Should a Tissue Cuff Be Preserved During Auricular Lobule Keloid Excision to Reduce Recurrence?

Auricular keloids of the lobule remain a frustrating problem for otolaryngologists and facial plastic surgeons because recurrence is common, lesions are visible, and treatment must preserve ear contour. A persistent technical question is whether the surgeon should intentionally preserve a peripheral cuff of keloid tissue during excision, or instead remove all clinically abnormal tissue to decrease risk of recurrence.

The traditional rationale for “intralesional”, “intramarginal” or “core,” excision is practical. Leaving a thin peripheral rim may avoid violating adjacent keloid-prone skin, reduce wound tension, and minimize distortion of the lobular contour. Conventional treatment paradigms therefore have supported conservative excision combined with adjuvant therapy, particularly corticosteroid injection^1,2 This approach remains attractive when complete excision would create a large defect, require excessive skin recruitment, or compromise cosmesis.

However, the biologic argument for leaving keloid tissue behind can be concerning to some surgeons. Histologic and clinical studies suggest that residual proliferative keloid tissue may act as a nidus for regrowth. Chong et al reported reduced recurrence after complete excision of the proliferating core in auricular keloids, and Lemperle et al and Tan et al emphasized that residual active keloid tissue may contribute to recurrence.^3-5 These findings support complete excision of clinically abnormal tissue when closure can be achieved without undue tension or anatomic distortion.

The counterpoint is that recurrence is not determined by margin status alone. Surgical tension, lesion size, location, patient biology, postoperative surveillance, and adjuvant therapy all influence outcome. Recent evidence supports the continued role of intralesional excision in selected cases. Lawera et al found a pooled recurrence rate of 13% after keloid intralesional excision in a meta-analysis of 608 keloids, and Ran et al concluded that core excision can achieve low recurrence when combined with adjuvant therapy.^6,7 Thus, preserving a cuff should not be considered inherently wrong; rather, it should be reserved for circumstances in which complete excision would create a worse reconstructive problem.

In my practice, the decision is individualized. For small and medium auricular lobule keloids, I favor complete removal of clinically abnormal tissue if a low-tension closure can be achieved. This avoids deliberately leaving fibroproliferative tissue behind. For large auricular lobule keloids, limited cuff-preserving core excision or staged serial excision or stellate excisions should be considered to minimize a high-tension closure. If a keloid cuff is left, the preserved cuff should be minimal and should serve a reconstructive purpose. (Table 1)

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Table 1.

Intralesional Core vs Extralesional Complete Auricular Lobule Keloid Excision

Category	Intralesional core excision	Extralesional complete excision
Definition	Debulks the central keloid while leaving a peripheral rim	Removes all clinically abnormal keloid tissue
Rationale	Reduces defect size and closure tension	Avoids leaving active fibroproliferative tissue
Advantages	Easier closure; may preserve auricular lobule contour	Better margin control; avoids intentional residual disease
Limitations	Residual tissue may regrow	Larger defect; may increase tension or distortion
Best Use	Large lesions where complete excision would deform anatomy	Small to medium lesions amenable to low-tension closure
Practical Recommendation	Use selectively and preserve the smallest cuff necessary	Preferred when closure can be achieved safely

Regardless of the excisional plan, excision alone is insufficient. Serial intralesional corticosteroid injection should be strongly considered after surgery. Pressure therapy, silicone therapy, 5-fluorouracil, and radiotherapy may be appropriate for selected recurrent or high-risk lesions.^8-10 The most defensible approach is therefore, not “always preserve” or “never preserve,” but rather be tension and contour conscious when planning auricular lobule keloid removal and closure.