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Arneja, Jugpal S. M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 425-426
doi: 10.1097/PRS.0b013e318194d2a4
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I thank Drs. Akaishi et al. for their comments as well as their contributions to the literature. I appreciate the opportunity to respond, and I believe the comments found herein are germane to this discussion.

What the authors do not seem to conceptualize is the mechanism of action of the radiation delivery via brachytherapy.1Figures 1 and 2 represent axial and sagittal computed tomography scans of the brachytherapy treatment plan. After keloid excision, the brachytherapy catheter is placed within the wound and the wound is closed. Next, the physicist plans the appropriate amount of radiation delivery, off of the axis of the catheter, measured in millimeters. Figures 1 and 2 show concentric circles that represent the amount of radiation delivery off-axis in percentage form. For example, the red circle represents 100 percent delivery within the circle, while the green circle represents 75 percent radiation delivery. As such, the entire lobule (anterior and posterior) is treated with radiation delivered via the brachytherapy technique.

Fig. 1.
Fig. 1.:
Axial computed tomography scan of the brachytherapy treatment plan. Concentric circles illustrate the amount of radiation delivery off-axis in percentage form: blue, 150 percent; yellow, 125 percent; red, 100 percent; green, 75 percent.
Fig. 2.
Fig. 2.:
Sagittal computed tomography scan of the brachytherapy treatment plan. Concentric circles illustrate the amount of radiation delivery off-axis in percentage form: blue, 150 percent; yellow, 125 percent; red, 100 percent; green, 75 percent.

Without question, for pierced ear lobules, the mechanism of injury and subsequent keloid formation is a blast injury, since the ear-piercing device is administered to the ear from the anterior to the posterior direction. This creates a more significant injury on the posterior surface, analogous to a shotgun blast injury. Therefore, the majority of lobule keloids are found on the posterior surface; however, I agree that anterior lobule keloids are possible. When an anterior and/or posterior ear lobule keloid is present, I treat this in a similar manner, with excision and closure over the catheter, and as described above, the radiation is also delivered to the anterior region of the ear lobule.

I respectfully disagree with the authors' statement that “earlobe keloids can be controlled without any infections with a protocol of 10 Gy/two fractions/2 days of 4-MeV electron-beam external irradiation.” In fact, the use of radiation therapy may increase the rate of infection given the delayed wound healing inherently associated with the radiated wound.2

Furthermore, recurrence should be defined as tumor recurrence, as described by Cosman and Wolff,3 not simply redness associated with a scar. It has recently been illustrated that maturation and redness elimination from a scar occur over a period of 12 months4; therefore, redness alone does not equate with recurrence, and keloids must be followed for 24 months to ensure treatment success.1

Finally, the use of brachytherapy is reserved for recurrent tumors; the literature is replete with adjuvant treatments, including silicone and pressure earring therapies, that have varying degrees of recurrence. I contest the authors' statement that “the most important thing in the treatment of earlobe keloids is postoperative self-management.” Rather, the most important variable to prevent recurrence is the adjuvant administration of radiation, not whether one slept on one's ear at night, which would seem to be a most difficult variable to control.


The author has no conflict of interest associated with the preparation or submission of this communication.

Jugpal S. Arneja, M.D.

Wayne State University School of Medicine

Children's Hospital of Michigan

Plastic Surgery

3rd Floor, Carls Building

3901 Beaubien Boulevard

Detroit, Mich. 48201


1. Arneja JS, Singh GB, Dolynchuk KN, Murray KA, Rozzelle AA, Jones KD. Treatment of recurrent earlobe keloids with surgery and high-dose-rate brachytherapy. Plast Reconstr Surg. 2008;121:95–99.
2. Dormand EL, Banwell PE, Goodacre TE. Radiotherapy and wound healing. Int Wound J. 2005;2:112.
3. Cosman B, Wolff M. Bilateral earlobe keloids. Plast Reconstr Surg. 1974;53:540–543.
4. Bond JS, Duncan JA, Sattar A, et al. Maturation of the human scar: An observational study. Plast Reconstr Surg. 2008;121:1650–1658.

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