Surgical management of auricular keloids: a clinical study on strategies to minimize recurrence conducted in South Korea

Article information

Arch Aesthetic Plast Surg. 2025;31(4):93-99

Publication date (electronic) : 2025 October 31

doi : https://doi.org/10.14730/aaps.2025.01466

Hong Sil Joo, Tae Wan Kim

Department of Plastic and Reconstructive Surgery, Hanil General Hospital, Seoul, Korea

Correspondence: Hong Sil Joo, Department of Plastic and Reconstructive Surgery, Hanil General Hospital, 308 Uicheon-ro, Dobong-gu, Seoul 01450, Korea, Email: 14610030@hanilmed.net

Received 2025 June 15; Revised 2025 September 4; Accepted 2025 October 3.

Abstract

INTRODUCTION

Keloids are benign, fibroproliferative scars characterized by excessive collagen deposition that extends beyond the boundaries of the original wound, producing raised, often disfiguring lesions. Unlike hypertrophic scars, keloids do not regress spontaneously and frequently recur after treatment. Ear keloids, a distinct subset primarily involving the earlobes or surrounding auricular tissues, typically present as firm, rubbery, or nodular growths that vary in size and may cause itching, tenderness, or pain [1,2]. In severe cases, they can lead to psychological distress or cosmetic disfigurement, significantly impairing patients’ quality of life [3].

Non-surgical treatments, including intralesional corticosteroids and radiotherapy, often have limited efficacy, making surgery the mainstay of management despite the potential risk of auricular deformity. Various surgical techniques for ear keloids have been described, including simple excision, core excision with flap closure, and wedge resection. However, the unique anatomical characteristics of the ear (i.e., its isolated position, limited skin and cartilage availability, and high visibility) pose particular challenges compared with keloids at other body sites. These features intensify cosmetic concerns, especially among younger patients or those prioritizing aesthetic outcomes.

Despite meticulous surgical intervention, recurrence rates remain high and contribute to significant psychological distress, including persistent anxiety and emotional fatigue. To minimize recurrence, we performed surgery based on two strict principles: complete resection of keloid fibrous tissue, including the piercing channel, and exclusion of keloid-covered skin during reconstruction. This strategy was combined with postoperative intralesional corticosteroid injections and oral tranilast, an inhibitor of transforming growth factor-β.

The authors aimed to evaluate the effectiveness of this multimodal therapy and demonstrate that performing wide resection, including the keloid, adjacent cartilage, and skin, can preserve the aesthetic shape of the ear, thereby providing a reference for the treatment of ear keloids.

METHODS

This study included 58 patients who underwent surgery for ear keloids between February 2023 and April 2025. Patient demographics, previous treatments, symptoms, surgical complications, follow-up duration, and keloid recurrences were recorded. All patients were thoroughly informed that complete keloid excision, including a portion of normal skin and cartilage, was necessary for reconstruction. They were also advised of the possibility of auricular deformity resulting from insufficient skin tissue after excision, and written informed consent was obtained. Patients with significant concerns about postoperative cosmetic deformity were excluded.

Surgery was performed under local anesthesia (2% lidocaine with 1:80,000 epinephrine). One patient was hospitalized, whereas all others were treated as outpatients. Regardless of the defect size after keloid removal, two key principles guided the surgical procedure. First, even when the scar lesion was confined to one side, the piercing channel was dissected across to the opposite side, and the cartilage penetrated by the channel was removed. The keloid tissue and adjacent normal skin, cartilage, and soft tissue were completely excised. Second, the altered skin covering the keloid was not reused for reconstruction. After excision, surrounding tissues were palpated to ensure complete removal of fibrous tissue. Meticulous hemostasis was performed to minimize hematoma formation, which is a known risk factor for recurrence.

When the keloid was located on the helix, wedge-shaped excision was primarily employed. To achieve adequate closure of the resulting defect, the excision length was designed to be 1.2 to 1.5 times the diameter of the keloid, creating a wide wedge excision. For lesions located on the scapha, an elliptical excision was performed along the longitudinal axis. In cases involving the earlobe, where postoperative cosmetic deformity is most apparent, particular emphasis was placed on preserving lobular volume. Local skin flaps were utilized for reconstruction. When direct closure of bilateral skin flaps was attempted, linear closure often caused protrusion of the lobular edge. Therefore, to maintain the natural contour of the lobular margin, Z-plasty was applied along the lobular border (Fig. 1) [4].

Fig. 1

Schematic illustration showing the surgical steps of lobular Z-plasty for ear lobule reconstruction: excision of the defect (A), design of Z-shaped incision (B), and final closure (C).

The postoperative regimen included intralesional corticosteroid injection (1 mL of 40 mg/mL triamcinolone acetonide) administered intradermally on the day of suture removal, before suture removal, to prevent wound dehiscence. Oral tranilast was prescribed for 1 month to reduce recurrence risk. Patients were followed up monthly. If an increase in scar height exceeding 2 mm or changes in pigmentation, firmness, or pruritus at the previous keloid site suggested recurrence, one or two additional sessions of intralesional corticosteroid injections combined with oral tranilast were administered. Even in the absence of a visibly elevated scar, cases with persistent symptoms such as pruritus, pain, or a burning sensation were regarded as recurrences and treated accordingly. Patients were instructed to avoid unnecessary stimulation of the surgical site, and the use of piercings or earrings was strictly prohibited.

RESULTS

A total of 63 keloid lesions from 58 patients were analyzed (Table 1). The mean patient age was 28.2 years, with three males (5.2%) and 55 females (94.8%). The most common etiology was ear piercing, while trauma-induced keloids were observed in three patients (5.2%), including two males. Nineteen patients (32.8%) had received prior treatment: six underwent surgical excision, 10 received intralesional corticosteroid injections, and three received both. Pruritus was the most common preoperative symptom, reported by 13 patients (22.4%). Anatomically, 41 lesions (65.1%) were located on the helix or antihelix, and 22 (34.9%) were on the earlobe. Postoperative complications included one case of wound dehiscence and one hematoma. Recurrence occurred in three patients (5.2%). One patient received a single additional intralesional corticosteroid injection, resulting in complete lesion flattening. The other two patients, both with type V lesions and multiple prior treatments, underwent revision surgery for recurrent lesions smaller than 1 cm at their request. The same postoperative regimen was applied following revision surgery.

Table 1

Summary of patients’ characteristics

Case 1

A 65-year-old woman presented with a type I pedunculated keloid on the left helix resulting from a sutured laceration (Fig. 2A). The keloid extended to the scapha. Wedge excision, including the suture scar, was performed, followed by primary closure (Fig. 2B). On postoperative day 10, sutures were removed, and a single intralesional corticosteroid injection was administered, followed by 1 month of oral tranilast. No recurrence or symptoms were reported during the 3-month follow-up. The surgical site remained soft and flat without signs of recurrence. At the 1-year follow-up, the patient remained asymptomatic with no evidence of recurrence (Fig. 2C).

Fig. 2

Keloid on helix. (A) Pedunculated-type keloid scar on helix of ear. (B) After wide wedge excision. (C) Postoperative photographs at 1-year follow-up.

Case 2

A 23-year-old woman presented with an asymptomatic type II keloid on the antihelix secondary to ear piercing (Fig. 3A). Elliptical excision encompassing both the anterior and posterior aspects of the antihelix was performed (Fig. 3B), followed by primary closure. Sutures were placed along the antihelix line so that the resulting scar followed the natural contour of the antihelix. A single intralesional corticosteroid injection was administered at suture removal, and oral tranilast was prescribed for 1 month. No recurrence was observed.

Fig. 3

Keloid on antihelix. (A) Sessile-type keloid scar on the antihelix of the ear. (B) After longitudinal excision.

Case 3

A 19-year-old woman presented with a keloid classified as type II according to the Chang–Park classification, located at the triangular fossa of the ear near the crus of the helix. The scar tissue extended through both the anterior and posterior aspects of the ear along the piercing tract (Fig. 4A). A wedge excision encompassing the lesion and adjacent helical tissue was designed and performed to achieve complete removal. The wedge excision successfully removed the keloid; however, due to the lesion’s proximity to the helical crus, a minor notching deformity occurred at the suture site, caused by asymmetry in the helical dimensions after excision (Fig. 4B). A single intralesional corticosteroid injection was administered at suture removal, and the patient was prescribed oral tranilast for 2 months. No recurrence was noted during the 3-month follow-up. At the 11-month follow-up, imaging confirmed the absence of the root of the helix, but the overall ear shape was preserved without significant deformity. The patient reported no symptoms and expressed satisfaction with the outcome (Fig. 4C).

Fig. 4

Keloid on helical crus. (A) Keloid scar on triangular fossa proximity to the helical crus. (B) After wedge excision. Well preserving auricular contour. (C) Postoperative photographs at 11-month follow-up.

Case 4

A 47-year-old woman presented with a keloid classified as type II according to the Chang–Park classification, originating from an earlobe piercing site (Fig. 5A). Complete excision of the keloid was performed, followed by primary closure using adjacent tissue. To prevent distortion, such as bulging of the lobular margin caused by a long linear scar, Z-plasty was employed to preserve the natural curvature of the lobule (Fig. 5B). A single intralesional corticosteroid injection was administered at suture removal, and oral tranilast was prescribed for 1 month. No recurrence was observed during the 3-month follow-up period.

Fig. 5

Keloid on earlobe. (A) A keloid scar is located on the earlobe. (B) Reconstruction with Z-plasty.

DISCUSSION

Keloids are benign fibroproliferative tumors characterized by excessive collagen deposition in response to cutaneous injury, such as ear piercing or trauma. They arise from an aberrant wound-healing process driven by dysregulated fibroblast activity, inflammation, and mechanical tension. Keloids are defined by their growth beyond the original wound boundaries and typically present as firm, raised, and discolored scars [1,2]. The etiology of ear keloids is multifactorial, involving genetic predisposition, skin tension, and local trauma. Among these factors, piercing-related trauma is the most common trigger, with an estimated incidence of approximately 2.5% following ear piercing [5]. Additional contributing factors in individuals genetically predisposed to abnormal wound healing include surgical procedures, burns, and minor abrasions. The Chang–Park classification categorizes auricular keloids by morphology—pedunculated (type I), sessile-single nodular (type II), multinodular (type III), buried (type IV), or mixed (type V)—based on the ratio of the contact surface to maximum diameter (sessile, ≥2/3). Although this classification aids surgical planning, it does not predict recurrence risk [6].

The treatment of auricular keloids is challenging due to their high recurrence rates and the anatomical constraints of the ear, where limited skin availability and the need to preserve aesthetic form complicate surgical procedures. Various techniques have been described, including core excision, fillet flap reconstruction, and wide excision, each with distinct advantages and limitations [1,3,7,8]. Core excision, which removes central keloid tissue while preserving the overlying skin, and fillet flap reconstruction, which uses the keloid’s surface as a local flap, are frequently employed. However, the use of keloid surface skin in these methods often leaves residual scar tissue, a major factor contributing to recurrence. One study reported a recurrence rate of 76.8% in cases with marginal remnant scar tissue compared to 23.2% in cases with clear resection margins, underscoring the importance of complete keloid removal [7]. Furthermore, the overlying skin of keloids—characterized by a shiny surface, telangiectasia, and pink-to-purple discoloration—is pathologically altered and unsuitable for reconstruction due to residual fibrotic tissue [2].

No universal treatment protocol has been established, and variable outcomes with high recurrence rates have led to the development of diverse surgical and adjuvant therapies (Table 2). Reported recurrence rates range from 45%–100% for surgical excision alone [3], 3%–25% for excision combined with intralesional corticosteroids [3,5], 4%–27% with radiotherapy [5,8], and 14%–20% with compression therapy [9]. Multimodal approaches integrating excision, corticosteroids, and radiation have been shown to reduce recurrence to 6%–21% [5,10]. Notably, keloids are more prevalent among certain populations, particularly Asians and Africans, with African populations exhibiting comparably high incidence rates. A 2022 study in Annals of Plastic Surgery reported postoperative recurrence rates of 43% for primary keloids and 58% for secondary keloids in African patients treated with excision alone. Specific treatment modalities yielded variable outcomes: excision alone resulted in a 54% recurrence rate, excision with postoperative radiation 83%, excision with intraoperative triamcinolone injection 33%, and excision with both intraoperative triamcinolone and postoperative radiation 33% [11].

Table 2

Recurrence rate

Intralesional corticosteroids suppress fibroblast proliferation and collagen synthesis and show substantial benefit when combined with surgical excision. Radiotherapy, which targets fibroblasts and inflammatory cells, is effective in recurrent cases but poses risks of adverse effects, limiting its widespread use. Compression therapy, which is hypothesized to reduce wound tension and induce localized hypoxia, has shown potential efficacy but suffers from poor patient compliance. Emerging modalities, such as laser-assisted drug delivery and cryotherapy, are promising yet lack standardized protocols [2]. In our study, wide excision combined with intralesional corticosteroids and oral tranilast achieved a recurrence rate of 5.2% (3 out of 58 patients), notably lower than the 33%–83% rates reported in other studies. This suggests that our multimodal approach—emphasizing complete resection and adjunctive tranilast to modulate fibroblast activity—may provide superior outcomes for auricular keloid management.

In this study, we performed wide excision to completely remove the keloid scar, including the piercing channel, thereby minimizing residual scar tissue. The overlying keloid skin was deliberately excluded from reconstruction due to its pathological changes. Postoperatively, all patients received intralesional steroid injections at suture removal and were prescribed oral tranilast for 1 month, with one or two additional treatment cycles as indicated by clinical response. This regimen resulted in a recurrence rate of 5.2% (3 out of 58 patients), markedly lower than those reported in prior studies, such as 25% for incomplete excision with fillet flap reconstruction and 44% for fillet flap reconstruction alone. However, the substantial heterogeneity in lesion size and location likely influenced recurrence rates, as larger or more complex keloids may respond differently to treatment. The absence of a control group limits the ability to definitively attribute favorable outcomes solely to the intervention, which weakens causal inference. Additionally, comparisons with previous studies are complicated by differences in patient demographics, prior treatments, surgical techniques, and follow-up durations. The pathophysiology of keloids and hypertrophic scars suggests that most recurrences occur within 3 months after surgery, supporting the efficacy of our approach in achieving early scar stabilization [1]. Nevertheless, the relatively short follow-up duration remains a limitation, as keloids can recur months or even years postoperatively due to their chronic, progressive nature. Long-term follow-up and controlled studies are therefore necessary to confirm the durability of these findings and address the limitations related to lesion heterogeneity and study design.

In conclusion, wide excision combined with intralesional corticosteroids and oral tranilast offers an effective strategy for managing auricular keloids, achieving a low recurrence rate in our cohort. However, extended follow-up is crucial to validate the long-term stability of these results, given the potential for delayed recurrence. Our findings highlight the importance of complete keloid resection and individualized postoperative care, particularly for patients prioritizing recurrence prevention over cosmetic outcomes. This study also aims to provide a clinical reference for optimizing surgical strategies in auricular keloid management.

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