A Four-Color Aesthetic Evaluation System for Auricular Keloids: A Pilot Retrospective Cohort Study Based on Contour...

Area of Science:

• Plastic Surgery
• Dermatology
• Medical Aesthetics

Background:

• Auricular keloids significantly impact ear contour and visibility.
• Traditional scar scales may not adequately capture three-dimensional contour integrity.

Purpose of the Study:

• To develop a pragmatic Four-Color Aesthetic Evaluation System for auricular keloids.
• To assess the preliminary real-world applicability of this novel grading system.

Main Methods:

• Retrospective single-center study of patients treated between January 2022 and December 2025.
• Ears graded using a four-tier color system (Black-Red-Orange-Green) based on framework integrity, contour distortion, and visibility at 1 meter.
• Inter-rater agreement assessed using quadratically weighted Cohen's kappa.

Main Results:

• Fifty percent of ears were initially graded Red and 50% Orange.
• Post-treatment, 75% of ears improved to Green, and 25% remained Orange.
• 93.8% of ears showed improvement by at least one color level, with high inter-rater agreement (kappa 0.88-1.00).

Conclusions:

• The Four-Color system is feasible and sensitive to clinically meaningful contour improvements in auricular keloids.
• This system may improve follow-up communication by separating aesthetic grades from recurrence.
• Prospective multicenter validation with patient-reported outcomes is recommended.