Surgical Treatment of Keloids Secondary to Ear Piercing A. Paul Kelly, MD Los Angeles, California
Keloids are medically benign, but often psychologically and cosmetically malignant lesions. They are most commonly located on the posterior aspect of the ear lobes. The author's treatment of choice is the combined intralesional steroid and surgical approach. Surgically, the best results are obtained when some of the skin overlying the keloid is used as a split thickness graft after all of the keloidal tissue has been removed. Explicit postoperative wound care instructions are important in insuring complication-free surgery. Keloids are medically benign, but often psychologically and cosmetically malignant lesions. The most common location is on the ear lobes, especially the posterior aspect. Since most ear lobe keloids are found in people with pierced ears, it is assumed that the growths are precipitated by the trauma of piercing and inserting earrings or from infection secondary to ear trauma. Patch testing by the author proved that nickle or chrome allergy is not a causative factor. There is no therapeutic modality that is best for all keloids. Location, size, and depth of the lesion, age of the patient, and duration of the keloid determine the type of therapy used.
Operative Technique Treatment of choice for most ear lobe keloids (from the author's experience) is the combined intralesional steroid and surgical approach. Corticosteroids are injected every two or three weeks (four injections) prior to surgery. Triamcinolone acetonide (Kenalog-1O) diluted with equal parts of two percent lidocaine (Xylocaine) is preferred. Xylocaine does not relieve the pain of the injection, but it does prevent most post-injection pain and allows for multiple injections with minimal discomfort. Intralesional injections are best accomplished with a 1 cc insulin syringe. If the response to 5 mg/cc of Kenalog is minimal to absent, then Kenalog-40, 40 mg/ml, diluted to various strengths with two percent From the Division of Dermatology, Department of Internal Medicine, Martin Luther King, Jr. General Hospital, and Charles R. Drew Postgraduate Medical School, Los Angeles, California. Requests for reprints should be addressed to Dr. A. Paul Kelly, Division of Dermatology, Martin Luther King, Jr. General Hospital, 12021 South Wilmington Avenue, Los Angeles, CA 90059.
Xylocaine, is recommended. Since the injected Kenalog is under such great pressure, it often leaks out. To prevent this, the keloid is painted with tincture of benzoin and the injected site covered with a piece of butterfly bandage. The surgical method varies according to the location and configuration of the lesion and to the time needed to perform the surgery: 1. For posterior pedunculated ear lobe keloids, where time is short and cosmetic consideration is not paramount, shaving with one side of a double-edge razor blade, followed by pressure and oxidized cellulose for hemostasis, is simple and efficient. The spring-type clothespin is ideal for exerting pressure on the ear lobe. 2. For all other ear lobe keloids, an elliptical excision of the middle part of the lesion is made, leaving enough skin on either side of the excised piece of the keloid to be approximated without tension. Then with patience and gentleness, the skin over the remaining parts of the keloid tissue is carefully dissected from the underlying white glistening fibrous tissue. Careful dissection is continued until all or almost all of the fibrous tissue is removed. Then, the two thin pieces of skin are approximated with 6-0 nylon interrupted sutures. Sometimes, 6-0 nylon sutures are used to tack down the covering skin to the underlying connective tissue because, due to its thinness and lack of any significant dermal tissue, it is essentially a split thickness graft. The sutures are left in for 10 to 14 days, since earlier removal seems to cause wound dehiscence. Using either of the above surgical procedures, the base of the postoperative site is injected with a 5 mg/cc Kenalog-Xylocaine mixture every two
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
or three weeks. A total of four injections is sufficient. None of the patients demonstrated clinical evidence that either pre- or post-operative corticosteroid injections had an adverse effect on wound healing.
Comment The author has treated more than 60 ear lobe keloids with the combined intralesional steroid-surgical approach and has had only one known recurrence. This was in a 14-year-old female who failed to return for her postoperative corticosteroid injections. Five months after surgery she returned, complaining of a tender keloid-like lesion in the original excision site. After four injections of 5 mg/cc KenalogXylocaine (one injection every two weeks), her newly formed posterior lobe lesion flattened. On follow-up visits, one and two years later, there was no evidence of keloid regrowth. None of the patients had postoperative wound hemorrhage, necro-
sis, dehiscence, or prolonged pain. Only a few had slight wound inflammation which cleared in two to three days with alcohol cleansing and application of neomycin sulfate, polymyxin B sulfate, and bacitracin zinc ointment (Neo-Polycin). This dearth of complications may be partially explained by giving the patients explicit verbal postoperative care instructions as well as a printed page on postoperative wound care and the necessity of getting postsurgery intralesional corticosteroid injections. If a patient insists, the previously involved ear lobe will be repierced six weeks or more postoperatively. So far none of the eight patients who had her ears repierced have noticed any evidence of new keloid formation at the site of piercing. In summary, the author has found keloids secondary to ear piercing can be removed surgically without fear of recurrence or other complications if combined with pre and postoperative corticosteroid injections. Explicit postoperative wound care instructions are important in insuring complication-free surgery. 349
Keloids are medically benign, but often psychologically and cosmetically malignant lesions. They are most commonly located on the posterior aspect of the ear lobes. The author's treatment of choice is the combined intralesional steroid and surgical approach. Surgically, the best results are obtained when some of the skin overlying the keloid is used as a split thickness graft after all of the keloidal tissue has been removed. Explicit postoperative wound care instructions are important in insuring complication-free surgery. Keloids are medically benign, but often psychologically and cosmetically malignant lesions. The most common location is on the ear lobes, especially the posterior aspect. Since most ear lobe keloids are found in people with pierced ears, it is assumed that the growths are precipitated by the trauma of piercing and inserting earrings or from infection secondary to ear trauma. Patch testing by the author proved that nickle or chrome allergy is not a causative factor. There is no therapeutic modality that is best for all keloids. Location, size, and depth of the lesion, age of the patient, and duration of the keloid determine the type of therapy used.
Operative Technique Treatment of choice for most ear lobe keloids (from the author's experience) is the combined intralesional steroid and surgical approach. Corticosteroids are injected every two or three weeks (four injections) prior to surgery. Triamcinolone acetonide (Kenalog-1O) diluted with equal parts of two percent lidocaine (Xylocaine) is preferred. Xylocaine does not relieve the pain of the injection, but it does prevent most post-injection pain and allows for multiple injections with minimal discomfort. Intralesional injections are best accomplished with a 1 cc insulin syringe. If the response to 5 mg/cc of Kenalog is minimal to absent, then Kenalog-40, 40 mg/ml, diluted to various strengths with two percent From the Division of Dermatology, Department of Internal Medicine, Martin Luther King, Jr. General Hospital, and Charles R. Drew Postgraduate Medical School, Los Angeles, California. Requests for reprints should be addressed to Dr. A. Paul Kelly, Division of Dermatology, Martin Luther King, Jr. General Hospital, 12021 South Wilmington Avenue, Los Angeles, CA 90059.
Xylocaine, is recommended. Since the injected Kenalog is under such great pressure, it often leaks out. To prevent this, the keloid is painted with tincture of benzoin and the injected site covered with a piece of butterfly bandage. The surgical method varies according to the location and configuration of the lesion and to the time needed to perform the surgery: 1. For posterior pedunculated ear lobe keloids, where time is short and cosmetic consideration is not paramount, shaving with one side of a double-edge razor blade, followed by pressure and oxidized cellulose for hemostasis, is simple and efficient. The spring-type clothespin is ideal for exerting pressure on the ear lobe. 2. For all other ear lobe keloids, an elliptical excision of the middle part of the lesion is made, leaving enough skin on either side of the excised piece of the keloid to be approximated without tension. Then with patience and gentleness, the skin over the remaining parts of the keloid tissue is carefully dissected from the underlying white glistening fibrous tissue. Careful dissection is continued until all or almost all of the fibrous tissue is removed. Then, the two thin pieces of skin are approximated with 6-0 nylon interrupted sutures. Sometimes, 6-0 nylon sutures are used to tack down the covering skin to the underlying connective tissue because, due to its thinness and lack of any significant dermal tissue, it is essentially a split thickness graft. The sutures are left in for 10 to 14 days, since earlier removal seems to cause wound dehiscence. Using either of the above surgical procedures, the base of the postoperative site is injected with a 5 mg/cc Kenalog-Xylocaine mixture every two
JOURNAL OF THE NATIONAL MEDICAL ASSOCIATION, VOL. 70, NO. 5, 1978
or three weeks. A total of four injections is sufficient. None of the patients demonstrated clinical evidence that either pre- or post-operative corticosteroid injections had an adverse effect on wound healing.
Comment The author has treated more than 60 ear lobe keloids with the combined intralesional steroid-surgical approach and has had only one known recurrence. This was in a 14-year-old female who failed to return for her postoperative corticosteroid injections. Five months after surgery she returned, complaining of a tender keloid-like lesion in the original excision site. After four injections of 5 mg/cc KenalogXylocaine (one injection every two weeks), her newly formed posterior lobe lesion flattened. On follow-up visits, one and two years later, there was no evidence of keloid regrowth. None of the patients had postoperative wound hemorrhage, necro-
sis, dehiscence, or prolonged pain. Only a few had slight wound inflammation which cleared in two to three days with alcohol cleansing and application of neomycin sulfate, polymyxin B sulfate, and bacitracin zinc ointment (Neo-Polycin). This dearth of complications may be partially explained by giving the patients explicit verbal postoperative care instructions as well as a printed page on postoperative wound care and the necessity of getting postsurgery intralesional corticosteroid injections. If a patient insists, the previously involved ear lobe will be repierced six weeks or more postoperatively. So far none of the eight patients who had her ears repierced have noticed any evidence of new keloid formation at the site of piercing. In summary, the author has found keloids secondary to ear piercing can be removed surgically without fear of recurrence or other complications if combined with pre and postoperative corticosteroid injections. Explicit postoperative wound care instructions are important in insuring complication-free surgery. 349
