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.
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
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.
2. Dormand EL, Banwell PE, Goodacre TE. Radiotherapy and wound healing. Int Wound J.
3. Cosman B, Wolff M. Bilateral earlobe keloids. Plast Reconstr Surg.
4. Bond JS, Duncan JA, Sattar A, et al. Maturation of the human scar: An observational study. Plast Reconstr Surg.
Letters to the Editor, discussing material recently published in the Journal, are welcome. They will have the best chance of acceptance if they are received within 8 weeks of an article’s publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters are published at the discretion of the Editor.
Authors will be listed in the order in which they appear in the submission. Letters should be submitted electronically via PRS’ enkwell, at www.editorialmanager.com/prs/.
We reserve the right to edit Letters to meet requirements of space and format. Any financial interests relevant to the content of the correspondence must be disclosed. Submission of a Letter constitutes permission for the American Society of Plastic Surgeons and its licensees and asignees to publish it in the Journal and in any other form or medium.
The views, opinions, and conclusions expressed in the Letters to the Editor represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.