ArticleAesthetic plastic surgery2026
A Four-Color Aesthetic Evaluation System for Auricular Keloids: A Pilot Retrospective Cohort Study Based on Contour Integrity and Social-Distance Visibility.
Article in Aesthetic plastic surgery, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundAuricular keloids can disrupt three-dimensional auricular contour and remain noticeable at social distance, while surface-focused scar scales may not fully capture contour integrity.
objectivesTo develop a pragmatic Four-Color Aesthetic Evaluation System for auricular keloids and assess its preliminary real-world applicability.
methodsThis single-center retrospective study included patients treated between January 2022 and December 2025. Ears were graded using a four-tier color system (Black-Red-Orange-Green) based on framework integrity, contour distortion, and visibility at ~ 1 m. Postoperative grading used the same contour-first logic with a predefined visible-defect threshold and a "no downgrading for tiny scars" principle. Recurrence was recorded independently using an R0-R3 label. For the primary analysis, postoperative status was defined as the most recent photographic assessment within 12 months (preferably at 12 months, otherwise at 6 months, then 3 months). Two clinicians independently graded baseline and postoperative status; inter-rater agreement was assessed using quadratically weighted Cohen's kappa.
resultsThirteen patients (16 ears) were analyzed. Preoperatively, 8/16 ears (50.0%) were graded Red and 8/16 (50.0%) Orange; none were Black or Green. At the most recent assessment within 12 months, 12/16 ears (75.0%) were graded Green and 4/16 (25.0%) Orange. Overall, 15/16 ears (93.8%) improved by ≥ 1 color level and 1/16 (6.3%) remained stable; no ear deteriorated. All ears were recorded as R0 within 12 months, with no R1-R3 events observed. Inter-rater agreement was high (kappa 0.88 at baseline; 1.00 postoperatively).
conclusionsThe Four-Color system is feasible and sensitive to clinically meaningful contour improvement in a pilot cohort and may facilitate follow-up communication by separating aesthetic grades from recurrence labels. Prospective multicenter validation incorporating patient-reported outcomes is warranted. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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