Complete Earlobe Keloid Resection With Fistulectomy ZhengHua Zhu, MD,*† YingJun Shan, MD,† LiYun Ying, MD,† Jiong Zheng, MD,*† Sadik Mohamed, MD,‡ and ZhaoXin Ma, MD†
BACKGROUND The earlobe is a location with a high risk of keloid scar formation. Keloid scars pose a surgical challenge from recidivation. The objective of this study was to investigate a new surgical approach for the treatment of auricular keloids. METHODS AND RESULTS In the past 4 years, 11 earlobe keloids of 9 patients have been excised by fistulectomy (perforation operation). All of the patients were followed up for at least 12 months without recurrence. CONCLUSIONS lobular keloids.
As a new surgical approach, a perforation operation together with fistulectomy is suitable for
The authors have indicated no significant interest with commercial supporters.
T
he incidence of earlobe keloid is high with the general use of piercings in the external ear. The external ear keloid can be a devastating process for people worried about their appearance. After resection, the wound heals with a scar, and some lobular keloids reappear. With marsupialization (to resect the core of the lesion but preserve the peri-membrane or skin of the lesion),1 a conservative method, the recurrence rate is very high. Some doctors choose more radical methods such as a wedge-like operation,2 and with these, recurrence rates drop but there is a decrease in lobular volume. Generally speaking, total fistulectomy is important in thyroglossal duct cysts or fistulas. Typically, in the same manner, the earlobe keloid grows through the pierced tract. Therefore, the authors believe that the cutaneous piercing hole in the earlobe is the core of the keloid and part of the reason for its recurrence. The authors have therefore devised a new surgical approach with incisions on the bilateral surfaces of the earlobe, which allows total fistulectomy and
perforation surgery together, to prevent recurrence and preserve earlobe volume.
Methods and Results The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Institutional Review Board of Tongji University School of Medicine, Shanghai, and the Institutional Research Ethical Board of Medical Academy of Taza Province, Morocco. Informed consent for surgery was obtained from each study participant. Eleven cases from 9 patients (8 women and 1 man; age range, 17–62 years) were enrolled in the past 4 years (from January 2010 to May 2013). Two patients had bilateral earlobe keloids and the other 7 had unilateral earlobe keloids: major parts in the front of earlobe in 1 case and behind the earlobe in 10 cases. None of them had undergone earlobe keloidectomy before. Perforative surgery involved the following steps1: 1 incision was made in the base of the lobular keloid
*Chinese Medical team, Ibnou Baja Provincial Hospital of Taza, Taza, Morocco; †Department of Otolaryngology—Head Neck Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China; ‡Department of Otolaryngology—Face Neck Surgery, Ibnou Baja Provincial Hospital of Taza, Taza, Morocco Z. Zhu and Y. Shan are the joint first authors. These authors contributed equally to this work.
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© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:83–86 DOI: 10.1097/DSS.0000000000000214
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Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EARLOBE KELOID RESECTION WITH FISTULECTOMY
(on the posterior surface in Figure 1)2; the other incision was made around the orifice of the fistula (on the anterior surface in Figure 2)3; dissection around the keloid scar using a sharp curved pair of scissors4; meticulous dissection around the fistula on the other side5; cutting off the keloid scar with the intact fistula (Figures 5 and 6)6; and suturing the 2 sides of the earlobe, respectively. According to the pathologic examination, the size of the 11 keloids was between 0.8 · 1.0 cm and 1.5 · 2.5 cm. No other special adjuvant therapy was applied. All of the patients were followed up for at least 12 months without recurrence, and the volume of the earlobe was relatively preserved (Figures 5 and 6). Discussion Surgery Plays an Essential Role Treatments for earlobe keloids include surgical excision (scalpel, scissors, or laser3), postoperative radiotherapy,2 steroid injection,1,4 and pressure therapy.5,6 However, to date, the most accepted treatment strategy for earlobe keloids is surgical excision. Despite the need to be combined with a range of adjuvant treatments, especially for recurrent cases, appropriate surgical treatment is essential for successful keloid treatment.
Figure 2. The orifice of the fistula and the keloid in the front of the earlobe. The incision line is indicated in black.
earlobe requires reconstruction, after repetitive surgery in the case of keloid recurrence. For auricular keloids and persistent hypertrophic scars, Yang and Yang7 recommended intrascar excision with debulking. In the debulking procedure, they recommended removal of the underlying scar tissue beneath the area undermined, all the way down to healthy subcutaneous tissue. Total excision can decrease the necessity for adjuvant treatment, such as intralesional corticosteroid injections,1,4 radiotherapy,2 cryosurgery,8 or 5-fluorouracil.9 An operation with partial excision1,8 often requires combined
Complete Versus Partial Excision Complete excision is the general surgical principle to prevent recurrence, therefore the intact keloid with fistula needs to be removed. The volume of the earlobe is often significantly reduced and sometimes the
Figure 1. The keloid in the back of the earlobe. The incision line is indicated in black.
84
Figure 3. Side view of the keloid.
DERMATOLOGIC SURGERY
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ZHU ET AL
Figure 4. Anterior view of the keloid with resection of the orifice of the fistula (arrow).
assistive therapy. Some authors believe that brachytherapy10 as adjuvant therapy has a definitive effect for recurrent cases. Figure 6. Front view of the earlobe 12 months after surgery.
Perforation Surgery With Fistulectomy
Figure 5. Rear view of the earlobe 12 months after surgery.
Park and colleagues 11 called the complete excision procedure standard keloidectomy, and focused on the base or peduncle, but they did not consider the opening and the fistula of the keloid and did not include fistula-type in their classification system. Some authors 4,11 have indicated that excision of the keloidal channel should be performed using a penetrating technique, making a hole in the lobule if an anterior and posterior portion of the earlobe keloid is present. The authors emphasize that it is also necessary for the orifice of the fistula and the keloid to be removed together. The second incision (Figure 2) is convenient for confirmation of the dimensions and location of the surgical perforation of the fistula. The orifice and the fistula of the earlobe are the origin of the keloid, therefore they play a very important role in recurrence. Penetrating both surfaces is necessary to prevent an incomplete excision.
41:1:JANUARY 2015
85
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EARLOBE KELOID RESECTION WITH FISTULECTOMY
Expectation There is no standardized regimen for the treatment of earlobe keloids. In this article, all of the patients were followed up for 1 to 3 years without recurrence. A 1-year follow-up is very short to know if the keloids might recur, so larger studies, longer follow-up, and multicenter experience are necessary to confirm the long-term efficacy of this novel treatment modality: complete earlobe keloid resection with fistulectomy. References 1. Wang F, Yang H, Liao H, et al. Treatment of auricular keloids with surgery and intralesional injection of compound betamethasone [in Chinese]. Zhonghua Zheng Xing Wai Ke Za Zhi 2014;30:7–10. 2. Ogawa R, Huang C, Akaishi S, et al. Analysis of surgical treatments for earlobe keloids: analysis of 174 lesions in 145 patients. Plast Reconstr Surg 2013;132:818e–25e. 3. Tenna S, Aveta A, Filoni A, et al. A new carbon dioxide laser combined with cyanoacrylate glue to treat earlobe keloids. Plast Reconstr Surg 2012;129:843e–6e. 4. Al AI, Alawadhi SA, Alkhawaja FA, et al. Earlobe keloids: a pilot study of the efficacy of keloidectomy with core fillet flap and adjuvant intralesional corticosteroids. Dermatol Surg 2013;39:1514–9.
86
5. Park TH, Seo SW, Kim JK, et al. Outcomes of surgical excision with pressure therapy using magnets and identification of risk factors for recurrent keloids. Plast Reconstr Surg 2011;128:431–9. 6. Kadouch DJ, van der Veer WM, Mahdavian DB, et al. Therapeutic hotline: an alternative adjuvant treatment after ear keloid excision using a custom-made methyl methacrylate stent. Dermatol Ther 2010; 23:686–92. 7. Yang JY, Yang SY. Are auricular keloids and persistent hypertrophic scars resectable? The role of intrascar excision. Ann Plast Surg 2012;69: 637–42. 8. Careta MF, Fortes AC, Messina MC, et al. Combined treatment of earlobe keloids with shaving, cryosurgery, and intralesional steroid injection: a 1-year follow-up. Dermatol Surg 2013;39:734–8. 9. Khare N, Patil SB. A novel approach for management of ear keloids: results of excision combined with 5-fluorouracil injection. J Plast Reconstr Aesthet Surg 2012;65:e315–7. 10. Reiffel AJ, Sohn AM, Henderson PW, et al. Use of integra and interval brachytherapy in a 2-stage auricular reconstruction after excision of a recurrent keloid. J Craniofac Surg 2012;23:e379–80. 11. Park TH, Seo SW, Kim JK, et al. Earlobe keloids: classification according to gross morphology determines proper surgical approach. Dermatol Surg 2012;38:406–12.
Address correspondence and reprint requests to: ZhaoXin Ma, MD, Department of Otolaryngology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai 200120, China, or e-mail: [email protected]
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
BACKGROUND The earlobe is a location with a high risk of keloid scar formation. Keloid scars pose a surgical challenge from recidivation. The objective of this study was to investigate a new surgical approach for the treatment of auricular keloids. METHODS AND RESULTS In the past 4 years, 11 earlobe keloids of 9 patients have been excised by fistulectomy (perforation operation). All of the patients were followed up for at least 12 months without recurrence. CONCLUSIONS lobular keloids.
As a new surgical approach, a perforation operation together with fistulectomy is suitable for
The authors have indicated no significant interest with commercial supporters.
T
he incidence of earlobe keloid is high with the general use of piercings in the external ear. The external ear keloid can be a devastating process for people worried about their appearance. After resection, the wound heals with a scar, and some lobular keloids reappear. With marsupialization (to resect the core of the lesion but preserve the peri-membrane or skin of the lesion),1 a conservative method, the recurrence rate is very high. Some doctors choose more radical methods such as a wedge-like operation,2 and with these, recurrence rates drop but there is a decrease in lobular volume. Generally speaking, total fistulectomy is important in thyroglossal duct cysts or fistulas. Typically, in the same manner, the earlobe keloid grows through the pierced tract. Therefore, the authors believe that the cutaneous piercing hole in the earlobe is the core of the keloid and part of the reason for its recurrence. The authors have therefore devised a new surgical approach with incisions on the bilateral surfaces of the earlobe, which allows total fistulectomy and
perforation surgery together, to prevent recurrence and preserve earlobe volume.
Methods and Results The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Institutional Review Board of Tongji University School of Medicine, Shanghai, and the Institutional Research Ethical Board of Medical Academy of Taza Province, Morocco. Informed consent for surgery was obtained from each study participant. Eleven cases from 9 patients (8 women and 1 man; age range, 17–62 years) were enrolled in the past 4 years (from January 2010 to May 2013). Two patients had bilateral earlobe keloids and the other 7 had unilateral earlobe keloids: major parts in the front of earlobe in 1 case and behind the earlobe in 10 cases. None of them had undergone earlobe keloidectomy before. Perforative surgery involved the following steps1: 1 incision was made in the base of the lobular keloid
*Chinese Medical team, Ibnou Baja Provincial Hospital of Taza, Taza, Morocco; †Department of Otolaryngology—Head Neck Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China; ‡Department of Otolaryngology—Face Neck Surgery, Ibnou Baja Provincial Hospital of Taza, Taza, Morocco Z. Zhu and Y. Shan are the joint first authors. These authors contributed equally to this work.
·
© 2014 by the American Society for Dermatologic Surgery, Inc. Published by Lippincott Williams & Wilkins ISSN: 1076-0512 Dermatol Surg 2015;41:83–86 DOI: 10.1097/DSS.0000000000000214
·
·
· 83
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EARLOBE KELOID RESECTION WITH FISTULECTOMY
(on the posterior surface in Figure 1)2; the other incision was made around the orifice of the fistula (on the anterior surface in Figure 2)3; dissection around the keloid scar using a sharp curved pair of scissors4; meticulous dissection around the fistula on the other side5; cutting off the keloid scar with the intact fistula (Figures 5 and 6)6; and suturing the 2 sides of the earlobe, respectively. According to the pathologic examination, the size of the 11 keloids was between 0.8 · 1.0 cm and 1.5 · 2.5 cm. No other special adjuvant therapy was applied. All of the patients were followed up for at least 12 months without recurrence, and the volume of the earlobe was relatively preserved (Figures 5 and 6). Discussion Surgery Plays an Essential Role Treatments for earlobe keloids include surgical excision (scalpel, scissors, or laser3), postoperative radiotherapy,2 steroid injection,1,4 and pressure therapy.5,6 However, to date, the most accepted treatment strategy for earlobe keloids is surgical excision. Despite the need to be combined with a range of adjuvant treatments, especially for recurrent cases, appropriate surgical treatment is essential for successful keloid treatment.
Figure 2. The orifice of the fistula and the keloid in the front of the earlobe. The incision line is indicated in black.
earlobe requires reconstruction, after repetitive surgery in the case of keloid recurrence. For auricular keloids and persistent hypertrophic scars, Yang and Yang7 recommended intrascar excision with debulking. In the debulking procedure, they recommended removal of the underlying scar tissue beneath the area undermined, all the way down to healthy subcutaneous tissue. Total excision can decrease the necessity for adjuvant treatment, such as intralesional corticosteroid injections,1,4 radiotherapy,2 cryosurgery,8 or 5-fluorouracil.9 An operation with partial excision1,8 often requires combined
Complete Versus Partial Excision Complete excision is the general surgical principle to prevent recurrence, therefore the intact keloid with fistula needs to be removed. The volume of the earlobe is often significantly reduced and sometimes the
Figure 1. The keloid in the back of the earlobe. The incision line is indicated in black.
84
Figure 3. Side view of the keloid.
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
ZHU ET AL
Figure 4. Anterior view of the keloid with resection of the orifice of the fistula (arrow).
assistive therapy. Some authors believe that brachytherapy10 as adjuvant therapy has a definitive effect for recurrent cases. Figure 6. Front view of the earlobe 12 months after surgery.
Perforation Surgery With Fistulectomy
Figure 5. Rear view of the earlobe 12 months after surgery.
Park and colleagues 11 called the complete excision procedure standard keloidectomy, and focused on the base or peduncle, but they did not consider the opening and the fistula of the keloid and did not include fistula-type in their classification system. Some authors 4,11 have indicated that excision of the keloidal channel should be performed using a penetrating technique, making a hole in the lobule if an anterior and posterior portion of the earlobe keloid is present. The authors emphasize that it is also necessary for the orifice of the fistula and the keloid to be removed together. The second incision (Figure 2) is convenient for confirmation of the dimensions and location of the surgical perforation of the fistula. The orifice and the fistula of the earlobe are the origin of the keloid, therefore they play a very important role in recurrence. Penetrating both surfaces is necessary to prevent an incomplete excision.
41:1:JANUARY 2015
85
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
EARLOBE KELOID RESECTION WITH FISTULECTOMY
Expectation There is no standardized regimen for the treatment of earlobe keloids. In this article, all of the patients were followed up for 1 to 3 years without recurrence. A 1-year follow-up is very short to know if the keloids might recur, so larger studies, longer follow-up, and multicenter experience are necessary to confirm the long-term efficacy of this novel treatment modality: complete earlobe keloid resection with fistulectomy. References 1. Wang F, Yang H, Liao H, et al. Treatment of auricular keloids with surgery and intralesional injection of compound betamethasone [in Chinese]. Zhonghua Zheng Xing Wai Ke Za Zhi 2014;30:7–10. 2. Ogawa R, Huang C, Akaishi S, et al. Analysis of surgical treatments for earlobe keloids: analysis of 174 lesions in 145 patients. Plast Reconstr Surg 2013;132:818e–25e. 3. Tenna S, Aveta A, Filoni A, et al. A new carbon dioxide laser combined with cyanoacrylate glue to treat earlobe keloids. Plast Reconstr Surg 2012;129:843e–6e. 4. Al AI, Alawadhi SA, Alkhawaja FA, et al. Earlobe keloids: a pilot study of the efficacy of keloidectomy with core fillet flap and adjuvant intralesional corticosteroids. Dermatol Surg 2013;39:1514–9.
86
5. Park TH, Seo SW, Kim JK, et al. Outcomes of surgical excision with pressure therapy using magnets and identification of risk factors for recurrent keloids. Plast Reconstr Surg 2011;128:431–9. 6. Kadouch DJ, van der Veer WM, Mahdavian DB, et al. Therapeutic hotline: an alternative adjuvant treatment after ear keloid excision using a custom-made methyl methacrylate stent. Dermatol Ther 2010; 23:686–92. 7. Yang JY, Yang SY. Are auricular keloids and persistent hypertrophic scars resectable? The role of intrascar excision. Ann Plast Surg 2012;69: 637–42. 8. Careta MF, Fortes AC, Messina MC, et al. Combined treatment of earlobe keloids with shaving, cryosurgery, and intralesional steroid injection: a 1-year follow-up. Dermatol Surg 2013;39:734–8. 9. Khare N, Patil SB. A novel approach for management of ear keloids: results of excision combined with 5-fluorouracil injection. J Plast Reconstr Aesthet Surg 2012;65:e315–7. 10. Reiffel AJ, Sohn AM, Henderson PW, et al. Use of integra and interval brachytherapy in a 2-stage auricular reconstruction after excision of a recurrent keloid. J Craniofac Surg 2012;23:e379–80. 11. Park TH, Seo SW, Kim JK, et al. Earlobe keloids: classification according to gross morphology determines proper surgical approach. Dermatol Surg 2012;38:406–12.
Address correspondence and reprint requests to: ZhaoXin Ma, MD, Department of Otolaryngology, Shanghai East Hospital, Tongji University School of Medicine, 150 Jimo Road, Shanghai 200120, China, or e-mail: [email protected]
DERMATOLOGIC SURGERY
Copyright © American Society for Dermatologic Surgery. Unauthorized reproduction of this article is prohibited.
