Earlobe Rotation for Prevention and Correction of Pixie Ear During Rhytidectomy in Asian Patients

Authors: Chung Hee Han

Abstract

Background

The most common deformity of the ear or earlobe appearing after a facelift is the pixie ear deformity.

Objectives

The purpose of this study was to devise and exercise a method to prevent ear deformity, including pixie ear, when performing a facelift and to correct it if it has already occurred.

Methods

Extended deep-plane rhytidectomy was performed between January 2017 and May 2024, and 76 patients who had passed 12 months post-surgery were included in this study. Group 1 consisted of 40 patients, who underwent W-plasty of incision and a combined botulinum neurotoxin type A (BoNTA) injection around the incision site. Group 2 consisted of 36 patients, who underwent rotation of the lower earlobe after W-plasty of the incision and combined BoNTA injection around the incision site.

Results

In a postoperative comparison between the 2 groups, Group 2 demonstrated superior outcomes over Group 1 by 8.4% on the right and 8.9% on the left, which was statistically significant (P = .007, P = .006).

Conclusions

Partial rotation of the earlobe is demonstrated as a practical and effective surgical approach to prevent and correct pixie ear deformity.

Level of Evidence: 3 (Therapeutic)

For image description, please refer to the figure legend and surrounding text.

Scars, sideburn distortion, lateral sweep, and deformities of the ear and earlobe are representative stigmata that reveal to others that a facelift has been performed after surgery and subsequent healing. Among these, there are some that cannot be avoided or are difficult to predict or prevent despite one's best efforts, but sideburn distortion or earlobe deformity can be improved with even minor efforts.^1^

The most common deformity of the ear or earlobe appearing after a facelift is the pixie ear deformity.^2-7^ Pixie ear deformity means that the cranial attachment segment increases, and conversely, the cranial free segment decreases. Furthermore, it refers to the loss or obliteration of the sulcus existing between the earlobe and the cheek's skin. The causes of occurrence are congenital cases and acquired cases because of distortion of the ear and earlobe caused by traction forces applied to the skin flap, scar retraction, and superficial musculoaponeurotic system (SMAS) flap. In fact, most acquired cases occur after a facelift, and even if efforts are made to eliminate the cause, the possibility of occurrence remains.^8,9^

Therefore, a predictable, reliable, and definitive method is needed to prevent earlobe deformity while performing a facelift or to correct side effects already caused by a previous facelift. Accordingly, the purpose of this study was to devise and exercise a method to prevent ear deformity, including pixie ear, when performing a facelift and to correct it if it has already occurred. Having obtained good results, the author reports the research results and experience together with a literature review.

METHODS

Extended deep-plane rhytidectomy was performed between January 2017 and May 2024, and 76 patients who had passed 12 months post-surgery were included in this study. Patients were divided into 2 groups. Group 1 consisted of 40 patients operated on until June 2022, who underwent W-plasty of incision and combined botulinum neurotoxin type A (BoNTA) injection around the incision site. After this combination, the author made changes to obtain better results. Group 2 consisted of 36 patients operated on after July 2022, who underwent rotation of the lower earlobe after W-plasty of the incision and combined BoNTA injection around the incision sit. Patients with a history of hypertrophic, keloid, or adverse scarring, use of systemic corticosteroids within the preceding year, recent heavy smoking, previous radiation treatment to the head or neck, or a history of rhytidectomy were excluded.

This study was conducted at a private clinic. The patients’ medical records and photographs were retrospectively reviewed. Formal institutional review board (IRB) approval (P01-202506-01-020, Public Institutional Bioethics Committee designated by the Ministry of Health and Welfare, Seoul, Republic of Korea) was obtained. All procedures performed in studies involving human participants were in accordance with the 1964 Declaration of Helsinki. Written consent was obtained from the patients, granting permission for the use and analysis of their data.

Earlobe Assessment

On the patient's lateral photograph, the distance from the intertragal notch (I) to the otobasion inferius (O, the lower-most point of the attached cephalic segment) was named I-O, and the distance from the intertragal notch (I) to the subaurale (S, the lowest point of the earlobe) was named I-S. Subsequently, each was measured and expressed as a ratio. This study also includes 25 congenital cases and 7 patients with pixie ears that occurred after a facelift. In such cases, the criterion for selecting the subaurale (S, the lowest point of the earlobe) was defined as the place where the tissue is thicker than other areas or where the contour of the lower earlobe changes abruptly (Figure 1). An I-O/I-S value of 1 or less indicates normal, and 1 or more indicates a pixie ear. Also, to investigate the directionality of shape change before and after surgery, a 4-bin classification was performed. All measured values were classified into 4 sections (<0.8: excellent; 0.8 ≤ x < 0.9: good; 0.9 ≤ x < 1.0: fair; and ≥1.0: poor), and the rows represented the preoperative grade, the columns represented the postoperative grade, and the diagonal items represented no change (maintenance), improvement, and deterioration. In addition, a Sankey diagram was created to make it easy to recognize the changes before and after surgery at a glance.

Scar Assessment

For scar assessment, the Manchester Scar Scale (MSS), the Modified Scar Rating Scale (MSRS), and the Stony Brook Scar Evaluation Scale (SBSES) were used.^10-12^ Photographs were taken before surgery and approximately 12 months after surgery. A handout was created using these 2 photographs, and 2 aesthetic surgeons performed independent and blinded photographic analysis. They were shown the handout and asked to record the score of the scar assessment. Afterward, the data were aggregated and analyzed.

Statistical Analysis

Statistical analysis for this study was performed using Python 3.11. General and clinical characteristics of the participants were summarized using descriptive statistics. Continuous variables, such as age, preoperative and postoperative I-O/I-S ratios, and scar assessment scores, were characterized by mean and standard deviation. Categorical variables, including sex, history of rhytidectomy, and the etiology of pixie ears, were expressed as frequencies and percentages.

Changes in continuous variables within the same group before and after surgery were analyzed using paired t-tests, whereas independent t-tests were used to compare continuous variables between Group 1 and Group 2. Changes in the I-O/I-S ratio were analyzed separately for the right and left sides. The mean difference between preoperative and postoperative values was calculated for each group, along with 95% CIs. Additionally, Cohen's d was calculated to quantify the effect size of the surgical changes. All statistical analyses were 2-tailed, and a P-value of <.05 was considered statistically significant.

Surgical Procedure

Extended deep-plane rhytidectomy with intravenous or general anesthesia was performed. After anesthesia, the design for surgery was made. It was designed in a small-sized zigzag pattern from the temporal area to the tragus. In Group 1, the zigzag pattern incision starts from the prehelical area and passes through the midpoint of the tragus (Figure 2A).^13^ Then, the small zigzag pattern incision continues from the intertragal notch to the otobasion inferius. Once it passes the otobasion inferius and moves to the posterior auricular area, a medium-sized zigzag incision passes through the postauricular groove and reaches the occipital hairline. After all processes are completed, the remnant skin is trimmed in a zigzag pattern and sutured (Figure 2B). In Group 2, other areas except the earlobe are designed and incised in the same way as Group 1. On the other hand, in the earlobe, a 5 mm segment is drawn at a 45° angle anteriorly from the intertragal notch (Figure 3A, red segment), and from there, a 1 cm segment is drawn at a right angle in a clockwise direction (orange segment). Then, a 5 mm segment is drawn at a right angle in a counter-clockwise direction (yellow segment), and a segment is drawn again at a right angle in a clockwise direction to the otobasion inferius (white segment). When passing the otobasion inferius and going up along the back of the earlobe, it ascends in a mirror-image form with the front. Then, before skin trimming and excision, the yellow segment of the pre- and postlobular area is rotated 90°, the skin is sutured to the orange segment, and the inner tissue is fixed to the preauricular fascia. Afterward, the remaining skin is trimmed, and the surgery is completed with the remaining skin suture (Figure 3B, Video).

RESULTS

A total of 76 patients underwent extended deep-plane rhytidectomy. The characteristics of the patients before surgery are summarized in Table 1. The mean patient age was 49.6 years (range, 38-68 years). The mean follow-up period was 12.5 months (range, 11-18 months). There were no complications such as infection, permanent nerve damage, severe asymmetry, or sialocele during the follow-up period. However, there were 5 cases of minimal skin necrosis and 3 cases of temporary nerve paralysis of the mandibular branch.

The preoperative and postoperative I-O/I-S of the 2 groups were classified. Before surgery, the <1.0 and ≥1.0 groups were the most numerous, and after surgery, most moved to the <0.8 group (Table 2). Regarding the I-O/I-S ratio of the right ear, a comparison of Group 1's preoperative and postoperative results showed a 13.5% decrease from 0.978 ± 0.1 to 0.846 ± 0.14, which was statistically significant (P < .001). In Group 2, there was a 20.5% decrease from 0.974 ± 0.03 to 0.775 ± 0.07, showing statistical significance (P < .001; Table 3). Although there was no statistically significant difference between the 2 groups in the preoperative comparison, Group 2 demonstrated an 8.4% greater value than Group 1 on the right ear in the postoperative comparison, which was statistically significant (P = .007). For the left ear, a comparison of Group 1's preoperative and postoperative results showed a 14.6% decrease from 0.983 ± 0.09 to 0.84 ± 0.14, which was statistically significant (P < .001). In Group 2, there was a 22% decrease from 0.981 ± 0.02 to 0.766 ± 0.08, showing statistical significance (P < .001). Although there was no statistically significant difference between the 2 groups in the preoperative comparison, Group 2 demonstrated an 8.9% greater value than Group 1 on the left ear in the postoperative comparison, which was statistically significant (P = .006). A 4-bin classification was established to determine the directionality of changes before and after surgery (Figure 4). In Group 1, the improvement rate was 52.5% for both the left and right sides, whereas the maintenance rates were 32.5% and 42.5%, and the deterioration rates were 15.0% and 5.0%, respectively. Conversely, in Group 2, the improvement rate was high at over 80% for both sides, with maintenance rates of 16.7% and 19.4%, respectively, and no reported cases of deterioration. In other words, improvement in condition was observed in nearly all patients in Group 2, demonstrating a distinctly higher pattern of improvement efficacy compared with Group 1. The Sankey diagram created to visualize these results also confirmed a shift toward better outcomes in Group 2 (Figure 5).

In the results regarding the MSS, the MSRS, and the SBSES for scar assessment, there was no statistical significance between groups in all 3 items (Table 4). In other words, this indicated that even if rotation was performed, there was no difference in scarring compared with the control group.

DISCUSSION

Pixie ear deformity means that the cranial attachment segment increases, and conversely, the cranial freesegment decreases. The causes of occurrence are congenital origin or acquired origin occurring after trauma, rhytidectomy, or total reconstruction of the ear, and most of the acquired origins are because of rhytidectomy.^2,4,7^ It has been reported that the incidence of pixie ear deformity after rhytidectomy is 5.7%.^5,8^ This figure accounts for a large proportion of the side effects caused by rhytidectomy. And another important reason is that it is a telltale sign. Therefore, efforts to reduce the frequency of such side effects must be made, and unlike other side effects, the frequency of occurrence can be significantly reduced with only minor effort (Figures 6-8).

The fundamental cause of pixie ear deformity occurring after rhytidectomy is skin overresection. It is considered that this creates a strong traction force, which leads to hypertrophic scarring and an imbalance between preauricular (vertical) and postauricular (horizontal) skin-lift vectors.^9^ Therefore, the first thing that must be preceded to not create a pixie ear is to avoid skin overresection. However, in the author's view, this alone cannot prevent side effects. This is because there were no problems in the early stages after surgery, but as time passes and more skin sagging occurs than expected, pixie ear deformity naturally follows.

Therefore, various surgical methods have been devised to correct or prevent pixie ear deformity.^14-24^ These range from simple methods involving the removal of a portion of the earlobe skin to techniques that lift the entire ear using earlobe rotation flaps, skin redraping, or barbed sutures. The surgical method proposed by the author possesses several comparative advantages over other methods. First, existing surgical techniques are often limited to either the correction or the prevention of pixie ear deformity.^3,17-19,21,23^ In contrast, although the author's technique primarily emphasizes prevention, it is also effective for correcting preexisting pixie ear deformities. Consequently, it is a viable routine procedure for rhytidectomy. Second, the surgical procedure is simple. Compared with traditional flap rotation methods, this technique is more intuitive and easier to master, allowing for immediate clinical application.^9,15^ Third, It requires no additional procedures other than suturing following the preoperative design and incision. Furthermore, it avoids the need for the additional incisions and subsequent scarring often associated with conventional skin redraping or wedge resection methods.^22-24^ Fourth, it is easy to adjust the earlobe's volume, curvature, or free caudal segment. This can be achieved during the preoperative design by elongating the orange segment and creating an obtuse angle between the orange and yellow segments. Doing so increases the volume of the earlobe to be resected and significantly elevates the lower part of the earlobe. Fifth, it does not negatively affect scarring. When compared with the author's previous research results, this method proved superior to the straight incision and showed no difference in results when compared with the control group (Group 1) where the same W-incision was applied.^13^ Additionally, some may express concern regarding the potential formation of an additional scar (specifically where the orange and yellow segments overlap). However, there is no need for significant concern, because this area is neither conspicuous nor significant enough to impact the final outcome. Sixth, neither the occurrence nor recurrence of pixie ear deformity appears even after 1 year. Among the patients in Group 1 of this study, there were 6 cases where the pixie ear persisted because of insufficient correction on one or both sides, and 2 cases where it developed despite not being present previously. In contrast, there were no such cases in Group 2. The success rate was higher than those reported in previous studies.^15,23^

However, disadvantages also exist. First, the operation time increases because of the additional suture and zigzag pattern skin trimming. Second, there is a possibility of wound dehiscence or delayed wound healing. Third, the ear might need to be pierced again. However, the disadvantages can be sufficiently overcome with little effort and meticulous suturing. In conclusion, the surgical method presented in this study can be routinely applied to all for preventive purposes when there is no pixie ear deformity and for therapeutic purposes when pixie ear deformity is present.

This study also has limitations. First, because preoperative and postoperative photographs of patients were used when comparing results, there is a possibility that they were influenced by the patient's posture. Second, because the study was conducted on Asians, there may be differences when compared with other races. Third, a satisfaction survey to capture the patients’ subjective experiences was not conducted. Therefore, it is thought that studies with more patients, more items and over a longer period will be needed in the future.

CONCLUSIONS

Partial rotation of the earlobe appears to be a useful surgical method that may provide clinical value in preventing and correcting pixie ear deformity.

Supplementary Material