Should a general surgeon or a plastic surgeon treat a keloid on the ear after piercing?

Keloid Treatment: Plastic Surgeon Preferred

For an ear keloid following piercing, a plastic surgeon is the preferred specialist due to their expertise in precise excision techniques, cosmetic outcomes, and management of complex wound closure that minimizes recurrence risk. 1, 2

Rationale for Plastic Surgery Referral

Technical Expertise Requirements

• Loupe magnification is critical for identifying and removing the keloid tract (present in 73% of piercing-related ear keloids), pseudopods, and all keloid tissue—techniques routinely used by plastic surgeons 1
• Specialized closure techniques such as the "keloid fillet flap" (where skin over the keloid is dissected and preserved as a flap after complete keloid removal) require plastic surgery training and significantly reduce recurrence 2
• Meticulous adherence to the "5 As and one B" principle (Asepsis, Atraumatic technique, Absence of raw surface, Avoidance of tension, Accurate approximation, and complete Bleeding control) is essential for reducing recurrence and is a plastic surgery standard 2

Cosmetic Considerations

• The ear is a highly visible anatomic location where cosmetic outcome directly impacts quality of life 3
• Once an abscess develops or improper excision occurs, good cosmetic preservation of auricular cartilage is difficult to maintain 4, 5
• Plastic surgeons are trained in aesthetic outcomes and can better manage the delicate balance between complete keloid removal and tissue preservation 1, 2

Treatment Algorithm

Initial Assessment

• Confirm keloid diagnosis versus hypertrophic scar (keloids extend beyond original injury site and rarely regress spontaneously) 1
• Document keloid size, presence of tract, and patient risk factors (family history of keloids, previous keloid formation, skin type) 4, 3
• Counsel patients with keloid history that outcomes are uncertain with any skin trauma 4

Surgical Approach

• Extralesional excision under loupe magnification to identify and remove the tract connecting to the piercing site 1
• Avoid subcutaneous sutures and close with fine monofilament sutures after trimming the keloid fillet flap 2
• Never use epinephrine in local anesthesia for ear procedures as it compromises blood supply 6

Adjuvant Therapy (Essential for Preventing Recurrence)

• Topical silicone gel applied immediately postoperatively is effective for primary 1-3 cm ear keloids and avoids painful injections 1
• For high-risk patients (previous treatment failure, strong keloid tendency), consider "sandwich" radiotherapy: 10 Gy external beam radiation given 1 day before and 1 day after excision, with 79-91% control rates at 5 years 7, 8
• Reserve intralesional triamcinolone for recurrences or as alternative to radiotherapy 1, 3

Critical Pitfalls to Avoid

• Do not perform simple excision with primary closure alone—recurrence rates are unacceptably high without specialized techniques and adjuvant therapy 2, 7
• Failure to identify and remove the keloid tract leads to recurrence in the majority of cases 1
• Inadequate magnification results in incomplete removal of keloid pseudopods and tissue 1
• Creating tension on wound closure or leaving raw surfaces significantly increases recurrence risk 2

When General Surgery May Be Appropriate

• If the keloid is infected or has formed an abscess, initial surgical drainage may be performed by a general surgeon, but definitive keloid excision should still be referred to plastic surgery after infection resolution 4, 5
• For simple embedded earrings without keloid formation, general surgeons can perform removal under local anesthesia 4

Prevention Counseling

• Patients with personal or family history of keloids should avoid ear piercing entirely as outcomes are unpredictable with any skin trauma 4
• Keloid formation occurs in approximately 2.5% of ear piercings, making prevention counseling important for at-risk populations 4