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

Auricular keloids can disrupt three-dimensional auricular contour and remain noticeable at social distance, while surface-focused scar scales may not fully capture contour integrity.

To develop a pragmatic Four-Color Aesthetic Evaluation System for auricular keloids and assess its preliminary real-world applicability.

This 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.

Thirteen 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).

The 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.

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