A Modified Technique for Removing Earlobe Keloids

Earlobe keloids are frustrating to patients and

surgeons for their aesthetic deformity. The purpose

of surgery is to remove the fibrous core of the

keloid and to cover the defect, restoring the normal

contour of the ear. There have been numerous

methods described to achieve this, including

healing by secondary intention, direct closure, skin

grafts, and local flaps.

Many different types of local flaps of varying com-

plexity have been described for different situations.

Lee et al.1 and Kim et al.2 proposed an interesting

and effective design in which the skin over the

keloid was dissected from the keloid core and pre-

served as a flap to cover the defect. Based on the

principles of this technique, we describe a modifi-

cation that allows for accurate preoperative mea-

surement and planning, allowing for safe and

simple elevation and insetting of the flap during

the procedure (Figure 1).

Preoperative Measurements and Marking

Before surgery, we use a silk suture to form a circle

around the base of the keloid. The circumference

of the resulting ellipse and its long and short axes

are measured and documented (Figure 2). These

measurements represent the dimensions of the skin

flap required to reconstruct the defect after enucle-

ation of the keloid core. Using the same silk suture,

this ellipse is transposed onto the body of the

keloid with one side aligned along the base of the

keloid, representing the dermal pedicle of the skin

flap (Figure 3). The remaining surface area of the

keloid not covered by our elliptical flap is excised

along with the keloid core in our modified

technique.

Technique

Local anesthesia (2% lidocaine and 1:100,000

epinephrine) is infiltrated around the earlobe. After

waiting several minutes, we use a scalpel to cut

through the skin along the incision lines described

above. The keloid core is then dissected and

removed from under the skin of our marked

Figure 1. The edge of keloid and incision line in our noveltechnique.

Figure 2. A tie is used to form a circle according to thebase of the keloid.

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ellipse, which is raised as a flap (Figure 4).

The defect is then resurfaced by insetting the

skin flap. The wound is closed with one layer of

6–0 Prolene interrupted sutures without ten-

sion. The ear retains good shape after the surgery

(Figure 5).

Discussion

Our modified technique based on Kim’s and Lee’s

methods is an effective way to accurately measure

and elevate the skin flap. The ability to design the

required flap accurately and mark the incision lines

has many advantages. First, by raising only what is

required to cover the defect, we significantly reduce

the time of flap elevation. We do not need to sepa-

rate all the skin off the keloid core, and there is no

redundant flap to trim. Second, we eliminate the

likelihood of an excessively trimmed flap, with

resulting tension on the sutures and distortion of

the earlobe. Our technique, relying on accurate

original measurements, significantly reduces the

need for refashioning of the flap once raised.

Third, we generally choose the keloid base parallel

to long axis as the pedicle so that sufficient width

is retained to ensure adequate blood supply to the

skin flap. In major cases, we locate the flap pedicle

anteriorly so scarring is less visible.

Based on the principles of atraumatic surgery,

accurate approximation, and avoidance of tension

proposed by Kim and Lee, we believe our modified

technique provides a safe, efficient, effective

Figure 3. The basal circle is projected to the surface ofkeloid.

Figure 4. A flap is elevated, and the keloid core, togetherwith the skin between two incision lines, is removed as awhole mass.

Figure 5. The surgical result is good (3 weeks after sur-gery).

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method to reconstruct the earlobe after keloid

removal.

Acknowledgments The authors thank Hua L,

Ying H (Department of Plastic and Reconstructive

Surgery, Sir Run Run Shaw Hospital, Medical

College, Zhejiang University) and Frank Lin (Royal

Melbourne Hospital, Australia) for their excellent

assistance in this work.

References

1. Lee Y, Minn K, Baek R, Hong JJ, et al. A new surgical treatment

of keloid: keloid core excision. Ann Plast Surg 2001;46:135–40.

2. Kim D, Kim E, Eo S, Kim K, et al. A surgical approach for

earlobe keloid: keloid fillet flap. Plast Reconstr Surg

2004;113:1668–74.

YAN SHAO, PHD

XING HE, PHD

Department of Plastic and Reconstructive Surgery

Sir Run Run Shaw Hospital

Medical College

Zhejiang University

Hangzhou, China

Regarding Assisting Pincer Nail Deformity by Haneke's Procedure

We read with interest the article “Pincer Nails:

Definition and Surgical Treatment” by Baran

and colleagues1 that encompassed a variety of

surgical “tricks” to assist the correction of

pincer nail deformity. They mentioned Haneke’s

technique followed by a median incision of the

nail bed from the border of the lunula to 2 mm

beyond the hyponychium and extending down to

the bone. During this incision, the traction

osteophyte was felt with the scalpel, although it

was not obvious on the roentgenogram. The

pinched nail bed was dissected from the

terminal phalanx, the distal dorsal tuft with

the osteophyte was rongeured off, and the nail

bed was expanded and sutured using 6–0

monofilament absorbable sutures. Reverse tie-over

sutures were placed in the lateral nail folds, with

small rubber tubes used as cushions to prevent

the sutures from cutting through the nail folds.

These sutures kept the nail bed stretched over

the bone and were removed after approximately

3 weeks.

We have five important suggestions that could

further refine this procedure. First, fungal nail

infection should be treated and then excluded by

negative results on microscopic examination

(KOH test) and fungal culture before reconstruc-

tion. Second, after exsanguination of the toe, the

deformed nail plate should be removed using the

rolling method, preventing unnecessary trauma to

the nail bed and matrix. Third, after the nail bed

is exposed, the surrounding fibrous tissues can be

excised using scissors to obtain a regular nail bed

for smooth growth of the new nail (Figure 1A).

Fourth, surface irregularities such as traction

osteophytes and the periosteum are more easily

removed using a bone burr or rasp than using a

bone rongeur (Figure 1B). Fifth, the original nail

could also be trimmed thin using the bone burr or

rasp for final coverage of the nail bed

(Figure 1C).

We examined the cases of four patients who

underwent treatment on five great toes using

Haneke’s procedure. Satisfactory results were

obtained using this simple, effective, nail matrix–

sparing technique without any complications

(Figure 1D). In conclusion, we believe that by

adopting the abovementioned steps for further

refining this technique, Haneke’s procedure can

be easily performed with low morbidity and can

be a good option for treatment of pincer nail

deformity.

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