Contour first—retrospective study of an algorithmic approach of auricular keloids

Auricular keloids are difficult to treat, and recurrent keloids are more aggressive and more likely to develop aural deformities. Surgical excision, injections, or radiotherapy alone have high recurrence rates. An algorithmic approach of auricular keloid remains to be explored.


| INTRODUC TI ON
A keloid is a particular pathological scar that typically appears on the anterior sternum, upper back, ears, and shoulders. 1 Keloid scars can develop spontaneously or as a result of skin trauma. Clinically, it is distinguished by an ongoing expansion of hard, encrusted nodular, striated, or lumpy tissue that goes beyond the initial skin lesion. 2 Auricular keloids are difficult to treat because of their three-dimensional and exposed shape, and they frequently result in deformities that have an impact on the patient's appearance and even social life 3,4 Surgical excision, injections, or radiotherapy alone have high recurrence rates.
Recurrent keloids are more aggressive and more likely to develop aural deformities. The goal of treating auricular keloids is to minimize appearance loss, increase recurrence rate reduction, and as much as possible restore the patient's ear to its normal appearance. From 2018 to 2021, our center has applied the auricular contour priority-Algorithmic treatment concept to provide comprehensive treatment for auricular keloid with 12-40 months of postoperative follow-up, with excellent clinical results, which are reported below.  Table 1 contains statistics on disease causes, location of onset, family history, and additional sites involved. Exclusion criteria were as follows: (1) those with severe systemic disease; (2) those who were pregnant or breastfeeding, with a requirement for childbirth within 1 year; (3) those who required a guarantee that the keloid would not recur after surgery;

| Patients information
(4) those who did not receive postoperative drug injections or had contraindications to drug injections; and (5) those who did not receive postoperative radiotherapy or had contraindications to radiotherapy. All patients were thoroughly informed of the treatment plan and the various possible complications, signed the relevant informed consent forms, and complied with the Declaration of Helsinki.

| Surgical treatment
A customized surgical strategy is used to establish bilateral symmetry wherever possible, depending on the size and shape of the keloid.
The incision is designed with regard to the size and proportions of the opposing auricle.

| Earlobes
If a single keloid is present on either the front or rear of the earlobe, or present on both the front and back of the earlobe, and it has clear borders and does not significantly impact the size of the earlobe contour, it can be excised using a pike excision with complete excision of the keloid tissue via the front and back, using tension-free sutures to trim the wound margins. If the keloid on the earlobe is substantial, it can be removed by making a curving incision at its base, removing its core, leaving the keloid flap to cover the wound, and then tightly suturing it. (Figure 1A-C).
If there is a large number of keloids in front of and behind the earlobe, and the earlobe is severely distorted, direct excision and suturing will result in a malformed earlobe. To keep the patient's earlobe substantially symmetrical with the contralateral earlobe, the length and width of the contralateral earlobe must be measured before surgery. The defects were closed with Z-plasty or local flap transfer. (Figure 1D-F).
A recurrent earlobe keloid has a widespread growth of the entire earlobe and no discernible boundary separating it from normal skin. Before surgery, the earlobe on the opposite side is measured for length and width. A curved earlobe flap is then built behind the earlobe, the keloid is removed from the core, and the earlobe flap is folded posteriorly and superiorly to remove the extra skin and create a new earlobe.

| Helix
The helix is a significant aesthetic feature of the ear; thus, it is crucial to handle keloids at the helix. The contour line of the auricular rim and the visual appeal of the ear will be altered if the keloid is directly removed and sutured. A curved incision at the base of the postauricular keloid can be utilized to totally remove the core of a single keloid at the helix while perfectly retaining the thin keloid flap. The keloid is first entirely removed from the auricular cartilage; then, the membrane covering the auricular cartilage is used to cover the wound and apply the keloid flap to restructure the auricle.

| RE SULTS
The three grades classification method 5 is used to evaluate the treat-

| Typical cases 1
A 27-year-old female has had a keloid in her right ear for more than 2 years after having her ear pierced. The keloid grew significantly during her pregnancy a year ago, and she was treated with an external excision before coming to our clinic 6 months later.

| Typical cases 2
A 31-year-old female patient suffered from left earlobe keloid for more than 5 years. The keloid core was excised, and the earlobe was reshaped by a keloid flap with good morphology. After 6 months of follow-up, there was no recurrence tendency ( Figure 5).

| Typical cases 3
A 23-year-old female patient suffered from right keloid located at helix and a recurrence keloid located at postauricle area ( Figure 6).

| DISCUSS ION
Keloidectomy is the primary therapeutic choice for auricular keloids, 6  the epidermis and dermal papillae were the only parts of the scar skin that thinned following "core excision," which did not increase the recurrence rate by leaving behind some of the scar skin and resulted in a recurrence rate 8,9 that was statistically identical to that of "complete excision." The recurrence rate is statistically identical to that of "complete excision." Therefore, for keloids of various morphologies and anatomical locations, we employ a standardized and individualized sequence of treatments. The keloid is specifically chosen for "complete excision" or "core excision," and the wound is then repaired with tension-free sutures.
We utilize a sequential therapy strategy of radiation combined with local compression and drug injections after excision, which contains first electron beam irradiation within 24 h after surgery, second irradiation around 1 week after surgery, local compression using magnetic sheet ear staples after removal of the stitches, and Triamcinolone is a long-acting glucocorticoid that suppresses inflammation, diminishes the production of collagen and glycosaminoglycan, 15 and prevents the proliferation of fibroblasts. 16 Injections of intra-lesional steroid hormones have been demonstrated to be 50%-100% effective in preventing the recurrence of hyperplastic keloids and keloids 17,18 The timing of postoperative injections, however, is currently in dispute. Some experts 19

ACK N OWLED G M ENT
None.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.