|Year : 2013 | Volume
| Issue : 4 | Page : 135-138
Custom-made different designs of pressure clips for the management of ear lobe keloids
Anshul Chugh1, Anita Hooda2, Punam Bishnoi1
1 Department of Prosthodontics, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India
2 Department of Oral Anatomy, Post Graduate Institute of Dental Sciences, Rohtak, Haryana, India
|Date of Web Publication||4-Dec-2013|
UH-7, Medical Campus, Post Graduate Institute of Medical Sciences, Rohtak - 124 001, Haryana
Source of Support: None, Conflict of Interest: None
Introduction : Keloids are frequent finding after physical trauma. Keloids of ear lobe are common complication of ear piercing, although its incidence remains unknown. The use of intrakeloid resection and a form pressure device to treat pinna keloids. The recommendation of this therapy is to maintain constant pressure and duration of pressure therapy was about 25 weeks. Clinical innovation : This article will present inexpensive custom made pressure clips of various designs. The dimensions of polymethylmethacrylate (PMMA) plates in ear lobe clip presented by us though they esthetically not so good, but colored PMMA has been used to make it decorative and acceptable by most of the patients. This has been an encouraging experience to use the different designs. Discussion : Ear clip prosthesis has been developed for maintaining pressure on ear lobe keloids before and after surgical removal. The prosthesis includes an ear clip to which heat-polymerized acrylic resin is attached, which covers the keloid area. Pressure therapy is widely used to help in the early maturation of scar tissue and to prevent the recurrence of keloid. The preliminary report by Brent revealed that constant light pressure was an effective means of preventing post excision recurrence of ear lobe keloids using a decorative, spring-pressure earring.
Keywords: Custom made clips, ear lobe, keloid, poly methyl methacrylate, pressure clips, pressure therapy
|How to cite this article:|
Chugh A, Hooda A, Bishnoi P. Custom-made different designs of pressure clips for the management of ear lobe keloids. Dent Hypotheses 2013;4:135-8
| Introduction|| |
An keloid is an abnormal proliferation of fibroblasts with over production of collagen.  Various techniques, such as radiotherapy, cryosurgery, intralesional corticosteroids, laser therapy, and combination of these have been described for the management of keloids.  Ear piercing is performed for both esthetic and cultural reasons.
Pressure therapy has been established as an effective option, to reduce the amount of scar tissue.  This is thought to occur as a result of localized hypoxia, resulting in fibroblast degeneration and cell breakdown. 
A variety of pressure devices have been established including Snyder's compression suture,  Bent spring pressure earring, U-loop pressure clip, spring loaded pressure devices, etc. However, the majority of these devices need to be custom-made. Keloid formation is distressing and potential permanent complication of ear piercing. They spread beyond the boundaries of original wound and do not regress spontaneously. These features differentiate then from simple hypertrophic scars. The distinction is difficult, but it is important because the history of hypertrophic scar is one of spontaneous softening and flattening. Whereas keloids remain thick and raised for years. It is more difficult to excise keloid completely and to affect primary skin closure on external ear than at many other body sites.
Many different treatments for keloids have been tried, most with limited success and results reported are highly variable. In this article we will discuss different designs of pressure clips. The pressure clips are made aesthetics with use of colored polymethylmethacrylate (PMMA). The recommendation of this therapy is to maintain constant pressure and duration of pressure therapy was about 25 weeks. 
The principle is that pressure accelerates the remodeling process and result in early maturation and flattening of scar. Constant pressure of 25 mm Hg has been recommended by various authors,  as prolonged and excessive pressure could result in circulatory disturbances and pressure ulcers.
There are many commercial available pressure earrings on keloids. Many other noncommercial products have been published. These clippings appliances will generate variable pressure depending on size of keloid. Therefore, no constant pressure can be generated in all patients or when the size of keloid is decreasing.
There are commercial available pressure earrings with plates that exert pressure on keloids (Glori Pressure Earring, Delasco, USA); these clips are expensive. In this article various custom-made inexpensive designs of pressure clips have been presented.
| Clinical Innovation|| |
First, the impression of ear lobe with keloid is made using standard methods for fabrication of facial and body prosthesis, and fabricate the definitive cast [Figure 1], [Figure 2], [Figure 3].
The ear lobe pressure clips are fabricated using PMMA and 19 gauge stainless steel orthodontic wire (Samit, Delhi, India). The orthodontic wire is prepared in V shape with helix at the apex of both V (like safety pin) [Figure 3]. Other ends are bent to have better grip with acrylic. The shape and size of the discs vary depends on the size of the ear lobe with keloid. Adapt modeling wax to the clips so that compression is applied to the intended surface. Pressure should neither be so tight as to lead to necrosis nor so loose as to permit recurrence. The wax is replaced with heat-polymerized acrylic resin (DPI, Mumbai, India).
The pressure clip discs can be made more esthetic and colorful by adding color to PMMA [Figure 4]. Once the PMMA sets the plates are trimmed and polished. Disinfect the ear clip with sodium hypochlorite (PKI, Godhra, Gujarat) 1:10 solution and dip for not more than 10 min. Place the prosthesis in disposable plastic cup, container, or a zipped plastic bag and make it sure it is submerged in a nontoxic solution and rinse the prosthesis thoroughly before insertion in mouth.
For the continuous use of these clips the patients need to be motivated and trained. Train the patient to wear and remove the appliance comfortably with the help of face mirror and clean the keloid scar area with clean water and appliance with toothbrush thoroughly every day. For initial days, patients are instructed to remove the clip whenever it causes pain. Encourage the patient to use clip as long as possible, increasing wear time gradually.
The pressure clip is applied after 2 weeks of keloid or reconstruction [Figure 5]. Recall the patient every 2 weeks to note the progress. If clip is applying excessive pressure adjust the clip with orthodontic plier. All ear lobe scars following keloid excision are injected with triamcinolone acetonide 40 mg fortnightly five to six times. Patients are asked to keep clip continuously for minimum of 6 months. However, [Figure 6] summarized various designs of pressure clips.
|Figure 6: (a) U-loop pressure clip for ear lobe keloid, (b) other design of pressure clip, (c) button design self-fabricated pressure clip for the ear lobe, (d) zimmer splintage (Plastic Surgery Unit, Northwood, UK)|
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| Discussion|| |
The different designs have been tried in various patients in Department of Prosthodontics, Post Graduate Institute of Dental Sciences, with the referred cases from Department of General Surgery and Plastic Surgery, Post Graduate Institute of Medical Sciences (PGIMS). The results were same were the different designs. Just we tried to change the design of loop or helix extensions. Furthermore, studies can be looked for how much pressure is exerted by these designs.
An ear clip prosthesis has been developed for maintaining pressure on ear lobe keloids before and after surgical removal. The prosthesis includes an ear clip to which heat-polymerized acrylic resin is attached, which covers the keloid area. Pressure therapy is widely used to help in the early maturation of scar tissue and to prevent the recurrence of keloid.  The preliminary report by Brent  revealed that constant light pressure was an effective means of preventing post excision recurrence of ear lobe keloids using a decorative, spring pressure earring [Figure 6]. The dimension of the PMMA plates in the ear lobe clip presented by us is modifiable depending upon the area requiring pressure and it can be extended to apply pressure to helical scar. Button compression  and the thermoplastic compression splints  require an ear bore for application and there is a risk of necrosis with the button. This simple, self-fabricated and inexpensive pressure earring is effective in applying light pressure therapy to the ear lobe. The dimension of the plates and the pressure are modifiable as required. The light pressure exerted by these clips helps in early maturation of ear lobe scars. With careful use and experience, pressure ulceration is avoidable.
The addition of the U-loop component to the clip allows for adjustment in both the amount and direction of pressure, whereas the conventional ear clips do not have this capability. Surgery followed by pressure treatment has shown a good response rate of 90-100%.  Conventional ear clips may cause excessive pressure and frequent bleeding with the increased possibility of infection and/or necrosis of the surrounding soft tissues.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]