Dermal hinge flap with adjuvant corticosteroid injection for ear keloid

Keloid formation is characterized by abnormal wound healing, which leads to the excessive accumulation of extracellular matrix (ECM) components caused by a pathologically uncontrolled proliferation of fibroblasts in the dermal layer.1-3 Despite various therapeutic modalities, such as intraregional steroid injection, pressure garments, cryosurgery, laser therapy, and radiotherapy, effective management of keloids remains a challenge, with satisfactory clinical outcomes and high efficacy often difficult to achieve.4, 5 The surgical treatment of keloids typically involves complete removal of the keloid tissue.6 However, in the case of ear keloids, complete excision can result in a dysmorphic appearance.7 There are many patients who want active treatment because ear keloids are relatively visible and tend to occur in women who frequently get piercings. It is difficult to obtain satisfactory results in these patients with surgical excision only. To confront this issue, we developed the "dermal hinge flap method," which involves selectively removing the superficial layer of keloid tissue while preserving the deeper layer for structural support. In this case, we present satisfactory results using a dermal hinge flap with adjuvant corticosteroid injection for ear keloid. Preoperative corticosteroid is injected into the superficial layer of dermis. Surgery is planned when the keloid tissue and epidermis are soft enough to be exfoliated. After designing an incision line on the keloid lesion, incision was performed thinly using a No. 15 surgical blade. After thinly elevating the skin flap from the keloid tissue, the keloid tissue is removed leaving a part of the bottom for structural support. The hinge flap is designed according to the contour and the defect is covered to complete the surgery. A thin flap was exfoliated while leaving only a little of the epidermis and upper layer of the dermis surrounding the keloid. The keloid tissue was partially removed leaving a part of the bottom to prevent dimpling of surgical site after surgery. The skin from which the keloid was peeled off with a flap was trimmed and then repaired with a 6-0 Nylon suture (Figure 1). The patient is a 19-year-old female patient who complained of a 1.5 × 1 cm size keloid on the left upper helix that occurred after piercing 15 months ago. The shape of the keloid scar was a round shape with the same color of the surrounding outer skin (Figure 2A). Triamcinolone injection was performed three times for 3 months, and scar tissues are sufficiently softened so surgery was planned. After surgery, foam dressing on the surgical site was performed for 1 week. Total stich out was performed at 10 days after surgery. Postoperative triamcinolone injection was performed 3 weeks after the surgery. Injections were performed with follow-up at 1-month intervals. 2 months after the surgery, the contour was maintained without recurrence and the patient showed high satisfaction with the outcome (Figure 2B). A keloid is the abnormal healing response to skin injury, and is shown clinically as a firm, frequently pruritic or painful nodular or protuberant scar, and projects beyond the site of the original injury.1 Keloid can be treated by medical or surgical methods such as compression, intralesional corticosteroids, systemic immunosuppressive drugs, silicone gel dressings, intralesional interferon, cryosurgery, surgical excision, radiotherapy and laser surgery.6 Intralesional injection of steroids is currently the most commonly used treatment method.7 However, nonsurgical conservative therapies alone do not seem to be effective for treating keloids. Keloid should be treated with surgical treatment combined with adjuvant nonsurgical therapy.8 Ear keloids have a poor impact on the quality of life of patients cosmetically due to the characteristics of keloids that grow beyond the boundaries of the primary wound and the prominent anatomical position of the ear, so more active treatment is desired than other areas.7 There have been many attempts to remove only the keloid tissue of the dermal layer. These attempts were called by various names like core excision and fillet flap.9, 10 In this study, we used dermal hinge flap. The difference from other procedures is that the keloid tissue of the dermal layer is not completely removed, leaving a part of the bottom. Through this process, we can prevent the surgical site from dimpling and expect better outcomes. Jiao et al divide dermis layer of keloid into three layers: superficial dermis, middle dermis, and deep dermis. Increased fibroblasts in the superficial dermis produce collagen and it cause keloid formation.11 Therefore, it is important to exfoliate to leave only the epidermis layer as much as possible in dermal hinge flap. However, keloid tissue usually has a hard property, so it is difficult to exfoliate it as thinly as possible. Even if exfoliation is done as thinly as possible, part of the superficial dermis of keloid remains and there is a possibility of recurrence. We performed adjuvant intralesional corticosteroid injection for 3 months before surgery. Corticosteroids suppress inflammation and miosis while increasing vasoconstriction in the scar and this has the effect of softening and flattening scars.12 In addition, pre- and postoperative steroid injections can suppress the activity of fibroblasts, thereby preventing recurrence due to the activity of keloid fibroblasts that may remain.13 Therefore, the target for drug injection should be as close as possible to the epidermis-dermis junction of the lesion. we administered corticosteroid injections targeting the most superficial region of the dermis prior to the surgery. In our experience, as keloids were softened by triamcinolone injection before surgery, the epidermis could be exfoliated as thinly as possible more easily during core excision. The outcome of 6 months after surgery in our case was a satisfactory result without recurrence. We need studies with more patients and longer follow-up because it was reported that 8 out of 31 surgical lesions after ear keloid surgery recurred from 1 to 4 months after surgery.7 it is necessary to create guidelines for appropriate dosage and duration of steroid injection before surgery through further study since long-term use of steroids requires attention to side effects. Joon Suk Bae, Chang Yong Choi, Eun Soo Park, Seung Min Nam, and Han Gyu Cha performed the research. Chang Yong Choi designed the research study. Joon Suk Bae wrote the paper. This work was supported by Soonchunhyang University Research Fund and the grant of the Basic Science Research Program through the National Research Foundation (NRF) of Korea (2022R1I1A3071416). None declared. This study was approved by the electronic Institutional Review Board (IRB) of Soonchunhyang University Bucheon Hospital (IRB no.: 2023-04-006). Written informed consent was obtained from participant and legal guardians. All procedures were performed in accordance with the Declaration of Helsinki. Data sharing not applicable to this article as no datasets were generated or analysed during the current study.