Earlobe Keloid Excision

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: Earlobe Keloid Excision

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Introduction

Keloids are benign, hard, persistent fibrous proliferations that develop in predisposed persons at sites of cutaneous injury. These deposits of collagen expand beyond the original size and shape of the wound, frequently invading the surrounding skin. Keloids are thought to develop from abnormalities in the synthesis and degradation of collagen. 
Earlobe keloids usually appear as shiny, smooth, globular growths on one or both sides of the earlobe. Ear piercing is the most common cause, but other causes include trauma, surgical procedures, and burns. Patients with earlobe keloids usually complain of the cosmetic abnormality, but they may also report pruritus, pain, or paresthesias. Patients may be extremely embarrassed about this condition, and some persons consider keloids to be a major deformity. 
Dumbbell-shaped keloids often distort the pinna. They grow through the pierced ear tract and protrude from both sides of the earlobe. Keloids that are limited to one side of the pinna more commonly appear on the posterior surface of the earlobe. Factors attributable to the piercing technique, allergy to the metal in the earring fastener, or infection behind the ear may explain the increased frequency of posterior growths. 
Multiple therapeutic options are available for the treatment of keloids. The location, size, and depth of the keloid, as well as the length of time the keloid has been present, influence the choice of therapy. Combination therapy appears to be the most effective, although there are few comparative studies. Surgical excision, combined with corticosteroid injections and pressure therapy, is the mainstay of therapy for earlobe keloids. 
Keloids may be softened and flattened by intralesional corticosteroid therapy. Corticosteroids act on the keloids by producing changes in the ground substance and increasing collagen degradation. Small lesions may be treated using corticosteroid injection as monotherapy. Larger keloids may be softened using corticosteroids, either to relieve pain or as the initial therapy before surgery. Triamcinolone acetonide (10 mg/mL or 40 mg/mL mixed with an equal amount of 1% or 2% lidocaine) is frequently used. A Luer-Lok (twist-on) syringe should be used to administer the injection to prevent separation of the needle when injecting under pressure into a hard keloid. Some providers provide preoperative injections every 3 to 4 weeks for 2 months. Postoperative injections are administered for periods of weeks to months, depending on the patient’s clinical progress. 
Pressure therapy may be an effective treatment for keloids of the ear following piercing. Pressure earrings, also called Zimmer splints, are splints that are inexpensive and molded to the appropriate size, cosmetically altered to appear as earrings. Simple aluminum finger splints may also be cut, folded, and clamped to the earlobe. The patient may reapply these splints every evening. 

Equipment

  • A 1-cc Luer-Lok (twist-on) syringe with 27- or 30-gauge needle

  • Nonsterile gloves

  • An alcohol swab

  • Gauze, 4 × 4 inches

  • Protective eyewear

Indications

  • Painful or unsightly earlobe keloids

Contraindications (Relative)

  • Local infection

  • Severe bleeding disorders

  • Extreme illness that would make wound healing difficult

  • Cellulitis in the tissues to be incised

  • Conditions that may interfere with wound healing (collagen vascular diseases, smoking, diabetes)

  • Concurrent medications that may increase the likelihood of intraoperative bleeding (aspirin, other nonsteroidal anti-inflammatory drugs, warfarin)

  • Uncooperative patient

The Procedure

Core Excision Technique

Step 1

Skin closure is designed to minimize distortion of the earlobe contour and make the lobes look as similar as possible. Inject local anesthetic into the lobe (see Local Anesthesia Administration), or administer a triamcinolone/lidocaine combination as the local anesthetic. Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E). 
  • Pearl: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

  • Pearl: If the keloid is only in the posterior side, the pinna may be taped over to facilitate removal.

Step 2

Drape the area. Perform a fusiform (elliptical) excision around the base of the keloid. Feel the base of the excision to see if the keloid has formed a “core” or keloid band along the pierced path through the ear. Some providers excise the core, while others leave it in place and inject it with steroids. Other providers will incise the most inferior portion of earlobe creating a V-shape wedge and then close the earlobe. 
  • Pearl: Placing a cotton ball in the external ear canal will prevent blood from draining into the canal.

  • Pearl: Bleeding is common during earlobe keloid excisions. Although closure and pressure clamping will stop most of the minor bleeding, active bleeders need to be addressed by direct pressure or short-term clamping with hemostats.

Step 3

Using gentle tissue handling, close the defect with fine, simple, interrupted, nonabsorbable, monofilament sutures. 
  • PITFALL: Absorbable sutures should be avoided, because nonabsorbable sutures such as 5-0 nylon may cause less tissue reaction.

Step 4

With both techniques, triamcinolone/lidocaine (without epinephrine) combination can be administered as an injection immediately after surgery if it was not used as the anesthetic solution. Apply ointment to the incision and place a clean gauze over the site. 

Step 5

A simple pressure device may be made by taking aluminum finger splints and cutting, folding, and clamping the splint to the earlobe. 
  • Pearl: Leakage of the steroid from the wound can be reduced by applying tape over the incision site.

Complications

  • Systemic absorption of steroid, with potential worsening of control for diabetic patients

  • Burning sensation for up to 3 to 5 minutes after injection

  • Local skin atrophy

  • Hypopigmentation (temporary or permanent)

  • Telangiectasia formation

  • Sterile abscess formation

  • Reformation of keloid

  • Bleeding

  • Infection

Pediatric Considerations

Keloids are less common in children, but when they occur, the procedure is essentially the same. Consider the use of an occluded topical anesthetic to decrease the pain of injection in children. 

Postprocedure Instructions

Injections can be repeated at monthly intervals. Some providers increase the concentration of triamcinolone by 10 mg/mL each visit on nonfacial lesions until the lesion softens and flattens, then decrease the strength of injections. Keloids often need multiple treatments 3 to 4 weeks apart until there is adequate flattening of the lesion. 

Coding Information and Supply Sources

If a lesion is removed, use the “excision—benign lesion” codes (11400 to 11471). 

ICD-9 Code

Suppliers

Recommended supplies and sources may be found in Appendix I

Bibliography

Brent  B . The role of pressure therapy in management of earlobe keloids: preliminary report of a controlled study. Ann Plast Surg.  1978;1:579–581.  [View Abstract]
Cheng  LH . Keloid of the ear lobe. Laryngoscope.  1972;82:673–681.  [View Abstract]
Golladay  ES . Treatment of keloids by single intraoperative perilesional injection of repository steroid. South Med J.  1988;81:736–738.  [View Abstract]
Hirshowitz B, Lerner D, Moscona AR Treatment of keloid scars by combined cryosurgery and intralesional corticosteroids. Aesthetic Plast Surg.  1982;6:153–158.  [View Abstract]
Jackson IT, Bhageshpur R, DiNick V, et al Investigation of recurrence rates among earlobe keloids utilizing various postoperative therapeutic modalities. Eur JPlast Surg.  2001;24:8–95.
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Salasche SJ, Grabski W Keloids of the earlobes: a surgical technique. J Dermatol Surg Oncol.  1983;9:552–956.  [View Abstract]
Stashower  ME . Successful treatment of earlobe keloids with imiquimod after tangential shave excision. Dermatol Surg.  2006;32(3):380–386.  [View Abstract]
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Weimar VM, Ceilley RI Treatment of keloids on earlobes. J Dermatol Surg Oncol.  1979;5:591–593.
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2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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