Annals of Burns and Fire Disasters - vol. XII - n° 4 - December 1999

EXTENSIVE KELOIDS IN THE AURICLE - SURGICAL TREATMENT BY MEANS OF AUTOLOGOUS GRAFTS

Masellis M., Ferrara M.M.

Division of Plastic Surgery and Plastic Surgery, Civic Hospital, Palermo, Italy

SUMMARY. This article considers two cases of keloid formation in the auricle. Keloids usually affect the dermis and are characterized by the presence of thick collagenous fibres of vitreous and hyalinized aspect. Some related fibroblasts are also present. ln the early stages the formations tend to be more vascularized, especially in peripheral zones, while in the more mature phase they are more hyalinized. The removal of an ample keloid, as in the cases reported here, and the repair of an exposed area with a dermo-epidermal full-thickness skin graft cause both general and specific modifications in the healing process. The removal of an ample keloid, as reported here, and the repair of an exposed area with a denno-epidermal full-thickness skin graft cause both general and specific modifications in the healing process. The surgical techniques employed are described and the various problems involved are considered. Although only two cases are considered, the experience obtained makes it possible to repropose the treatment of keloids with the free skin graft technique, at least in cases located in the auricle, without the supplementary assistance of medical or physical therapy.

Introduction

Keloids are generally defined as abnormal fibrous proliferations of the dermis. Clinically they appear as nodular, frequently lobulated, solid masses extending laterally into healthy tissue. They grow continuously but intermittently, and show no evidence of significant regression.
During the initial phase of development and during the period of active growth, the lesions are reddish or violet, with modest vascularization and small blood vessels visible beneath the skin covering.
During the phase of development and in periods of quiescence, keloids are less tense and vascularized, but remain raised and more compact than tiormal tissue. Unlike hypertrophic scars, they do not cause retraction.
The commonest age for the onset of keloids is between 15 and 45 yr. They are more frequent in females and a certain degree of familial heredity has been reported. Blacks are the most frequently affected race, in particular Africans and East Indians.
The onset can be triggered by a skin lesion even of limited dimensions such as an acne or smallpox pustule, a wart, an insect bite, a vaccination scratch, a tattoo, a electrocauterization, or a surgical operation.
Following a surgical operation the onset is late, with a marked tendency to recidivation after excision.
The typical features of keloids, i.e. their nonregression in time, tendency to recidivation, and spreading to normal tissue, are useful in diagnosis for differentiating from hypertrophic scars.
These features will however appear in time and thus it is not always possible to make an early clinical differentiation between a hypertrophic scar and a keloid.
Some body areas show a particular predisposition for keloid formation. These are mostly concentrated in the upper half of the body, for example the head, neck, thorax, shoulders, and arms. In these specific areas the most commonly affected are the earlobes, the pre-sternal area, and the deltoid region. Keloids are also sometimes seen in the umbilical and pubic zones.
Certain conditions, in addition to endogenous factors, facilitate the onset of keloids, e.g. the local tension to which a wound suture is subjected, the orientation of a lesion in relation to lines of cutaneous tension, the presence or absence of infection and foreign objects (hair, endogenous keratinized material, etc.), and second-intention healing.

Histology

The histological picture of the keloid is well defined. The condition usually affects the dermis and is characterized by the presence of thick collagenous fibres of vitreous and hyalinized aspect. A limited number of related fibroblasts are present, embedded in a rich matrix of mucinous material.
In the early stages the formation tends to be more vascularized, especially in peripheral zones; in the more mature phase the appearance is more hyalinized, with a lower vascular component and an almost scar-like appearance. The overlying epidermis may appear normal or acanthoid.
The fibroblasts present a clearly evident Golgi complex and a well-developed rough endoplasmic reticulum.
In fresh keloids, chemical analysis indicates the presence of a disproportionate increase in the synthesis of collagen, protocollagen, and fibronectin compared with hypertrophic scars and mature keloids, confirming that the anabolic phase in keloids is exaggeratedly accelerated.
Under the polarized-light microscope the birefrangent collagen fibres appear yellow-green in colour and composed of thick fibres arranged in parallel or irregular bundles. No myofibroblasts are present.

Materials and methods

We observed two cases of extensive keloid formations involving both auricles in one case and the left auricle only in the other.
The patients were subjected to general anaesthesia, followed by complete removal of the keloid formations peripheral to the healthy skin tissue down to the perichondrial planes.
The exposed area was reconstructed with a free full-thickness skin graft taken from the inguinal fold and fixed with 4/0 silk suture and normal containment dressings, which were removed on day 7.
The follow-up was scheduled for 3-6-12-24 months.
No pharmacological or physical treatment was performed.

Clinical cases

Case I
A.A., female, aged 33 yrs
Anamnesis: the patient reported that 3 yr previously (1990) she had been subjected to otoplasty surgery for the correction of the "satyr" look of both her auricles.
The operation was performed with exposure and modelling of the helix by a marginal incision. This left a scar which in the next few months developed into a clearly keloid formation.
Two years later (1992; the patient was subjected to a further unspecified operation for removal of keloid tissue in both auricles.
Also in this case the scars developed into keloids, which the patient presented when she came to our observation in 1995.
Right auricle
Mass of clearly keloid tissue involving nearly the entire lateral face of the helix, the antihelix forward and as far as the edge of the concha and down as far as the upper edge of the lobe, extending over the border of the auricle in nearly all the medial face.
In places the mass was 4-5 cm thick.
The mass was reddish, lumpy, and in places grooved, with irregular margins at its base. It was itchy and painful (Figs. 1, 2).

Figs. 1, 2 - Keloid in right auricle.

Left auricle
Also in this auricle the mass was large in extent, involving a stretch of the upper edge of the helix, the descending edge, the groove of the helix, and nearly all the medial face. Thickness in lower part, 3-4 cm (Figs. 3, 4).

Figs. 3, 4 - Keloid in left auricle.

Clinical treatment
The clinical picture was similar to that described in the previous case.
On 1 July 1996 we removed the keloid masses in both auricles as far as 1/2 cm, on the edges of the healthy skin tissue, to the depth of the perichondrium.
The exposed areas were covered using full-thickness free skin grafts taken from the left inguinal region.
The histological examination of the pieces removed yielded the following results:
"The neoformations are characterized by the presence at chorion level of thick bundles of collagen. These are intensely eosinophil and irregular in arrangement. The bands are immersed in a fair-sized matrix rich in acid mucopolysaccharides. The periphery of the lesion is the site of marked vascularization, and the overlying skin shows a modest degree of atrophy. Conclusion: the histological picture is compatible with a diagnosis of keloid."
Follow-up was performed at 3-6-12-24 months.
The follow-up examinations indicated progressive consolidation of the skin graft and a phase of mimimal retraction followed by a phase of distension and softening. There were no signs of keloid recidivation (Figs. 5-8).

Figs. 5-8 - Follow-up after 3 yr.

Examination of the donor sites did not reveal any sign of scar pathology (Fig. 9).

Fig. 9 - Normal scarring process in inguinal donor site.

Case 2
R.A., male, aged 11 yr.
Anamnesis: the parents reported that at the age of 4 yr (1991), following an insect (tick ?) bite in the medial face of the right auricle, a progressive scarring reaction began, of hypertrophic-keloid appearance. This was surgically removed at the age of 7 yr (1993).
The histological examination of the part removed was not available.
Recidivation occurred some months later, and surgical removal was performed in January 1994.
The histological examination reported: "Diffuse myofibroblast proliferation of the dermis with highly vascularized collagenization. Picture compatible with hyperplastic scar lesion".
An objective examination performed in 1997 indicated a clearly fibrous area of tissue involving the edge of the radix and the ascendant and upper part of the helix. This occupies the lateral face of the triangular fossa.
In the medial face the upper third of its surface (1-2 cm thick) is lobulate in appearance and reddish in colour, hard in consistency, and often painful and itchy (Figs. 10, 11).

Figs. 10, 11 - Keloid in upper third of auricle.

Surgical treatment
On 1 July 1997, radical excision was performed on the keloid mass as far as the peripheral planes and 1.5 cm on healthy skin tissue.
The exposed area was covered with free full-thickness skin graft removed from the right inguinal fold.
Histological examination: exuberant tissue neoformation of mesenchymatic origin giving a "collagenized" aspect to both papillar and reticular dermis. ne connective. bundles in these districts were massed, with either a parallel arrangement in relation to the major axis of the epidermis or an irregular presentation, appearing to be mainly composed of hyalinized collagen fibres of acidophilic appearance. The interstice contains random aggregates of fibroblasts and myofibroblasts in a matrix containing foci of Alcian-positive mucinous material. Moderate presence of vascular structures surrounded by reticules of argentophile fibres. The epidermal covering is adequately represented in every district and is often acanthotic.
The picture was that of a "nodular keloid" in a histologically florid phase.
Follow-up was performed at 6-9-12 months. The postoperative course up to 12 months showed progressive consolidation of the skin graft in the various phases of retraction, distension, and softening. There were no signs of recidivation (Figs. 12, 13).

Figs. 12, 13 - Follow-up after one yr

The inguinal donor area healed normally with no sign of scar pathology (Fig. 14).

Fig. 14 - Inguinal donor site after one yr.

Considerations

The removal of an ample keloid,. as in the cases reported here, and the repair of an exposed area with a dermo-epidermal full-thickness skin graft cause both general and specific modifications in the healing process.
In cases of extensive wounds with loss of cutaneous substance, it as known that healing occurs by second intention through processes of angiogenesis, granulation, fibroblast migration, collagen synthesis, the appearance of myofibroblasts, and modelling of the scar.
During this phase extrinsic and mechanical infective and iatrogenic factors, together with intrinsic dysmetabolic and hormonal factors, impair the process of the regulation of collagen production and degradation. This may trigger pathological mechanisms that affect and/or delay wound healing.
The application of a skin graft, with the transfer to the exposed area of epidermis and derrms and all its mesenchymal components, causes modifications in the healing process. These determine the success of graft take in the successive phases of serum imbibition, vascularization, and neoangiogenesis.
It is likely that the fibroblasts of the grafted dermis and those of the recipient area together initially activate hydrolysis of the proteoglycans by means of the lysosomial enzymes, which act on the polysaccharide connections and then cause degradation of the collagen fibres.
The purpose of the digestion of the fibres and ground substance is to process molecules that have to adapt themselves to a precise organizational pattern in which the final collagen fibres interact electrostatically with the proteoglycans and arrange themselves according to the lines of force acting in the area.
The synthesis of fibrils and amorphous substance is regulated by correct balancing between absorption and synthesis.
This function is performed equally by fibroblasts in the receiving area and in the grafted dermis, which take on the ultrastructural characteristics of active cells.
Phagocytic activity and that of fibroblast synthesis determine an area of transition between the connective tissue already existing and that newly formed.
The final positioning of the aggregated collagen fibres and of the macromolecules of the ground substance in a state of gel determines the alignment of the fibres.
The remodelling of the tissue is thus related to the activity of the cell components involved in the re-absorptior of the fibres and in the production of fibres and grounc substance. The composition and orientation of the fibre depend on the forces that act on the fibres and macro molecules of the matrix.
With regard to the specific problem of keloid formation it has been shown that besides the familial element there is the finding that the fibroblasts of patients suffering from keloids are phenotypically different from those of healthy persons. This suggests that the pathology may have genetic cause.
Keloid fibroblasts are thought to present a reduction in the normal feedback of the regulation of production of the extracellular matrix. These fibroblasts would appear to respond more energetically to the action of growth factors, even if the obligatory affinities and densities of the receptors are identical to those of normal cells.
The observation in our cases that the graft donor area did not in time manifest any keloid transformation suggests a non-generalized tendency to keloid formation reserved to certain specific areas, such as the very common forms frequently encountered in the sternal region, the auricles, the deltoid region, and the abdominal area.
These areas would thus appear to present a particular "field activity" related in some way to the characteristics of the skin, an immunological organ that is the site of histocompatibility antigens.
There are however other factors that should not be neglected, as stressed by various researchers, such as tension on the wound, the position of the wound in relation to skin orientation, the presence of infection, and healing by first or second intention.
It may also be supposed that, following dermoepidermal graft, biological activity in loco is modified by the input of mesenchymal cell elements and in particular of fibroblasts from other districts. In particular, the fibroblasts transferred with the dermis, which are activated by the graft trauma and are possibly numerically superior to those present in the recipient area, an area exposed down to the perichondrial stratum, would appear to dominate the regulatory feedback activity of production and degradation of the collagen fibres and the ground substance, thus restoring a condition of normal healing.
It should not be forgotten that the treatment of keloids by excision and repair with skin graft has been proposed by various researchers but the results obtained have been judged unfavourably as the recidivation rate was 46%.
In modem practice surgical excision is associated either with pharmacological treatment, e.g. cortisones, antiphlogistics, and interferon, or with physical treatment, e.g. elastic compression, radiotherapy, and plesiotherapy administered pre- or post-operatively.

Conclusions

The limited number of our cases does not permit us to draw definitive conclusions. The experience obtained in the treatment of the two patients described does however enable us to repropose the treatment of keloids with the free skin graft technique, at least in cases localized in the auricle, without the supplementary assistance of medical or physical therapy.

RESUME. Les Auteurs présentent deux cas de la formation de chéloïdes dans l'auricule. Généralement les chéloïdes se produisent dans le derme et sont caracterisées par la présence de fibres collagéneuses épaisses d'aspect vitreux et hyalinisé. On note aussi la présence de fibroblastes connexes. Dans les phases précoces les formations sont généralement plus vascularisées, particulièrement dans les zones périphériques, tandis que dans les phases plus matures elles sont plus hyalinisées. L'ablation d'une chéloïde diffuse, comme dans les cas décrits par les Auteurs, et la réparation d'une zone exposée moyennant l'emploi d'une greffe cutanée dermoépidermique à toute épaisseur provoquent des modifications générales et spécifiques dans le processus de la guérison. Les Auteurs décrivent les techniques chirurgicales et les problèmes qui peuvent se produire. Bien qu'ils considèrent seulement deux cas l'expérience gagnée leur permet de reproposer le traitement des chéloïdes moyennant la technique de la greffe libre, au moins dans les cas situés dans l'auricule, sans l'assistance supplementaire de la thérapie médicale ou physique.

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