic scars (HSs) and keloids are histologically characterized by excessive extracellular matrix (ECM) deposition. ECM deposition depends on the balance between matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteases (TIMPs). TIMP-1 has been linked to ECM degradation and is therefore a promising therapeutic strategy. In this study, we generated super carbonate apatite (sCA) nanoparticle-encapsulated TIMP-1 small interfering RNA (siRNA) (siTIMP1) preparations and examined the effect of local injections on mouse HSs and on ex vivo-cultured keloids. The sCA-siTIMP1 injections significantly reduced scar formation, scar cross-sectional areas, collagen densities, and collagen types I and III levels in the lesions. None of the mice died or exhibited abnormal endpoints. Apatite accumulation was not detected in the other organs. In an ex vivo keloid tissue culture system, sCA-siTIMP1 injections reduced the thickness and complexity of collagen bundles. Our results showed that topical sCA-siTIMP1 injections during mechanical stress-induced HS development reduced scar size. When keloids were injected three times with sCA-siTIMP1 during 6 days, keloidal collagen levels decreased substantially. Accordingly, sCA-siRNA delivery may be an effective approach for keloid treatment, and further investigations are needed to enable its practical use.

Auricular keloid management in Asian skin: Clinical outcome of intralesional excision and postoperative triamcinolone acetonide intralesional injection

BACKGROUND

Various options such as surgical excision, steroid injection, cryotherapy, pressure dressing, and radiation therapy are available for the treatment of auricular keloids. In particular, auricular keloid therapy using surgical excision is important because recurrence rates are low compared with keloids occurring in other parts of the body.

AIMS

We aimed to evaluate the clinical outcomes of intralesional excision followed by postoperative triamcinolone acetonide intralesional injection (TA ILI) as auricular keloid treatments.

METHODS

We conducted a surgery records and chart review of patients who underwent auricular keloid treatment with intralesional excision and TA ILI. Reduction in height and volume was assessed by two blinded dermatologists. We also analyzed the recurrence rate over a 2-year period and evaluated patient satisfaction using an 11-point questionnaire (0-10).

RESULTS

Eighteen Korean patients (2 males and 16 females) with a mean age of 26.5 years and a total of 20 lesions were evaluated. Lesion types by descending frequency were lobular (n = 10, 50%), anterior/posterior button (n = 3, 15%), wrap-around (n = 3, 15%), dumbbell (n = 2, 10%), and sessile (n = 2, 10%). The total recurrence rate was 5% (1/20) within the 24-month follow-up period. Significant reduction (> 50%) in height and volume was achieved in 95% of patients. No serious or persistent adverse events were reported during the follow-up period.

CONCLUSION

We confirmed that TA ILI after intralesional excision can be effective for auricular keloid management. A low recurrence rate similar to that of postoperative radiation therapy was obtained with an effective surgical procedure and minimal postoperative treatment.

Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018

There has been a long-standing need for guidelines on the diagnosis and treatment of keloids and hypertrophic scars that are based on an understanding of the pathomechanisms that underlie these skin fibrotic diseases. This is particularly true for clinicians who deal with Asian and African patients because these ethnicities are highly prone to these diseases. By contrast, Caucasians are less likely to develop keloids and hypertrophic scars, and if they do, the scars tend not to be severe. This ethnic disparity also means that countries vary in terms of their differential diagnostic algorithms. The lack of clear treatment guidelines also means that primary care physicians are currently applying a hotchpotch of treatments, with uneven outcomes. To overcome these issues, the Japan Scar Workshop (JSW) has created a tool that allows clinicians to objectively diagnose and distinguish between keloids, hypertrophic scars, and mature scars. This tool is called the JSW Scar Scale (JSS) and it involves scoring the risk factors of the individual patients and the affected areas. The tool is simple and easy to use. As a result, even physicians who are not accustomed to keloids and hypertrophic scars can easily diagnose them and judge their severity. The JSW has also established a committee that, in cooperation with outside experts in various fields, has prepared a Consensus Document on keloid and hypertrophic scar treatment guidelines. These guidelines are simple and will allow even inexperienced clinicians to choose the most appropriate treatment strategy. The Consensus Document is provided in this article. It describes (1) the diagnostic algorithm for pathological scars and how to differentiate them from clinically similar benign and malignant tumors, (2) the general treatment algorithms for keloids and hypertrophic scars at different medical facilities, (3) the rationale behind each treatment for keloids and hypertrophic scars, and (4) the body site-specific treatment protocols for these scars. We believe that this Consensus Document will be helpful for physicians from all over the world who treat keloids and hypertrophic scars.

Chondrocutaneous Bilateral Advancement Flap with Postoperative Radiation Therapy for a Helical Rim Keloid

Keloids can be recalcitrant, and a well-planned treatment strategy is essential. Multiple ear piercings have recently become popular, particularly among younger age groups. Management of keloids that develop after piercing of the ear cartilage may be particularly problematic. Helical rim keloids are difficult to excise because of the complex, three-dimensional, cartilaginous structure of the helix and its thin and tightly adherent covering layer of skin. The chondrocutaneous advancement flap introduced by Antia and Buch may be a useful reconstructive option for a helical rim keloid after marginal loss of a segment of the helix as a result of trauma, a burn, or excision of a malignant tumor. However, this technique is limited to wounds that involve only the helix. In this technical note, we describe the use of a chondrocutaneous bilateral advancement flap with postoperative radiation therapy to treat a more invasive and relatively large keloid on the scapha. This technique is straightforward and safe in terms of preserving the blood supply. The addition of adjuvant radiation therapy can help to decrease the risk of recurrence and preserve the morphological structure of the ear and patient satisfaction.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgical excision and postoperative radiotherapy for keloids

Keloids can be treated in a number of ways, including by surgery. Multiple studies now show that while surgical monotherapy associates with extremely high rates of recurrence (50%-80%), postoperative radiotherapy can significantly reduce these recurrence rates. Ongoing improvements in radiation technology have further increased the safety and efficacy of this combination protocol. Of the various radiotherapies that have been used in this setting, electron beam (β-ray) irradiation is currently the best due to its excellent dose distribution and safety. The maximal biologically effective dose (BED) for keloids is 30 Gy (using an estimated α / β ratio of 10); increasing the dose has no further benefits and elevates side effects. Over the last two decades, we have modified and then fine-tuned our radiotherapy protocol for keloid excision wounds. Thus, our early protocol was used for all body sites and consisted of 15 Gy/3 fr/3 days. We then customised the radiotherapy protocol so that body sites that are highly prone to recurrence (e.g. the anterior chest) receive higher doses while low recurrence sites like the earlobe receive a much smaller dose. More recently, we tweaked this body site-customised protocol so that fewer fractions are employed. Therefore, we currently apply 18 Gy/3 fr/3 days to high-recurrence sites, 8 Gy/1 fr/1 day to earlobes and 15 Gy/2 fr/2 days to other body sites. These radiotherapy protocol changes were accompanied by the evolution of body site-customised surgical approaches. As a result of these developments, our overall keloid recurrence rate is now below 10%.

Helical rim advancement - A technique to avoid keloid recurrence

Introduction

Helical rim keloids occur commonly following ear piercings, trauma and previous surgeries and can be disfiguring. Many techniques have been developed to treated these disfiguring lesions with varying successes, however, individuals prone to developing keloids inadvertently recur despite best efforts.

Objective

To determine whether helical rim advancement flap reconstruction following helical rim keloid excision can reduce recurrences.

Design

Case series followed up to 2 years.

Setting

Single Centre Tertiary Hospital Facial Plastics Service.

Participants

All patients who consented to helical rim advancement reconstruction after keloid excision.

Results

The authors report a series of 7 patients with helical rim keloids ranging from 1.2 cm to 5 cm in widest diameter treated with keloid excision and reconstruction with helical rim advancement flap technique. There were no recurrences within a mean of about 19 months post-operatively. Most patients report satisfaction with the cosmetic end-result.

Discussion

From the authors’ experience, helical rim advancement reconstruction following excision of keloids about 2.5 cm in widest diameter is an excellent tension-free option to avoid recurrence of helical rim keloids. Wound tension is a key risk factor for keloid formation. We hypothesise that the reason why there was no recurrence is because in helical rim advancement flap reconstruction, the underlying helical rim takes all the tension of closure off the dermis, resulting in tension-free skin closure.

Conclusion

Helical rim advancement flap reconstruction is a viable technique to avoid recurrence and minimise cosmetic deformities of the pinna for selected helical rim keloids.

A retrospective analysis of surgical resection of large ear keloids

OBJECTIVE

To investigate surgical methods for the removal of larger ear keloids.

METHODS

Two different surgical techniques were used: Method A, tumour excision followed by in situ scar flap repair; and Method B, wedge resection of an auricular lesion followed by primary closure or local flap repair. After the treatment, patients received postoperative, local radiotherapy. Follow-up was for 1-3 years (median 28.9 months).

RESULTS

Twenty patients with 35 large ear keloids were reviewed. In Method A, six ears were cured, three ears improved, five ears relapsed after 1 year and one ear recurred within 1 year. In Method B, 17 ears were cured, two ears improved and one ear recurred within 1 year.

CONCLUSION

Keloid scars can be effectively treated with a combination of radiotherapy and surgical excision.

Piercing Ear Keloid: Excision Using Loupe Magnification and Topical Liquid Silicone Gel as Adjuvant

Background

Keloid is an abnormal growth of scar at the site of skin injury, which usually does not regress. It proliferates beyond the original scar. The ear keloid usually develops after piercing injury to wear ornaments. A patient usually asks for removal of keloid, as it is aesthetically unpleasant. Patient may sometimes complain of itching and pain.

Aim

The study was conducted to analyze results following excision of keloid with its tract and topical silicone gel as the postsurgical adjuvant.

Materials and Methods

Ear keloids measuring less than 0.5cm or more than 5cm in maximum dimension were excluded from the study. Nonpiercing causes such as burns, trauma, and recurrent keloid were excluded from the study. The study was carried out on 22 patients who had keloid because of piercing injury, including 4 cases with both ear keloids. Of 26 ear keloids, 19 had the tract or connecting tissue. The lesion was excised under anesthesia using magnification. For all the operated cases, topical liquid silicone gel was used as postsurgical adjuvant therapy. The method of application of topical silicone gel was taught to each patient and was considered significant.

Result

The magnification helped in identification of tract in 73% of the cases in this study. Twenty patients had successfully responded to proposed treatment, and two patients developed recurrence while using topical silicone gel as the adjuvant. These two patients were managed with conventional triamcinolone injection.

Conclusion

The topical silicone gel as postsurgical adjuvant therapy avoided the use of painful postsurgical injection or radiotherapy for the 1-3cm primary ear keloids. The advantages of magnification were better clearance of keloid tissue, easier identification of tract and removal of keloid pseudopods, meticulous suturing, and comfortable elevation of a small local flap.

A Case of Keloids Complicated by Castleman's Disease: Interleukin-6 as a Keloid Risk Factor

Keloids are a manifestation of a fibroproliferative scarring disorder of the skin and develop in response to dermal injury in patients with a susceptible background. Local, systemic, and genetic factors contribute to keloid susceptibility. These factors include tension on the edges of the wound, hormonal influences, and ethnicity, respectively. Castleman's disease is a rare lymphoproliferative disorder that is characterized by the unregulated overproduction of interleukin-6, which leads to systemic lymphadenopathy and constitutional inflammatory symptoms. This case report shows that the bilateral auricular keloids of an adult woman were greatly exacerbated by the onset of Castleman's disease. We present our multimodal management algorithm for auricular keloids, which involves core excision and radiation therapy and achieves excellent aesthetic outcomes. The current treatment pathway for auricular keloids and the possible relationship between interleukin-6 and keloid progression will be discussed.

Histological analysis of hyalinised keloidal collagen formation in earlobe keloids over time: collagen hyalinisation starts in the perivascular area

Keloids grow and do not regress. They are characterised histologically by hyalinised keloidal collagen (HKC). HKC amounts vary, and the mechanism by which they form is unclear. To clarify how HKCs form and whether their formation associates with specific clinical features, we studied the histological findings of earlobe keloids and compared them with respective clinical features. A total of 50 earlobe keloids from 43 patients were used for histological analysis of keloid size (mm² ), HKC area (mm² ) and HKC area ratio (%). As a result, keloid durations ranged from 3 months to >13 years. Early-stage keloids exhibited little HKC and a tendency for the HKCs to locate in perivascular regions. In later-stage keloids, the HKCs were extremely interconnected and formed a thick bitten donut-shaped region. HKC area ratios correlated positively with keloid duration (r² = 0·58, P<0·05). HKC area ratios and keloid durations did not correlate with keloid sizes. These patterns of HKC formation and growth may explain why local therapies, which effectively remove fibroblasts and accumulated collagen but not HKCs, are ineffective in older keloids. Keloids should be promptly treated after diagnosis, and older keloids with extensive HKCs may require surgical excision followed by radiotherapy.