Treatment of Earlobe Keloids by Extralesional Excision Combined with Preoperative and Postoperative “Sandwich” Radiotherapy:

Efficacy and Safety of Excision Combination Therapies for Earlobe Keloids: A Systematic Review and Meta-analysis

BACKGROUND

Different combinations of excision and adjuvant therapies have been applied to improve outcomes for earlobe keloids, though evidence in this field is still lacking.

OBJECTIVES

This study sought to systematically investigate efficacy and safety of these treatments.

METHODS

We conducted a systematic search on PubMed, Embase, Web of Science, and Cochrane Library to find all relevant studies. Meta-analysis of recurrence rates (RRs) and adverse event rates with 95% confidence intervals, and individual participants data (IPD) were calculated for each intervention when possible. Otherwise, narrative syntheses were performed.

RESULTS

A total of 85 articles, covering 23 treatments for earlobe keloids, were included, indicating a preference for multiple combination therapy. The estimated RRs for 6 interventions (i.e., excision monotherapy, combinations of excision with imiquimod, pressure therapy, radiotherapy, steroids, and steroids with pressure therapy) appeared to be comparable. Electron radiotherapy was found to have potential advantages over X-ray treatment, contributing to the observed heterogeneity. Further meta-analysis using IPD revealed that both combination therapies of excision plus steroid therapy (p=0.003) and excision plus radiotherapy (p=0.003) yielded better recurrence-free survival compared to excision alone. The median recurrence-free interval for combination therapy was 10 months. Adverse event rates were similar among different intervention groups.

CONCLUSIONS

This study suggests that combining excision with radiotherapy or perioperative steroid therapy has the potential to improve prognosis of earlobe keloids without increasing the risk of adverse events. Overall evaluation of patients' conditions and further studies with sufficient follow-up are warranted for clinical practice.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comprehensive treatment of ear keloid: A case report

RATIONALE

Ear keloid is one of the more common forms of keloid, which may cause pain and itching, and is aesthetically unappealing. Recurrence is common with any monotherapy which prompted a comprehensive, multidimensional approach.

PATIENT CONCERNS

A 24-year-old female was evaluated in our department on April 6, 2021, due to an "8-year recurrence following a left ear keloid resection." In July 2013, a left auricle keloid excision was performed in a local hospital. One year following the operation, the scar at the surgical site had proliferated, gradually spreading beyond the original scar borders. Patients worry about recurrence after surgery affecting the appearance of the ear.

DIAGNOSIS

Ear keloid.

INTERVENTIONS

The patient underwent a 2-stage re-resection of the keloid, followed by postoperative radiotherapy, and triamcinolone acetonide injection around the incision at the time of the second operation. Finally, silicone gel was applied for antiscar treatment.

OUTCOMES

There has been no postoperative recurrence of ear keloid during the 12-month follow-up.

LESSONS

For ear keloids, combination therapy offers an improved approach with an excellent aesthetic appearance and less risk of recurrence than traditional monotherapy.

Controlling Inflammation Pre-Emptively or at the Time of Cutaneous Injury Optimises Outcome of Skin Scarring

Inflammation plays an active role during the wound healing process. There is a direct association between the extent of injury as well as inflammation and the amount of subsequent cutaneous scarring. Evidence to date demonstrates that high levels of inflammation are associated with excessive dermal scarring and formation of abnormal pathological scars such as keloids and hypertrophic scars. In view of the multiple important cell types being involved in the inflammatory process and their influence on the extent of scar formation, many scar therapies should aim to target these cells in order to control inflammation and by association help improve scar outcome. However, most current treatment strategies for the management of a newly formed skin scar often adopt a watch-and-wait approach prior to commencing targeted anti-inflammatory therapy. Moreover, most of these therapies have been evaluated in the remodelling phase of wound healing and the evaluation of anti-inflammatory treatments at earlier stages of healing have not been fully explored and remain limited. Taken together, in order to minimise the risk of developing a poor scar outcome, it is clear that adopting an early intervention prior to skin injury would be optimal, however, the concept of pre-emptively priming the skin prior to injury has not yet been thoroughly evaluated. Therefore, the aim of this review was to evaluate the available literature regarding scar therapies that aim to target inflammation which are commenced prior to when a scar is formed or immediately after injury, with a particular focus on the role of pre-emptive priming of skin prior to injury in order to control inflammation for the prevention of poor scarring outcome.

Adjuvant Radiotherapy for Keloids

Radiotherapy is one of the therapeutic methods for keloids, and the irradiation technique has innovated from superficial X-ray to brachytherapy after decades of clinical practice. At present, the application of adjuvant radiotherapy has been widely accepted by clinicians, while the consensus of optimal adjuvant radiotherapy strategies for keloids has not been reached. Factors such as radiation timing, dose, fractions, and lesion locations may be associated with the clinical outcomes of patients with keloids after radiotherapy while a comprehensive review is lacking. Herein, this review summarized the published literature of adjuvant radiotherapy for keloids involving mechanism, timing, dose, fractions, and complications, etc., which may facilitate clinical decision making.Level of Evidence III This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A 7-year Experience with Keloid Fillet Flap and Adjuvant Intralesional Corticosteroids

Context:

Keloids are fibroproliferative scars characterized by excessive collagen deposition beyond the margins of the original wound. Although many treatment modalities were described in the literature, no single first-line therapy is recommended, and its recurrence rate remains high.

Aims:

The aim of this study was to investigate the efficacy rate in treating auricle keloids after fillet flap excision combined with adjuvant intralesional steroid injections.

Settings and Design:

This was a retrospective study.

Materials and Methods:

Between 2012 and 2019, a total of 16 auricle keloids were treated at our center with fillet flap excision and adjuvant steroid injections. Intralesional steroid injections were given at the end of the first week and then administered at 4-week intervals until the lesions were soft and flat. Postoperative efficacy, complications, recurrence, and patient satisfaction were analyzed.

Results:

A high improvement of the keloid was observed in 13 (81.2%) lesions. No major complications and no recurrence of the keloid were detected during the follow-up period (mean, 35 months). Regarding patient satisfaction, nine (81.8%) considered their result as excellent.

Conclusion:

This study showed that this approach is effective regardless of the keloid location at the auricle.

Individualized surgery combined with radiotherapy and triamcinolone acetonide injection for the treatment of auricular keloids

Background

Although multiple methods have been proposed to treat auricular keloids, low curative effects and high recurrence rates are currently major clinical problems. Thereinto, surgery combined with radiotherapy and triamcinolone acetonide injection is considered to be the proper choice for comprehensive treatment of auricular keloids. This study aimed at evaluating the therapeutic effect of individualized surgery combined with radiotherapy for the treatment of auricular keloids.

Methods

From February 2014 to February 2017, 67 patients with 113 auricular keloids in total were enrolled in this study. According to specific conditions of lesions, the local tissue and patients’ individual wishes, different surgical methods were selected to analyze the scar excision and repairment of the defect. Within 24 h after the keloid was excised, 5 MeV electron beam irradiation by the linear accelerator was used by radiotherapy with a total dose of 20 Gy at interval of 1 day for 10 consecutive times. Triamcinolone acetonide was injected immediately after surgery, and per month afterward in the following three months.

Results

113 keloids in total were received treatment. The follow-up period was 24 months. Fourteen keloids (12.39%) showed subjective recurrence with a success rate of 87.61%. Wilcoxon matched-pairs rank-sum test was used to compare the differences of the 24-month postoperative VSS scores and the preoperative VSS scores. The VSS scores were as follows: 82 keloids (72.57%) scored less than 5 points (good result), 21 keloids (18.58%) scored 6 to 10 points (fair result), and only 10 keloids (8.85%) scored more than 10 points (bad result). The effective rate was 91.15%.

Conclusions

Individualized surgery combined with early postoperative radiotherapy and triamcinolone acetonide injection is an ideal treatment method to ensure good auricular appearance, low incidences of complications and recurrence based on effective treatment of auricular keloids.

What Do We Know About Treating Recalcitrant Auricular Keloids? A Systematic Review and Meta-Analysis

Background:

Recalcitrant auricular keloids are keloids that have recurred after any previous treatment. They have been shown to have an increased likelihood of recurrence. There is no consensus on how best to treat recalcitrant auricular keloids. Here, we perform the first systematic review and meta-analysis investigating the evidence for treating recalcitrant auricular keloids.

Methods:

We searched MEDLINE, EMBASE, CINAHL, and EBM Reviews using specific keywords. Prespecified inclusion and exclusion criteria were used to assess article eligibility. Data were extracted for number of recalcitrant keloids, treatment modality, recurrence, and minimum follow-up time. Included articles were stratified by treatment and assigned a level of evidence (LOE) based on the Oxford Centre for Evidence-Based Medicine guidelines. A meta-analysis was performed to estimate recurrence rates with 95% confidence intervals for each treatment modality.

Results:

A total of 887 unique articles were identified and 13 included. Eleven were LOE III and 2 were LOE IV. Recurrence rates were found to be 9% (95% CI: 3%-25%) for excision with adjuvant brachytherapy, 14% (95% CI: 12%-17%) for excision with adjuvant compression therapy, 17% (95% CI: 3%-56%) for excision with adjuvant external beam radiation, and 18% (95% CI: 4%-53%) for excision with adjuvant steroid injections. No statistical significant difference was found.

Conclusions:

Data for treatment of auricular keloids are heterogeneous with few high-quality studies. Excision with adjuvant brachytherapy has the lowest recurrence rate in our analysis. Narrow confidence intervals reported here for brachytherapy and compression therapy may help surgeons more confidently recommend either of these treatment modalities to patients.

The Efficacy of Surgical Excision Plus Adjuvant Multimodal Therapies in the Treatment of Keloids: A Systematic Review and Meta-Analysis

BACKGROUND

Research evaluating the efficacy of multimodal therapy for the treatment of keloids has reported combination regimens are most effective.

OBJECTIVE

To compare recurrence rates for keloids treated with surgery plus one adjuvant intervention (dual therapy) versus surgery plus 2 or more adjuvant interventions (triple therapy).

MATERIALS AND METHODS

Systematic literature review and meta-analysis of combination treatment for keloids.

RESULTS

After full-text review, we included 60 articles representing 5,547 keloids: 5,243 received dual therapy, 259 received triple therapy, and 45 received quadruple therapy (the latter 2 groups were combined for analysis). The difference in recurrence rates between dual (19%) and triple therapy (11.2%) was not significant (p = .343). However, the difference in recurrence rates between dual therapy using surgery and radiation (18.7%) and triple therapy using surgery, radiation, and a third intervention (7.7%) was significant (p = .002). The differences for surgery and intralesional triamcinolone (TAC) showed trends toward significance, because keloids treated with dual therapy (21.7%) had a higher recurrence rate than those treated with triple therapy comprised of surgery, TAC, and another intervention (13.7%; p = .099).

CONCLUSION

Triple therapy using surgery plus radiation and/or TAC as one of the adjuvant treatment modalities may achieve the lowest recurrence rates for keloids.

Outcome of recurrent auricular keloid treatment with a combination of surgical excision and perioperative corticosteroid injection

Background:

Auricular keloids that occur after ear piercing or other traumas can challenge surgeons as recurrence is frequent; there has been no consensus about the best management protocol. Surgical excision combined with perioperative corticosteroid injections is frequently used as first-line therapy, but recurrent auricular keloids are usually shifted to a combination of radiotherapy and surgical excision.

Objectives:

The objective is to evaluate the rate of recurrence when recurrent auricular keloids are treated with surgical excision with perioperative corticosteroid injections.

Materials and Methods:

Between February 2017 and January 2020, 41 patients (52 auricles) with recurrent auricular keloids were treated by extralesional keloid excision combined with five corticosteroid steroid injections (two preoperative, one intraoperative, and two postoperative doses). Recurrence was recorded if the surgical scar showed hypertrophy or started to rise above the level of the margins.

Results:

The mean postoperative follow-up was 13.04 months (ranging from 6 to 24 months). Recurrence was recorded in five auricles (9.6%) during the follow-up period.

Conclusion:

Perioperative corticosteroid injections combined with surgical excision of auricular keloids are still a valid option in recurrent cases, and it is a useful choice when radiotherapy facilities are limited.

Outcomes of Surgical Excision and High-Dose-Rate Brachytherapy for Earlobe Keloids

BACKGROUND

Radiotherapy as an adjuvant therapy to surgical resection has shown variable rates of recurrence treating earlobe keloids. The purpose of this study was to describe our experience with surgical excision followed by high-dose-rate brachytherapy and present our outcomes after 24 months of follow-up.

METHODS

Retrospective chart of 14 patients with 14 earlobe keloids treated with surgical excision followed by high-dose-rate brachytherapy, between January 2015 and May 2016 were enrolled. Database included demographics, Fitzpatrick skin type, laterality, lesion size, and follow-up visits information. Outcomes were assessed in terms of keloid recurrence rates, complications, and patient subjective aesthetical result satisfaction after 24 months of follow-up.

RESULTS

All procedures were completed without complications. Three patients experienced keloid recurrence after 6 (14.28%) and 12 months (7.14%). Three patients experienced mild signs of self-limited post-radiation dermatitis. Self-assessment of aesthetical result was considered "very good" in 71.43% of patients.

CONCLUSION

Surgical excision followed by high-dose-rate brachytherapy is secure and effective to treat earlobe keloids, and can be considered a first line combined treatment. Larger clinical trials comparing different irradiation protocols are still needed.

Contemporary treatment of keloids: A 10-year institutional experience with medical management, surgical excision, and radiation therapy

INTRODUCTION

We evaluate a single center's, decade-long experience utilizing 3 approaches to keloid treatment: corticosteroid medical management (MM), surgical excision (SE), and surgical excision + radiation therapy (SE + RT).

STUDY DESIGN

Patients undergoing keloid treatment were identified (2008-2017). Outcomes were symptomatology/cosmesis for MM, and recurrence and complications for SE and SE + RT. Logistic regression was used to determine factors associated with recurrence and complications.

RESULTS

284 keloids (95 MM, 94 SE, 95 S E + RT) corresponded to patients with a median age of 39.1 (IQR: 26.1-53), 68.1% Black, and followed-up for 15.4 months (IQR: 5.6-30.7). For MM, 84.6% and 72.5% reported improvement in cosmesis and symptoms, respectively. SE and SE + RT recurrence were 37.2 and 37.9%, respectively. In adjusted analyses, higher radiation doses were associated with decreased recurrence whereas male gender (OR 3.3) and postoperative steroids (OR 9.5) were associated with increased recurrence (p < 0.01). There were more complications in the SE + RT group.

CONCLUSIONS

MM resulted in at least some improvement. Recurrence rates after SE and SE + RT were similar. Female sex is protective, race does not affect outcomes.

Long-wave Ultraviolet Ray Promotes Inflammation in Keloid-derived Fibroblasts by Activating P38-NFκB1 Signaling Pathway

One of the main mechanisms of keloid formation is the persistent chronic inflammation, which initiates the activation of keloid-derived fibroblasts (KFs) and boosts the production of extracellular matrix. Meanwhile, 95% of the ultraviolet rays that reach the earth are long-wave ultraviolet (UVA). However, the effect of UVA on keloids is currently unclear. The objective of our research is to investigate UVA's impact on keloids. Cell viability assay, migration assay, and cell cycle analysis were conducted. UVA's impacts on gene expressions were detected by real-time quantitative polymerase chain reaction, western blot analysis, enzyme-linked immunosorbent assay, and immunofluorescence. Our results indicated that UVA inhibited the proliferation and migration of KFs. In addition, after UVA irradiation, the expressions of matrix metallopeptidase 1 and matrix metallopeptidase 2 markedly increased in KFs. Moreover, the expression of α-smooth muscle actin and collagen I decreased. Furthermore, KFs with UVA irradiation secreted more interleukin-6 and interleukin-8 in the culture medium. And it was confirmed that the protein expressions of inflammation-related factors, including P38, CK2A, NFκB1, and P65, increased observably in KFs with UVA irradiation. The protein expression of IKBα, also known as NFκB inhibitor α, decreased. All these observations suggested that UVA irradiation could inhibit cellular activity and collagen production in KFs while promoting inflammation by activating P38-NFκB1 signal pathway.

Pediatric earlobe keloids: Outcomes and patterns of recurrence

PURPOSE

Keloids occur as a result of abnormal wound healing and as many as 70% of keloids and hypertrophic scars affect the pediatric population. Earlobe keloids, similar to lesions elsewhere in the body, remain a challenging problem given the high rates of recurrence and lack of consensus regarding treatment strategy. This study aims to evaluate the outcomes and patterns of recurrences following treatment of earlobe keloids in a large cohort of pediatric patients to facilitate identification of the optimal treatment strategy.

METHODS

All pediatric patients who underwent surgical therapy for earlobe keloids over a 10-year period (2004-2015) were identified and demographic, clinical and outcomes data were collected. A follow-up phone survey was administered to assess rates of long-term recurrence and overall satisfaction with the treatment strategy. Data analysis was performed using Student's t-test and Fisher's exact as appropriate.

RESULTS

A total of 94 patients with 135 keloids were identified. Mean age was 14 years with slight preponderance of females (52%) and a majority (75%) of the patients were African American (AA). Mean keloid size was 2.4 cm (0.25-11 cm) with ear piercing being the most common inciting etiology. Excision with steroid injection (59%) was the most frequent treatment approach followed by excision alone (25%). During a median follow up of 2 years, keloid recurrence occurred in 27 (28.7%) patients, 19 (70.4%) underwent additional therapy with 10 (52.6%) re-recurrences noted. Median time to recurrence was 23 months, with a slightly higher recurrence rate in AA patients (32%; p = 0.26) and in those age < 10 years (50%; p = 0.11).

CONCLUSION

This represents the largest series of earlobe keloids treatment in children. Our data suggest that recurrence rates are unaffected by the age at excision and race of the patient. Moreover, adjuncts to excisional therapy such as steroid injection, compression therapy and radiation also did not appear to influence recurrence. Given the pattern of recurrences studies with longer term follow-up are needed to assess the efficacy of treatment strategies.

TYPE OF STUDY

Case series.

LEVEL OF EVIDENCE

IV.

Laser pretreatment for the attenuation of planned surgical scars: A randomized self-controlled hemi-scar pilot study

BACKGROUND

Nonsurgical scar attenuation options include compression garments, silicone gel, intralesional drug therapy, radiation therapy, laser, and light therapies. Laser application preceding surgical intervention has been shown to modify the wound-healing process and affect subsequent scar formation. The objective of this study was to evaluate the safety, efficacy, and final cosmesis of a single presurgical laser treatment on surgical scar formation.

METHODS

This was a randomized, controlled, intraindividual split-scar pilot study with blinded assessments of treated versus untreated planned incision sites. One half of each planned scar was treated by means of an Erbium glass, 1540 nm laser, 24 h before surgery, and the other half was not treated and served as the control. Clinical evaluations and the measurements of patient and physician POSAS scales were done at 1 and 12 months following surgery.

RESULTS

Eleven patients completed the study and were included in the analyses. Laser pretreatment showed a significant beneficial effect compared with no treatment. Both the patient and physician mean Patient and Observer Scar Assessment Scale scores were significantly lower for the laser-treated half of the scars compared with the control side (1.55 to 3.00, p = 0.02 and 2.28 to 4.42, p = 0.03). There was a highly significant interobserver correlation in the evaluation of the overall posttreatment changes (r = 0.904, p < 0.001).

CONCLUSION

A single presurgical laser treatment of a planned incision site is a simple, safe, and painless strategy to significantly improve the final scar appearance.

Clinical efficacy of intermittent magnetic pressure therapy for ear keloid treatment after excision

BACKGROUND

Keloids are benign fibro-proliferative lesion, related to excessive inflammatory reactions in certain anatomical areas, including the auricles. Their specific etiology remains unclear; nonetheless they exhibit tumor-like characteristics of significant recurrence and cause emotional distress, even with various treatment strategies. We applied intermittent magnetic pressure therapy on ear keloids in combination with surgical excision, and present its effectiveness herein.

METHODS

Ear keloid patients were treated with surgical excision followed by magnetic pressure therapy. The keloid tissues underwent excision and keloid marginal flaps were utilized for wound closure. Intermittent magnetic pressure therapy was applied 2 weeks after the surgical procedure. The pressure therapy consisted of a 3-hour application and 2-hour resting protocol (9 hr/day), and lasted for 6 months. The results were analyzed 6 months after the therapeutic procedures, using the scar assessment scale.

RESULTS

Twenty-two ear keloids from 20 patients were finally reviewed. Among the keloids that completed the therapeutic course, 20 ear keloids out of 22 in total (90.9%) were successfully eradicated. Two patients (2 keloids) exhibited slight under-correction. Postoperative complications such as wound dehiscence or surgical site infection were not noted. The scar assessment scale demonstrated a significant improvement in each index. The intermittent pressure therapy led to patient compliance, and avoided pressure-related pain and discomfort.

CONCLUSION

Excision followed by intermittent pressure application using a magnet successfully reduced the burden of fibro-proliferative keloids, and had good patient compliance. The role of intermittent pressure application and resting should be studied with regard to keloid tissue remodeling.

The "Sandwich Therapy": A Microsurgical Integrated Approach for Presternal Keloid Treatment

Background

Keloid therapy remains a great challenge for plastic surgeons, especially when the defect cannot be closed primarily, necessitating tissue transplantation. Here, we introduce a new treatment modality, called the sandwich therapy, for presternal keloids; the sandwich therapy incorporates preradiotherapy, superficial circumflex iliac artery perforator (SCIP) flap transplantation, and postradiotherapy.

Methods

From December 2012 to October 2013, 12 patients received the “sandwich therapy.” For the protocol, all patients went through 5 days of specific events: the precut procedure, preradiotherapy, resection and SCIP flap transplantation, donor site radiotherapy, and final presternal radiotherapy.

Results

All the flaps survived completely. No complication was observed during the perioperative period. With a mean follow-up of 12 months, only 1 case was reported with an incisional hypertrophic scar. In all patients, the main discomfort complaints were resolved postoperatively.

Conclusions

A low-tension or without-tension closure could be achieved with SCIP flap transplantation. The perioperative radiotherapy could further lower the risk of keloid recurrence. The sandwich therapy provides a new surgical approach to presternal keloid treatment.

Combination therapy for bulky auricular keloids: a clinical experience

Auricular keloids are common following ear piercing, infection, trauma, burns, or spontaneously, and they are highly resistant for treatment and are followed by severe cosmetic problems, especially for patients with bulky auricular keloids. The risk of recurrence and the need to return to the normal anatomy of external ear following resection is a challenge to the plastic surgeon. The authors present their experience of treating bulky auricular keloids with surgical excision, followed by immediate postoperative radiotherapy and intralesional steroid injection.

Radiation Therapy Following Total Keloidectomy: A Retrospective Study over 11 Years

BACKGROUND

Radiotherapy treatment after keloidectomy is known to be an effective method for reducing the rate of recurrence. However, to date, the appropriate total radiation dose and fractionation have not yet been confirmed. The authors performed a retrospective analysis to identify the appropriate radiation dose and fractionation in post-keloidectomy radiotherapy.

METHODS

From May 2000 to February 2011, postoperative radiotherapy was performed on 39 lesions in 28 patients after total keloidectomy. The keloid lesions were confined to the ear lobes. Between May 2000 and May 2004, 14 keloids were treated with surgical excision, followed by a total radiation dose of 1,200 cGy in three fractions over four to five days (group 1). Between June 2004 to February 2011, 25 keloids were treated with surgical excision, followed by a total radiation dose of 1,500 cGy in three fractions over four to five days (group 2). Patients were given a survey asking them to report their experiences regarding reoperation, recurrence of symptoms, recurrence of the lesion, and satisfaction with the operation.

RESULTS

Of the 28 patients who were treated, 20 underwent follow-up. Group 2 had more cases showing elevation with erythematous changes, whereas group 1 had more cases showing progressive stages of elevation than group 2. These differences were statistically significant. Moreover, a correlation was observed between the level of keloid elevation and the extent of symptoms.

CONCLUSIONS

We suggest 1,500 cGy of radiation in three fractions following keloidectomy for ear lobe keloids. A further randomized study is needed to assess the recurrence of keloids after radiotherapy.

Treatment of retroauricular keloids: Revision of cases treated at the ENT service of HC/UFPR

Introduction: Keloids are benign tumors arising from abnormal healing of the skin, and there are several procedures available for their treatment.

Objective: The objective of this study was to evaluate the outcomes of patients undergoing treatment of keloids after ear, nose, and throat (ENT) surgeries at our service center.

Method: We conducted thorough, retrospective and prospective analysis of records of patients undergoing treatment of retroauricular keloids at our center.

Results: Nine patients were evaluated, and 6 underwent resection and adjuvant beta-therapy, 2 underwent resection with local application of corticosteroids, and only 1 underwent resection without adjuvant therapy. There was no recurrence of keloids in patients that were treated with beta-therapy in the early postoperative period. One patient had relapsed despite corticosteroid administration and late beta-therapy.

Discussion: Several techniques have been used for the treatment of retroauricular keloids, and beta-therapy is thought to yield the best results, followed by the use of intralesional corticosteroids.

Conclusion: Treatment of retroauricular keloids remains a challenge. While new techniques are being developed, resection followed by early beta-therapy is still the best treatment option.

High-dose-rate brachytherapy for the treatment of recalcitrant keloids: a unique, effective treatment protocol

BACKGROUND

Keloids cause aesthetic disfigurement and physical complaints, mainly pain and pruritus. Treatment of these scars is difficult, with high recurrence rates forming the main issue. Surgical excision with adjuvant radiotherapy is considered the most efficacious treatment. At their institution, the authors have been treating keloids with a high-dose-rate brachytherapy procedure for over 10 years, using a protocol with the lowest total radiation dosage known in the literature.

METHODS

This prospective study included 43 patients of all Fitzpatrick skin types, with 67 keloids in total. After extralesional excision, a radiation scheme of 2 × 6 Gy was administered in two fractions: the first within 4 hours after surgery and the second within 24 hours. Scars were measured and recurrence was judged. Scar appearance was evaluated using the Patient and Observer Scar Assessment Scale.

RESULTS

The recurrence rate was 3.1 percent at a mean follow-up of 33.6 months. A significant average scar surface decrease of 56.7 percent was measured (p = 0.01). Complaints of pain and pruritus decreased by 82.9 and 87.2 percent, respectively. Patients were satisfied with the treatment in 88.6 percent of the cases and with the cosmetic result in 77.1 percent. Pigmentation problems were seen in 21.4 percent of the patients, mostly in Fitzpatrick type V and VI/African American individuals.

CONCLUSIONS

The results of this prospective study show a good cosmetic outcome with a low recurrence rate. The unique radiation schedule proves the efficacy and safety of high-dose-rate brachytherapy and suggests the importance of immediate postoperative irradiation. In addition, only one outpatient treatment is required after surgery, enhancing patient convenience.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ionizing irradiation inhibits keloid fibroblast cell proliferation and induces premature cellular senescence

Keloids are one of the common refractory conditions in dermatology and aesthetic plastic surgery. The most effective treatment is superficial radiotherapy followed by surgical removal. The rate of recurrence is strongly associated with the total dose of ionizing irradiation, and the underlying mechanism remains unclear. In this study, we used primary keloid fibroblasts (KFb) isolated from patient samples to investigate the effects of X-ray radiation on cell proliferation, cell toxicity and cell cycle, as detected by CCK-8 assay kit and flow cytometer. In addition, we examined senescence-associated β-galactosidase activity and the associated gene expression using real-time polymerase chain reaction and western blot in KFb exposed to X-ray radiation. X-ray radiation inhibited cell proliferation and induced cell senescence in KFb in a dose-dependent manner. Inhibition of cell proliferation and induction of cellular senescence were mediated by interruption of the cell cycle with an extended G0/G1 phase. Furthermore, the expressions of senescence-associated genes p21, p16 and p27 were upregulated both at mRNA and protein levels in KFb exposed to X-ray radiation. Taken together, our data indicate that X-ray radiation may prevent the recurrence of keloids by controlling fibroblast proliferation, arresting the cell cycle and inducing premature cellular senescence.

New insights on keloids, hypertrophic scars, and striae

This article presents an overview of the literature regarding treatments for keloid disease, hypertrophic scars, and striae distensae in dark pigmented skin. Striae, keloid, and hypertrophic scarring present a challenging problem for both the clinician and patient. No single therapy is advocated for hypertrophic scars, keloid scars, or striae distensae. New therapies have shown promise in the treatment of hypertrophic and keloid scars, and in patients with dark pigmented skin. This article provides guidance on the assessment and determination of patients' suitability for certain treatment options, as well as advice on the follow-up of patients affected with problematic scarring and striae.

Use of Integra and interval brachytherapy in a 2-stage auricular reconstruction after excision of a recurrent keloid

Keloids present a formidable clinical challenge. Surgical excision in conjunction with radiation therapy may decrease the chance of keloid recurrence. Split-thickness skin grafts, however, are more prone to failure in the setting of radiation. In this report, we present a patient with a recurrent auricular keloid who underwent excision and immediate Integra (Integra LifeSciences, Plainsboro, NJ) application, followed by high-dose rate brachytherapy and interval split-thickness skin graft placement. A 23-year-old woman with a history of a recurrent auricular keloid after previous surgical excision, corticosteroid injection, and radiation underwent reexcision of her keloid. Integra was used to cover the resultant exposed auricular perichondrium. The patient then received high-dose rate brachytherapy (1500 cGy) on postoperative days 1 and 2, followed by definitive split-thickness skin graft placement 3 weeks after her initial surgery. The patient recovered from all interventions without complication. There was no evidence of keloid formation 27 months after the interval split-thickness skin graft placement at either the auricular recipient or thigh donor sites. We report the first case of a 2-stage reconstruction of a recurrent auricular keloid (composed of keloid excision and placement of Integra in conjunction with high-dose rate brachytherapy, followed by interval split-thickness skin grafting), resulting in an acceptable cosmetic result without evidence of recurrence at long-term follow-up.

Minimally invasive aesthetic procedures in young adults

Age is a significant factor in modifying specific needs when it comes to medical aesthetic procedures. In this review we will focus on young adults in their third decade of life and review minimally invasive aesthetic procedures other than cosmetics and cosmeceuticals. Correction of asymmetries, correction after body modifying procedures, and facial sculpturing are important issues for young adults. The implication of aesthetic medicine as part of preventive medicine is a major ethical challenge that differentiates aesthetic medicine from fashion.