Esthetic and reconstructive options for earlobe deformities

INTRODUCTION

Earlobes play an important role in facial esthetics. In general, young people present a good position, adequate shape, and pleasant appearance. The use of adornments, such as earrings, supports the earlobes with an area of esthetic prominence. Age, gender, culture, ethnicity, and fashion affect the esthetic ideal.^1,2

The aging process, its characteristics, and changes in the human body also affect the earlobes. Located in a plane perpendicular to the face, ideally, the lobes should be elastic and have a good volume that does not indicate sagging. The deflation or emptying of these structures, as well as their ptosis and stretching, reflect esthetically unpleasant signs.³

The deflated and flaccid appearance of the earlobes with loss of their elastic capacity, position, and size compromises facial esthetics and must be observed in facial rejuvenation procedures. Ptosis and elongation of the lobes are the most obvious signs of aging in this anatomical area, leading to an unattractive appearance. In addition to congenital deformities, the main acquired changes related to earlobes are produced by trauma, placement of earrings and adornments, and surgery.⁴ One study showed that the length of the lobes increases by 30–35% from the age of 30 to the age of 60.⁵

Treatments for earlobe changes depend fundamentally on the causes and appearance of the deformities. Options can be non-surgical with fat or filler injection or surgical with soft-tissue remodeling. The earlobe contains no cartilage. As a result of the natural aging process, the combination of persistent gravitational forces and a decline in tissue elasticity leads to ptosis and wrinkling.⁶

According to Alexander, earlobe ptosis is defined as a lobe >25% of the total length of the ear. The normal length of the earlobes (distance from the antitragus to the lower edge of the ear) is between 1.5 cm and 2.5 cm in children and adults.⁷

ANATOMY OF THE EARLOBE

The earlobe (lobulus auriculae) is the inferior portion of the external ear and consists predominantly of soft tissues, including areolar connective tissue and adipose tissue, which provide its flexible and pliable nature. The areolar tissue contains a matrix of collagen and elastin fibers that provide structural support and flexibility. Adipose tissue enhances the softness and pliability of the earlobe while also serving as an energy reserve. Unlike the rest of the auricle, the earlobe lacks cartilage, contributing to its distinct flexibility.

Due to its rich vascular and nerve supply, the earlobe can play a role in thermoregulation and sensory perception. The arterial supply comes from branches of the posterior auricular artery, the superficial temporal artery, and branches of the external carotid artery. Venous vessels drain into the external jugular vein. The great auricular nerve, a branch of the cervical plexus, mainly provides the sensory innervation of the earlobe. The auriculotemporal nerve extends some fibers into the earlobe.^8,9

There are two major types of earlobe morphology – attached and pendulous. The pendulous type can be further classified into acute angled earlobes (Type A), right-angled earlobes (Type B), and obtuse-angled earlobes (Type C).¹⁰ Another classification includes four types of earlobes: arched, tongue-shaped, square, and triangular.¹¹

AGE-RELATED CHANGES AND ESTHETIC ASPECTS

As earlobes age, they undergo several esthetic changes. A common feature is volume loss, where a reduction in adipose and connective tissue leads to a deflated or atrophic appearance. This is often accompanied by sagging and lengthening of the earlobes, particularly in individuals who have worn heavy earrings.¹² In addition, aging results in the development of wrinkles and creases on the earlobe surface. Torn or enlarged earlobe holes are common earlobe changes. Skin texture changes such as roughness or irregularity may develop by photodamage.¹³

Deformities of the earlobes, whether associated with aging or not, can represent an esthetic concern. Numerous surgical and non-surgical modalities aim to enhance the appearance, texture, shape, deformities, and size of these structures. Hence, the importance of the surgeon’s knowledge of the various reconstructive options cannot be underestimated. Sometimes, the combination of more than one procedure can bring benefits to the repair process. Individualized treatment based on a precise diagnosis of the alterations yields effective, safe, natural, and anatomical results for the earlobes.

METHODS

Since the earlobes play an important role in facial esthetics, this manuscript aims to demonstrate, in a didactic and objective manner, the different surgical options for each type of existing deformity.

We have completed a narrative review on treatment options on PUBMED^©. A systematic review was not feasible due to the high heterogeneity of articles on this topic. The focus of this review is on traumatic ear lobe loss, pixie ear, earlobe ptosis, and correction of earlobes after gauging. Articles referring to traumatic, congenital, and acquired cleft deformities were excluded. Articles on earlobe keloid treatment were also excluded. Key terms in the search included “earlobe AND reconstruction” and “earlobe AND rejuvenation.” Languages included were English, Spanish, Portuguese, and German. The considered articles were published between 2000 and 2024. We obtained 359 hits for “earlobe reconstruction” and 21 hits for “earlobe rejuvenation.” We searched the reference lists of relevant articles and added seven more articles. We included case reports (n = 11), case series (n = 9), reviews (n = 4), and uncontrolled trials (n = 4).

We noted limitations since no randomized controlled trials were available. Most case series had single-digit numbers of patients. Not all publications provided data for both earlobes and/or earlobe symmetry.

TREATMENT OPTIONS FOR EARLOBE REJUVENATION

Minimal invasive methods

A variety of non-surgical and surgical treatment options are available for addressing the esthetic aspect and deformities of the earlobe. Dermal fillers are frequently used to restore volume and rejuvenate deflated earlobes. The main fillers are hyaluronic acid (HA), calcium hydroxylapatite, and polyL-lactic acid. For the earlobes, HA fillers are preferred for Mowlavi Grade I and II patients. Results are immediately visible after injection, as the volume is restored, improving the fullness, laxity, and wrinkles [Figure 1]. HA fillers also restore impaired protective skin barrier function. Fillers provide a temporary improvement, lasting up to 14 months. Risks associated with the treatment are usually mild, including potential swelling, bruising, or infection at the injection site.^14-16

Close

Figure 1:

(a, b) A 46-year-old female patient with loss of volume and fine wrinkling of the ear lobe. Rejuvenation with hyaluronic acid filler treatment. (a) Before treatment. (b) After filler injection reduced wrinkling and increased fullness.

Export to PPT

Fat grafting or autologous fat transfer is an alternative method for restoring volume to aging or deflated earlobes. Usually, fat grafting provides safe results since it uses the patient’s tissue, minimizing the risk of allergic reactions. The method increases earlobe volume and decreases fine wrinkles and creases [Figure 2]. The results are often long-lasting compared to dermal fillers. Fat resorption should be considered. Risks include potential fat infection or hypercorrection. In some cases, multiple sessions may be needed to achieve optimal results.^17,18

Close

Figure 2:

(a) Atrophic and wrinkled earlobe. (b) Fat grafting into the earlobe during rhytidoplasty. (c) Result 3 months after the procedure.

Export to PPT

Fat injection and fillers are effective, minimally invasive techniques for restoring earlobe volume and enhancing a youthful appearance. Fat transfer uses autologous fat harvested from donor sites such as the abdomen, thighs, or submental region, which is processed and injected in small amounts into the central body, medial, and lateral edges of the earlobe. This approach provides natural, long-lasting results, improves skin quality through adipose-derived stem cells, and is ideal for addressing atrophy, elongation, and trauma-related volume loss.

Fillers, such as HA, offer immediately for mild-to-moderate volume loss, wrinkles, and soft-tissue atrophy. Injection points include the central body, peripheral margins, and areas around stretched piercing holes. HA is safe, while alternatives such as calcium hydroxylapatite or poly-L-lactic acid provide longer-lasting effects.

Both techniques require precise placement using small-gauge cannulas or needles to prevent lumps or asymmetry. Fat injections have greater longevity but may need multiple sessions, while fillers typically last 6–12 months. Younger patients may benefit more from fillers, while fat transfer suits those with significant volume loss. Patient selection and careful technique represent important cars to achieve natural results.

Earlobe repair surgery

Earlobe repair surgery is the most effective treatment for individuals with torn, split, or stretched earlobe holes and after traumatic loss of the earlobe [Figures 3 and 4]. These procedures can close large or torn piercings, restore the natural contour of the earlobe, and correct overly elongated lobes. For patients with Mowlavi stages III and IV earlobe ptosis, surgery is the only solution. The existing deformity or deformities determine the best surgical procedure.^19,20

Close

Figure 3:

(a) A 61-year-old patient with ptosis and stretching of the earlobe. (b) Surgical planning. (c) Result 1 month after surgical procedure.

Export to PPT

Close

Figure 4:

(a) Elongated earlobe in a 72-year-old patient. (b) Planning of surgical resection and reconstruction flaps. (c) One month postoperatively with esthetic improvement.

Export to PPT

For earlobe ptosis, it is essential to remove excessive tissue but obviate earlobe deformity. In case of severe ptosis, the sub-antitragal groove technique aims to preserve the lateral edge of the ear lobule and minimize the risk of free-border notching.²¹ In case of an attached, tapered, and low-set earlobe (pixie ear), infraauricular skin re-draping is suitable. From the frontal view, no scar is visible, and the earlobe size is preserved.²² For protruding earlobes, a modified fish-tail excision on the posterior site is an option.²³

For earlobe reconstruction, various techniques are available [Table 1]. Two-stage procedures include the Zenteno Alanis technique with an infraauricular vertical flap,²⁴ the modified Limberg flap,²⁵ the preauricular flap,²⁶ and the posterior-based interpolation flap with the addition of a double Z-plasty.²⁷

Due to a lesser downtime, one-stage procedures have gained increasing interest, such as the superiorly based preauricular transposition flap,²⁸ the inferior pedicle flap,²⁹ the freestyle perforator-flap surgery (Doppler-sonography is crucial for flap design),³⁰ and a combination of two rotation flaps, one from the lower auricle and the other from the infraauricular area with a V–Y advancement flap closure of the donor defect.³¹ A commonly used surgical technique is the modified bilobed Gavello flap, which is achieved by elevating a bilobed flap horizontally below the earlobe defect and then folding the two flap lobes together.^24,32 Another option for a single-stage procedure is the combined preauricular, retro auricular bilobed flap for earlobe reconstruction when various esthetic units are involved.³³

Table 1: Some surgical techniques for earlobe reconstruction: Advantages and limitations.

Technique	Indication (s)	Advantages	Limitations
Modified fish-tail flap	Protruding earlobe	Achieves adjustable vertical height & sufficient correction through asymmetric oblique suturation with minimal skin excision and reduced risk of keloids, good esthetic outcome.	Might need dog-ear excision.
Infraauricular skin redraping method	Pixie ear	One-stage reconstruction, simple and easy to perform, natural appearance of the earlobe, tension-free; the retroauricular scar is inconspicuous from frontal view.	None known.
Zenteno Alanis technique	Traumatic loss of earlobe	Two-stage procedure with an infraauricular vertical flap, good esthetic outcome.	Division of the flap 3 weeks after primary surgery.
Gavello technique	Traumatic loss of earlobe	Single-stage procedure with a horizontal bilobed flap on postauricular mastoid skin, acceptable esthetic outcome.	Some risk of hypertrophic scarring.
Doubled-over Limberg flap	Traumatic loss of earlobe	Two-stage procedure, no shrinkage, minimal necrosis, good esthetic outcome.	Needs defatting after 3–4 months.
Preauricular flap	Traumatic loss of earlobe	Two-stage procedure, simple technique, good esthetic outcome.	Second step after formation of the folded flap 6 months later
Superiorly based preauricular transposition flap	Traumatic loss of earlobe	Single-stage procedure, technically simple and safe, satisfying esthetic outcome.	May narrow the auriculotemporal sulcus.
Posterior-based interpolation flap with the addition of a double Z-plasty	Traumatic loss of earlobe	Two-stage procedure for defects of several esthetic units, acceptable esthetic outcome.	Needs a revision after 4 weeks for pedicles and cicatricial contour by V-Y plasty.
Posterior auricle bilobed cartilage-skin flap	Traumatic loss of earlobe	Single-stage minimal invasive surgery; cartilage harvested from the same region; it can reconstruct a relatively large earlobe with a natural shape; recreates the otobasion inferius-to-subaurale distance seen in the contralateral ear, good esthetic outcome	There is a risk of bulky reconstructed earlobe, harvesting the first flap generates a narrow auriculotemporal sulcus.
Combined preauricular, retroauricular bilobed flap	Traumatic loss of earlobe	Single-stage, easy to perform, acceptable esthetic outcome.	None known.
Freestyle perforator flap	Traumatic loss of earlobe	One-stage reconstruction which provides more flexibility in selecting the donor site, esthetic outcome.	Pre-surgical Doppler-ultrasound is necessary.
Anteriorly based post-auricular flap	Traumatic loss of earlobe	One-stage procedure also for larger defects, acceptable esthetic outcome.	Hematoma. Risk of damage of sensory nerves of the earlobe.
V to Y advancement flap	Small lobular defects after surgery	One-stage procedure, well-vascularized flap, minimal risks, and good esthetic outcome.	Not for larger defects.
Double opposing perpendicular linear repair	Dilated ear lobules after gauge ear piercing	One-stage procedure, easy to perform, dog-ears are avoided, does not violate the thin inferior rim of the lobule, prevents notching, good esthetic outcome	None known.
Local flap technique by Williams and Majumder34	Dilated ear lobules after gauge ear piercing	One-stage procedure, local flap, uncomplicated, good esthetic outcome.	Creating an earlobe slightly smaller and flatter than it was before gauge ear piercing, imprecise cuts could lead to suboptimal reconstruction.
Local flap technique of Henderson and Malata35	Dilated ear lobules after gauge ear piercing	One-stage procedure, easy, good esthetic outcome.	Insufficient tissue may lead to a small lobule with a flat appearance.
Wedge excision according to De la Sotta et al.36	Dilated ear lobules after gauge ear piercing	One-stage procedure, minimal excisions, good esthetic outcome.	Requires sufficiently thick tissue on the rims of the lobule.
Double opposing perpendicular linear closure	Dilated ear lobules after gauge ear piercing	One-stage procedure even for larger defects, good esthetic outcome, dog-ear formation is avoided, prevents notching.	None known.

Reconstruction of earlobe defects after gauging (flesh tunnel) can be challenging [Figure 5]. One technique uses the removal of the inferior portion of the dilated earlobe and repair of the hole by de-epithelialization of the margin. This is followed by a subsequent approximation of the remaining earlobe. The technique results in a slightly smaller and flatter earlobe compared to gauge.³⁴ A related technique removes the excess tissue from the anterior half of the defect. The remaining posterior flap is de-epithelialized and sutured to the superior rim in an L-shaped pattern.³⁵

Close

Figure 5:

34-year-old patient, who has been using (a) earlobe gauging (rings) for 20 years. (b) Preparation of a local flap, de-epithelization of the inner rim of the hole. (c) Flap positioned and sutured. (d) Result 1 month after surgery (Henderson-Malata technique).

Export to PPT

For patients with thick tissue on the rims of the lobule, it is possible to create 3 wedge excisions around the rim of the dilated lobule, followed by an approximation of these wedges with anterior and posterior sutures.³⁶ Another option is a double opposing perpendicular linear repair. The inner circle of the defect is undermined by fat. A linear closure is then placed on the anterior aspect of the circular lobular defect, followed by a linear closure on the posterior site at a 90° angle. This results in a natural appearance with minimal scarring.³⁷ In most patients, surgical repair provides a permanent solution with minimal risk of complications.

Multiple and creative technical options involving flaps and mobilization of soft tissues, support the surgical option in correcting earlobe deformities. Risks include infection, scarring, or asymmetry.^38-45

DISCUSSION

Acquired or non-acquired earlobe deformities can lead to esthetic impairment. Deflation, ptosis, loss of volume, and changes in skin texture and quality are the main changes found in this region. The most frequent acquired deformity from aging involves elongation or ptosis of the earlobe. Loss of elastic fibers and a consequent gravitational pull contribute to this deformity. Reconstruction considers the type of deformity, remaining tissues, scars, and characteristics such as shape, size, and volume of the lobes. The aging process, intrinsic and extrinsic causes, and trauma or adornment are the main factors related to changes in these structures. It is not uncommon for sagging and facial and cervical aging to be accompanied by esthetic changes to the earlobes. Studies showing patients’ opinions on the esthetic standards of the ear revealed that the helix and earlobe were the structures people found most concerning. Notable differences emerged between genders, with educational background also playing a role in these concerns.⁵¹

Mowlavi et al. proposed a classification system for earlobe ptosis. This classification aims to enhance the precision of earlobe reduction or reconstruction treatments.³ Correction or improvement of these unsightly characteristics must seek a harmonious result, restoring and respecting the proportional dimensions of the lobe with the ear, its volume, texture, and position.

Numerous types of surgical and non-surgical treatments are described for rejuvenating earlobe changes. Treatment must be based on the anatomical changes present and seek a global esthetic improvement in this region.^41,52

There is good evidence that HA fillers improve mild earlobe ptosis, but severe ptosis may require surgery.^14,19 Fat transfer is effective in volumizing and reduction of creases and wrinkles in earlobe rejuvenation. The results are less predictable but often last longer than fillers.¹⁷

Removal of excess tissue and the use of triangular flaps to correct elongated earlobes, minimizing scar represents an option for earlobe reconstruction.⁴⁰

In general, a period of 2–3 months is allowed before placing a new piercing after reconstruction of earlobe deformities. This period varies according to the type of deformity, technique used, and, mainly, the recovery and healing process of each patient. A new hole should be avoided over the scarred area to minimize the risk of the problem recurring.

CONCLUSION

Deformities of the earlobes, whether associated with aging or not, can represent an esthetic concern. Numerous surgical and non-surgical modalities aim to enhance the appearance, texture, shape, deformities, and size of these structures. Individualized treatment based on a precise diagnosis of the alterations yields effective, safe, natural, and anatomical results for the earlobes.