Keloids of the helical rim are less common than those on the earlobe but equally disfiguring and more challenging to treat. Keloid excisions of the helix nearly always result in exposed cartilage because of the lack of soft tissue overlying the cartilaginous structures. Techniques for closure include core excision, preserving some of the skin over the keloid to allow for primary closure, full thickness helical wedge excision, and grafting.  Split thickness grafts may have suboptimal cosmetic results while full thickness grafts (FTSG) are generally considered too unreliable over the poorly vascularized perichondrial bed. A technique of marginal de-epithelialization of the recipient bed was designed to address this concern. If a new healthy bed with rich vascularity is added on the periphery, the entire graft will have a better chance of survival. The graft center can more easily survive over a narrow, avascular, cartilaginous area via the bridging phenomenon. For this reason, we de-epithelialized the margin of normal skin around the defect, converting a sub-optimal bed to one able to support a FTSG. We present a series of seven cases of helical rim keloids treated by total excision and full thickness skin graft using a novel technique to improve graft take.

  Seven helical keloids in seven patients (ranging in age from 11 to 31 years) were reconstructed. Two keloids occurred after a burn, three after ear-piercing, one after an insect bite, and one after a sting. The length of the keloids ranged from 2 to 8 cm. The keloid was completely excised, with preservation of the helical cartilage and the perichondrium. The surrounding normal skin was de-epithelialized over the region 2 to 3 mm in width to provide the graft with a new healthy bed. This was followed by full thickness skin grafting (Fig. 1). The donor site of the graft was the mastoid or the inguinal area, depending on the graft size. In defatting the harvested graft, the subdermal plexus on the central area of the skin graft was preserved, corresponding to the area of the exposed cartilage. The deep dermis on the peripheral margin was partially excised to make its thickness the same as that of normal skin. A bolster dressing was applied and then removed on postoperative day 4, followed by simple compressive dressings for 2 weeks.

  All grafts survived completely, even on the bed of exposed cartilage. In two patients, a triamcinolone injection was performed to treat elevation of the graft margin. None of the keloids recurred and they all showed an excellent aesthetic result during the follow-up period ranging from 9 months to 6 years (Fig. 2).

  In reconstruction of helical keloids, FTSG with marginal de-epithelialization of the surrounding normal skin is a novel and effective method of treatment.

Fig. 1. Schematic diagram of full-thickness skin grafting for reconstruction of a helical keloid. (Left) Total keloid excision preserving the helical cartilage and the perichondrium, followed by de-epithelialization of the surrounding normal skin (2 to 3 mm) to extend the healthy recipient bed. (Right) Full-thickness skin grafting preserving the subdermal plexus on the central area of the graft and partially excising the deep dermis on the peripheral margin.

Fig. 2. (Above, left) Huge keloids of the helix from a burn injury and a postoperative view (above, right) 6 years after surgery. (Below, left) A recurrent keloid after excision of a previous keloid from an insect bite and a postoperative view (below, right) 9 months after surgery.