April 2020 HSC Section 4 - Plastic and Reconstructive Problems

F.A. Khan et al. / Journal of Pediatric Surgery xxx (xxxx) xxx

steroid injection, radiotherapy, cryotherapy and cryosurgery. [6 – 8] Un- fortunately, majority of these treatment strategies are known to be as- sociated with frequent recurrences. [10] While numerous management options are available as discussed above there are no spe- ci fi c guidelines for the pediatric and adolescent population and evi- dence supporting or refuting each approach is either extrapolated from adult studies or relies on very small pediatric studies. [2,11] Given the paucity of data in pediatric/adolescent population, our study aims to review the outcomes of various treatment strategies, factors as- sociated with recurrence and options for management of recurrences.

Table 1 Patient demographics/ lesion characteristics ( n = 94).

Age (years)

Mean

14.0

Range

2 – 19

Gender

Male

42 (45%) 52 (55%) 75 (80%) 12 (12%)

Female

Race

African American

Caucasian Hispanic

5 (5%) 2 (2%)

Asian

Etiology

Earrings

84 (89%) 10 (11%) 72 (76%) 13 (14%)

Surgery/Trauma

1. Methods

Architecture

Nodular

Pedunculated

Mixed Mean Range

9 (9%)

1.1. Patient selection

Size (cm)

2.4

0.25 – 11

Following approval by the institutional review board at the Univer- sity of Florida, divisional, hospital and institutional databases were searched for pediatric patients having undergone surgical interventions for earlobe keloids over a 10-year period. The International Classi fi ca- tion of Diseases, Ninth Revision (ICD-9) and Current Procedural Termi- nology (CPT) codes were used to identify all the cases treated by any service (Pediatric surgery, plastic surgery, or dermatology) Patients between the ages of 1 and 19 years were identi fi ed using Current Procedural Terminology (CPT) codes 11,440 – 11,446 and Inter- national Classi fi cation of Diseases-9 (ICD-9) code 701.4 treated between 2004 and 2015. Patient demographics, presurgical clinical characteris- tics of the lesion (location, laterality and size), details of treatment strat- egy and postoperative follow-up data were collected. We also attempted to reach each patient by telephone and mail and administered a questionnaire (supplement 1) with an aim to evaluate keloid recurrence, additional surgical procedures and overall satisfac- tion with the treatment strategy. This survey instrument was not inde- pendently validated; however, focus groups within the department were used to test it prior to phone call. Each subject was sent a letter two weeks prior to attempted contact for informational purposes, and four separate attempts to call the patient were made. The rationale for the phone follow up was to increase the follow-up duration, as well as ascertain patients who may have been lost to our center, and also see the satisfaction with the results. Majority of the patients (96%) had rou- tine postoperative follow-up (median follow-up duration of 8 months) in addition to the phone survey. 1.2. De fi nitions and data

2.2. Treatment strategy

Treatment strategies utilized were (i) excision alone ( n = 24), (ii) excision with intralesional injection of triamcinolone acetonide (Kenalog, Bristol-Myers Squibb, New York NY) n = 56, (iii) excision with intralesional injection of triamcinolone acetonide and compression earrings ( n = 5) and (iv) excision with postoperative radiation ( n = 9). ( Table 2 ) In all cases, the technical aspects of the procedure including the choice of suture were made by the attending surgeon, but absorb- able sutures were universally used. Most common was polyglactin acid (braided) suture (VICRYL R ; Ethicon, Somerville, NJ) for the deep layer, while mono fi lament absorbable suture (MONOCRYL R ; Ethicon, Somerville, NJ) was used in the super fi cial layer. Most patients (70%) re- ported being satis fi ed or very satis fi ed with the eventual cosmetic out- come based on a 5-point Likert scale (Very Satis fi ed, Satis fi ed, Neutral, Dissatis fi ed, Very Dissatis fi ed) irrespective of the treatment strategy employed. This satisfaction included those with mild recurrences as well. Overall rate of recurrences in the entire cohort was n = 27 (28.7%). No statistically signi fi cant effect was noted on the rate of recurrences re- lated to the patient's age (p = .08), gender (p = .05), race (p = 0.08), size (p = 0.09), type (nodular vs peduncular) of the lesion (p = 1.00) or treatment strategy employed (p = 0.53). When patients were strat- i fi ed by age in two groups (less than or more than 10 years of age at the time of initial treatment) no differences were noted in the rate of recur- rence (p = 0.11). Similarly, no differences in the rate of recurrences were noted when strati fi ed by gender (p = 0.17) or by race (p = 0.26). 2.3. Risk factors for recurrence

1.3. Statistical analysis

Data analysis was performed using Minitab 17 Statistical Software (2010); State College, PA: Minitab, Inc. ( www.minitab.com ). Continu- ous variables were analyzed using Student's t-test, or the Mann – Whitney U test for nonparametric data. Categorical variables were ana- lyzed using proportional statistics (Fisher's exact test). Signi fi cance was inferred at p b 0.05.

2.4. Re-recurrence

Among the 27 patients who had a recurrence 19 (70.4%) underwent additional therapy for the recurrence. The following treatment strate- gies were used, and 10 (52.6%) re-recurrences were observed: (1) Exci- sion alone in 2 patients (1 re-recurrence), (2) Steroids alone in 2 patients (1 re-recurrence), (3) Excision and steroids in 12 patients (6 re-recurrences) and (4) Excision with postoperative radiation in 3

2. Results

2.1. Demographic data

Table 2 Recurrence by treatment groups.

A total of 94 patients with 135 keloids were identi fi ed. Mean agewas 14 (2 – 19) years with slight preponderance of female (52%) patients and a majority (75%) of the patients were African American (AA). Mean ke- loid size was 2.4 cm (0.25 – 11 cm), with nodular morphology being the most common and ear lobe piercing was the most common inciting eti- ology. ( Table 1 ) The phone survey was attempted on all patients, with an overall response rate of 54%.

Treatment Group

Recurrence N (%)

Overall Median FUP (months)

N

Excision alone

24 7 (24%) 56 13 (23%)

22 22 27 70

Excision + Steroids

Excision + Steroids + Compression 5 3 (60%)

Excision + Radiation

9 4 (44%)

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