[Case Series in Dermatologic Surgery] #3. The Most Effective Method for Surgical Treatment of Earlobe Keloid and Prevention of Its Recurrence

CASE

▶ Patient: a 21-year-old woman

▶ Chief complaint: The patient visited the hospital for hard nodular lumps accompanying pain in bilateral earlobes growing bigger in size (duration: for 1 year).

▶ Past medical history and family history: She had received intralesional injection of triamcinolone for 1 year and pressure therapy for several months at a private clinic.

▶ Skin findings: Hard nodular lumps developed from ear piercing scars in bilateral earlobes (Figure 1).

▶ Diagnosis: Earlobe keloid solely based on clinical findings

▶ Treatment: Intramarginal excision (see Figure 5 below) immediately followed by radiation therapy (see the description below), resulting in full recovery without recurrence so far.

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Figure 1. Hard nodular lumps in bilateral earlobes.

Histology findings: Postoperative histological images and histopathologic findings (see Figure 2).

Figure 2. Histopathological findings of keloids (H & E, A, B, C)

Histopathologic findings of the keloids

1. Inside the scar tissue are thick hyaline collagen fibers, with homogeneous eosinophilic staining, proliferated disorderly and widely in bundle (A and B) compared to relatively normal collagens in the lower part (A and C).

2. Proliferation of skin fibroblasts and mucopolysaccharides, especially chondroitin-4-sulfate, is identified between collagen fibers.

3. The blood vessels are decreased unlike in hypertrophic scar or normal tissue recovered after injury.



Histopathologic findings of the keloids

1. Basic knowledge for earlobe surgery

• Skin in front of the ear: The skin is thin and directly attached to the cartilage without adipose layer.

• Local anesthetic injection induces a lot of pain. Tissue dissection and primary skin suture are difficult to perform.

• Skin behind the ear: Relatively thick and loosely attached to the lower cartilage.

• Cartilage: One cartilage shapes the ear. Cartilage injury should be monitored at all times because cartilage infection may develop to fulminant necrotic cartilage in rare cases.

• Auricular region: Wedge resection is available to approximately 1/4 of all, with tie-over dressing that passes through the cartilage.

• Occlusive treatment: Dressing should be removed within 3-4 days due to the risk of Pseudomonas aeruginosa infection, and complete occlusive treatment is contraindicated.

• When a large area of the soft tissue on top of the cartilage has been removed, making it hard to perform primary suture or to expect the formation of granulation tissue by secondary suture, the cartilage should be resected by punch (1.5-2mm) to induce granulation tissue from the soft tissue on the opposite side, or the punching should be immediately followed by skin graft directly to the defect.

• Find the anatomical structures of the ear and their names in the diagram below(Figure 3).

- Helix, Antehelix, Scaphoid Fossa, Triangular Fossa, Crus of Helix, Tragus, Antitragus, Concha, Symba.

 

Figure 3. Diagram.

2. Things to be considered before surgical treatment of earlobe keloids

1) Conventional local treatments include intralesional injection of steroid, bleomycin or 5-FU, silicone gel application or silicone pressure sheet, metal pressure earring such as magnets or splint and cryotherapy, which have limited effect on preventing recurrence.

2) Simple excision followed by pressure has been reported as successful in some cases, although there are few reports on long-term follow-up results. Simple surgical removal is not currently recommended due to high risks of recurrence and exacerbation, but intralesional resection (core, subtotal or intramarginal excision) entails less recurrence.

3) Perioperative steroid injection and postoperative imiquimod application have been attempted to prevent postoperative recurrence, although these methods are not recognized as effective methods due to weak prevention effect.

4) Radiation therapy was found as the most effective method in comparative studies on various treatments.

5) Uncontrolled cases by conventional treatments or recurrent cases after surgery require radiation therapy and should be transferred to a hospital that provides one.

6) Radiation therapy is most effective and successful when performed 3 times consecutively (low-dose fractionated radiotherapy: 12Gy in three fractions) within 24 hours after surgery.

3. Surgical techniques for treatment of keloids

1) Intra-marginal or Subtotal Excision.

Figure 4. Intra-marginal Excision. JAAD 2002;47:307~9.

2) Core Excision with Supra-keloidal Flap.

Figure 5. Core Excision with Supra-keloidal Flap.

3) Preop TRA + Core Excision + RT.

4) My Current Approach: Summary.

4-6 weeks before surgery: Intralesional triamcinolone injection 20mg/ml/2 weeks.

Surgery: core excision with suprakelidal flap under local anesthesia

Radiation therapy within 2 hours after surgery: fractionated RT(12Gy in three fractions).

Figure 6. Preop TRA + Core Excision + RT.

References

1. Dinh Q, Veness M, Richards S. Role of adjuvant radiotherapy in recurrent earlobe keloids. Australas J Dermatol. 2004 Aug;45(3):162~6. Review.

2. Sclafani AP, Gordon L, Chadha M, Romo T 3rd. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy: a randomized, prospective study and review of the literature. Dermatol Surg. 1996 Jun;22(6):569~74.

3. Field LM. Subtotal keloid excision--a preferable preventative regarding recurrence. Dermatol Surg. 2001 Mar;27(3):323~4.

4. Lee Y, Minn KW, Baek RM, Hong JJ (2001) A new surgical treatment of keloid: Keloid core excision. Ann Plast Surg 46:135–140.

5. Brian B. Adams, Hugh M. Gloster. Surgical Pearl: Excision with suprakeloidal flap and radiation therapy for keloids. J Am Acad Dermatol 2002;47:307-9.

6. Berman B, Villa A. Imiquimod 5% cream for keloid management’ Dermatol Surg. 2003 Oct;29(10):1050~1.

- To be countinued -

▶ Previous Artlcle : #2. Pigmented Basal Cell Carcinoma on the Face Mimicking a Nevus

[Case Series in Dermatologic Surgery] #2. Pigmented Basal Cell Carcinoma on the Face Mimicking a Nevus

Case

▶ Patient: a 43-year-old female

▶ Chief complaint: Bleeding black spot (which lasted for 3 years).

▶ Past medical history and family history: The patient received CO₂ laser 3 times for a year at a private clinic.

▶ Skin findings: Black nodule was observed at the tip of the nose (Figure 1).

▶ Histology findings: Basal cell carcinoma of pigmented, nodular type was diagnosed by punch biopsy (Figure 2).

▶ Surgical finding: Mohs surgery of the first stage with 4mm margin was performed, and the patient has been completely recovered without recurrence. Mohs surgery will be described in details in the following case series.

Figure 1. Black nodule at the right tip of the nose

Figure 2. Asymmetric proliferation of basal cell infiltrating the full thickness of the dermis with nodule formation

Figure 3. Episcopy finding: 6-mm sized, irregular punctuated proliferation with asymmetric color and shape

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Study on the diagnostic process ①

Excluding the differential diagnoses to be made by visual inspection with experienced eyes (macroscopic examination) (Table 1), the necessity for histology should be determined and the diagnosis should be confirmed by histology. In order to reduce errors in visual inspection and to determine the necessity of histology, the following objective approach should be exercised in addition to the intuitive approach than depends on experiences.

Noninvasive objective diagnostic approach for pigmented lesions on the face

1. Macroscopic observation– the lesions should be analyzed and diagnosis should be made according to the following ABCD rule.

1) Asymmetry extension: One half doesn’t match the other

2) Border Irregularity: Blurred, Notched, Ragged

3) Color: Pigmentation not uniform, Brown, Black, Tan, Red, White, Blue

4) Diameter/Difference (family resemblance) :> 6mm is significant

2. Diagnosis using Dermoscopy, Dermatoscopy, Episcopy: Characteristic findings of pigmented basal cell carcinoma on clinical photographs and on dermoscopy (see picture below) should be acquainted and diagnosis should be made considering racial difference.

Asian (Korean F/37)

Caucasian

1) Typical characteristic findings of basal cell carcinoma: Ulceration, Ovoid blue nest of pigmentation, Spoke-wheel structure, Arborizing telangiectasia, Maple-leaflike areas.

2) Asymmetry of color and structure, multicomponent global pattern, irregular brown globules, irregular streaks, irregular bluish-black blotch and regression are findings detectable in malignant melanoma and require differentiation. Spoke-wheel structure, on the other hand, does not appear in malignant melanoma and is often detected in basal cell carcinoma, allowing the diagnosis of basal cell carcinoma. Globules mean a melanotic lesion.

3) Recent studies reported more varied findings for darker pigmentation, and dermoscopy specialists made accurate (98% sensitivity) and reliable (87%) diagnoses (JAAD 2010;62:67-75).

Study on the diagnostic process ②

Pigmented basal cell carcinomas grow in superficial or nodular shape, and grey, blue or brown colors are observed in all or part of the lesion. Therefore, differentiation with malignant melanoma is a necessity in Caucasian patients and histology should be performed always before removal. On the other hand, early phase lesions are very similar to typical melanocytic nevus among Asians including Koreans, rendering the lesion very easy to be missed, as often experienced recently. According to the medical history, most patients removed the nevus for aesthetic purpose but experienced recurrence several time. During aesthetic nevus removal, it is hard to differentiate among malignant melanocytic nevus, dysplastic nevus, malignant pigmented basal cell carcinoma as in the above case, and early stage malignant melanoma with the naked eye. Among non-white Asians, pigmented lesions on the face are mostly common lesions, including pigmented nevus such as freckles, melanocytic nevus, seborrheic keratosis, solar lentigo and sebaceous hyperplasia, making it easily removed based on simple clinical determination without detailed differentiation (Table 1). On the other hand, it is a necessity to differentiate black spots in Caucasians with malignant melanoma, because the differentiation is forensically important in Western countries including the US. Therefore, periodic skin examination of the whole body by a dermatologist and an approach for early detection, such as histology for suspicious lesions, are established as a standard practice guideline. However, malignant melanoma on the face is very rare in non-white Asians including Koreans. When a black spot is present on the exposed area of the face, as in the above case, more common pigmented basal cell carcinoma should be suspected first before malignant melanoma.

Pigmented basal cell carcinoma is common among Asians because of the activity of melanin pigment cell and the difference of melanin pigment cell in the melanosome. When examining a patient chiefly complaining of pigmentation or a nevus, close macroscopic examination using an objective approach should be performed before conducting a procedure unlike in the past. Currently available methods for early differentiation of benign and malignant lesions (actinic keratosis, Bowen’s disease, keratoacanthoma, basal cell carcinoma, squamous cell carcinoma, etc.) are macroscopic examination using the ABCD rule and finding microscopic subclinical infiltration change using noninvasive dermoscopy. Knowledge and understanding gained from cases as above would be of great help in detecting clinical characteristics certainly distinguishable from typical nevus, so as to prevent unnecessary procedure, surgery or inappropriate treatment, and in performing histology in the early phase, so as to recover the lesion by early diagnosis and treatment without missing early skin cancer, such as melanoma.

References

1. Jae Hong Park, Jeung Tae Jeong, Hae Jun Song, Chil Whan Oh, Il Hwan Kim. Case Report : Diagnostic Trial of Epiluminescence Microscopy in Two Cases of Pigmented     Basal Cell Carcinomas. Annals of Dermatology.2001;39(10):1127~1132.

2. Peris K, Altobelli E, Ferrari A, Fargnoli MC, PiccoloD, Esposito M, et al. Interobserver agreement on dermoscopic features of pigmented basal cell carcinoma. Dermatol Surg 2002;28:643~5.

3. Telfer NR, Colver GB, Morton CA. Guidelines for management of basal cell carcinoma. Br J Dermatol2008;159:35~48.

4. Altamura D, Menzies SW, Argenziano G, Zalaudek,Peter Soyer. Dermatoscopy of basal cell carcinoma: Morphologic variability of global and local features and accuracy of diagnosis. J Am Acad Dermatol2010;62:67~75.

- To be continued -

▶ Previous Artlcle : #1. Epidermal Cyst Surgery

▶ Nest Artlcle : #3. The Most Effective Method for Surgical Treatment of Earlobe Keloid and Prevention of Its Recurrence

[Case Series in Dermatologic Surgery] #1. Epidermal Cyst Surgery

Dermatology performs various surgical procedures. However, the number of surgical procedures is decreasing relative to the increased popularity of noninvasive procedures with recent introduction of lasers. The information on dermatological surgery seems lacking accordingly. This article is a dermatological case series by Professor Kim Il-Hwan at the Department of Dermatology in Korea University Ansan Hospital. Prof. Kim will present patients he had treated in the past, with detailed explanations on the diagnoses, examinations and the course of treatments as well as vivid clinical photographs. He will also present analyses about the diseases and treatments. This dermatological case study by Prof. Kim Il-Hwan will be of help for treatment of various diseases in the clinical setting.

Case #1

■ Patient: a 30-year-old male

■ Chief complaint: He visited the hospital for a cystic subcutaneous nodule palpated at the right nasolabial fold for 10 days before the visit.

■ Past medical history and family history: The lesion was resected at private clinics for the last 2 years but recurred 3 times. The symptom reappeared without any specific triggering factor.

■ Skin findings: Palpation of a skin-colored cystic subcutaneous nodule at the right nasolabial fold (Figure 1)

■ Surgical findings: Excisional biopsy was performed and the well-defined fibrous cyst was completely dissected (Figure 2).

■ Histology findings: The epidermal cyst had layered epithelial cells containing a granular layer and inside the cyst were keratin contents and some of fragmented remaining wall (Figure 3). 

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[Figure 1. A subcutaneous nodule is palpated at the right nasolabial fold.]

[Figure 2. Well-defined pocket-like cyst is dissected.]

[Figure 3. Histological image (x12.5)]

Analyses on the examination and diagnosis

1. Diagnosis: Commonly diagnosed by confirming an opening of the cyst or the characteristic odor and confirming mushy palpation. When the opening is hard to find or it is necessary to confirm whether it’s a cyst, the opening can be found by injecting normal saline with a syringe and the lesion can be diagnosed as a cyst when nucleated keratinocytes and wavy keratin materials are detected by Wright-Giemsa stain of the extracted and smeared content.



2. Necessity of examination: Generally unnecessary, although bacterial culture is needed in case of infection without response to antibiotics. Ultrasonography, CT or MRI can be performed for imaging when the lesion is large and deep. 



3. Histology findings: The wall of the epidermal cyst is consisted of layered epithelial cells containing a granular layer and inside the cyst are keratin contents. Older lesions become calcified, and ruptured lesion often presents foreign body granuloma reaction. 





Treatment and surgical methods for each epidermal cyst 

1. Excision: wide excision, mini-incision, punch excision

2. Removal by case and size

1)    Size ≥2㎝, past history of rupture or squeeze or recurrence after mini-incision technique – the lesion including the cyst wall is removed completely by wide excision.

2)    Size ≤1㎝ or lesion on the face – mini-incision technique is performed.

3)    In the presence of active inflammation – the inflammation is treated first.

Epidermal cyst surgery and surgical technique

1. Wide excision: As a standard treatment, the cyst is completely removed with the surrounding tissue after fusiform incision and subdermis dissection. This method is used mostly in areas other than the face as novices take much time for the dissection and leave a large scar from the incision.



2. Mini-incision and punch excision: 2-3㎜ incision or a disposable biopsy punch is used to cut a hole, through which the content of a cyst is squeezed out with suction, dissected pocket is carefully removed. This method reduces hemorrhage, recovery time and scar formation but requires extensive hands-on experiences due to a higher risk of recurrence after incomplete removal. The author often uses a combination of both wide excision and mini-incision technique. More specifically, an incision is made minimally according to the size of a cyst so as to reduce scar formation, and an opening for removal of the content is made to reduce dissection.



3. Surgical techniques required for complete removal: In order to obtain visibility during the surgery, bleeding should be minimized and hemostasis should be applied at the right time. 1% dental lidocaine containing epinephrine should be used for local anesthesia before the surgery, and suction should be applied during the surgery to find accurate bleeding point. Hemostasis is available mostly by electrocautery. Blade No. 15 is used, instead of scissors, for precise dissection.



Frequent recurrence and measures to be taken

1. Treatment of inflammatory and infectious cysts: Inflammation or infection should be treated beforehand for easier rupture of the lesion, making the cyst wall more definite and enabling complete removal of the cyst. An inflammatory and swollen cyst with pain can rupture easily while attempting to remove it before treating the inflammation, and if only incision and drainage are performed, the remaining cyst wall may cause recurrence. In this case, 10-20㎎/㎖ of triamcinolone can be injected to the surrounding tissues, which can calm the inflammation within several days allowing easier removal. Infection is generally uncommon and is mostly a secondary inflammatory response to a foreign body when the cyst wall is damaged and the keratin content is leaked to the surrounding tissues.



2. Treatment of a ruptured cyst and cases of rupture during removal: A large cyst ruptures easily during a surgery if the incision line is small. Once ruptured, thicker dissection can be attempted again on the other side of the ruptured cyst wall for complete removal. In this case, a knife, rather than small scissors, is suitable for a precise procedure. If dissection is not available on the other side either, the remaining tissues and expected regions should be removed at once together with some of fat layer tissues, and suspected remnants can be removed with a curette. 



References

1. Mehrabi D, Leonhardt JM, Brodell RT. Removal of keratinous and pilar cysts with the punch incision technique: analysis of surgical outcomes. Dermatol Surg 2002;28:673-7.

2. Zuber TJ. Minimal excision technique for epidermoid(sebaceous) cysts. Am Fam Physician 2002;65:1409-12, 17-8, 20.

3. Diven DG, Dozier SE, Meyer DJ, et al. Bacteriology of inflamed and uninflamed epidermal inclusion cysts. Arch Dermatol 1998;134:49-51.

4. Lee HE, Yang CH, Chen CH, et al. Comparison of the surgical outcomes of punch incision and elliptical excision in treating epidermal inclusion cysts: a prospective, randomized study. Dermatol Surg 2006;32:520-5.

5. Marks J, Miller J, editors. Lookingbill and Marks’ Principles of Dermatology 3rd ed: Saunders; 2006.

- To be continued -

▶ Next Artlcle : #2. Pigmented Basal Cell Carcinoma on the Face Mimicking a Nevus