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

INTRODUCTION

Keloid develops because of abnormal wound healing. The risk of development of keloid is higher in pigmented population.[1] The proposed etiology of keloid are genetic, hormonal, poor wound healing due to skin tension, inflammation, and infection.[2] The recent studies show peripheral region of keloid to be more active than the center.[3] The perilesional fibroblast is more active than intralesional fibroblast. These stimulate surrounding normal fibroblast to become keloidal fibroblast by its paracrine-secreting substances.[4] The study was based on this concept to excise keloid entirely from the margin. The aim was to remove all abnormal fibrous tissue with minimal loss of healthy tissue. The excision was achieved using loupe magnification. Usually piercing injury leads to the formation of a tract in the subdermal region.[5] The tract can be removed by magnification. After surgery, patients were prescribed topical liquid silicone gel as the adjuvant to prevent recurrence.

MATERIALS AND METHODS

Only piercing primary ear keloid was included in the study. The large ear keloid (more than 5cm), recurrent keloid, and nonpiercing causes such as trauma and burns were not included in the study. The small ear keloids (less than 0.5cm) primarily treated with injection triamcinolone and silicone gel were not included in the study. Of 30 cases operated from January 2015 to June 2016, 22 cases available for follow-up were involved in the research [Table 1]. All the managed cases were females. The age of presentation was from 10 to 29 years in this study, except a patient who was 45 years old. The patient presented with a slow increase in the size of keloid, itching, and pain. The maximum size of anterior or posterior keloid in any of its plane without calculating interconnecting tract was recorded.

Table 1 Patient details

Surgical procedure

The ear was scrubbed with povidone-iodine, and local anesthetic 1% lignocaine was given at the appropriate site. The incision was made in the healthy tissue at the margin of the keloid. The dissection was carried out using 4× surgical loupe magnification, which identifies plane just outside the keloid. The dumbbell keloid with its connecting tissue (tract) was removed as a single entity [Figure 1A and B]. In anterior- or posterior-only ear keloid, the tract was identified by loupe magnification. The tract was either a conical mass from the base of keloid or a linear tissue emanating from the base of a keloid. The tract that was either fleshy or fibrous was removed [Figure 2A and B]. The use of magnification helped to remove any residual fingerlike processes of keloid tissue left on the wound. The removal of keloid with its tract on cartilaginous part of auricle sometimes needs coring of involved cartilage. Suturing was done with 5-0 monofilament nonabsorbable materials, without tension. If the initial approximation of wound edges produced suture line tension, local flap (commonly Limberg) was used to close the defect. The magnification further helps to do small local flaps better [Figures 3A–C and 4A–D].

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Figure 1

(A) Large dumbbell keloid. (B) Anterior and posterior keloid masses removed along with its connecting tissue (tract)

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Figure 2

(A) Ear keloid. (B) Fleshy tract completely removed using loupe magnification

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Figure 3

(A) Dumbbell keloid with large posterior mass. (B) Posterior defect covered with Limberg flap. (C) Ten months after surgery no recurrence

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Figure 4

(A) Anterior view piercing mark seen on helix. (B) Posterior view keloid ear helix. (C) Conical tract removed with keloid under magnification. (D) Defect covered with small Limberg flap to avoid notching deformity of helix

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Patients were discharged after applying pressure dressing along with antibiotic and analgesic prescriptions. They were then advised the twice-daily application of antibiotic ointment to prevent infection for first 7 days. Sutures were removed on the 14th day of surgery. The postoperative adjuvant therapy was to use topical silicone gel twice daily from the third week after surgery and continued daily for 6 months. The method of application of topical silicone gel was taught to each patient. They were instructed to massage silicone gel on scar area for 5min twice daily. At the end of massage, excess silicone gel wiped off, so that thin film remains. During this treatment, if the keloid reappeared as nodularity, they were considered as nonresponsive to silicone gel. In nonresponsive cases, silicone gel treatment was stopped, and intralesional triamcinolone injection was started.[6] The injection triamcinolone 10mg/mL was given every 3 weeks for 6 cycles.

Patients were followed up every month for 6 months and then every third month for next 1 year. After 1.5 years of follow-up, if swelling reappeared, patient was asked to review. They are strictly advised to defer ear helix piercing forever. However, if patient insists to wear earrings on earlobe, the surgeon does the piercing after 1 year of surgery. Patients were also instructed to wear pure gold ornaments, as gold is the least reactive element.

RESULTS

Eighteen patients had single ear keloid. Four patients presented with both ear keloids. Hence, the total number of ear keloids operated was 26. Keloid was present in earlobe in 19 cases and in helical part of the ear in 7 cases. Nine instances presented as dumbbell keloid on one ear and two cases on both ears. Two cases had the wraparound keloid. The loupe magnification dissection identified the root or connecting tissue in 19 (73% of piercing ear keloid) of 26. The operated specimen was subjected to histopathological examination. The report was keloid in all the cases. The tract was said to contain granuloma in eight cases. Of 22 patients (90%), 20 responded to proposed treatment and did not develop recurrence at 1.5 years of follow-up. Two cases, including one patient with both ear keloids, did not respond to silicone gel [Tables 1 and 2]. The unresponsive cases in this study were wraparound keloids and keloid size of 4cm or more. These two patients had intralesional triamcinolone injection and did not develop recurrence. Patients were followed up every month for 6 months and then every third month for next 1 year. After 1.5 years of follow-up, they were suggested to review when swelling reappears.

Table 2 Ear keloid

DISCUSSION

Keloids are characterized by their continued growth following trauma and extension into healthy tissue. The keloid may grow up to 1 year after injury. It does not regress on its own. Simple surgical excision without adjuvant therapy causes recurrence.[7] The extralesional excision of keloid mass with its tract (active perilesional keloid fibroblast removed) may help to avoid recurrence.[6]

Earlobe keloids are classified as minor keloids according to the international clinical recommendation on scar management.[89] They cause cosmetic deformities, itching, pain, and psychological distress to the patient.[10] The typical age of presentation is between 10 and 30 years.[11] The common size of ear keloid when presented to surgeons is 1–3cm. The common cause of ear keloid is piercing injury.[12] The entity of ear piercing keloids is unique when compared with other reasons. The ear is usually pierced with a sharp instrument passed through earlobe or helix. Hence, there is an injury to the skin on one side with a penetrating subdermal fat or cartilage injury and injury to surface on opposite side. Scarring develops on both sides of the ear and in between soft tissue. The piercing effect tends to form keloid tissue on anterior, posterior, or both surfaces with a connecting tract. The dumbbell keloid is a classical presentation of piercing injury. The dumbbell keloid has a tract connecting anterior and posterior keloid masses. They are treated by complete excision of both keloid masses with its tract.[1314] If only anterior or posterior keloid is present, there is still a tract or root going inside soft tissue. It is either fibrous or fleshy. The use of magnification facilitates removal of root and surrounding keloid pseudopods with less removal of surrounding fat. Minimal removal of surrounding tissue helps in tension-free closure after keloid excision. If tension is still present, smaller flaps with less deformity to the ear can meticulously be done with magnification. The extraction without magnification may result in significant loss of healthy tissue, leading to higher chance of ear deformity after suturing, tension along suture line, or a larger flap to cover the defect.

Keloid formation is often considered to be the result of a persistent inflammation, prolonged proliferative phase of wound healing, and delayed remodeling phase of wound healing.[1516] Apart from ornaments, persistent inflammation might be because of foreign bodies such as dirt getting inside by piercing injury. The tiny foreign body can get deposited along the tract. The histopathology of tract shows granuloma in 8 of 19 cases in our study. The removal of tract helps in clearing persistent inflammatory cause of keloid because of a microscopic foreign body.

A healing wound can become an unsightly scar during the remodeling phase.[171819]

A keloid has normal epidermis, a tonguelike advancing edge, a horizontal fibrous band in the upper reticular dermis, prominent fascia like a band, and keloidal collagen.[20] The perilesional or peripheral region of keloid has abundant T-cell lymphocytes[21] and increased collagen production.[322] The collagen bundles are thicker in keloid than the hypertrophic scar or normal scar.[23] Silicone gel modifies the abnormal remodeling phase of wound healing in keloid. The proposed mechanisms of action of silicone gel are the reduction of wound-site tension,[24] hydration,[25] downregulating fibroblast, and altered fibrogenic cytokines.[2627] The study uses topical silicone gel as an adjuvant for preventing recurrence of the keloid.[28] The adjuvant prevented recurrence in 20 (90% of patients) of 22 patients operated in this study. The liquid silicone gel is a useful method to overcome the difficulties of applying silicone gel sheet on an irregular surface.[29] The prolonged application up to 6 months or 1 year is useful in keloid patients as their remodeling phase of wound healing is longer. The method of application of topical silicone gel is critical. Twice daily circular motion massaging is to be done for 5min on the ear keloid excised region. At the completion of massage, a thin film remains on the surface. Topical silicone gel is easy to apply and cosmetically acceptable.[3031] The cases that did not respond to silicone gel were either wraparound or more than 4-cm-sized keloids in this study. In our opinion, silicone gel avoids series of painful postoperative injection and hence provides better patient compliance. The various postsurgical adjuvant treatments may be reserved for cases not responding to topical liquid silicone gel. Excellent results by excision and postoperative radiotherapy are shown in multiple studies.[123233] The problem is the availability of radiation in all centers and management of its complications. Surgical removal combined with radiotherapy may be reserved as a last resort in the treatment of therapy-resistant keloids.[34]

CONCLUSION

Piercing earlobe keloids need to be considered differently from other keloids, as they have a tract. This study shows a good response after complete surgical excision and postsurgical topical liquid silicone gel as adjuvant therapy for 1- to 3-cm-sized earlobe keloid. Magnification ensures complete removal of pseudopods of keloid tissue and its tract. It also helps to do meticulous suturing. Tension-free closure of wound may require small local flaps. With the use of silicone gel, patient may not need radiotherapy or painful postsurgical intrascar injections. Adjuvant therapy is needed for cases not responding to silicone gel treatment in 1- to 3-cm-sized keloids, wraparound keloids, and more than 4-cm-sized keloids.