Keywords
earlobe - earlobe reduction - earlobe ptosis - earlobe reshaping - earlobe surgery
Although the earlobe constitutes a small visible portion of the face during social
interaction, deformities of the earlobe are often associated with unattractiveness.
Congenital earlobe deformities are quite rare and are seen in 1:1500 live births with
cleft earlobe being the most frequent presentation. Acquired earlobe deformities are
much more frequently encountered and can be caused by trauma, surgery, utilization
of gauging earrings, and aging.[1]
As with all tissues that undergo the aging process, the aging earlobe also presents
itself with loss of elasticity, ptosis, wrinkling, and volume loss. The earlobe elongates
∼30 to 35% with age and also presents with increased creasing.[2] Nonsurgical interventions such as mesotherapy and the usage of dermal fillers are
of benefit in the case of wrinkles and mild loss of elasticity associated with volume
loss.
In the case of ptosis, however, surgical correction is warranted. A range of surgical
techniques has been proposed to reshape and reduce the earlobe. However, most of these
techniques result with scars on the anterior or inferior aspect of the ear lobule.
Other postoperative distortions include dog–ear deformities, distortions on the subantitragal
groove, or posterior notching which reduce the aesthetics of the ear lobule and ultimately
result in decreased overall patient satisfaction.[3]
[4]
[5]
[6]
Herein, we present a modified technique for earlobe reduction and reshaping that results
with an acceptable scar set on the natural groove of the anterior surface of the earlobe.
Material and Method
Fifteen healthy female patients that presented consecutively to the plastic surgery
outpatient clinic between March 2017 and March 2018 requesting the reduction and reshaping
of their earlobes were recruited for this retrospective study. Written informed consent
was obtained from all patients in the study. This study was designed in accordance
with the national law and the World Medical Association Declaration of Helsinki (1964)
with its ethical principles for medical research involving human subjects and subsequent
amendments.
A detailed medical history was obtained from all patients prior to the procedure.
Patients under the age of 18 years and those who were breastfeeding or pregnant were
considered ineligible, while patients with chronic illnesses and those under treatment
with medications, especially anticoagulants and corticosteroids were excluded from
the study. The most important initial evaluation consisted of determining whether
or not a patient was a good candidate for earlobe reduction. Patients that presented
with isolated tissue atrophy or wrinkling without earlobe ptosis were referred for
either hyaluronic acid-based tissue filler applications or fat injections. If earlobe
ptosis was clinically determined through measurements, these patients were evaluated
as good candidates for earlobe reduction surgery. Lateral earlobe piercings were approached
with caution, and patients with gaping piercings were not operated due to the risk
of circulatory compromise, while those with very small piercings were operated.
The classification system[7] for earlobe ptosis previously described by Mowlavi et al was utilized in our study.
The height of the earlobe was determined on the basis of anatomic landmarks, including
the intertragal notch (I), the otobasion inferius (O) (the caudal-most anterior attachment
of the earlobe with the cheek skin), and the subaurale (S) (the caudal-most extension
of the earlobe free margin) ([Fig. 1]). The acceptable distance of the free caudal segment of the earlobe (O–S distance)
was determined to be between 1 and 5 mm, and any distance above 5 mm was considered
to be unattractive. Therefore, patients with free caudal segments over 5 mm which
translate to Grade II ptosis or higher were operated surgically for earlobe reduction.
Surgical Technique
Surgeries were done under local anesthesia or general anesthesia if additional procedures
were performed. Regional infiltration of local anesthetics was limited to the base
of the earlobe, to avoid distortion of the area to be incised.
The preoperative markings started ∼1 to 2 mm below the O point depending on the patients'
earlobe anatomy and continued upward toward the intertragal notch until the level
of the O point was passed by 1 to 2 mm to point A. This maneuver allowed the earlobe
to have a natural swoop at the cheek–earlobe interface. From this point A, the markings
were continued in a slight curved line by following the normal groove of the anterior
topography of the earlobe to point B, the pivot point. Care was given to preserve
a width of at least 6 to 8 mm of tissue at the lateral border of the earlobe to avoid
vascularization-related flap problems. Then a curved line with the same length was
drawn at the medial margin of the earlobe flap that ended at point C. Finally, a final
slightly curved line was drawn toward the caudal edge of the earlobe, depending on
the amount of excision that was planned that ended at point D. This line was drawn
in similar length to the first line ([Fig. 2]).
Fig. 1 Earlobe segments. Yellow line indicates O–S distance (I: intertragal notch, O: the
otobasion inferius, S: subaurale).
Fig. 2 A 62-year-old female patient with preoperative markings. Note that markings start
1 to 2 mm below the O point and continue to the point A, continues in a slight curved
line by following the normal groove of the anterior topography of the earlobe to point
B, the pivot point. Yellow line indicates preserved 6 to 8 mm of tissue at the lateral
border of the earlobe. Curved line with the same length was drawn at the medial margin
of the earlobe flap that ended at point C, a final slightly curved line ended at point
D.
The incisions were made with a number 11 blade, taking care to cut through both the
anterior and posterior surface of the earlobe simultaneously. The excision resulted
with a double-crescentic defect in which points A and C coincided and the lateral
earlobe flap fit in without any necessary modifications ([Fig. 3]). Absorbable 5/0 polyglactin sutures were used for subcutaneous sutures, while skin
closure was obtained with a few 6/0 polypropylene sutures. Patients were instructed
to use mupirocin ointment twice daily for 10 days, and suture removal was done on
day 7 ([Fig. 4]). The healing period was uneventful and no complications were encountered during
follow-ups in any of the patients ([Figs. 5], [6], [7]). Piercing holes were generally excised during surgery and patients were informed
that they would require repiercing once healing was completed after 3 months. Patients
were followed up 1 week and 3 months after surgery and the postoperative O–S distance
was measured at these time frames. Patients were also asked to rate their satisfaction
regarding the appearance of their earlobe at the postoperative third month from a
scale of 0 to 3 (0 being poor, 1 being no difference, 2 being better and 3 being much
better).
Fig. 3 Intraoperative view: the excision resulted with a double-crescentic defect in which
points A and C coincided and the lateral earlobe flap fit in.
Fig. 4 Postoperative 1 week of the patient.
Fig. 5 Postoperative 30th day of the patients' earlobe.
Fig. 6 Preoperative view of the right earlobe.
Fig. 7 Postoperative 9th month of the patient's earlobe.
Results
Of the 15 patients seeking earlobe reshaping, 6 had isolated earlobe atrophy and wrinkling.
These patients were determined to be unsuitable for earlobe reduction surgery and
following clinical evaluation, were treated with either tissue fillers or fat injection
for voluminization.
A total of 18 earlobes were evaluated on 9 female patients who were operated on for
earlobe ptosis. The mean age of the patients was 60.11 years (range; 52–67 years),
while the mean follow-up period was 9.9 months (range; 6–14 months). Six patients
only had earlobe reduction, while three patients had other procedures in combination
with earlobe correction. These procedures were blepharoplasty, abdominoplasty, and
breast lift.
The postoperative and preoperative O–S distances of nine patients who underwent earlobe
surgery were evaluated ([Table 1]). According to the measurements, the preoperative mean O–S distance of the right
lobule was 13.1 ± 1.8 mm and the left lobule was 12.8 ± 1.9 mm, while the postoperative
O–S distance of the right side was 3.4 ± 1 mm and the left side was 3.4 ± 0.7 mm ([Table 2]). This translated to an approximate pre- and postoperative O–-S distance difference
of 9 mm, a significant reduction that resulted with ideal O–S values.
Table 1
Preoperative and postoperative measurements of O–S distance
|
O–S distance right ear (mm)
|
O–S distance left ear (mm)
|
|
Patient no.
|
Preoperative
|
Postoperative
|
Preoperative
|
Postoperative
|
|
1
|
16
|
3
|
15
|
3
|
|
2
|
13
|
2
|
13
|
2
|
|
3
|
11
|
4
|
10
|
4
|
|
4
|
14
|
5
|
13
|
4
|
|
5
|
12
|
4
|
12
|
4
|
|
6
|
15
|
2
|
14
|
3
|
|
7
|
14
|
4
|
15
|
4
|
|
8
|
12
|
3
|
13
|
3
|
|
9
|
11
|
4
|
10
|
4
|
Abbreviation: OS, otobasion inferius (O)–subaurale (S) distances.
Table 2
Preoperative and postoperative mean O–S distances
|
Mean O–S distance (mm)
|
Preoperative
|
Postoperative
|
|
Right
|
13.1 ± 1.8
|
3.4 ± 1
|
|
Left
|
12.8 ± 1.9
|
3.4 ± 0.7
|
Abbreviation: OS, otobasion inferius (O)–subaurale (S) distances.
Patients were asked to rate their satisfaction in terms of the shape, suppleness,
and overall appearance of their earlobes at the postoperative third month from a scale
of 0 to 3. According to this, seven patients (77.7%) stated that their earlobes were
much better, while two patients (22.2%) stated that the appearance of their earlobes
following reduction was better.
Discussion
The size and orientation of the ear along with congenital and acquired ear deformities
have been thoroughly studied in literature, but minimal attention has been directed
to the shape and size of the ear lobule.[1]
[2] Besides trauma and iatrogenic or congenital deformities, aging is an important factor
that causes earlobe deformity. The aging earlobe frequently presents with elongation
or ptosis, along with volume loss and excessive creasing.[8]
Several surgical techniques have been described to address the changes in the aging
earlobe. These techniques range from simple wedge excision to complex geometrical
designs and each technique comes with advantages and limitations.[4]
[5]
[6] Simple wedge excision for the reduction in the earlobe was first introduced by Miller
in 1925 followed by several other geometric excisional techniques for earlobe correction.[9]
[10]
[11] Although these techniques succeeded in decreasing the length and width of the earlobe,
the main disadvantages were prominent anterior scarring and unnatural creasing. To
avoid prominent anterior scars, elliptical skin excision from the free inferior edge
of the earlobe was introduced by Stark and Mccoy,[12]
[13] a technique that is still widely practiced by plastic surgeons. Although the scar
is hidden on the inferior and posterior aspect of the lobule, there is a high probability
of distortion at the free lateral edge with this method.
Recently, a technique by Van Putte and Colpaert has been described for earlobe reduction
which follows general geometric principles and results with undisturbed free borders
and ideal anterior scar locations.[14] Our technique shares the advantage of an untouched lateral edge with this technique.
The maneuver of transposing a superior pedicled lateral earlobe flap prevents unsightly
notching in this area. The main difference of our technique from the latter method
is that our incision starts 1 to 2 mm below the O point and preserves the earlobe–cheek
skin interface to provide a natural swoop in the medial portion of the earlobe while
preventing rotation and traction following surgical correction. Another advantage
of our technique is that the free edge of the lateral earlobe flap can be angled according
to each patient's helical and conchal anatomy where preserving more tissue results
with a wider earlobe and less distal tissue results with a less-wider earlobe. This
allows the surgeon to reduce the earlobe in both the vertical (height) and horizontal
(width) directions by adjusting the excision depending on which dimension is more
problematic. As the antitragal groove is a slightly curved anatomical landmark, the
resulting scar with this technique is also a slightly curved one located right under
the natural groove, resulting with a less conspicuous scar. Although none of the procedures
were done in combination with facelift surgery, preserving the small amount of tissue
at the earlobe–cheek interface and thereby separating the incisions of rhytidectomy
and earlobe reduction can be a very beneficial tool in preventing the frequent manifestation
of pixie ear deformity caused by traction during the healing phase.
We approached lateral earlobe piercings with caution as compromise in the circulation
of the lateral flap can be encountered in patients with widened holes at the lateral
aspect. This is also a potential issue for patients that present with earlobe ptosis
due to gauging piercings, in which another surgical technique should be opted for
to minimize the risk of lateral flap necrosis.[15]
In conclusion, the presented approach has numerous advantages including inconspicuous
scarring, smooth lateral earlobe contours, and undisturbed free borders.
Preservation of minimal tissue at the cheek–earlobe interface prevents traction and
provides a natural swoop in the medial portion of the earlobe with optimal shape that
yields high patient satisfaction.
