Ear keloid and epidermal cyst following auricular cartilage harvest for rhinoplasty: A case report

Abstract

BACKGROUND

This case report highlights a rare instance of concurrent keloid and epidermal cyst development at an ear cartilage harvest site following rhinoplasty in a 25-year-old woman. Both conditions, which typically stem from skin trauma, seldom occur together, demonstrating the exceptional characteristics of this case.

CASE SUMMARY

The patient underwent successful surgical removal of both the keloid and the epidermal cyst. Postoperative treatment included the use of silicone sheets, gel, and oral tranilast to reduce scarring. No recurrence was observed over a 6-mo follow-up period, indicating effective management of the condition.

CONCLUSION

The effective management of complex skin trauma cases underscores the need for individualized treatment strategies in plastic surgery.

Key Words: Ear keloids; Epidermal cysts; Auricular cartilage harvesting; Rhinoplasty complications; Case report

Core Tip: This case report documents a rare co-occurrence of a keloid and an epidermal cyst at the site of auricular cartilage harvest used in rhinoplasty, emphasizing the complex interplay of surgical trauma and genetic predisposition in scar formation. It highlights the challenges in managing such dual complications, illustrating the necessity for meticulous surgical removal and postoperative care strategies to minimize recurrence and optimize cosmetic outcomes. The case underscores the importance of considering potential adverse sequelae in surgical planning and patient counseling.

INTRODUCTION

Keloids, which arise from surgical interventions or other trauma, are benign but persistent fibroproliferative scar lesions that seldom resolve without medical or surgical treatment. They extend beyond the boundaries of the original wound and tend to recur even after surgical removal[1,2]. Keloids often manifest as irregular, dark red lesions accompanied by itching or pain, causing significant cosmetic concerns when occurring on the face. Pierced ears are particularly considered a common precursor to keloid formation[3]. By contrast, epidermal cysts are intradermal or subcutaneous cystic lesions characterized by the presence of keratin and stratified epithelium[4,5]. These cysts frequently occur in individuals aged 20-29 years and vary in distribution based on body location, with the face being the most common site[6]. They often occur spontaneously but are especially common in the ear area after piercing or surgical intervention[3]. Although both keloids and epidermal cysts may develop after trauma, their coexistence is rarely reported[7]. This report presents a case of an ear keloid co-occurring with an epidermal cyst.

CASE PRESENTATION

Chief complaints

A 25-year-old woman presented with a chief complaint of significant alteration in the appearance of her left ear, characterized by keloid tissue formation at the site of a previous cartilage harvest for rhinoplasty. The patient reported considerable cosmetic concern and psychological distress due to the presence of the large keloid tissue.

History of present illness

Approximately 9 mo after undergoing rhinoplasty using ear cartilage, the patient noticed the development of a firm, palpable keloid tissue, which progressively worsened, prompting her to seek medical advice 1 year after surgery.

History of past illness

The patient denied having any relevant past illnesses that could directly contribute to the current condition; however, the surgical history of cartilage harvesting was noted.

Personal and family history

The patient did not report any family history of keloids or other related dermatological conditions, suggesting that this occurrence might have been sporadic or primarily trauma-induced.

Physical examination

Physical examination revealed a firm, palpable scar tissue measuring 2 cm × 2 cm × 1.5 cm located posterior to the patient’s left ear, with no tenderness or paresthesia (Figure 1).

Figure 1 Keloid scar on the posterior side of the left ear. A 25-year-old woman presented with a keloid scar measuring 2 cm × 2 cm × 1.5 cm on the posterior side of her left ear.

FINAL DIAGNOSIS

Keloid co-existing with an epidermal cyst.

TREATMENT

Initially, the lesion was diagnosed as a typical keloid based on the clinical evaluation. However, during this process, we observed an epidermal cyst encapsulated within the keloid tissue, characterized by a dirty white, cheese-like substance (Figure 2). This finding led to a revised final diagnosis of a keloid coexisting with an epidermal cyst at the ear cartilage harvest site after rhinoplasty. Both the keloid and the cyst were carefully excised, and the area was covered using a fillet flap.

Figure 2 Intraoperative view of the ear keloid containing an epidermal cyst. A: Rupture of the epidermal cyst upon incision; B: Keloid tissue containing an encapsulated epidermal cyst.

OUTCOME AND FOLLOW-UP

Histologic analysis of the excised tissue via hematoxylin and eosin staining revealed the presence of a cyst surrounded by stratified squamous epithelium containing thick collagen bundles and keratin, characteristic of the keloid tissue (Figure 3). These histologic findings confirmed the diagnosis of an epidermal cyst coexisting within the ear keloid. Postoperatively, a silicone sheet and gel were applied to the scar area, and the patient was prescribed oral tranilast 300 mg/d for 3 mo, to mitigate scar formation (Figure 4). During subsequent regular outpatient follow-ups, the patient reported no ear discomfort, and no recurrence was observed at the 6-mo follow-up.

Figure 3 Histological characteristics of the keloid with adjacent epidermal cyst. Histological image showing thick collagen bundles, a characteristic feature of keloid tissue, marked with circles. The adjacent area is encapsulated by stratified squamous epithelium containing keratin, indicative of an epidermal cyst, marked with asterisks. The tissue is stained with hematoxylin and eosin.

Figure 4  Follow-up photograph taken during suture removal on postoperative day 9.

DISCUSSION

Keloids and epidermal cysts are distinct pathological entities that may arise from skin trauma, with their coexistence within the same lesion being an exceptionally rare occurrence. This case illustrates the unique challenge presented by the simultaneous development of a keloid and an epidermal cyst, a phenomenon that, while uncommon, underscores the complexity of skin responses to injury. Epidermal cysts can originate either congenitally or as acquired lesions, often attributed to the implantation of epithelium following surgical procedures or other forms of skin trauma[4,5]. This implantation process is a significant etiological factor in cyst formation, highlighting the role of injury in triggering aberrant epithelial growth within the dermis[8]. Keloids, on the other hand, represent an overgrowth of scar tissue that extends beyond the boundaries of the original wound, with their formation influenced by genetic predisposition, the anatomical location of the wound, and the nature of the skin injury[2]. The pathophysiological mechanisms driving keloid formation are complex and not fully understood, although they are known to involve a dysregulated healing response characterized by excessive collagen deposition[1]. The simultaneous occurrence of keloids and epidermal cysts within scar tissue is rare, with both conditions potentially resulting from the grafting effects of traumatic injuries[1,2,5]. Park et al[9] highlighted the risk of keloid formation following auricular cartilage harvesting for rhinoplasty, suggesting that such surgical interventions can predispose individuals to both keloids and epidermal cysts. In the presented case, the chronological sequence of the keloid and epidermal cyst development was unclear, and the patient did not exhibit any specific symptoms apart from the presence of these conditions[7]. The role of ear cartilage grafting in rhinoplasty as a causative factor for their concurrent development is noteworthy, presenting a complex challenge for effective management. The primary strategy for managing epidermal cysts involves complete cyst wall removal to avert recurrence, with surgery deferred in the presence of active infections to mitigate infection and recurrence risks[8]. The initial treatment for ear keloids favors less invasive options such as trichloroacetic acid injections, with pressure therapy after excision showing notable efficacy. For substantial keloids, staged removal may be necessary, and if trichloroacetic acid is insufficient, combination therapies are considered. The treatment choice, potentially including radiation therapy in well-equipped facilities, depends on physician preference and available resources[10]. When ear keloids coexist with epidermal cysts, the treatment strategy must address the complexities introduced by the recurrence risk of the cyst and the presence of keloids. Prioritizing the complete excision of the epidermal cyst is crucial to prevent its recurrence while managing the keloid’s tendency to recur despite thorough surgical measures, possibly through combination therapies. In this case, the patient opted against further invasive treatments following surgical removal. Consequently, silicone sheets and gel were applied to the scar area, and the patient was prescribed oral tranilast at 300 mg/d for 3 mo to mitigate scar formation.

CONCLUSION

In conclusion, the coexistence of epidermal cysts and keloids necessitates a treatment paradigm that prioritizes the thorough removal of the epidermal cyst to avert its recurrence. This targeted surgical strategy accentuates the primacy of cyst excision in addressing the complexities of such conditions, ensuring that the initial surgical endeavors are concentrated on reducing the recurrence risk and fostering optimal healing. This paradigm highlights the significance of bespoke, patient-centric treatment plans in plastic surgery, where the concurrent management of multiple conditions demands meticulous and strategic planning.

ACKNOWLEDGEMENTS

We extend our sincere gratitude to all individuals who contributed to the completion of this manuscript. We especially thank the patient who dedicated her time and effort to this research. We also express our gratitude to all healthcare professionals and researchers involved in the study. Additionally, we would like to thank everyone who assisted in the presentation and publication of this paper.