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RECONSTRUCTIVE
Outcomes of Surgical Excision with Pressure
Therapy Using Magnets and Identification of Risk
Factors for Recurrent Keloids
Tae Hwan Park, M.D.
Sang Won Seo, M.D.
June-Kyu Kim, M.D.
Choong Hyun Chang, M.D.,
Ph.D.
Seoul, Korea
Background: In a previous study, the authors described an adjuvant pressure
therapy using magnets for the management of ear keloids. The purpose of the
present study was to build on this previous study by expanding the cohort of
patients, evaluating treatment outcomes by means of a prospective study and
identifying risk factors for recurrent ear keloids.
Methods: The authors treated 1436 ear keloids in 883 patients with surgical
excision followed by pressure therapy using magnets at Kangbuk Samsung
Hospital over the 7.25-year period from December of 2002 to February of 2010.
Six hundred eighteen of 883 patients (70 percent) had histories of treatment
failure at other hospitals. The follow-up period was 18 months. Therapeutic
outcomes were evaluated as recurrence or nonrecurrence. Comparisons be-
tween the two groups (recurrence versus nonrecurrence) were made using
Mann-Whitney tests for continuous variables, the chi-square test and the Fisher’s
exact test for categorical variables, and multivariate logistic regression for in-
vestigating associations between possible risk factors and keloid recurrence.
Results: The overall recurrence-free rate was 89.4 percent after a follow-up
period of 18 months. Keloid recurrence was significantly associated with the
presence of prior treatment history, keloid low growth rate, and high patient
body mass index.
Conclusions: The authors’ protocol results in excellent outcomes in cases of ear
keloids. Patients with prior treatment history, low growth rates of keloids because
of longer duration of disease, and high body mass index should be monitored
closely for signs of recurrence and managed cautiously during ear keloid
treatment. (Plast. Reconstr. Surg. 128: 431, 2011.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
Keloids can appear months or even years after
the primary injury and tend not to regress.1
Keloids are often resistant to treatment and
have high recurrence rates.2Earlobes are com-
mon sites for keloids following ear piercing, with
an incidence of approximately 2.5 percent.3Given
the consequences of ear keloids, including cos-
metic deformity and psychological trauma, under-
standing of risk factors for recurrence is impera-
tive to provide optimal treatment.4Although some
possible risk factors for overall keloid recurrence
have been described,5most reports in the litera-
ture suffer from small numbers of patients and
inadequate follow-up.6Numerous treatment
methods have been proposed for earlobe keloids,
suggesting that no single method has surfaced as
the accepted standard.7Pressure therapy has
evolved as an important adjuvant treatment for ear
keloids, and numerous pressure earrings have
been introduced.8–13 Although clinical studies de-
scribing it are scarce, adjuvant pressure therapy
is widely used in the treatment of ear keloids,
and recurrence-free rates generally exceed 60
percent.14,15 In a previous study, we described an
adjuvant pressure therapy that included the use of
magnets for the management of ear keloids.12 The
current report expands on those experiments by
From the Department of Plastic and Reconstructive Surgery,
Kangbuk Samsung Hospital, Sungkyunkwan University
School of Medicine.
Received for publication December 13, 2010; accepted Feb-
ruary 25, 2011.
Copyright ©2011 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0b013e31821e7006
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.
www.PRSJournal.com 431
investigating keloid recurrence rates in a prospec-
tive study analyzing the outcomes of this treatment
protocol. We conclude that surgical excision com-
bined with pressure therapy using magnets im-
proves outcomes over conventional approaches
for keloid treatment.
PATIENTS AND METHODS
Inclusion and Exclusion Criteria and Study
Design
Patients were treated with surgical excision
combined with magnetic disk pressure therapy
over a period of 7.25 years from December of 2002
to February of 2010 at our hospital. Patients with
ear keloids who presented to the outpatient clinic
were included in the study according to the fol-
lowing criteria: (1) the scar was elevated and ex-
tended beyond the dimensions of the initiating
injury site or lesion; (2) the patients were older
than 8 years; (3) surgical excision with primary
closure was scheduled; and (4) patients did not
undergo additional ear piercing during treatment
before final outcome measurement. Patients were
excluded from the study if they were unavailable
for follow-up, and all patients who were included
agreed to comply with the treatment protocol.
Patients were also excluded from the study if they
received additional adjuvant therapy during treat-
ment or histologic confirmation was not obtained.
All included patients consented to the require-
ment for final follow-up after 18 months. We an-
alyzed data including patient age, sex, age of ke-
loids before treatment, anatomical locations,
previous treatment history and modality, recur-
rence, and clinical photographs.
Surgical Technique and Postoperative Care
All procedures were performed under local
anesthesia. We excised lesions as completely as
possible, and bleeding was controlled by step-by-
step bipolar coagulation. We closed wounds with
appropriate approximation using nylon 5-0 inter-
rupted sutures. We inserted Silastic drains if the
excised mass was large and created dead space. We
also applied compressive wound dressing to pre-
vent dehiscence caused by hematoma of the sur-
gical wound. All keloids were sent for histologic
examination to confirm clinical diagnoses. The
drains were removed on postoperative day 1, if
present, and stitches were removed on postoper-
ative days 14 to 21. Pain was controlled by admin-
istration of nonsteroidal antiinflammatory drugs.
Adjuvant Pressure Therapy Using Magnets
Patients were instructed to use the magnets for
approximately 12 hours per day for 6 months until
the therapy was completed. During the adjuvant
pressure therapy, patients were seen frequently for
follow-up for recurrence and evaluation of the suc-
cess of the therapy (Fig. 1). Our protocol included
five cycles of application repeated throughout the
day. Each cycle was composed of 2 hours of magnet
application followed by a half hour of relief. The
applied pressure was 35 mmHg, which was estimated
using a digital manometer. Despite a strict protocol,
the discomfort experienced when pressure was ap-
plied to the ear keloids was not prominent. Even in
postauricular lesions where application of magnets
was not feasible, we used conventional magnets with-
out any customized pressure device.
Follow-Up and Outcome Assessment
In all patients, a follow-up period of 18 months
was required. Treatment outcome was recorded as
recurrence or nonrecurrence. Complications were
also recorded. Nonrecurrence was defined as a scar
without signs of elevation and extension, although
slight scarring or redness could be present (Fig. 2).
Recurrence was defined as any elevation of the scar
or extension beyond the original surgical field.
Statistical Analysis
All statistical analyses were conducted using
SPSS version 17.0 (SPSS, Inc., Chicago, Ill.). Our
Fig. 1. Versatility of magnets.
Plastic and Reconstructive Surgery •August 2011
432
data were not normally distributed; consequently,
nonparametric tests were used. Descriptive statis-
tics are presented as medians with interquartile
ranges or as numbers and percentages. To com-
pare medians of continuous variables (i.e., patient
age, keloid size, maximal keloid size, age of ke-
loids, keloid growth rate, and patient body mass
index), Mann-Whitney tests were used. Chi-square
tests were used to assess any differences between
categorical variables (i.e., sex, anatomical location
of keloid, previous treatment history, cause, and
number of ear keloids). Fisher’s exact tests were
used in place of chi-square tests when expected
cell values were less than or equal to 5. Multivariate
logistic regression analysis was then applied, in-
corporating possible risk factors that had been
linked to recurrence in univariate analysis for the
purpose of determining which, if any, factors in-
teracted with each other in keloid recurrence.
Odds ratios and associated 95 percent confidence
intervals were calculated for each of the indepen-
dent variables in the multivariate logistic regres-
sion models. Two-tailed values of p⬍0.05 were
considered statistically significant.
RESULTS
Patient Characteristics
Sex, Age, and Anatomical Locations
Of the 883 patients, 827 (93.7 percent) were
women and 56 (6.3 percent) were men (Table 1).
The average age was 24 years (range, 21 to 27
years), and patients aged 21 to 30 years showed the
highest prevalence. The locations of ear keloids in
order of frequency were the lobule [635 patients
(71.9 percent)] (Figs. 3 and 4), helix [193 patients
Fig. 2. (Above,left) Helix keloid, (above,right) postoperative view (18 months after
surgical excision with adjuvant pressure therapy using magnets), and (below) gross
specimen are shown.
Volume 128, Number 2 •Ear Keloid
433
(21.9 percent)] (Fig. 5), both lobule and helix [41
patients (4.6 percent)] (Fig. 6), and other areas
[14 patients (1.6 percent)] (Figs. 7 and 8).
Age of Keloids before Treatment (Duration
of Presence), Size of Keloid before Treatment,
and Keloid Growth Rate
The average time interval between keloid for-
mation (or prior complete treatment) and time of
treatment was 3 years (range, 2 to 5 years). The
average pretreatment total size of lesions was 2.0 cm
(range, 1.3 to 3.0 cm), and average diameter of the
largest lesion of a single patient was 1.5 cm (range,
1.0 to 2.0 cm). The growth rate was calculated by
dividing the maximal diameter of the largest lesion
of a single patient with its duration of presence (age
of keloids before treatment). The average growth
rate was 0.50 cm/year (range, 0.33 to 1.00 cm/year).
Previous Treatment History
The number of patients treated for a primary
ear keloid was 265 (30 percent), and 618 patients
(70 percent) were treated for a recurrent ear ke-
loid that failed to respond to other treatments.
These other treatments included single therapies
such as prior excision surgery [155 patients (17.6
percent)]; prior intralesional steroid injection
[333 patients (37.7 percent)]; and prior other sin-
gle therapy alone including laser therapy, acu-
puncture, cryotherapy, or Botox injection [12 pa-
Table 1. Baseline Patient Characteristics*
Characteristic Value
Total no. of patients 883
Continuous variables
Age, years 24.00 (21.00–27.00)
Total size, cm 2.00 (1.30–3.00)
Maximal diameter, cm† 1.50 (1.00–2.00)
Age of keloids, years 3.00 (2.00–5.00)
Growth rate, cm/yr 0.50 (0.33–1.00)
BMI, kg/m221.00 (19.00–22.00)
Categorical variables
Sex
Female 827 (93.7)
Male 56 (6.3)
Anatomical locations
Lobule 635 (71.6)
Helix 193 (21.9)
Both lobule and helix 41 (4.8)
Other portions 14 (1.6)
Previous treatment history
No 265 (30.0)
Yes 618 (70.0)
Surgical excision 155 (17.6)
Steroid injection 333 (37.7)
Excision plus steroid injection 32 (3.6)
Excision plus pressure therapy 78 (8.8)
Other treatments 20 (2.3)
Cause
Ear piercing 855 (96.8)
Laceration 11 (1.2)
Surgery 10 (1.1)
Infection 3 (0.3)
Idiopathic 4 (0.5)
No. of ear keloids
One 435 (49.3)
Two 366 (41.4)
Three 61 (6.9)
Four 20 (2.3)
Six 1 (0.1)
*Values are expressed as median (interquartile range) for continu-
ous variables and number (percentage) for categorical variables.
†Maximal diameter means the maximal diameter of the largest lesion
of a single patient.
Fig. 3. Unilateral earlobe keloid.
Fig. 4. Bilateral earlobe keloids.
Plastic and Reconstructive Surgery •August 2011
434
tients (0.3 percent)]. Of these 12 patients, eight
had laser therapy (0.9 percent), three had prior
acupuncture (0.3 percent), and one had prior
cryotherapy (0.1 percent). The other therapies
also included combination treatments such as
combination of excision with pressure therapy [78
patients (8.8 percent)], combination of excision
with intralesional steroid injection [32 patients
(3.6 percent)], and other combination of thera-
pies [eight patients (0.9 percent)]. None of the
patients was previously treated with magnets.
Outcome Assessment
All patients completed the treatment proto-
col, with a follow-up interval of 18 months (Ta-
ble 2). Of these patients, 89.4 percent had suc-
cessful treatment of their ear keloids, whereas
10.6 percent had recurrences. The postopera-
tive course was uneventful, with the exception of
three patients (0.3 percent) (Fig. 9) who pre-
sented with tissue necrosis after magnet appli-
cation and eight patients (0.9 percent) who had
a minor dehiscence caused by hematoma of the
surgical wound.
Patient demographics and keloid characteris-
tics were evaluated as possible risk factors for ke-
loid recurrence. As shown in Table 2, events of
keloid recurrence were associated with a signifi-
cantly lower degree of keloid growth rate com-
pared with events of nonrecurrent cases (0.5
Fig. 5. Bilateral helix keloids.
Volume 128, Number 2 •Ear Keloid
435
cm/yr versus 0.42 cm/yr, p⫽0.012). Patients with
keloid recurrence were significantly associated
with both higher body mass index and the pres-
ence of previous treatment history as compared
with nonrecurrent cases (21.5 compared with
21.0, p⫽0.017; and 92.6 percent compared with
67.3 percent, p⬍0.001, respectively). No signif-
icant effects on keloid recurrence were noted for
patient age and sex, keloid total size, maximal size,
anatomical locations, number, and cause.
Risk Factor Identification Using Multivariate
Logistic Regression Analysis
After we performed univariate analysis using
the entire study sample (Table 2), all factors that
were found to be significant to the 0.20 level were
included in the multivariate logistic regression
analysis (Table 3). The variables included in the
analysis were age (p⫽0.174), age of keloids (p⫽
0.017), growth rate (p⫽0.012), previous treat-
ment history (p⬍0.001), and number of ear ke-
loids (p⫽0.178). We then performed backward
stepwise elimination to ensure that only those vari-
ables significantly influencing keloid recurrence
were included in the final logistic regression anal-
ysis. After multiple eliminations, the only factors
that were found to play significant roles in keloid
recurrence were growth rate (p⫽0.002), body
mass index (p⫽0.009), and previous treatment
history (p⬍0.001). Table 3 illustrates the relative
weights the three variables played in influencing
keloid recurrence. Notably, the presence of pre-
vious treatment history (which includes surgical
excision, steroid injection, combination therapies,
and other treatments) had a 6.92 increased odds
ratio of recurrence in comparison with absence of
prior treatment history.
DISCUSSION
Ear keloids remain challenging reconstructive
problems with serious aesthetic implications. Ke-
loids are relatively resistant to treatment, and pa-
tients tend to experience high recurrence rates
when treated with a single-treatment modality.16
Keloids have a tendency to recur after surgical
excision alone, with rates up to 80 to 100 percent.17
According to the literature, radiation therapy is an
effective adjuvant modality for treating earlobe
keloids.18,19 However, in using radiation therapy,
there is a risk of the development of radiation-
induced malignancy.20 In our experience, many
patients seen at our hospital have fears of possible
radiation-induced malignancy after being told
about radiation therapy at other hospitals.
Although the mechanism of pressure therapy
has not been fully determined, a combination of
surgical excision and adjuvant pressure therapy is
considered highly efficacious in reducing keloid
recurrences, with minimal adverse effects.21 This
effectiveness is hypothesized to occur as a result of
altered wound tension and pressure-induced lo-
calized hypoxia.15 Numerous pressure earrings
Fig. 6. Keloid on both helix and lobule.
Fig. 7. Keloid on the left posterior auricular area.
Plastic and Reconstructive Surgery •August 2011
436
have been described as adjuvant therapies for ear
keloids. Among them, magnet pressure therapy
has several positive attributes, including ability to
treat keloids on any portion of the ear (lobule,
helix, and other regions), low cost, easy applica-
tion and removal by patients, and no hearing im-
pairment (Fig. 2).
In the current study, recurrent cases were
strongly associated with poor compliance to adju-
vant pressure therapy. When using postoperative
pressure therapy for the treatment of keloids, pa-
tient compliance is essential, as the keloid may
recur as soon as the external pressure is relieved
prematurely. Therefore, improved patient train-
ing may further decrease the recurrence rate of
ear keloids when using this device. In addition, as
our patients were recruited from a medical refer-
ral center for treatment of ear keloids, our cohort
of patients tend to have symptoms that are more
severe than those of average patients. If applied to
average patients, we suspect that our protocol
would yield more satisfactory outcomes than those
of severe cohorts for ear keloids.
Although ear keloids have been discussed ex-
tensively in the medical literature, only a few stud-
ies have focused on risk factors of keloid recur-
rence. Our study has yielded several novel and
surprising observations on keloid recurrence. An
interesting and novel observation was made re-
garding growth rate and keloid recurrence. In
contrast to other studies, low growth rate was sig-
nificantly associated with high recurrence rate.6
Surprisingly, the maximal diameter of the largest
lesion of a single patient between the recurrent
and nonrecurrent groups was not a significant
factor in recurrence. Nevertheless, longer dura-
tion of keloid presence before treatment partially
explains the high recurrence rates associated with
low growth rate, considering the inverse relation-
ship between duration of disease and growth rate.
Another unique finding was the association of
previous treatment history with the risk of keloid
recurrence. This relationship had been strongly
suspected in our clinical practice and was there-
fore specifically investigated. Skin trauma includ-
ing ear piercing, laceration, and blunt trauma can
cause keloids, and previous treatment history is
considered a form of trauma.
The link between body mass index and keloid
recurrence is also a novel finding. We found that
high body mass index was associated with high
keloid recurrence rates. This implies that obese
patients are more likely to have recurrent ear ke-
loids than those with normal body mass index.
A recurrence risk assessment table (Table 3)
was constructed that presents a prospective pa-
tient’s individualized risk based on these preop-
eratively identifiable characteristics, and this table
has facilitated our preoperative counseling by
changing how we can predict, to some degree,
keloid recurrence.
Strengths of this study include excellent fol-
low-up rates with a constant follow-up period (out-
come assessment at 18 months postoperatively for
all patients). In addition, our study was a well-
scheduled prospective outcome study in which pa-
tients were surveyed at predetermined times be-
fore and after surgery. Lastly, our study included
Fig. 8. Keloid on the right posterior auricular area and gross specimen.
Volume 128, Number 2 •Ear Keloid
437
the largest cohort ever conducted in any ear keloid
study.
This study also had some limitations. First, our
patients were all Korean, and had more severe
presenting symptoms compared with those in
most other hospitals, as 70 percent of our patients
had a history of treatment failure. For these rea-
sons, our results cannot be generalized to patients
in other circumstances. Second, recurrence risk
assessment results are somewhat incomplete, as
they do not provide adjustments for risk factors
not included in our study such as additional keloid
presentation, family history of keloids, and histo-
pathologic findings.
CONCLUSIONS
Ear keloids are a cosmetic disfigurement that
is challenging to treat, with a high recurrence rate.
The increasing trend for cosmetic piercing and for
multiple ear piercing suggests that ear keloids will
become a more frequent part of plastic surgery
practice. There is no consensus as to the optimal
treatment of keloids. As the treatment modality of
surgical excision followed by postoperative pres-
sure therapy provides reasonably positive results in
the reviewed literature, our postoperative pres-
sure therapy with a magnet is efficacious, safe, well
tolerated, and successful at preventing recur-
rences. As patient compliance was poor in the
recurrent cases, improved patient training may
further decrease the recurrence rate of ear keloids
when using magnets. Based on our study of 1436
keloids in 883 patients, two patient characteristics
(patients with a prior treatment history or high
body mass index) and one keloid characteristic
Table 2. Baseline Characteristics between Nonrecurrence and Recurrence Groups*
Nonrecurrence Recurrence p
No. of patients 789 97
Continuous variables
Age, years 24.00 (22.00–27.00) 23.00 (21.00–27.00) 0.174
Total size, cm 2.00 (1.30–3.00) 2.00 (1.50–3.00) 0.410
Maximal diameter, cm† 1.50 (1.00–2.00) 1.50 (1.00–2.00) 0.964
Age of keloids, years 3.00 (1.00–5.00) 3.00 (2.00–5.00) 0.017‡
Growth rate, cm/yr 0.50 (0.33–1.00) 0.42 (0.25–0.88) 0.012‡
BMI, kg/m221.00 (19.00–22.00) 21.50 (22.00–22.00) 0.017‡
Categorical variables
Sex 0.986
Female 739 (93.7) 88 (93.6)
Male 50 (6.3) 6 (6.4)
Anatomical locations 0.857
Lobule 565 (71.6) 70 (74.5)
Helix 173 (21.9) 20 (21.3)
Both lobule and helix 38 (4.8) 3 (3.2)
Other portions 13 (1.6) 1 (1.1)
Previous treatment history ⬍0.001‡
No 258 (32.7) 7 (7.4)
Yes 531 (67.3) 87 (92.6)
Previous treatment modalities ⬍0.001‡
None 258 (32.7) 7 (7.4)
Surgical excision 122 (15.5) 33 (35.1)
Steroid injection 297 (37.6) 36 (38.3)
Excision plus steroid injection 27 (3.4) 5 (5.3)
Excision plus pressure therapy 68 (8.6) 10 (10.6)
Other treatments 17 (2.2) 3 (3.2)
Cause 0.442
Ear piercing 765 (96.9) 90 (95.7)
Laceration 10 (1.3) 1 (1.1)
Surgery 8 (1.0) 2 (2.1)
Infection 3 (0.4) 0 (0.0)
Idiopathic 3 (0.4) 1 (1.1)
No. of ear keloids 0.178
One 393 (49.8) 42 (44.7)
Two 319 (40.4) 47 (50.0)
Three 59 (7.5) 2 (2.0)
Four 17 (2.2) 3 (3.2)
Six 1 (0.1) 0 (0.0)
*Values are median (interquartile range) for continuous variables and number (percentage) for categorical variables. The pvalues for
continuous variables were obtained by using the Mann-Whitney test; pvalues for categorical variables were obtained by using chi-square tests
or Fisher’s exact tests.
†Maximal diameter means the maximal diameter of the largest lesion of a single patient.
‡Statistically significant.
Plastic and Reconstructive Surgery •August 2011
438
(keloid with low growth rate) were linked to risk
of keloid recurrence. This information can be
used to clinically counsel a patient on the indi-
vidualized risk of keloid recurrence, and with this
added information, patients and surgeons can
make more informed decisions. However, a pro-
spective multicenter study or meta-analysis would
be beneficial in optimizing treatment to provide
patients and surgeons with the best possible man-
agement of ear keloids.
Choong Hyun Chang, M.D.
Department of Plastic and Reconstructive Surgery
Kangbuk Samsung Hospital
Sungkyunkwan University School of Medicine
108 Pyung-Dong
Jongno-Gu, Seoul 110-746, Korea
eppeen@hanmail.net
ACKNOWLEDGMENTS
The authors acknowledge Yun-Joo Park, M.D., and
Ji-Hae Park, M.D., for helpful assistance in editing the
article. The authors also acknowledge Mi-Yeon Lee for
statistical assistance.
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Fig. 9. Tissue necrosis after adjuvant pressure therapy using
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Table 3. Multivariate Logistic Regression Analysis
Keloid Recurrence
Independent Variable Odd Ratio (95% CI) p
Growth rate 0.67 (0.48–0.94) 0.020
BMI 1.16 (1.04–1.29) 0.009
Previous treatment history 6.92 (3.13–15.29) ⬍0.001
CI, confidence interval; BMI, body mass index.
Volume 128, Number 2 •Ear Keloid
439
