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Use of keloid skin as an autograft for earlobe reconstruction after excision
Vol. ~
IVo. 0
J u n e 2UUO
CLINICAL NOTES Use of keloid skin as an autograft for earlobe reconstruction after excision Vincent B. Ziccardi, DDS, MD, a and Jennifer Lamphier, DMD, b Newark, NJ UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:674-5)
A keloid is defined as an exuberant healing of skin with a "crab-like" growth that extends beyond the original boundaries of a wound. Keloids occur only in humans. They are uncommon at the extremes of life and occur with equal frequency in men and women. There is a predilection for keloids to occur more frequently in d a r k - s k i n n e d individuals. Keloids tend to r e m a i n elevated over time, in contrast to hypertrophic scars, which will eventually flatten. Regional susceptibility to keloid formation is well known to exist on the back, posterior neck, and presternal areas. The ears, deltoid region, anterior chest, and neck are moderately susceptible. The least susceptible regions include the abdomen, forearms, and non-hair-bearing portions of the face. Keloids almost never appear on very lax skin such as the upper eyelids, scrotum, and breast areolae, t The causes of keloid formation are unknown; however, several theories have been postulated, including imbalances in hormonal levels (such as during pregnancy), the presence of ingrown hairs, and genetic predisposition. Keloids are characterized by a random organization of collagen bundles with no clear relationship to the skin surface, in contrast to the collagen bundles that run parallel to the surface in normal skin. Itching, pain, and paresthesia may occur from ear keloids, in addition to the resultant aesthetic deformity. The most common cause of earlobe keloids is earlobe piercing. 2
CASE REPORT A 26-year-old African American man was first seen at the oral and maxillofacial surgery clinic for evaluation and treataAssistantProfessor and Residency Program Director. bResident, Department of Oral and Maxillofacial Surgery. Received for publication Apr 2, 1999; returned for revision June 14, 1999; accepted for publication June 30, 1999. Copyright © 2000 by Mosby, Inc. 1079-2104/2000/$12.00 + 0 7/12/1111611 doi:10.1067/moe.2000.101611 674
ment of an earlobe keloid, which had developed secondary to ear piercing a few years earlier. He had noticed a slow and insidious subsequent growth that now prevented him from wearing earrings. The keloid was dumbbell-shaped with a 5mm lateral protrusion and a 2-cm diameter sessile portion on the posterior surface of the earlobe. It was centered over the pierced earring hole with a palpable core of tissue through the entire dimension of the lobe (Fig 1). Each of the 2 components was primarily excised after local anesthesia was induced, as was the core of the keloid joining the 2 regions. The lateral lobe defect was amenable to primary closure; however, the posterior aspect of the lobe had a defect of almost 2 cm in diameter. Primary closure of the wound would have resulted in gross distortion of the earlobe. Alternative treatment options included healing by secondary intention, local rotational flaps, skin grafts from a distant donor site, or a skin graft from the surface of the excised keloid. After discussing options with the patient, we decided that a skin-grafting technique was the best option. To avoid potential scarring at a distant site, we decided to use skin from the excised keloid specimen. A full-thickness skin graft was harvested and prepared by removing all residual keloid tissue until the graft was thinned to the point where the edges rolled in toward the dermal surface. The graft was perforated and sutured over the defect, and some bolster sutures were placed to remove any potential dead space (Fig 2). The wound was dressed with antibiotic ointment, and a pressure dressing was applied to the ear and head. At the 2-week follow-up visit, the graft clinically appeared to have taken, and the ear maintained a normal anatomic appearance. The patient has since relocated, but on telephone follow-up he stated that he was satisfied with the result and that no recurrence was noted 6 months after surgery.
DISCUSSION One reported benefit of using a full-thickness skin graft in this case is the minimization of scar contracture and concomitant earlobe deformities. The use of the keloid skin itself is additionally beneficial because there is no donor site, which would bring the potential for further
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Ziccardi and Lamphier 675
Volume 89, Number 6
Fig 1. Appearance of ear keloid before surgery.
keloid formation. 3 The second advantage of this technique is that the skin is thinned from the slow expansile growth of the keloid, and the texture and color are a comparable match because they originate from the same site. Many therapeutic options are available for the treatment of earlobe keloids. This variety in treatment modalities reflects the complex nature of keloids and the high relapse potential. Our protocol generally includes surgical excision with preoperative, intraoperative, and postoperative corticosteroid injections. In addition, commercially available pressure earrings with a broad contact area are recommended, to be worn at all times by female patients and in the evening hours by male patients. Pressure therapy is a popular treatment modality for earlobe keloids. It is often combined with other treatments, such as surgical excision and corticosteroid injections. The mechanism by which pressure influences keloid formation is unknown, but it has been postulated that pressure can create ischemia, which limits fibroblastic activity and encourages collagen degradation. Standard clip-on earrings may be useful for small keloid treatment; however, they come in contact with only a small area of the earlobe. Commercially available earrings with large baseplates that cover the entire earlobe are manufactured by Padgett Instrument (Kansas City, Mo) in a variety of fashionable styles, which encourage their use at all times. 4 The most common treatment adjunct for keloid management is the use of intralesional corticosteroids. Keloids may be softened and flattened with this treatment before, during, or after surgery. The presumed effect is through increased collagen degradation and other changes in the ground substance. Triamcinolone acetonide is the most commonly used corticosteroid for
Fig 2. Skin graft sutured in place on posterior ear defect.
intralesional injection. The steroid must be administered every 2 to 4 weeks until results are clinically evident. Complications of steroid injection include subcutaneous or skin atrophy, hypopigmentation, and telangiectasia. 4 REFERENCES 1. Datubo-Brown DD. Keloids: a review of the literature. Br J Plast Surg 1990;43:70-7. 2. Stucker FJ, Shaw GY. An approach to management of keloids. Arch Otolaryngol Head Neck Surg 1992; 118:63-7. 3. Apfelberg DB, Maser MR, Lash H. The use of epidermis over a keloid as an autograft after resection of the keloid. J Dermatol Surg Oncol 1976;2:409-11. 4. Hendricks WM. Complications of ear piercing: treatment and prevention. Cutis 1991;48:386-94.
Reprint requests: Vincent B. Ziccardi, DDS, MD University of Medicine and Dentistry of New Jersey Department of Oral and Maxillofacial Surgery 110 Bergen St Room B 854 Newark, NJ 07103-2400 ziccarvb @umdnj.edu
IVo. 0
J u n e 2UUO
CLINICAL NOTES Use of keloid skin as an autograft for earlobe reconstruction after excision Vincent B. Ziccardi, DDS, MD, a and Jennifer Lamphier, DMD, b Newark, NJ UNIVERSITY OF MEDICINE AND DENTISTRY OF NEW JERSEY
(Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:674-5)
A keloid is defined as an exuberant healing of skin with a "crab-like" growth that extends beyond the original boundaries of a wound. Keloids occur only in humans. They are uncommon at the extremes of life and occur with equal frequency in men and women. There is a predilection for keloids to occur more frequently in d a r k - s k i n n e d individuals. Keloids tend to r e m a i n elevated over time, in contrast to hypertrophic scars, which will eventually flatten. Regional susceptibility to keloid formation is well known to exist on the back, posterior neck, and presternal areas. The ears, deltoid region, anterior chest, and neck are moderately susceptible. The least susceptible regions include the abdomen, forearms, and non-hair-bearing portions of the face. Keloids almost never appear on very lax skin such as the upper eyelids, scrotum, and breast areolae, t The causes of keloid formation are unknown; however, several theories have been postulated, including imbalances in hormonal levels (such as during pregnancy), the presence of ingrown hairs, and genetic predisposition. Keloids are characterized by a random organization of collagen bundles with no clear relationship to the skin surface, in contrast to the collagen bundles that run parallel to the surface in normal skin. Itching, pain, and paresthesia may occur from ear keloids, in addition to the resultant aesthetic deformity. The most common cause of earlobe keloids is earlobe piercing. 2
CASE REPORT A 26-year-old African American man was first seen at the oral and maxillofacial surgery clinic for evaluation and treataAssistantProfessor and Residency Program Director. bResident, Department of Oral and Maxillofacial Surgery. Received for publication Apr 2, 1999; returned for revision June 14, 1999; accepted for publication June 30, 1999. Copyright © 2000 by Mosby, Inc. 1079-2104/2000/$12.00 + 0 7/12/1111611 doi:10.1067/moe.2000.101611 674
ment of an earlobe keloid, which had developed secondary to ear piercing a few years earlier. He had noticed a slow and insidious subsequent growth that now prevented him from wearing earrings. The keloid was dumbbell-shaped with a 5mm lateral protrusion and a 2-cm diameter sessile portion on the posterior surface of the earlobe. It was centered over the pierced earring hole with a palpable core of tissue through the entire dimension of the lobe (Fig 1). Each of the 2 components was primarily excised after local anesthesia was induced, as was the core of the keloid joining the 2 regions. The lateral lobe defect was amenable to primary closure; however, the posterior aspect of the lobe had a defect of almost 2 cm in diameter. Primary closure of the wound would have resulted in gross distortion of the earlobe. Alternative treatment options included healing by secondary intention, local rotational flaps, skin grafts from a distant donor site, or a skin graft from the surface of the excised keloid. After discussing options with the patient, we decided that a skin-grafting technique was the best option. To avoid potential scarring at a distant site, we decided to use skin from the excised keloid specimen. A full-thickness skin graft was harvested and prepared by removing all residual keloid tissue until the graft was thinned to the point where the edges rolled in toward the dermal surface. The graft was perforated and sutured over the defect, and some bolster sutures were placed to remove any potential dead space (Fig 2). The wound was dressed with antibiotic ointment, and a pressure dressing was applied to the ear and head. At the 2-week follow-up visit, the graft clinically appeared to have taken, and the ear maintained a normal anatomic appearance. The patient has since relocated, but on telephone follow-up he stated that he was satisfied with the result and that no recurrence was noted 6 months after surgery.
DISCUSSION One reported benefit of using a full-thickness skin graft in this case is the minimization of scar contracture and concomitant earlobe deformities. The use of the keloid skin itself is additionally beneficial because there is no donor site, which would bring the potential for further
ORAL SURGERY ORAL MEDICINE ORAL PATHOLOGY
Ziccardi and Lamphier 675
Volume 89, Number 6
Fig 1. Appearance of ear keloid before surgery.
keloid formation. 3 The second advantage of this technique is that the skin is thinned from the slow expansile growth of the keloid, and the texture and color are a comparable match because they originate from the same site. Many therapeutic options are available for the treatment of earlobe keloids. This variety in treatment modalities reflects the complex nature of keloids and the high relapse potential. Our protocol generally includes surgical excision with preoperative, intraoperative, and postoperative corticosteroid injections. In addition, commercially available pressure earrings with a broad contact area are recommended, to be worn at all times by female patients and in the evening hours by male patients. Pressure therapy is a popular treatment modality for earlobe keloids. It is often combined with other treatments, such as surgical excision and corticosteroid injections. The mechanism by which pressure influences keloid formation is unknown, but it has been postulated that pressure can create ischemia, which limits fibroblastic activity and encourages collagen degradation. Standard clip-on earrings may be useful for small keloid treatment; however, they come in contact with only a small area of the earlobe. Commercially available earrings with large baseplates that cover the entire earlobe are manufactured by Padgett Instrument (Kansas City, Mo) in a variety of fashionable styles, which encourage their use at all times. 4 The most common treatment adjunct for keloid management is the use of intralesional corticosteroids. Keloids may be softened and flattened with this treatment before, during, or after surgery. The presumed effect is through increased collagen degradation and other changes in the ground substance. Triamcinolone acetonide is the most commonly used corticosteroid for
Fig 2. Skin graft sutured in place on posterior ear defect.
intralesional injection. The steroid must be administered every 2 to 4 weeks until results are clinically evident. Complications of steroid injection include subcutaneous or skin atrophy, hypopigmentation, and telangiectasia. 4 REFERENCES 1. Datubo-Brown DD. Keloids: a review of the literature. Br J Plast Surg 1990;43:70-7. 2. Stucker FJ, Shaw GY. An approach to management of keloids. Arch Otolaryngol Head Neck Surg 1992; 118:63-7. 3. Apfelberg DB, Maser MR, Lash H. The use of epidermis over a keloid as an autograft after resection of the keloid. J Dermatol Surg Oncol 1976;2:409-11. 4. Hendricks WM. Complications of ear piercing: treatment and prevention. Cutis 1991;48:386-94.
Reprint requests: Vincent B. Ziccardi, DDS, MD University of Medicine and Dentistry of New Jersey Department of Oral and Maxillofacial Surgery 110 Bergen St Room B 854 Newark, NJ 07103-2400 ziccarvb @umdnj.edu