Addressing Earlobe Elongation: A Systematic Review of Surgical Reduction Techniques in the Aging Population

Abstract

Background:

Aging affects all the components of the face, and the earlobe stands among them. Elongation of the earlobes necessitates surgical correction to restore the youthful ear shape.

Methods:

A comprehensive literature search was conducted across the PubMed, Google Scholar, and Cochrane databases. The quality of the included studies was systematically assessed, and data pertaining to surgical earlobe reduction was extracted.

Results:

Thirteen articles that closely matched the study objectives were included in this systematic review. We regrouped these techniques into 3 categories: those involving inferior margin excision of the earlobe, those involving anterior earlobe resection, and the third group comprising other methods. To aid in clinical decision-making, we created an algorithm to guide the choice of the procedure.

Conclusions:

Proper management of earlobe ptosis and pseudoptosis enhances facial harmony. By outlining the available techniques and providing a treatment algorithm, we emphasize the importance of incorporating earlobe reduction into comprehensive facial rejuvenation strategies.

Takeaways

Question: What are the available surgical methods for addressing earlobe ptosis and pseudoptosis in older patients?

Findings: We regrouped these techniques into 3 categories: those involving inferior margin excision of the earlobe, those involving anterior earlobe resection, and the third group comprising other methods. We created an algorithm to guide the choice of the procedure.

Meaning: Proper management of earlobe ptosis and pseudoptosis enhances facial harmony. By outlining the available techniques and providing a treatment algorithm, we emphasize the importance of incorporating earlobe reduction into comprehensive facial rejuvenation strategies.

INTRODUCTION

The earlobe is an important anatomic component of the ear, and its proper size, shape, and location are recognized as contributing to a pleasant appearance of the ear. Aging affects all the components of the face, and the earlobe stands among them: elongation and ptosis are attributed to the loss of elastic fibers and gravitational pull. The earlobe elongates 30%–35% from age 20 to 60 years and presents with increased creasing.¹ Increased creasing is treated with dermal fillers and autologous fat grafting. Elongation of the earlobes necessitates surgical correction to restore the youthful ear shape.

Classification of Earlobe Elongation and Implication for Earlobe Reduction

Earlobe length increases with age in both sexes.¹ Assessment of the earlobes is essential to determine if surgery is necessary and to choose the appropriate surgical procedure in each case. Evaluation of both ears should be performed individually because of intrapatient variability.² The assessment of the earlobes should divide the earlobe into 2 components: the attached cephalic segment (intertragal notch-to-otobasion inferius distance) and the free caudal segment (otobasion inferios-to-subaurale distance; Fig. 1). Mowlavi et al³ developed a classification system of earlobe ptosis (based on otobasion inferius-to-subaurale distances; Table 1) as well as a criterion for earlobe pseudoptosis (intertragal notch-to-otobasion inferius distance of greater than 15 mm; Table 2).

Fig. 1.

Earlobe image highlighting key anatomical landmarks: I, intertragal notch; O, otobasion inferius; S, subaurale.

Table 1.

Ptosis Classification by Mowlavi

Ptosis Grade	Otobasion Inferius-to-subaurale Distance (mm)
0	0
1	1–5
2	6–10
3	11–15
4	16–20
5	>20

Table 2.

Pseudoptosis Classification by Mowlavi

Pseudoptosis	Intertragal Notch-to-otobasion Inferius Distance, mm
Yes	>15
No	<15

According to this classification, earlobe reduction surgery is indicated for earlobes with ptosis grade 2–5 as well as earlobes with pseudoptosis, whereas augmentation may be beneficial for lobules with grade 0 ptosis.³ In contrast, McKinney et al⁴ recommended that earlobe surgery should be performed when the lobule height exceeds 33% of the total ear length without dividing the lobule into two segments.

When considering earlobe ptosis, we must consider the proper timing for reduction. Reduction should be performed when further earlobe elongation is minimal. Azaria et al¹ found that little change occurs after age 40 years. Therefore, earlobe reduction is often preferable after this age, as the results are likely to be more stable and long-lasting.

Various surgical techniques have been described, but no review has comprehensively categorized these methods. Our study is the first systematic review on this topic, aiming to provide an in-depth analysis of the available surgical methods for addressing earlobe ptosis and pseudoptosis in older patients.

MATERIAL AND METHODS

To maximize the retrieval of relevant articles, a comprehensive literature search was conducted across the PubMed, Google Scholar, and Cochrane databases. The search strategy utilized the keywords “earlobe,” “ear lobule,” “auricular lobe,” “ear auricle,” “pinna,” and “external ear,” in combination with a second group of keywords including “reduction,” “age effects,” “deformities,” “reconstruction,” “ptosis,” “pseudoptosis,” “elongation,” “rejuvenation,” “senile,” “aged,” and “elongated.” Boolean operators AND and OR were used to refine the search results.

A total of 1106 articles were identified. Before proceeding to title and abstract screening, 52 duplicate articles were removed, leaving 1054 articles for further evaluation. Three investigators screened the titles and abstracts, followed by full-text analysis. During this initial screening, the following exclusions were made: 366 articles addressing ear deformities unrelated to aging, such as congenital, traumatic, or oncological issues; 8 publications discussing rejuvenation techniques for senile earlobes without reference to surgical reduction methods; 24 review articles; 38 articles focused on regions of the ear other than the lobule; and 579 articles that did not align with the study objectives.

As a result, 1015 articles were excluded, and 39 were sought for retrieval. Of the 33 articles with full-text available, 15 were removed for not mentioning any surgical techniques, and 5 others were excluded for being unrelated to the objectives. Ultimately, 13 articles that closely matched the study objectives were included in this systematic review. (See table, Supplemental Digital Content 1, which displays a summary of studies evaluating earlobe reduction, http://links.lww.com/PRSGO/D863.) The only articles included are those that specifically address the study’s objective, which is to explore the various surgical techniques involved in correcting earlobe ptosis and pseudoptosis related to aging. The entire selection process is detailed in the PRISMA flow chart (Fig. 2).

Fig. 2.

PRISMA flow chart.

RESULTS

Various surgical techniques have been described to achieve earlobe reduction. We regrouped these techniques into 3 categories: those involving inferior margin excision of the earlobe, those involving anterior earlobe resection, and the third group comprising other methods.

Inferior Margin Resection

Tipton described a simple technique for reduction of the earlobe (Fig. 3).⁵ The exact shape of the desired earlobe is drawn on the anterior surface of the earlobe. Then, an incision is made through the skin, with cutting on an oblique angle so that the resulting scar would be on the posterior surface of the earlobe.

Fig. 3.

Tipton’s, Connell’s and De Oliveira and De Oliveira’s earlobe reduction techniques, with surgical markings on the earlobe.

Connell⁶ described a similar pattern for earlobe resection (Fig. 3). However, the resulting scar is located on the precise edge of the earlobe.

De Oliveira and De Oliveira⁷ used a modification of Tipton’s marginal method (Fig. 3). Cutaneous resection is only made on the posterior surface of the earlobe. The fat layer of the distal flap is preserved to create a thickened earlobe. The lobular ridge is elevated posteriorly and sutured. Their technique reduced the length of the earlobe while increasing lobular thickness. It is therefore useful in ptotic thin earlobes necessitating reduction in addition to increased thickness.

Another technique for inferior margin excision is described by Fuente-del-Campo and Lesta-Compagnucci.⁸ Two 5- to 7-mm triangular flaps with their base cephalad are drawn on the anterior surface of the earlobe (Fig. 4). The design of the triangular flaps may vary by making them wider, shorter, or longer depending on the lobe dimensions and the shape desired. On the posterior side, a line is drawn at the height desired to relocate the lower limit of the lobe. An incision is carried out at the level of the curved trace on the posterior surface of the lobule, continuing on its anterior surface, following the contour of the triangular flaps traced. The vertices of the flaps are relocated backward. The contours of the imprint left by these flaps on the posterior skin are excised, and the flaps are sutured in place.

Fig. 4.

Fuente-del-Campo and Lesta-Compagnucci’s earlobe reduction technique, with surgical markings on the earlobe. Note that the green line is drawn on the posterior side of the earlobe and the blue line on the anterior side.

These techniques have the advantage of creating a shorter lobule with a hidden inconspicuous scar on the posterior surface of the earlobe. Additionally, the simple design of the excised tissue permits a precise control of the shape and size. The Fuente-del-Campo and Lesta-Compagnucci technique was conceived to prevent the visible and retracted scar that may appear after a simple linear crescent excision. However, the design of the incisions is more complicated and requires practice to master the geometry involved and to apply the necessary adjustments for each case. These techniques deal with the lower marginal portion of the earlobe. Therefore, their use is limited to ptosis repair without adequately treating pseudoptosis of the earlobe.

Anterior Earlobe Resection

Excising the excess ptotic earlobe tissue with primary closure appears satisfying immediately postoperatively. However, it may result in a distorted free lateral edge. Techniques with anterior auricular resection avoid the lateral notching seen with other techniques and preserve the earlobe contour. Several techniques have been described.

Lassus⁹ described a simple technique in which the incision is situated in the anterior half of the earlobe in a relatively hidden space. A simple excision is made in the anterior half of the lobule with rotation of the flap to close the defect (Fig. 5).

Fig. 5.

Lassus’s earlobe reduction technique, with surgical markings on the earlobe.

The Loeb method consists of excising the anterior portion of the earlobe in addition to a central triangle.¹⁰ A posterior flap is rotated, closing the defect with the scar located in hidden areas (Fig. 6).

Fig. 6.

Loeb’s earlobe reduction technique, with surgical markings on the earlobe. I, intertragal notch; O, otobasion inferius; O′, point marked depending on the excess tissue to be removed.

Van Putte and Colpaert¹¹ described a similar technique but more versatile and geometrically reliable.

The markings are based on the individual ear’s otobasion inferius-to-subantitragal groove length and follows anatomic landmarks and geometric ratios (A = A′ and B = B′ = Bʺ; A′ is parallel to the free lateral edge of the lobule).¹¹ The excision results in an earlobe flap which is rotated in the excision defect. The scar is located at the subantitragal groove and at the cheek junction and is therefore hidden (Fig. 7).

Fig. 7.

Van Putte and Colpaert’s earlobe reduction technique, with surgical markings on the earlobe. O, otobasion inferius (A = A′, B = B′ = Bʺ).

The 2-triangle rotation flap technique described by Vasilakis et al¹² also utilizes the same principles of Loeb and Van Putte and Colpaert. It consists of excising 3 triangles with rotation and advancement of the flaps to achieve earlobe reduction (Fig. 8). It adds to the other techniques the excision of a Burrow triangle designed on the medial aspect of the apex of the triangle to prevent buckling or excess fullness during rotation. Adjustment in the sizes of the triangles allow for applicability in all shapes and degrees of ptosis.

Fig. 8.

Earlobe reduction technique by Vasilakis et al, with surgical markings on the earlobe. Burrow triangle is represented in red. Length of X should be two-thirds to twice the length of Y. I, intertragal notch; O, otobasion inferius; O′, point marked depending on the excess tissue to be removed.

Tatar and Sezgin’s technique is characterized by an incision that lies 1–2 mm below the otobasion point, preserving the earlobe–cheek skin interface.¹³ A double crescentic excision is performed, and the posterior earlobe flap is rotated anteriorly (Fig. 9). An advantage of the technique is that preserving the small amount of tissue at the earlobe–cheek interface would separate the facelift incision from the earlobe reduction, thereby preventing the pixie ear deformity caused by traction during the healing phase. However, the scar lies under the subantitragal groove.

Fig. 9.

Tatar and Sezgin’s earlobe reduction technique, with surgical markings on the earlobe. Markings start from 1 to 2 mm below the O point and continue in a slight curved line by following the normal groove of the anterior topography of the earlobe. Yellow line indicates preserved 6–8 mm of tissue at the lateral border of the earlobe. A = A′, B = B′.

The technique by Colombo et al relies on a triangular excision of the anterior earlobe below the point of earlobe insertion to the cheek.¹⁴ It is important to leave 0.5–0.8 cm for the posterior rotational flap (Fig. 10). The surgery is simple. The scar is hidden in continuity with a depression anatomical ear.

Fig. 10.

Earlobe reduction technique by Colombo et al, with surgical markings on the earlobe. Point O: Insertion point of the earlobe to the face. Point A is established from a transverse line to maintain a pedicle from 0.5 to 0.8 cm residual thickness of the free edge of the ear. Point B defined from an angle variable section circumference of 15- to 90-degree angles. This extension was determined as the excess skin.

Mowlavi et al¹⁵ described a component lobular surgical design that can differentially reduce ptotic or pseudoptotic earlobes. A medially based triangular excision is performed, allowing for differential reduction of the attached cephalic segment (for pseudoptosis) versus the free caudal segment (for ptosis) by placing the excision triangle over the I to O or the O to S (Fig. 11). A combined excision design spanning variably over the I to S segments will reduce both segments. This is the only study that acknowledges the separate segments of the ear lobules and reduces each component separately.

Fig. 11.

Earlobe reduction technique by Mowlavi et al, with surgical markings on the earlobe. Medially based triangular excisions allowing for differential reduction of the attached cephalic segment (blue triangle) vs the free caudal segment (green triangle). A combined excision design will reduce both segments (red triangle). I, intertragal notch; O, otobasion inferius; S, subaurale.

Other Techniques

Some other techniques are applied to the posterior portion of the earlobe, such as Enna and Delgado’s technique, Tanzer’s technique, and Joseph’s technique. However, no detailed articles specifically describing these techniques were found, though they are mentioned in various texts.

Earlobe reduction can be achieved with lasers. It was successively achieved with lithium borate laser technology. The advantages of using laser include no bleeding, less pain, and lower risk of keloids.¹⁶ In addition, reduction of the earlobe was achieved with high energy pulsed CO₂ laser.¹⁷ However, these laser techniques are not widely practiced, and further research is needed to determine their long-term validity and effectiveness compared with traditional surgical methods.

DISCUSSION

Various surgical techniques are available for earlobe reduction. To aid in clinical decision-making, we created an algorithm to guide the choice of the procedure (Fig. 12). For patients with ptosis of grade 2 or higher, multiple reduction methods can be used, such as inferior margin excision or anterior earlobe excision. The choice of surgical design depends on the surgeon’s experience. In cases of pseudoptosis, however, anterior resection is the preferred approach to reduce the size of the attached portion of the earlobe. Mowlavi’s differential lobular resection can reduce each part of the lobule separately.

Fig. 12.

Algorithm designed to aid in clinical decision-making for earlobe reduction surgery.

A study by Azaria et al¹ demonstrated a significant difference between the left and right earlobes in the adult population, highlighting the asymmetry that generally exists. This finding underscores the importance of thorough preoperative assessment in earlobe reduction surgery. Careful measurement and evaluation of both earlobes are essential to plan the surgery accurately, ensuring that the postoperative result will be symmetrical and aesthetically pleasing. By addressing these asymmetries preoperatively, surgeons can achieve more harmonious outcomes and prevent any noticeable imbalances following the procedure.

Additionally, men’s earlobes are longer than women’s,¹ which can play a role in surgical planning, especially in gender-affirming surgery. In procedures where facial feminization or masculinization is the goal, addressing the natural differences in earlobe size and shape becomes essential for achieving gender-congruent outcomes.

Variations in earlobe size are independent of skin tone.¹ However, cultural factors can play a role in patients’ perceptions of their earlobes. For example, in traditional Chinese culture, a large and full earlobe is often seen as a symbol of wealth and blessing. This highlights the importance of discussing cultural preferences and expectations with patients during the preoperative consultation. By understanding cultural significance, surgeons can ensure that the surgical plan aligns with the patient’s aesthetic and personal values.

Earlobe Reduction and Rhytidectomy

The earlobe is an integral component of facial aesthetics and should be carefully considered during a rhytidectomy consultation. Patients presenting with earlobe ptosis can effectively undergo earlobe reduction concurrently with a facelift procedure.² It is important to note that the attached cephalic segment, particularly the intertragal-to-otobasion distance, is more susceptible to elongation as a secondary effect of rhytidectomy.^15,18 Therefore, patients with borderline pseudoptosis—defined by an intertragal-to-otobasion distance of 15 mm—should be treated as pseudoptotic, anticipating the potential elongation of the cephalic segment during surgery.¹⁵

It is crucial to avoid placing excessive tension on the earlobe during rhytidectomy to prevent elongation and the development of the “pixie earlobe” deformity.¹⁴ Proper management of the earlobe during facial rejuvenation procedures ensures a more harmonious and aesthetically pleasing outcome.

Alternative Methods of Earlobe Rejuvenation

Other techniques for earlobe rejuvenation exist. Individuals with grade 0 ptosis may benefit from earlobe augmentation. Fat grafting is an effective method for addressing volume deficiency as well as fine wrinkles with minimal risks.¹⁹ Hyaluronic acid fillers are another alternative. They address all the parameters of aging, volume deficit, reduction in the number and depth of creases, and improvement in the number of wrinkles.²⁰

Finally, Lei et al²¹ revealed that when evaluating individual aesthetic units of the ear, both men and women ranked the earlobe as a key factor in determining overall ear attractiveness. As a result, earlobe surgery, whether for reduction or rejuvenation, becomes a crucial procedure for those seeking to enhance their facial appearance. Addressing earlobe concerns can have a profound impact on patient satisfaction, making it an essential consideration in cosmetic surgery.

One limitation of this review is the limited number of studies available on the topic. Additionally, there are no randomized controlled trials directly comparing the different surgical techniques and their outcomes. This lack of high-quality evidence makes it challenging to draw definitive conclusions about the superiority of one technique over another, and it highlights the need for further research in this area.

CONCLUSIONS

In conclusion, we have described various techniques for earlobe reduction in the aging population and provided an algorithm to guide treatment for both ptosis and pseudoptosis, tailored to individual earlobe variations. Although these methods offer effective solutions, further research is needed to compare outcomes and determine which technique yields the most optimal results for different patient populations.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.