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A Modified Technique for Removing Earlobe Keloids Earlobe keloids are frustrating to patients and surgeons for their aesthetic deformity. The purpose of surgery is to remove the brous core of the keloid and to cover the defect, restoring the normal contour of the ear. There have been numerous methods described to achieve this, including healing by secondary intention, direct closure, skin grafts, and local aps. Many different types of local aps of varying complexity have been described for different situations. Lee et al.1 and Kim et al.2 proposed an interesting and effective design in which the skin over the keloid was dissected from the keloid core and preserved as a ap to cover the defect. Based on the principles of this technique, we describe a modication that allows for accurate preoperative measurement and planning, allowing for safe and simple elevation and insetting of the ap during the procedure (Figure 1).

Figure 1. The edge of keloid and incision line in our novel technique.

Preoperative Measurements and Marking Before surgery, we use a silk suture to form a circle around the base of the keloid. The circumference of the resulting ellipse and its long and short axes are measured and documented (Figure 2). These measurements represent the dimensions of the skin ap required to reconstruct the defect after enucleation of the keloid core. Using the same silk suture, this ellipse is transposed onto the body of the keloid with one side aligned along the base of the keloid, representing the dermal pedicle of the skin ap (Figure 3). The remaining surface area of the keloid not covered by our elliptical ap is excised along with the keloid core in our modied technique.

Figure 2. A tie is used to form a circle according to the base of the keloid.

Technique Local anesthesia (2% lidocaine and 1:100,000 epinephrine) is inltrated around the earlobe. After

waiting several minutes, we use a scalpel to cut through the skin along the incision lines described above. The keloid core is then dissected and removed from under the skin of our marked

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Figure 3. The basal circle is projected to the surface of keloid.

Figure 5. The surgical result is good (3 weeks after surgery).

Discussion Our modied technique based on Kims and Lees methods is an effective way to accurately measure and elevate the skin ap. The ability to design the required ap accurately and mark the incision lines has many advantages. First, by raising only what is required to cover the defect, we signicantly reduce the time of ap elevation. We do not need to separate all the skin off the keloid core, and there is no redundant ap to trim. Second, we eliminate the likelihood of an excessively trimmed ap, with resulting tension on the sutures and distortion of the earlobe. Our technique, relying on accurate original measurements, signicantly reduces the need for refashioning of the ap once raised. Third, we generally choose the keloid base parallel to long axis as the pedicle so that sufcient width is retained to ensure adequate blood supply to the skin ap. In major cases, we locate the ap pedicle anteriorly so scarring is less visible. Based on the principles of atraumatic surgery, accurate approximation, and avoidance of tension proposed by Kim and Lee, we believe our modied technique provides a safe, efcient, effective

Figure 4. A ap is elevated, and the keloid core, together with the skin between two incision lines, is removed as a whole mass.

ellipse, which is raised as a ap (Figure 4). The defect is then resurfaced by insetting the skin ap. The wound is closed with one layer of 60 Prolene interrupted sutures without tension. The ear retains good shape after the surgery (Figure 5).

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method to reconstruct the earlobe after keloid removal.

2. Kim D, Kim E, Eo S, Kim K, et al. A surgical approach for earlobe keloid: keloid llet ap. Plast Reconstr Surg 2004;113:166874.

Acknowledgments The authors thank Hua L, Ying H (Department of Plastic and Reconstructive Surgery, Sir Run Run Shaw Hospital, Medical College, Zhejiang University) and Frank Lin (Royal Melbourne Hospital, Australia) for their excellent assistance in this work.

YAN SHAO, PHD XING HE, PHD Department of Plastic and Reconstructive Surgery Sir Run Run Shaw Hospital Medical College Zhejiang University Hangzhou, China

References
1. Lee Y, Minn K, Baek R, Hong JJ, et al. A new surgical treatment of keloid: keloid core excision. Ann Plast Surg 2001;46:13540.

Regarding Assisting Pincer Nail Deformity by Haneke's Procedure We read with interest the article Pincer Nails: Denition and Surgical Treatment by Baran and colleagues1 that encompassed a variety of surgical tricks to assist the correction of pincer nail deformity. They mentioned Hanekes technique followed by a median incision of the nail bed from the border of the lunula to 2 mm beyond the hyponychium and extending down to the bone. During this incision, the traction osteophyte was felt with the scalpel, although it was not obvious on the roentgenogram. The pinched nail bed was dissected from the terminal phalanx, the distal dorsal tuft with the osteophyte was rongeured off, and the nail bed was expanded and sutured using 60 monolament absorbable sutures. Reverse tie-over sutures were placed in the lateral nail folds, with small rubber tubes used as cushions to prevent the sutures from cutting through the nail folds. These sutures kept the nail bed stretched over the bone and were removed after approximately 3 weeks. We have ve important suggestions that could further rene this procedure. First, fungal nail infection should be treated and then excluded by negative results on microscopic examination (KOH test) and fungal culture before reconstruction. Second, after exsanguination of the toe, the deformed nail plate should be removed using the rolling method, preventing unnecessary trauma to the nail bed and matrix. Third, after the nail bed is exposed, the surrounding brous tissues can be excised using scissors to obtain a regular nail bed for smooth growth of the new nail (Figure 1A). Fourth, surface irregularities such as traction osteophytes and the periosteum are more easily removed using a bone burr or rasp than using a bone rongeur (Figure 1B). Fifth, the original nail could also be trimmed thin using the bone burr or rasp for nal coverage of the nail bed (Figure 1C). We examined the cases of four patients who underwent treatment on ve great toes using Hanekes procedure. Satisfactory results were obtained using this simple, effective, nail matrix sparing technique without any complications (Figure 1D). In conclusion, we believe that by adopting the abovementioned steps for further rening this technique, Hanekes procedure can be easily performed with low morbidity and can be a good option for treatment of pincer nail deformity.

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