We would like to comment on an article by Arneja and colleagues entitled “Treatment of Recurrent Earlobe Keloids with Surgery and High-Dose-Rate Brachytherapy,” published in the January 2008 issue of Plastic and Reconstructive Surgery (2008;121:95–99). We appreciate and encourage the authors' efforts to treat earlobe keloids using postoperative brachytherapy, but we think their work is in need of some critical appraisal.
First, we could not find any description regarding the anterior surface of the auricle in the “Treatment Protocol” section of their article. In our experience, almost all earlobe keloids penetrate the earlobe from the posterior to the anterior surface of the auricle (Fig. 1) and exhibit a dumbbell shape. The authors mention that all of the earlobe keloids were excised extralesionally, but there is a possibility that keloids remain on the anterior surface following this procedure. The brachytherapy catheter they used appeared to be positioned on the postauricle wound, but this may not be enough for the anterior wound. Moreover, a trochar was inserted through the stab incisions. We think it might be worthwhile to consider abandoning this unnecessary method because it causes damage to normal skin, resulting in a hole bigger than that of a piercing hole. In this respect, it is worth discussing which method is better, brachytherapy or electron-beam irradiation.1,2
Second, a nodule-like, unsmooth surface is visible in the authors' Figure 5, and it is stated that it is a recurrence-free lobule. We believe that the 2-year follow-up mentioned is enough to evaluate the efficacy of the method, but the term “recurrence” needs to be defined carefully. Cosman and Wolff3 defined recurrence as a growing, pruritic, nodular scar, and Ogawa et al.1,2 defined it as any redness or elevation of a scar. In this respect, the authors should define more clearly what they mean by recurrence in their article.
Third, the authors mention that infections were observed in two patients. Although the infections responded well to oral antibiotics, they should be prevented after earlobe keloid surgery, as the inflammation associated with postoperative infection can often lead to keloid recurrence and be a burden for the patient. We have no idea whether this infection was caused by radiotherapy or not, but the authors should exercise care in selecting the correct radiation dose. In our facility, 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.2
Lastly, we believe that the most important thing in the treatment of earlobe keloids is postoperative self-management by the patient. We suggest that patients apply a taping fixation before sleeping. Moreover, to avoid friction, we advise that patients not sleep with the affected side of their head against the pillow. Thus, we believe that complete excision, appropriate postoperative radiation therapy, and postoperative self-management are the most effective treatment for intractable earlobe keloids.
Satoshi Akaishi, M.D.
Rei Ogawa, M.D., Ph.D.
Hiko Hyakusoku, M.D., Ph.D.
Department of Plastic, Reconstructive, and Aesthetic Surgery
Nippon Medical School Hospital
1. Ogawa R, Mitsuhashi K, Hyakusoku H, Miyashita T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: Retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg.
2. Ogawa R, Miyashita T, Hyakusoku H, Akaishi S, Kuribayashi S, Tateno A. Postoperative radiation protocol for keloids and hypertrophic scars: Statistical analysis of 370 sites followed for over 18 months. Ann Plast Surg.
3. Cosman B, Wolff M. Bilateral earlobe keloids. Plast Reconstr Surg.
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