Background <p>Patients who undergo auricular reconstruction have a high risk of developing keloids. The traditional incision designs for keloid excision may appear inadequate to accommodate the biomechanical characteristics of different subunits of reconstructed ears.</p> Methods <p>A retrospective cohort of 86 patients (90 ears) with auricular keloids post-reconstruction from January 2020 to January 2024 underwent the keloid core removal surgery. We designed different incisions based on specific sites: earlobe, helix, crus of helix, and others. 24–48 h after surgery, all participants underwent superficial low-dose radiotherapy (3 Gy/session × 4).</p> Results <p>At the average 18.6 follow-up, the treatment protocol achieved a reduced recurrence rate of 6.7% compared to tradition treatments, with patient satisfaction as 92.2%. The Vancouver Scar Scale (VSS) score demonstrated marked improvement compared with that of pre-operation (<i>p</i> &lt; 0.05).</p> Conclusions <p>Site-specific incision designs combined with immediate postoperative radiotherapy effectively reduced the reconstructed ear keloids’ recurrence rate. This approach achieved optimal functional and aesthetic outcomes in keloids on congenital microtia reconstructed auricles.</p> Level of Evidence IV <p>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 <a href="https://www.springer.com/00266">www.springer.com/00266</a>.</p>