A total of 67 cases of auricular keloid patients with 113 auricular keloids were selected from plastic surgery in The First Hospital of China Medical University between February 2014 to February 2017. There were 11 males and 56 women. The patients ranged in age from 18 to 50 years, with an average age of 28.0 years. The primary cause of auricular keloids were 60 cases of ear piercing, 5 cases of trauma, and 2 cases of surgery. The medical history ranged from 1 year to 18 years. Before our treatment, 10 patients underwent surgical excision, 2 patients received external drug treatment, 3 patients received hormone treatment, and 2 patients received laser treatment, but all these treatments were ineffective.
The study was approved by ethical review board of China Medical University, which followed the ethical principles of the Declaration of Helsinki 1964, and all the patients provided the written informed consent.
All the patients were diagnosed with auricular keloids:
- The scar proliferation lasted for more than 12 months after formation, and there was no sign of stop.
- The scar was flush and higher than the surface of the normal skin, proliferating like a tumor to attract the surrounding normal skin and extend beyond the borders of the original wound, and causing itching and pain.
- Recurrence of patients after surgical excision, freezing, laser, hormone or radiotherapy.
- Suture immediately after excision (Ⅰ): For the small basal area of keloid, if the suture immediately after excision could have very little effect on the appearance of auricle, we could completely resect the keloid along the outer edge of the keloid or directly performed the fusiform excision. Sometimes, part of auricular cartilage needed to be resected together (Fig. 1).
- Keloid core excision and scar flap plasty (Ⅱ): For large basal area of keloid, if the suture immediately after excision had a great influence on the appearance of auricle, we can perform keloid core excision and scar flap plasty. We designed a "C" shape incision along the trailing edge of keloid or fusiform incision on keloid surface design. We then performed a sharp dissection between the keloid skin and the keloid core and between the keloid core and the ear cartilage. The keloid core excision and the scar flap formation were completed at the time. Finally,, we covered the ear cartilage with a scar flap (Fig. 2).
- Complete keloid excision and adjacent flap plasty (Ⅲ): For large basal area of keloid, if the suture immediately after excision could have a great effect on the appearance of auricle, but the patient urges complete keloid excision, we could excise keloid completely along keloid outer edge, and then use local advancing flap or rotating flap, such as postauricular flap, to repair ear deformation (Fig. 3).
In all operations, 1% lidocaine was used for local infiltration anesthesia, and a 6-0 nylon thread was applied to the skin. In addition, a local compression bandage was used appropriately, and the stitches was taken 7 days after the operation.
All patients received 5 Mev electron beam irradiation by the linear accelerator within 24 hours after excision of the keloid. According the conventional standard of the department of radiotherapy in our hospital, the total dose was 20 Gy (2 Gy for each time), and the total times of irradiation was 10 (1 day interval). The margin of the irradiated area was 0.5-1 cm around the scar, and all wounds were radiated when a local flap was used.
In this study, 1 mL of triamcinolone acetonide injection (Kunming Jida Pharmaceutical Co., Ltd., National Pharmaceutical Standard H53021604, 40mg/mL) and 1 mL of 2% lidocaine injection (Shanghai Zhaohui Pharmaceutical Co., Ltd. National Pharmaceutical Standard H31021072, 100mg/5mL) were mixed with a 2.5 mL syringe to prepare a 1:1 ratio mixture. The mixed solution in a 1 mL syringe was injected in parallel to the edge of the scar and the surrounding skin immediately 1, 2, and 3 months after surgery. The drug was uniformly and slowly injected into the scar at a distance of 1 cm, and 0.1 mL of the mixture was injected at each point. The infiltration range was 0.5 cm in diameter until the lesion became white.
Therapeutic Effect Evaluation Standard
According to Masoodi Z,10 subjective recurrence was diagnosed on the basis of clinical examination. When the lesion surfaced at the same site, it is difficult to feel because the patient’s perspective similar to the previous lesion), and the lesions remained at 24 months of follow-up.
The lesion was further measured at 24 months using the Vancouver Scar Scale (VSS). Scores were tallied by different observers. The observers did not know the pretreatment scores, which were categorized as follows: 0-5: Good Outcome; 6-10: Fair Outcome; and ＞10: Poor Outcome. Effective rate = (Good Outcome + Fair Outcome)/ Poor Outcome. Herein, 24-month postoperative VSS score was compared to the preoperative VSS scores.
All data was entered into a database and processed using the Statistical Package Social Sciences (SPSS version 18.0; SPSS Inc, Chicago). Wilcoxon matched-pairs rank-sum test was used to compare the differences of the 24-month postoperative VSS scores and the preoperative VSS scores. P＜0.05 was considered as statistically significant.