Superiorly Based Preauricular Flap for Total Ear Lobe Reconstruction Following a Large Keloid Excision

Abstract

A large keloid on the right earlobe that extended to the infraauricular region was the reason for the 42-year-old woman’s referral for treatment. The entire thickness of the earlobe was implicated in the surgical defect that resulted from the severe keloid excision. We employed a straightforward technique to provide a pleasing appearance while repairing the entire lobe in a single stage without the need for grafts. In addition to being ornamental, ear lobules provide a crucial point of reference for facial symmetry while wearing earrings. It is obviously unnatural from an aesthetic standpoint to lose them. Numerous techniques created to reconstruct this deformity have offered a range of benefits and drawbacks. A case of big ear lobe keloid with whole ear lobe reconstruction employing a new, single-stage, superiorly based Preauricular flap technique that is easy to master and produces good results in terms of absence of recurrence or no any deformity even after a lengthy follow-up period has been presented.

Introduction

A problematic clinical issue with wound healing is keloids. The Egyptian pyramid era is credited with producing the earliest documented account of keloids. The Greek phrase “crab like” was used by Alibert to invent the term “Cheloid” in 1806 [1, 2]. In1961, Cosman et al. conducted the first comprehensive review of keloids, documenting their presentation, features, and therapy. Unique to humans, keloids are dermal fibro proliferative diseases defined by excessive collagen deposition in the subcutaneous and dermal tissues. From race to race, keloid development occurs at different rates. These lesions are more common in Black and Asian individuals than in Caucasians, with incidences ranging from 5:1 to 15:1. The anatomic site most susceptible to adverse wound responses, including keloids, is the external ear. A typical reaction to ear piercings is ear lobe keloids, particularly in people with darker skin tones. Earlobe keloids are a dangerous condition with challenging treatment options [3]. We are presenting a case of superiorly based preauricular flap for rebuilding of the entire ear lobe after extensive keloid excision.

Case Presentation

The right ear lobe of a 42-year-old woman had been severely swollen for a year. She got her first earlobe piercing on her right side when she was a little child, and she got her second one a year later. She experienced excessive itching near the second puncture site and a little nodule formed. Firm and mildly tender, the swelling expanded quickly to its current size of 6 × 4 cm, extending to the right infraauricular region (Fig. 1). Keloid was determined to be the clinical diagnosis. She never had any previous surgical or medical history. For three weeks previous to surgery, weekly injections of triamcinolone acetonide were administered perilesionally at the keloid site. Local anaesthetic was used during the patient’s procedure. A combination of 2% lidocaine, adrenaline, and 40 mg/ml triamcinolone acetonide was used to anesthetize the surgical site prior to excision. She had a massive keloid excision (Fig. 2) and a superiorly based Preauricular flap was used to reconstruct the ear lobe (Figs. 3, 4, 5). She was then instructed to apply pressure ear dressings. Following excision, triamcinolone was administered locally once a week for 3 weeks. After the mass was excised, a light microscope revealed mild and profound dermal sclerosis with a dense bundle of collagen mixed in with many proliferating fibroblasts (Fig. 6), which is indicative of keloid. Patients’ follow-up at six months and a year later revealed no signs of recurrence or deformity.

Fig. 1.

A patient’s preoperative clinical picture showing a massive keloid over their right earlobe and extending to their right infraauricular region

Fig. 2.

Intraoperative image showing the complete excision of keloid, with the ensuing surgical defect compromising the whole ear lobe

Fig. 3.

An intraoperative picture demonstrating the Preauricular Transposition Flaplifting technique (Sequential steps from step 1 to step 3)

Fig. 4.

Intraoperative photograph showing the suturing of Preauricular Transposition Flap, primary donor site, infraauricular region using 3-0 ethilon suture material a Seen

Fig. 5.

A patient’s postoperative photo displaying the surgical site one month following the procedure

Fig. 6.

Histopathological photomicrograph showing earlobe keloid with typical haphazard thick collagen bundles (Blue arrow) with increased fibroblasts (Black arrow)

A line diagram depicting how the Preauricular flap has been fashioned to create rounded reconstructed ear lobule for right total ear lobule defect after complete excision of a large keloid (Fig. 7).

Fig.7.

A line diagram depicting how the Preauricular flap has been fashioned to create rounded reconstructed ear lobule for right total ear lobule defect

Discussion

A benign development of dense fibrous tissue that develops outside of the initial boundaries of the wound or inflammatory response following a cutaneous injury, such as surgery, is known as a keloid. Unlike regular scars, keloids typically get bigger over time and can cause deformities, tingling, and itching in addition to numbness [4]. Following surgical excision, earlobe keloids exhibit a high rate of recurrence of up to 80%. Shiny, smooth, spherical growths on one or both sides of the earlobe are the typical appearance of earlobe keloids. Dark-skinned people have a keloid look approximately 15 times more frequently than white people. Pregnancy and puberty, when the pituitary gland is hyperactive, are times of higher incidence. The etiology of keloid formation remains unknown despite the abundance of theories regarding its formation. It has recently been demonstrated that sucrose regulates type 1 and type 3 collagen metabolism in granulation tissue fibroblast cultures in a different way than it does in fibroblast cultures derived from fibrotic skin lesions, shifting the metabolism of collagen toward normal. Variations in other cytokines, including as interleukins 6, 13, and 15, may also contribute to the development of keloids [5]. There is now no one therapy option available, and trying to treat keloids could make things worse. The choice of therapy is influenced by the earlobe keloid’s location, size, depth, and duration. Excision can also be done to remove diseased areas or to debulk big keloids. Merely surgical removal of the keloid increases the risk of recurrence, which can range from 50 to 100% [6]. Because of this, it is rarely used as a mono therapy. Instead, supplementary therapies such intralesional corticosteroid injections, radiation, pressure therapy, and immunomodulators can help lower the risk of postoperative recurrence. In addition to being a useful point of reference for face symmetry, ear lobules are ornamental features. It is obviously unnatural from an aesthetic standpoint to lose them. Numerous techniques created to recreate this deformity have a number of benefits and drawbacks. The preauricular transposition flap based superiorly is a safe and straightforward procedure. The donor site is immediately closed, and just one operation (single-staged surgery) is needed [7–10].

A patient’s preoperative clinical picture shows a massive keloid over their right earlobe and extending to their right infraauricular region (Fig. 1). A surgical defect affecting the entire lobule resulted from the removal of the entire keloid and the underlying cartilage (Fig. 2). We have chosen to utilize the preauricular area for earlobe rebuilding because the patient possessed excess skin there. In the preauricular region, a superiorly based transposition flap was marked with the necessary proportions to reach and conceal the defect. The amputated earlobe used as a model for reconstructing the new earlobe, providing the proper flap measurements, in order to maintain the morphology and symmetry. Its length is equal to double the lobule’s front surface width plus an additional 3–4 mm to allow the flap to fold in on itself. Additionally, its width is one to two millimeters plus the lobule’s height in order to account for the anticipated contraction of the flap. A new lobule with skin covering on both surfaces was created by shaping the lower portion of the flap before it was elevated and transferred to the recipient site (Fig. 3).

The lower folded prolongation of the flap provided posterior coverage for the earlobe. After extensive undermining, the flap donor site’s secondary defect was primarily sutured. The flap was sutured into the main defect using a straightforward running suture with 3–0 ethilon suture material (Fig. 4). After a further year, no recurrence, surgical complications, or ear deformity were seen. The surgical site’s post-operative clinical appearance is depicted at postoperative one month follow-up (Fig. 5). A line diagram depicting how the Preauricular flap has been fashioned to create rounded reconstructed ear lobule for right total ear lobule defect after complete excision of a large keloid (Fig. 7).

Conclusion

A case of big ear lobe keloid with whole ear lobe reconstruction employing a new, single-stage, superiorly based Preauricular flap technique that is easy to master and produces good results in terms of absence of recurrence or no any deformity even after a lengthy follow-up period has been presented.

Declaration

Conflict of interest

All the authors declare that they have not any conflict of interest.

Human or Animal Rights

All procedure performed in study involving human participant was in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki Declaration.

Informed Consent

Informed consent was obtained from patient and patients guardian.