Correction and Prevention of the Pixie Ear Deformity: A Combined Technique

Correction and Prevention of the Pixie Ear Deformity: A Combined Technique Abstract Background Ear and earlobe deformities after surgical rhytidectomy are common and can significantly diminish the aesthetic outcome. The main causes of ear/earlobe distortion are skin overresection, an imbalance between vertical/horizontal skin-lift vectors, and tractional distortions through superficial muscularaponeurotic system (SMAS) tension. Objectives To demonstrate a new method for earlobe suturing and ear fixation that would prevent aesthetics-related complications after facelift surgery. Methods A total of 105 primary SMAS facelift surgeries were performed between 2015 and 2016 by the first author. A combination technique consisting of a posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) was executed bilaterally within each facelift procedure (n = 210). A retrospective data analysis was conducted (preoperatively and one year postoperatively) using our hospital information system and a photometric data analysis to assess auricular displacement, earlobe distortion, and hypertrophic scarring. Results Pseudoptosis of the earlobe was noted in two cases, and auricular displacement was observed in four cases. Bilateral mild hypertrophic scarring was seen in one patient. The postoperative photometric analysis showed a natural ptosis grade I/II in all the patients, with a statistically significantly reduced postoperative earlobe size (P < 0.05). The total rate of aesthetics-related complications was 4% in our cohort (earlobe distortion with pseudoptosis: 1%; auricular displacement: 2%; hypertrophic scarring: 1%). Conclusions Our modification of the facial flap anchoring at the ear base in combination with a CMSS stabilizes the natural position of the ear and prevents distortion while allowing better control over the earlobe’s aesthetic shaping. This novel method reduces the incidence of ear/earlobe deformities and hypertrophic scarring at the ear base after rhytidectomy and, therefore, promises to be a valuable advancement. Level of Evidence: 4 At the beginning of the 19th century, the first facelift procedures with plain skin resection were developed.1 A major step toward modern facelift procedures was achieved by the description of the superficial muscularaponeurotic system (SMAS) by Skoog et al in 1974. This scientific breakthrough made a multitude of surgical approaches within the following years possible.1 At present, most rhytidectomy techniques include the manipulation and stable anchoring of the SMAS, which optimizes long-term outcomes and diminishes deformation through skin traction. Nevertheless, the distortion of ear and earlobe shapes due to the traction forces caused by the skin flap, scar retraction, or the SMAS flap remains a commonly encountered aesthetic problem after facelift surgery. Neither the ear, as a whole anatomic unit, nor the earlobe, as a subunit, are anatomically fixed structures;2,3 thus, even slight changes in the tension vectors can lead to a distortion of the complete aesthetic unit of the ear, resulting in a diminished aesthetic outcome of an otherwise skillfully executed facelift surgery. As facelifts are performed to improve the patient’s looks, complications, which compromise the aesthetic outcome, are dreaded by every plastic surgeon. Ear and earlobe deformities still represent a common postoperative complication, often caused by skin overresection, resulting in stronger tractional forces leading to hypertrophic scarring and/or an imbalance between the preauricular (vertical) and postauricular (horizontal) skin-lift vectors. Tractional distortion can also be caused by the poorly planned SMAS vectors and may result in postoperative ear/earlobe position deformity. In this case, the ear itself is displaced and pulled toward a more inferior and medial position, with its lower pole undergoing more anterior displacement than its upper pole. Brink et al stated that notable auricular displacement was found in 62% of the analyzed results after patients underwent facelift surgery.2 Furthermore, they postulated that auricular displacement of varying degrees after rhytidectomy may be close to 90%.2 Earlobe deformities such as pseudoptosis, also known as pixie ear deformity (Figure 1), and ptosis grades III to IV are still common after facelift surgery. To prevent the incidence of these deformities, the authors of this paper propose a novel surgical combination technique to avoid auricular deformity and earlobe distortion after rhytidectomy, consisting of a posterior earlobe rotation flap (PERF) in combination with a concha-mastoid suspension suture (CMSS). Figure 1. View largeDownload slide Pixie ear deformity. A 50-year-old Caucasian woman with an aesthetic complication in the form of a pixie ear deformity is shown after receiving a facelift without the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique one year earlier. Pseudoptosis with no visible free auricular pedicle is visible; right oblique view. Figure 1. View largeDownload slide Pixie ear deformity. A 50-year-old Caucasian woman with an aesthetic complication in the form of a pixie ear deformity is shown after receiving a facelift without the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique one year earlier. Pseudoptosis with no visible free auricular pedicle is visible; right oblique view. This method offers the ability to tailor the desired earlobe of each patient, which is a major and sustainable advantage over existing techniques; it accounts for and corrects the aging-related changes of the earlobe itself. Therefore, this technique can not only be used for the prevention of ear and earlobe distortion, but also helps to reconstruct the shape of a desired earlobe. METHODS From January 2015 to September 2016, 105 primary SMAS facelift surgeries were performed under intravenous sedation by the first author (K.O.K.). A retrospective data analysis was done using the hospital information system, including standardized photographic documentation and photometric measurement of the earlobes and the ear position preoperatively and one year postoperatively. The exclusion criteria were as follows: any known previous rhytidectomies, otoplasty, lobuloplasty, and lower and upper blepharoplasty (including canthopexy), as well as unwillingness to receive a lobuloplasty during the facelift procedure. This research project has been 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. Written consent was obtained from each patient to perform earlobe tailoring during the facelift procedure. The patients were informed that existing earlobe piercings might be removed during this procedure. The intraoperative and postoperative settings followed published standard recommendations for major in-patient surgery procedures. During the primary facelift procedure, a novel technique—based on an advancement-rotation flap (PERF) originating from the retroauricular fold and designed to change the anchoring point of the facial skin flap at the ear base (otobasion inferius)—was performed on each side in combination with a CMSS to prevent tractional distortion of the ear caused by the SMAS tension vectors (n = 210; Figures 2-11, Video 1 [PERF], and Video 2 [CMSS]). The PERF and CMSS techniques were applied before the SMAS tightening to preserve the preoperative ear position. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Close Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Close Figure 2. View largeDownload slide Planning of the desired earlobe size. The new earlobe size (ranging from otobasion inferius to subaurale) is defined by the distance between the intertragal notch (I) and the placing of the B1-B2 incision line (red line) either more cranially or caudally to create a new subaurale. B1 = endpoint of planned earlobe resection line; B2 = starting point of planned earlobe resection line; subaurale (S) = most caudal part of free earlobe. The presented photograph is of a 59-year-old Caucasian woman. Figure 2. View largeDownload slide Planning of the desired earlobe size. The new earlobe size (ranging from otobasion inferius to subaurale) is defined by the distance between the intertragal notch (I) and the placing of the B1-B2 incision line (red line) either more cranially or caudally to create a new subaurale. B1 = endpoint of planned earlobe resection line; B2 = starting point of planned earlobe resection line; subaurale (S) = most caudal part of free earlobe. The presented photograph is of a 59-year-old Caucasian woman. Figure 3. View largeDownload slide Planning of the posterior earlobe flap (PERF). Planning of the rotation-advancement flap with its base in the retroauricular fold. Pivot point A2 is advanced to B2 (blue arrow), defining the new otobasion inferius, while the tip of flap A1 is rotated posteriorly toward the incision line B2-B1. A more cranial anchoring of A2-B2 results in a larger free segment of the new earlobe. A more caudal anchoring creates a smaller free segment and defines the grade of ptosis. The presented photograph is of a 59-year-old Caucasian woman. Figure 3. View largeDownload slide Planning of the posterior earlobe flap (PERF). Planning of the rotation-advancement flap with its base in the retroauricular fold. Pivot point A2 is advanced to B2 (blue arrow), defining the new otobasion inferius, while the tip of flap A1 is rotated posteriorly toward the incision line B2-B1. A more cranial anchoring of A2-B2 results in a larger free segment of the new earlobe. A more caudal anchoring creates a smaller free segment and defines the grade of ptosis. The presented photograph is of a 59-year-old Caucasian woman. Figure 4. View largeDownload slide Circumcision of the PERF flap. Flap circumcision follows the solid black line. The non-incised flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 4. View largeDownload slide Circumcision of the PERF flap. Flap circumcision follows the solid black line. The non-incised flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 5. View largeDownload slide Elevation of the posterior earlobe rotation flap (PERF) flap. Facelift omega pattern incision was performed. The former earlobe insertion (EI) is shaded. The flap is elevated but is not yet sutured in place. The incision lines of the flap are marked with a solid black line, and the nonincised flap base is outlined with a dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 5. View largeDownload slide Elevation of the posterior earlobe rotation flap (PERF) flap. Facelift omega pattern incision was performed. The former earlobe insertion (EI) is shaded. The flap is elevated but is not yet sutured in place. The incision lines of the flap are marked with a solid black line, and the nonincised flap base is outlined with a dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 6. View largeDownload slide Posterior earlobe rotation flap (PERF) before advancement-rotation. Demonstration of the flap shape and size before advancement-rotation. The incision lines of the flap are marked with a black line, and the flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 6. View largeDownload slide Posterior earlobe rotation flap (PERF) before advancement-rotation. Demonstration of the flap shape and size before advancement-rotation. The incision lines of the flap are marked with a black line, and the flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 7. View largeDownload slide Flap advancement and fixation at the new otobasion inferius. Flap advancement is performed, and the pivot point A2 is fixed at the desired height of the new otobasion (A2-B2) with a PDS 4-0 inverted suture. The caudal tip of flap A1 is rotated toward B1 (blue arrow), covering the defect of the caudal resection zone of the earlobe and shaping the new subaurale; A1 = caudal tip of the flap; B1 = endpoint of the earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 7. View largeDownload slide Flap advancement and fixation at the new otobasion inferius. Flap advancement is performed, and the pivot point A2 is fixed at the desired height of the new otobasion (A2-B2) with a PDS 4-0 inverted suture. The caudal tip of flap A1 is rotated toward B1 (blue arrow), covering the defect of the caudal resection zone of the earlobe and shaping the new subaurale; A1 = caudal tip of the flap; B1 = endpoint of the earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 8. View largeDownload slide Posterior earlobe rotation flap (PERF) flap insertion at the new earlobe base. The flap is rotated around the A2 pivot point and sutured to its new counterpart (B2) to define the new otobasion inferius. The caudal tip of the flap (A1) is moved toward B1 (blue arrow) and fixed with Prolene 5-0 transcutaneous single sutures. For a tension-free insertion of the flap and a stabilization the ear/earlobe position, a deep stitch is not needed to be placed into the Loré’s or mastoid fascia at the earlobe’s base. A1 = caudal tip of the triangular flap; B1 = endpoint earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 8. View largeDownload slide Posterior earlobe rotation flap (PERF) flap insertion at the new earlobe base. The flap is rotated around the A2 pivot point and sutured to its new counterpart (B2) to define the new otobasion inferius. The caudal tip of the flap (A1) is moved toward B1 (blue arrow) and fixed with Prolene 5-0 transcutaneous single sutures. For a tension-free insertion of the flap and a stabilization the ear/earlobe position, a deep stitch is not needed to be placed into the Loré’s or mastoid fascia at the earlobe’s base. A1 = caudal tip of the triangular flap; B1 = endpoint earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 9. View largeDownload slide Final frontal view after the posterior earlobe rotation flap (PERF) flap insertion. The flap is set completely with Prolene 5-0 transcutaneous sutures, creating a round appearance of the new subaurale (S), with its maximum at the A1-B1 point. The A2-B2 point defines the new earlobe base, also known as the otobasion inferius (O). With this novel technique, aesthetically pleasing earlobe proportions can be achieved easily. The presented photograph is of a 59-year-old Caucasian woman. Figure 9. View largeDownload slide Final frontal view after the posterior earlobe rotation flap (PERF) flap insertion. The flap is set completely with Prolene 5-0 transcutaneous sutures, creating a round appearance of the new subaurale (S), with its maximum at the A1-B1 point. The A2-B2 point defines the new earlobe base, also known as the otobasion inferius (O). With this novel technique, aesthetically pleasing earlobe proportions can be achieved easily. The presented photograph is of a 59-year-old Caucasian woman. Figure 10. View largeDownload slide Posterior-dorsal view of the earlobe after flap insertion and facial flap advancement. Resulting excess skin after superficial muscularaponeurotic system (SMAS) lifting is resected to match exactly the height of the new otobasion inferius (O), and the skin flap is anchored to the periauricular fascia using three inverted Monocryl 4-0 sutures (blue arrows), followed by single transcutaneous 4-0 Ethilon sutures; A1-B1 = subaurale (S) of the shaped earlobe; A2-B2 = the otobasion inferius (O); A4 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 10. View largeDownload slide Posterior-dorsal view of the earlobe after flap insertion and facial flap advancement. Resulting excess skin after superficial muscularaponeurotic system (SMAS) lifting is resected to match exactly the height of the new otobasion inferius (O), and the skin flap is anchored to the periauricular fascia using three inverted Monocryl 4-0 sutures (blue arrows), followed by single transcutaneous 4-0 Ethilon sutures; A1-B1 = subaurale (S) of the shaped earlobe; A2-B2 = the otobasion inferius (O); A4 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 11. View largeDownload slide Concha-mastoid suspension suture (CMSS). The CMSS is placed as a double-U PDS 2-0 suture, transfixing the periosteum of the mastoid and the cartilage of the dorsal face of the concha. This technique positions the ear in its natural position with a superolateral vector to prevent auricular displacement. It counterbalances the tractional SMAS tension and skin flap retraction forces, which are reinforced up to six months after a facelift surgery. The presented photograph is of a 59-year-old Caucasian woman. Figure 11. View largeDownload slide Concha-mastoid suspension suture (CMSS). The CMSS is placed as a double-U PDS 2-0 suture, transfixing the periosteum of the mastoid and the cartilage of the dorsal face of the concha. This technique positions the ear in its natural position with a superolateral vector to prevent auricular displacement. It counterbalances the tractional SMAS tension and skin flap retraction forces, which are reinforced up to six months after a facelift surgery. The presented photograph is of a 59-year-old Caucasian woman. The PERF technique consists of the following steps (Figures 1-10). The new earlobe size (ranging from otobasion inferius [O] to subaurale [S]) is defined by the distance between the intertragal notch (I) and the placement of the B1-B2 incision line either more cranially or more caudally to create a new S. The point B1 hereby represents the endpoint and B2 the starting point of the planned earlobe resection line. Furthermore, S is set to be the most caudal part of the free earlobe. A1 represents the caudal tip of the triangular flap, whereas A3 is defined as the posterior end of the flap base. The point A2 represents half of the distance between A1 and A3. A4 is defined as the anterior end of the flap base. The distance of point A2 from the original earlobe insertion defines the flap extent and the resulting new earlobe size after flap insertion. It can be inferior to the original insertion within a range of 3 to 5 mm. As the width of the flap is relatively small (approximately 3-5 mm), and the planning of the flap is performed from the retroauricular fold downwards, the authors believe that the small amount of skin transferred with the flap is always compensated by minimal trimming of the infra-auricular part of the advanced facial flap. In this specific region, excess skin is present to some extent in almost all cases. First, planning of the rotation-advancement flap with its base in the retroauricular fold occurs. The pivot point A2 is advanced to the point B2 (defining the new O), while the tip of the flap (A1) is rotated posteriorly toward the incision line B2-B1. A more cranial anchoring of A2-B2 results in a larger free segment of the new earlobe. A more caudal anchoring creates a smaller free segment and defines the grade of ptosis. In the following section, a sharp flap circumcision is performed with a 15 blade. Therefore, the flap pedicle is spared to prevent the compromise of the flap’s perfusion. The elevation of the PERF flap is combined with a facelift omega pattern incision. The former earlobe insertion is unleashed by scissor dissection during this procedure; the flap is elevated but not yet sutured in place. Then, the flap advancement is performed, and the pivot point A2 is fixed at the desired height of the new otobasion (A2-B2) with a PDS 4-0 inverted suture. The caudal tip of flap A1 is rotated toward B1, covering the defect of the caudal resection zone of the earlobe and shaping the new subaurale. In the next step, the flap is rotated around the A2 pivot point and sutured to its new counterpart (B2) to define the new O. The caudal tip of the flap (A1) is moved toward B1 and fixed with Prolene 5-0 transcutaneous single sutures. It is important that the sutures are placed in a manner such that a round appearance of the new S is created, with its maximum at the A1-B1 point. For a tension-free insertion of the flap and a stabilization the ear/earlobe position, a deep stitch is not needed to be placed into the Loré’s or mastoid fascia at the earlobe’s base. The resulting excess skin after SMAS lifting is resected to exactly match the height of the new O, and the skin flap is anchored to the periauricular fascia using three inverted Monocryl 4-0 sutures followed by single transcutaneous 4-0 Ethilon sutures. The concha-mastoid suspension suture (CMSS) consists of the following steps (Figure 11). To transfix the periosteum of the mastoid and the cartilage of the dorsal face of the concha, the CMSS technique is applied by placing a double-U PDS 2-0 suture. This technique positions the ear with a superolateral vector in its natural position to prevent auricular displacement. It counterbalances the tractional SMAS tension and skin flap retraction forces, which are reinforced for up to six months after a facelift surgery. The extra time needed for these two procedures is approximately five to seven minutes per side, depending on the experience and working speed of the surgeon. The incidence rate of major complications, such as infection, seroma, hematoma, skin necrosis, nerve injury, delayed healing, and other severe health problems, was assessed. This includes any complication requiring hospital readmission, an emergency-room visit, surgical revision, or prolonged wound care. Hypertrophic scarring, auricular displacement, and/or earlobe distortion with pseudoptosis or ptosis grades 0, III, and IV were defined as minor complications (ie, a deviation from the desired cosmetic outcome). A postoperative earlobe of ptosis grades I to II was set as the desired aesthetic outcome, using a grading system introduced by Mowlavi et al.4 For the assessment of auricular displacement, preoperative patient photographs were compared with photographs obtained 12 months postoperatively by using the standardized measurement of the auricular displacement (MAD) method on the 180-degree ear-side lateral-view images of each patient (Figure 12). Figure 12. View largeDownload slide Measurement of auricular displacement (MAD). The MAD technique was used to determine the auricular displacement. Here, it was measured by defining a vertical vector line running through the apex of the cranial ear helix (A) and the intertragal notch (I) to intersect with a horizontal vector line starting at the nasofrontal angle (N) and running through the lateral epicanthus (LE) (demonstrated in this image with red lines). Then the resulting vector angle (green) of the intersection of both lines was measured in strictly 180° lateral view photos (preoperative and one year postoperative) to detect vector angle changes. Any MAD change >5° was defined as postoperative auricular displacement. Figure 12. View largeDownload slide Measurement of auricular displacement (MAD). The MAD technique was used to determine the auricular displacement. Here, it was measured by defining a vertical vector line running through the apex of the cranial ear helix (A) and the intertragal notch (I) to intersect with a horizontal vector line starting at the nasofrontal angle (N) and running through the lateral epicanthus (LE) (demonstrated in this image with red lines). Then the resulting vector angle (green) of the intersection of both lines was measured in strictly 180° lateral view photos (preoperative and one year postoperative) to detect vector angle changes. Any MAD change >5° was defined as postoperative auricular displacement. A discrepancy greater than five degrees compared to the preoperative imaging was defined as auricular displacement. A downward and forward ear movement characterizes auricular displacement after facelift surgery with the ear’s lower pole undergoing more anterior displacement than its upper pole. The length of the earlobe is determined by measuring the distance from the intertragal notch (I) to the most caudal extension of the earlobe’s free margin (subaurale [S]; Figure 13).4 This earlobe length can be further subdivided by the lowest point at which the earlobe is attached to the cheek, namely, the otobasion inferius (O)4 (Figure 13). This divides the total length into an attached cephalic segment (I-to-O distance) and a free caudal segment (O-to-S distance).4 Figure 13. View largeDownload slide Anatomical landmarks of the earlobe. The anatomical landmarks of the earlobe are the intertragal notch (I), the otobasion inferius (O), and the subaurale (S).4 The otobasion inferius divides the total earlobe into an attached cephalic segment (I-to-O distance) and a free caudal segment (O-to-S distance).4 Figure 13. View largeDownload slide Anatomical landmarks of the earlobe. The anatomical landmarks of the earlobe are the intertragal notch (I), the otobasion inferius (O), and the subaurale (S).4 The otobasion inferius divides the total earlobe into an attached cephalic segment (I-to-O distance) and a free caudal segment (O-to-S distance).4 To assess earlobe distortion, the shape of the earlobe was analyzed by comparing the length of the attached cephalic segment (I-to-O distance, also referred to as the I-A2/B2 distance in the figure legends) and the length of the free caudal segment (O-to-S distance, also referred to as A2/B2-A1/B1 in the figure legends) preoperatively and 12 months postoperatively. The assessment of the ptosis grade or the existence of pseudoptosis was based on the definition given by Mowlavi et al5 as shown in Table 1. Table 1. Definition of Pseudoptosis/Ptosis and Distribution in our Patient Cohort Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Classification of pseudoptosis/ptosis following the scientific literature16 and distribution within our patient cohort preoperatively and 12 months postoperatively after SMAS facelift. Ptosis grade I/II was defined as an ideal postoperative outcome. I, intertragal notch; O, otobasion inferius; S subaurale. View Large Table 1. Definition of Pseudoptosis/Ptosis and Distribution in our Patient Cohort Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Classification of pseudoptosis/ptosis following the scientific literature16 and distribution within our patient cohort preoperatively and 12 months postoperatively after SMAS facelift. Ptosis grade I/II was defined as an ideal postoperative outcome. I, intertragal notch; O, otobasion inferius; S subaurale. View Large Statistical Analysis The data collection and primary statistical analysis were performed with Microsoft Excel (Microsoft Corporation, Redmond, WA), and an independent t test was applied. Statistical significance was defined as a P-value of <0.05. RESULTS The median age of the patient cohort at the time of surgery was 54 years (SD: 9.0; standard error [SE]: 0.88; range, 37-75 years) with a gender distribution of 95 female (90.5%) and 10 male patients (9.5%) (origin: Caucasian). Only the patients with a minimum of 12 months of follow-up time were included in the study (median follow up, 16 months; range, 12-30 months). The patients were followed up after one week, two weeks, one month, three months, six months, and one year postoperatively and then annually or if complications occurred. Two major complications were detected during the follow-up period—an apraxia of the mandibular branch of the facial nerve, which was resolved after three months, and a postoperative hematoma requiring surgical revision. This resulted in a 1.9% major complication rate (2/105) among our study cohort. One patient developed a bilateral pseudoptosis of 19 mm, which was counted as a minor complication (1% [2/210]). No cases of ptosis grades 0, III, or IV were detected after surgery (Table 1). A statistically significant correlation was shown for the reduction in the age-related enlargement of the earlobe (P > 0.05). The median preoperative and one-year follow-up measurements of the I-O distance (pseudoptosis) and O-S distance (ptosis), as well as the measurements of auricular displacement, are shown in Table 2. The free earlobe pedicle (O-S distance) was intraoperatively enlarged in 54 cases (right side: 24; left side: 30), reduced in 142 cases (right side: 73; left side: 69), and unchanged in size compared to the preoperative measurements in 14 cases (right side: 8; left side: 6) (n = 210). Furthermore, the authors did not detect any change of the lobule axis in their patient cohort. Table 2. Detailed Information About Preoperative and 1-Year Postoperative Patient Data Concerning Pseudoptosis, Ptosis, and Auricular Displacement Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Statistical analysis (t test) of patient data in our cohort showed no statistical significance for auricular displacement in a comparison of preoperative and postoperative MAD measurements (P > 0.05). Statistical significance was observed for the reduction of the age-related enlargement of the earlobe (P > 0.05). Any change in MAD angle measurement >5° was defined as postoperative auricular displacement. I, intertragal notch; MAD, auricular displacement; O, otobasion inferius; S, subaurale; SD, standard deviation; SE, standard error. View Large Table 2. Detailed Information About Preoperative and 1-Year Postoperative Patient Data Concerning Pseudoptosis, Ptosis, and Auricular Displacement Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Statistical analysis (t test) of patient data in our cohort showed no statistical significance for auricular displacement in a comparison of preoperative and postoperative MAD measurements (P > 0.05). Statistical significance was observed for the reduction of the age-related enlargement of the earlobe (P > 0.05). Any change in MAD angle measurement >5° was defined as postoperative auricular displacement. I, intertragal notch; MAD, auricular displacement; O, otobasion inferius; S, subaurale; SD, standard deviation; SE, standard error. View Large Only three patients presented a postoperative auricular displacement greater than five degrees (1× bilateral; 2× unilateral; 2% minor complication rate (4/210)). Detailed information is given in Table 3. No statistically significant differences in auricular displacement incidents could be detected in the comparison between preoperative and one-year postoperative results (P > 0.05). Table 3. Overview of Patients with Auricular Displacement Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Four cases of auricular displacement were found in a total of 210 operated ears (3/105 patients). The largest MAD angle change was 8°. Auricular displacement is defined as an MAD change greater than 5°. MAD, auricular displacement. View Large Table 3. Overview of Patients with Auricular Displacement Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Four cases of auricular displacement were found in a total of 210 operated ears (3/105 patients). The largest MAD angle change was 8°. Auricular displacement is defined as an MAD change greater than 5°. MAD, auricular displacement. View Large One patient showed a mild hypertrophic scarring of the retroauricular fold and the postauricular hairline incision on both sides, resulting in a 1% minor complication rate (2/210). The overall rate of minor complications—meaning a deviation from the desired aesthetic outcome—was 4% (8/210). Two representative cases are shown in Figures 14 and 15. Figure 14. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative (B) right lateral views of a 60-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 6 mm; otobasion inferius–subaurale (O-S) distance both sides: 11 mm; measurement of the auricular displacement (MAD): 63° right side/64° left side; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 6 mm; MAD: 67° right/68° left side (≤5° = no auricular displacement). Figure 14. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative (B) right lateral views of a 60-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 6 mm; otobasion inferius–subaurale (O-S) distance both sides: 11 mm; measurement of the auricular displacement (MAD): 63° right side/64° left side; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 6 mm; MAD: 67° right/68° left side (≤5° = no auricular displacement). Figure 15. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative right lateral views of a 65-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 13 mm; otobasion inferius–subaurale (O-S) distance both sides: 3 mm; MAD: 68° bilateral; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 5 mm; measurement of the auricular displacement (MAD): 71° bilateral (≤5° = no auricular displacement). Figure 15. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative right lateral views of a 65-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 13 mm; otobasion inferius–subaurale (O-S) distance both sides: 3 mm; MAD: 68° bilateral; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 5 mm; measurement of the auricular displacement (MAD): 71° bilateral (≤5° = no auricular displacement). DISCUSSION The understanding of the anatomy of the ear/earlobe and its surrounding ligamentous structures is fundamental to achieving a natural and aesthetically pleasing outcome after rhytidectomy. Normally, the ear is positioned with the superior helical rim and the superior orbital rim in alignment. Its long axis is defined as a line passing through the most superior point on the helix to the most caudal portion of the lobule.2 It is approximately 50% to 60% as wide as it is high, with a median overall length of 6.5 to 7.5 cm, inclining approximately 20 degrees and protruding approximately 1.5 to 2.0 cm outward from the lateral orbital rim.3 The vectors of the traction forces following rhytidectomy may rotate the ear around the external auditory canal, resulting in an unnatural position and contour of the ear.6 Ear and earlobe distortions are unpleasant complications after facelift surgery. Several methods to prevent earlobe deformity following rhytidectomy are described in the current literature,5-14 along with other techniques for earlobe reduction.15-18 Thus far, no standard procedure has been described to simultaneously prevent auricular displacement and earlobe distortion after rhytidectomy. Van Putte et al developed a technique to correct earlobe ptosis.19 Several publications focus on correcting the so-called pixie ear deformity following facelift surgery,5,20-26 while other techniques target earlobe reconstruction and earlobe augmentation.27,28 In 1973, Lindgren et al described a technique using a large postauricular advancement of the skin flap to prevent direct traction on the earlobe.29 This technique has the disadvantage of enlarging the earlobe itself and, therefore, is less suited for the majority of patients already having an age-related enlargement of the earlobe. Stark et al described a technique based on the complete detachment of the earlobe up to the cartilaginous base; followed by the direct closure of the anterior and posterior edges of the detachment area at the earlobe base.29 This technique always shortens the earlobe and is, therefore, not suited for already small earlobes; furthermore, it often creates an unnatural and wedge-shaped appearance of the earlobe. The average length of the earlobe increases during the natural aging process.19 Previous studies show a correlation between an increase in the patient’s age and the elongation of the free caudal segment as well as a connection between the elongation of the attached cephalic segment and previous rhytidectomy.16 A classification based on a survey published by Mowlavi et al on the appearance and shape of an aesthetically pleasing earlobe showed that an I-to-O distance greater than 15 mm is considered unattractive by both sexes (classified as pseudoptosis) and that an O-to-S distance of 1 to 10 mm (classified as ptosis grades I and II) is considered to be more attractive than ptosis grades 0, III, or IV.4 These proven correlations and the aesthetic expectations of our patients should be considered when performing a facelift procedure. The PERF technique is based on a retroauricular advancement-rotation flap, which allows the redefining of the position of the new otobasion inferius and, therefore, gives complete control of the aesthetic relation between the attached cephalic segment and the free caudal segment. Additionally, this method offers the option to reduce or enlarge the earlobe in size and tailor the desired shape and the length of the earlobe by choosing different flap sizes. Also, the relation between free pedicle and the fixed part of the earlobe can be tailored as desired. The lobule axis, which is set to be around 15 degrees posterior to the body of the ear axis,2 is not changed by this procedure and therefore intends to stay the same. Moreover, the results of our study indicate that our novel surgical approach may help to prevent traction-induced earlobe deformities such as the pixie ear. The pixie ear deformity is a well-known complication arising after rhytidectomy. It is characterized by an increase in the length of the attached cephalic segment (I-to-O distance) and a decrease in the length of the free caudal segment (O-to-S distance) to 0 mm.9 The deformity, which occurs when the earlobe is pulled along its longitudinal axis, can be easily recognized.7 As a result, the attached cephalic segment will lengthen, causing pseudoptosis.19 Common causes of the pixie ear deformity are traction forces due to excessive facial skin flap resection or failure to anchor the facial skin flap at Loré’s fascia at the otobasion inferius.6 In our patient cohort, two cases of pixie ear deformity (pseudoptosis) occurred during the 12-month follow-up period (1%) compared to a published incidence rate of 5.7% in patients receiving rhytidectomies.5 Apart from its use to redirect tension forces from the skin flap and to correct or prevent a pixie ear deformity, the authors use the flap routinely for earlobe shape modifications—either within a reduction or augmentation of the earlobe for a more natural outcome. If no earlobe modification is desired or needed, the PERF flap is not routinely necessary within a properly vectored facelift. The authors strongly believe that the use of the CMSS technique is a useful recommendation to minimize the possible distortion of the natural position of the ear caused by traction forces on the fascia periauricular (Loré). Comparing the data from our study with the current scientific literature, the PERF and CMSS combination technique achieves a more consistent cosmetic outcome regarding an aesthetically pleasing earlobe shape and size. In our study cohort, ptosis grade I was predominant (88%), followed by ptosis grade II (12%) and only two cases of pseudoptosis; the data published by Mowlavi et al show ptosis grade 0 in 7.5%, ptosis grade I in 37%, ptosis grade II in 37%, and ptosis grade III in 18.5% of patients after facelift surgery.30 We showed that the combined use of the described CMSS technique minimizes the occurrence of auricular displacement and rotation after SMAS facelifts by counterbalancing the tractional forces, which could occur during scarring, SMAS, and skin flap contraction. A retrospective metastudy by Brink et al analyzing preoperative and postoperative photographs in 12 facelift articles proves that auricular displacement is present in varying degrees in up to 62% of patients receiving facelift surgery and is postulated to be present in up to 90% as a true incidence.2 Within our patient cohort, no statistically significant auricular displacement was present (P > 0.05), showing a significantly reduced occurrence of postoperative auricular displacement in comparison to the scientific literature. Additionally, the surgeon can perform an individualized correction of age-related earlobe enlargement during rhytidectomy by using this technique in a reconstructive manner. Notably, a size reduction of the earlobe correlates with a more youthful overall facial appearance.30 This correlation should be discussed with every patient planning to have a facelift procedure, and adequate correction of existing age-related deformations should be planned to achieve a harmonious aesthetic outcome. Since 2005, approximately 75% of all rhytidectomy patients operated upon in our clinic have had additional earlobe reduction procedures. In our study cohort, no cases of hypertrophic scarring occurred within the area of the otobasion inferius or the inferior auricular base. However, one patient suffered from mild bilateral hypertrophic scarring of the retroauricular fold and the postauricular hairline incision (1%). No objective incidence rates for hypertrophic scarring within the periauricular region after rhytidectomy could be found in the scientific literature. Additional prospective studies regarding the general incidence of periauricular hypertrophic scarring after rhytidectomy would be needed for a comparison of our data with those of other techniques. Skin flap tension and retraction are mainly responsible for the pixie ear deformity—apart from other factors, such as wrong anchoring or scar retraction. This means that even with a tension-free closure of the dermal skin flap, skin and/or scar retraction after SMAS lifting are not always predictable. The CMSS technique, which may prevent movement of the ear as a whole unit in reference to the position on the skull (due to SMAS tension forces transferred to the periauricular fascia), is a useful tool for this purpose. Furthermore, the authors use the PERF technique in most cases to sculpt the earlobe and to prevent potential earlobe distortion, but the recommended utilization can be as well applied for correction purposes. Due to a proper anchoring/fixation of the SMAS, most of the retraction forces can be eliminated. Nevertheless, the authors believe that postoperative SMAS shrinking and scarring can be transposed to the ear itself (via Loré′s fascia)—resulting in auricular displacement. The retroauricular area is a preferred skin harvest location for various procedures due to its easy access, excellent quality of skin, and very thin skin layer.31 In our patient cohort the authors did not see any length retraction of the harvested flap. Due to the good properties of the dermis within the retroauricular sulcus, secondary retraction of the flap is according to this neglectable. Our work focuses on achieving a better postoperative earlobe shape in primary facelift surgeries. However, to date, the authors have used the technique successfully in many cases to correct earlobe deformities in secondary or tertiary rhytidectomy cases; therefore, a follow-up publication will address this topic. The authors believe that the techniques shown in this study present a useful and novel approach for the correction and prevention of the pixie ear deformity and therefore enhance the armamentarium of facial plastic surgeons. As aesthetically unpleasant results after facelifts are still common in daily practice due to the wide proliferation of facial rejuvenation procedures among treatment providers outside the surgical core specialties, the authors would like to contribute, with this study, toward the development of an effective treatment alternative for these cases. The results of this study and the resulting recommended use of the technique could only be shown on Caucasian skin and within a predominantly female study group; hence, further studies may be needed to prove the effectiveness in other skin types. CONCLUSIONS Our publication contributes toward minimizing the occurrence of postoperative auricular deformities by introducing a simple and effective technique combining the PERF and CMSS procedures. This method avoids the inherent disadvantages of the existing techniques and can be combined with any given SMAS facelift procedure. This novel technique grants the surgeon complete control over the aesthetic relation between the attached cephalic segment and the free caudal segment. Furthermore, the surgeon has the possibility to use this technique in a reconstructive approach to reduce or enlarge the earlobe in size by choosing the dimension of the flap to tailor the desired shape and length of the earlobe. In combination with the concha-mastoid suspension suture, this technique stabilizes the natural position of the ear, leading to significantly less auricular displacement and a reduced incidence of ear/earlobe deformities and hypertrophic scarring after rhytidectomy. The results of our study indicate that the technique may also help to prevent traction-induced earlobe deformities such as the pixie ear and, therefore, should be considered a valuable addition to any SMAS facelift procedure. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Wan D , Small KH , Barton FE . Face lift . Plast Reconstr Surg . 2015 ; 136 ( 5 ): 676e - 689e . Google Scholar CrossRef Search ADS PubMed 2. Brink RR . Auricular displacement with rhytidectomy . Plast Reconstr Surg . 2001 ; 108 ( 3 ): 743 - 752 . Google Scholar CrossRef Search ADS PubMed 3. Tolleth H . Artistic anatomy, dimensions, and proportions of the external ear . 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Lindgren VV , Carlin GA . Preventing a pulled-down or deformed earlobe in rhytidectomies . Plast Reconstr Surg . 1973 ; 51 ( 5 ): 598 - 600 . Google Scholar CrossRef Search ADS PubMed 30. Mowlavi A , Meldrum DG , Wilhelmi BJ , Zook EG . Effect of face lift on earlobe ptosis and pseudoptosis . Plast Reconstr Surg . 2004 ; 114 ( 4 ): 988 - 991 . Google Scholar CrossRef Search ADS PubMed 31. Li Y , Cui C , Zhang R , et al. Anatomical and histological evaluation of the retroauricular fascia flap for staged auricular reconstruction . Aesthetic Plast Surg . 2018 ; doi: 10.1007/s00266-018-1098-x . © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Correction and Prevention of the Pixie Ear Deformity: A Combined Technique

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Oxford University Press
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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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1527-330X
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10.1093/asj/sjy095
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Abstract

Abstract Background Ear and earlobe deformities after surgical rhytidectomy are common and can significantly diminish the aesthetic outcome. The main causes of ear/earlobe distortion are skin overresection, an imbalance between vertical/horizontal skin-lift vectors, and tractional distortions through superficial muscularaponeurotic system (SMAS) tension. Objectives To demonstrate a new method for earlobe suturing and ear fixation that would prevent aesthetics-related complications after facelift surgery. Methods A total of 105 primary SMAS facelift surgeries were performed between 2015 and 2016 by the first author. A combination technique consisting of a posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) was executed bilaterally within each facelift procedure (n = 210). A retrospective data analysis was conducted (preoperatively and one year postoperatively) using our hospital information system and a photometric data analysis to assess auricular displacement, earlobe distortion, and hypertrophic scarring. Results Pseudoptosis of the earlobe was noted in two cases, and auricular displacement was observed in four cases. Bilateral mild hypertrophic scarring was seen in one patient. The postoperative photometric analysis showed a natural ptosis grade I/II in all the patients, with a statistically significantly reduced postoperative earlobe size (P < 0.05). The total rate of aesthetics-related complications was 4% in our cohort (earlobe distortion with pseudoptosis: 1%; auricular displacement: 2%; hypertrophic scarring: 1%). Conclusions Our modification of the facial flap anchoring at the ear base in combination with a CMSS stabilizes the natural position of the ear and prevents distortion while allowing better control over the earlobe’s aesthetic shaping. This novel method reduces the incidence of ear/earlobe deformities and hypertrophic scarring at the ear base after rhytidectomy and, therefore, promises to be a valuable advancement. Level of Evidence: 4 At the beginning of the 19th century, the first facelift procedures with plain skin resection were developed.1 A major step toward modern facelift procedures was achieved by the description of the superficial muscularaponeurotic system (SMAS) by Skoog et al in 1974. This scientific breakthrough made a multitude of surgical approaches within the following years possible.1 At present, most rhytidectomy techniques include the manipulation and stable anchoring of the SMAS, which optimizes long-term outcomes and diminishes deformation through skin traction. Nevertheless, the distortion of ear and earlobe shapes due to the traction forces caused by the skin flap, scar retraction, or the SMAS flap remains a commonly encountered aesthetic problem after facelift surgery. Neither the ear, as a whole anatomic unit, nor the earlobe, as a subunit, are anatomically fixed structures;2,3 thus, even slight changes in the tension vectors can lead to a distortion of the complete aesthetic unit of the ear, resulting in a diminished aesthetic outcome of an otherwise skillfully executed facelift surgery. As facelifts are performed to improve the patient’s looks, complications, which compromise the aesthetic outcome, are dreaded by every plastic surgeon. Ear and earlobe deformities still represent a common postoperative complication, often caused by skin overresection, resulting in stronger tractional forces leading to hypertrophic scarring and/or an imbalance between the preauricular (vertical) and postauricular (horizontal) skin-lift vectors. Tractional distortion can also be caused by the poorly planned SMAS vectors and may result in postoperative ear/earlobe position deformity. In this case, the ear itself is displaced and pulled toward a more inferior and medial position, with its lower pole undergoing more anterior displacement than its upper pole. Brink et al stated that notable auricular displacement was found in 62% of the analyzed results after patients underwent facelift surgery.2 Furthermore, they postulated that auricular displacement of varying degrees after rhytidectomy may be close to 90%.2 Earlobe deformities such as pseudoptosis, also known as pixie ear deformity (Figure 1), and ptosis grades III to IV are still common after facelift surgery. To prevent the incidence of these deformities, the authors of this paper propose a novel surgical combination technique to avoid auricular deformity and earlobe distortion after rhytidectomy, consisting of a posterior earlobe rotation flap (PERF) in combination with a concha-mastoid suspension suture (CMSS). Figure 1. View largeDownload slide Pixie ear deformity. A 50-year-old Caucasian woman with an aesthetic complication in the form of a pixie ear deformity is shown after receiving a facelift without the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique one year earlier. Pseudoptosis with no visible free auricular pedicle is visible; right oblique view. Figure 1. View largeDownload slide Pixie ear deformity. A 50-year-old Caucasian woman with an aesthetic complication in the form of a pixie ear deformity is shown after receiving a facelift without the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique one year earlier. Pseudoptosis with no visible free auricular pedicle is visible; right oblique view. This method offers the ability to tailor the desired earlobe of each patient, which is a major and sustainable advantage over existing techniques; it accounts for and corrects the aging-related changes of the earlobe itself. Therefore, this technique can not only be used for the prevention of ear and earlobe distortion, but also helps to reconstruct the shape of a desired earlobe. METHODS From January 2015 to September 2016, 105 primary SMAS facelift surgeries were performed under intravenous sedation by the first author (K.O.K.). A retrospective data analysis was done using the hospital information system, including standardized photographic documentation and photometric measurement of the earlobes and the ear position preoperatively and one year postoperatively. The exclusion criteria were as follows: any known previous rhytidectomies, otoplasty, lobuloplasty, and lower and upper blepharoplasty (including canthopexy), as well as unwillingness to receive a lobuloplasty during the facelift procedure. This research project has been 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. Written consent was obtained from each patient to perform earlobe tailoring during the facelift procedure. The patients were informed that existing earlobe piercings might be removed during this procedure. The intraoperative and postoperative settings followed published standard recommendations for major in-patient surgery procedures. During the primary facelift procedure, a novel technique—based on an advancement-rotation flap (PERF) originating from the retroauricular fold and designed to change the anchoring point of the facial skin flap at the ear base (otobasion inferius)—was performed on each side in combination with a CMSS to prevent tractional distortion of the ear caused by the SMAS tension vectors (n = 210; Figures 2-11, Video 1 [PERF], and Video 2 [CMSS]). The PERF and CMSS techniques were applied before the SMAS tightening to preserve the preoperative ear position. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Close Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Video 2. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy095 Close Figure 2. View largeDownload slide Planning of the desired earlobe size. The new earlobe size (ranging from otobasion inferius to subaurale) is defined by the distance between the intertragal notch (I) and the placing of the B1-B2 incision line (red line) either more cranially or caudally to create a new subaurale. B1 = endpoint of planned earlobe resection line; B2 = starting point of planned earlobe resection line; subaurale (S) = most caudal part of free earlobe. The presented photograph is of a 59-year-old Caucasian woman. Figure 2. View largeDownload slide Planning of the desired earlobe size. The new earlobe size (ranging from otobasion inferius to subaurale) is defined by the distance between the intertragal notch (I) and the placing of the B1-B2 incision line (red line) either more cranially or caudally to create a new subaurale. B1 = endpoint of planned earlobe resection line; B2 = starting point of planned earlobe resection line; subaurale (S) = most caudal part of free earlobe. The presented photograph is of a 59-year-old Caucasian woman. Figure 3. View largeDownload slide Planning of the posterior earlobe flap (PERF). Planning of the rotation-advancement flap with its base in the retroauricular fold. Pivot point A2 is advanced to B2 (blue arrow), defining the new otobasion inferius, while the tip of flap A1 is rotated posteriorly toward the incision line B2-B1. A more cranial anchoring of A2-B2 results in a larger free segment of the new earlobe. A more caudal anchoring creates a smaller free segment and defines the grade of ptosis. The presented photograph is of a 59-year-old Caucasian woman. Figure 3. View largeDownload slide Planning of the posterior earlobe flap (PERF). Planning of the rotation-advancement flap with its base in the retroauricular fold. Pivot point A2 is advanced to B2 (blue arrow), defining the new otobasion inferius, while the tip of flap A1 is rotated posteriorly toward the incision line B2-B1. A more cranial anchoring of A2-B2 results in a larger free segment of the new earlobe. A more caudal anchoring creates a smaller free segment and defines the grade of ptosis. The presented photograph is of a 59-year-old Caucasian woman. Figure 4. View largeDownload slide Circumcision of the PERF flap. Flap circumcision follows the solid black line. The non-incised flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 4. View largeDownload slide Circumcision of the PERF flap. Flap circumcision follows the solid black line. The non-incised flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 5. View largeDownload slide Elevation of the posterior earlobe rotation flap (PERF) flap. Facelift omega pattern incision was performed. The former earlobe insertion (EI) is shaded. The flap is elevated but is not yet sutured in place. The incision lines of the flap are marked with a solid black line, and the nonincised flap base is outlined with a dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 5. View largeDownload slide Elevation of the posterior earlobe rotation flap (PERF) flap. Facelift omega pattern incision was performed. The former earlobe insertion (EI) is shaded. The flap is elevated but is not yet sutured in place. The incision lines of the flap are marked with a solid black line, and the nonincised flap base is outlined with a dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 6. View largeDownload slide Posterior earlobe rotation flap (PERF) before advancement-rotation. Demonstration of the flap shape and size before advancement-rotation. The incision lines of the flap are marked with a black line, and the flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 6. View largeDownload slide Posterior earlobe rotation flap (PERF) before advancement-rotation. Demonstration of the flap shape and size before advancement-rotation. The incision lines of the flap are marked with a black line, and the flap pedicle is outlined with a black dotted line; A1 = caudal tip of the triangular flap; pivot point A2 = half the distance between A1 and A3; A3 = posterior end of the flap base; A4 = anterior end of flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 7. View largeDownload slide Flap advancement and fixation at the new otobasion inferius. Flap advancement is performed, and the pivot point A2 is fixed at the desired height of the new otobasion (A2-B2) with a PDS 4-0 inverted suture. The caudal tip of flap A1 is rotated toward B1 (blue arrow), covering the defect of the caudal resection zone of the earlobe and shaping the new subaurale; A1 = caudal tip of the flap; B1 = endpoint of the earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 7. View largeDownload slide Flap advancement and fixation at the new otobasion inferius. Flap advancement is performed, and the pivot point A2 is fixed at the desired height of the new otobasion (A2-B2) with a PDS 4-0 inverted suture. The caudal tip of flap A1 is rotated toward B1 (blue arrow), covering the defect of the caudal resection zone of the earlobe and shaping the new subaurale; A1 = caudal tip of the flap; B1 = endpoint of the earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 8. View largeDownload slide Posterior earlobe rotation flap (PERF) flap insertion at the new earlobe base. The flap is rotated around the A2 pivot point and sutured to its new counterpart (B2) to define the new otobasion inferius. The caudal tip of the flap (A1) is moved toward B1 (blue arrow) and fixed with Prolene 5-0 transcutaneous single sutures. For a tension-free insertion of the flap and a stabilization the ear/earlobe position, a deep stitch is not needed to be placed into the Loré’s or mastoid fascia at the earlobe’s base. A1 = caudal tip of the triangular flap; B1 = endpoint earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 8. View largeDownload slide Posterior earlobe rotation flap (PERF) flap insertion at the new earlobe base. The flap is rotated around the A2 pivot point and sutured to its new counterpart (B2) to define the new otobasion inferius. The caudal tip of the flap (A1) is moved toward B1 (blue arrow) and fixed with Prolene 5-0 transcutaneous single sutures. For a tension-free insertion of the flap and a stabilization the ear/earlobe position, a deep stitch is not needed to be placed into the Loré’s or mastoid fascia at the earlobe’s base. A1 = caudal tip of the triangular flap; B1 = endpoint earlobe resection line. The presented photograph is of a 59-year-old Caucasian woman. Figure 9. View largeDownload slide Final frontal view after the posterior earlobe rotation flap (PERF) flap insertion. The flap is set completely with Prolene 5-0 transcutaneous sutures, creating a round appearance of the new subaurale (S), with its maximum at the A1-B1 point. The A2-B2 point defines the new earlobe base, also known as the otobasion inferius (O). With this novel technique, aesthetically pleasing earlobe proportions can be achieved easily. The presented photograph is of a 59-year-old Caucasian woman. Figure 9. View largeDownload slide Final frontal view after the posterior earlobe rotation flap (PERF) flap insertion. The flap is set completely with Prolene 5-0 transcutaneous sutures, creating a round appearance of the new subaurale (S), with its maximum at the A1-B1 point. The A2-B2 point defines the new earlobe base, also known as the otobasion inferius (O). With this novel technique, aesthetically pleasing earlobe proportions can be achieved easily. The presented photograph is of a 59-year-old Caucasian woman. Figure 10. View largeDownload slide Posterior-dorsal view of the earlobe after flap insertion and facial flap advancement. Resulting excess skin after superficial muscularaponeurotic system (SMAS) lifting is resected to match exactly the height of the new otobasion inferius (O), and the skin flap is anchored to the periauricular fascia using three inverted Monocryl 4-0 sutures (blue arrows), followed by single transcutaneous 4-0 Ethilon sutures; A1-B1 = subaurale (S) of the shaped earlobe; A2-B2 = the otobasion inferius (O); A4 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 10. View largeDownload slide Posterior-dorsal view of the earlobe after flap insertion and facial flap advancement. Resulting excess skin after superficial muscularaponeurotic system (SMAS) lifting is resected to match exactly the height of the new otobasion inferius (O), and the skin flap is anchored to the periauricular fascia using three inverted Monocryl 4-0 sutures (blue arrows), followed by single transcutaneous 4-0 Ethilon sutures; A1-B1 = subaurale (S) of the shaped earlobe; A2-B2 = the otobasion inferius (O); A4 = posterior end of the flap base. The presented photograph is of a 59-year-old Caucasian woman. Figure 11. View largeDownload slide Concha-mastoid suspension suture (CMSS). The CMSS is placed as a double-U PDS 2-0 suture, transfixing the periosteum of the mastoid and the cartilage of the dorsal face of the concha. This technique positions the ear in its natural position with a superolateral vector to prevent auricular displacement. It counterbalances the tractional SMAS tension and skin flap retraction forces, which are reinforced up to six months after a facelift surgery. The presented photograph is of a 59-year-old Caucasian woman. Figure 11. View largeDownload slide Concha-mastoid suspension suture (CMSS). The CMSS is placed as a double-U PDS 2-0 suture, transfixing the periosteum of the mastoid and the cartilage of the dorsal face of the concha. This technique positions the ear in its natural position with a superolateral vector to prevent auricular displacement. It counterbalances the tractional SMAS tension and skin flap retraction forces, which are reinforced up to six months after a facelift surgery. The presented photograph is of a 59-year-old Caucasian woman. The PERF technique consists of the following steps (Figures 1-10). The new earlobe size (ranging from otobasion inferius [O] to subaurale [S]) is defined by the distance between the intertragal notch (I) and the placement of the B1-B2 incision line either more cranially or more caudally to create a new S. The point B1 hereby represents the endpoint and B2 the starting point of the planned earlobe resection line. Furthermore, S is set to be the most caudal part of the free earlobe. A1 represents the caudal tip of the triangular flap, whereas A3 is defined as the posterior end of the flap base. The point A2 represents half of the distance between A1 and A3. A4 is defined as the anterior end of the flap base. The distance of point A2 from the original earlobe insertion defines the flap extent and the resulting new earlobe size after flap insertion. It can be inferior to the original insertion within a range of 3 to 5 mm. As the width of the flap is relatively small (approximately 3-5 mm), and the planning of the flap is performed from the retroauricular fold downwards, the authors believe that the small amount of skin transferred with the flap is always compensated by minimal trimming of the infra-auricular part of the advanced facial flap. In this specific region, excess skin is present to some extent in almost all cases. First, planning of the rotation-advancement flap with its base in the retroauricular fold occurs. The pivot point A2 is advanced to the point B2 (defining the new O), while the tip of the flap (A1) is rotated posteriorly toward the incision line B2-B1. A more cranial anchoring of A2-B2 results in a larger free segment of the new earlobe. A more caudal anchoring creates a smaller free segment and defines the grade of ptosis. In the following section, a sharp flap circumcision is performed with a 15 blade. Therefore, the flap pedicle is spared to prevent the compromise of the flap’s perfusion. The elevation of the PERF flap is combined with a facelift omega pattern incision. The former earlobe insertion is unleashed by scissor dissection during this procedure; the flap is elevated but not yet sutured in place. Then, the flap advancement is performed, and the pivot point A2 is fixed at the desired height of the new otobasion (A2-B2) with a PDS 4-0 inverted suture. The caudal tip of flap A1 is rotated toward B1, covering the defect of the caudal resection zone of the earlobe and shaping the new subaurale. In the next step, the flap is rotated around the A2 pivot point and sutured to its new counterpart (B2) to define the new O. The caudal tip of the flap (A1) is moved toward B1 and fixed with Prolene 5-0 transcutaneous single sutures. It is important that the sutures are placed in a manner such that a round appearance of the new S is created, with its maximum at the A1-B1 point. For a tension-free insertion of the flap and a stabilization the ear/earlobe position, a deep stitch is not needed to be placed into the Loré’s or mastoid fascia at the earlobe’s base. The resulting excess skin after SMAS lifting is resected to exactly match the height of the new O, and the skin flap is anchored to the periauricular fascia using three inverted Monocryl 4-0 sutures followed by single transcutaneous 4-0 Ethilon sutures. The concha-mastoid suspension suture (CMSS) consists of the following steps (Figure 11). To transfix the periosteum of the mastoid and the cartilage of the dorsal face of the concha, the CMSS technique is applied by placing a double-U PDS 2-0 suture. This technique positions the ear with a superolateral vector in its natural position to prevent auricular displacement. It counterbalances the tractional SMAS tension and skin flap retraction forces, which are reinforced for up to six months after a facelift surgery. The extra time needed for these two procedures is approximately five to seven minutes per side, depending on the experience and working speed of the surgeon. The incidence rate of major complications, such as infection, seroma, hematoma, skin necrosis, nerve injury, delayed healing, and other severe health problems, was assessed. This includes any complication requiring hospital readmission, an emergency-room visit, surgical revision, or prolonged wound care. Hypertrophic scarring, auricular displacement, and/or earlobe distortion with pseudoptosis or ptosis grades 0, III, and IV were defined as minor complications (ie, a deviation from the desired cosmetic outcome). A postoperative earlobe of ptosis grades I to II was set as the desired aesthetic outcome, using a grading system introduced by Mowlavi et al.4 For the assessment of auricular displacement, preoperative patient photographs were compared with photographs obtained 12 months postoperatively by using the standardized measurement of the auricular displacement (MAD) method on the 180-degree ear-side lateral-view images of each patient (Figure 12). Figure 12. View largeDownload slide Measurement of auricular displacement (MAD). The MAD technique was used to determine the auricular displacement. Here, it was measured by defining a vertical vector line running through the apex of the cranial ear helix (A) and the intertragal notch (I) to intersect with a horizontal vector line starting at the nasofrontal angle (N) and running through the lateral epicanthus (LE) (demonstrated in this image with red lines). Then the resulting vector angle (green) of the intersection of both lines was measured in strictly 180° lateral view photos (preoperative and one year postoperative) to detect vector angle changes. Any MAD change >5° was defined as postoperative auricular displacement. Figure 12. View largeDownload slide Measurement of auricular displacement (MAD). The MAD technique was used to determine the auricular displacement. Here, it was measured by defining a vertical vector line running through the apex of the cranial ear helix (A) and the intertragal notch (I) to intersect with a horizontal vector line starting at the nasofrontal angle (N) and running through the lateral epicanthus (LE) (demonstrated in this image with red lines). Then the resulting vector angle (green) of the intersection of both lines was measured in strictly 180° lateral view photos (preoperative and one year postoperative) to detect vector angle changes. Any MAD change >5° was defined as postoperative auricular displacement. A discrepancy greater than five degrees compared to the preoperative imaging was defined as auricular displacement. A downward and forward ear movement characterizes auricular displacement after facelift surgery with the ear’s lower pole undergoing more anterior displacement than its upper pole. The length of the earlobe is determined by measuring the distance from the intertragal notch (I) to the most caudal extension of the earlobe’s free margin (subaurale [S]; Figure 13).4 This earlobe length can be further subdivided by the lowest point at which the earlobe is attached to the cheek, namely, the otobasion inferius (O)4 (Figure 13). This divides the total length into an attached cephalic segment (I-to-O distance) and a free caudal segment (O-to-S distance).4 Figure 13. View largeDownload slide Anatomical landmarks of the earlobe. The anatomical landmarks of the earlobe are the intertragal notch (I), the otobasion inferius (O), and the subaurale (S).4 The otobasion inferius divides the total earlobe into an attached cephalic segment (I-to-O distance) and a free caudal segment (O-to-S distance).4 Figure 13. View largeDownload slide Anatomical landmarks of the earlobe. The anatomical landmarks of the earlobe are the intertragal notch (I), the otobasion inferius (O), and the subaurale (S).4 The otobasion inferius divides the total earlobe into an attached cephalic segment (I-to-O distance) and a free caudal segment (O-to-S distance).4 To assess earlobe distortion, the shape of the earlobe was analyzed by comparing the length of the attached cephalic segment (I-to-O distance, also referred to as the I-A2/B2 distance in the figure legends) and the length of the free caudal segment (O-to-S distance, also referred to as A2/B2-A1/B1 in the figure legends) preoperatively and 12 months postoperatively. The assessment of the ptosis grade or the existence of pseudoptosis was based on the definition given by Mowlavi et al5 as shown in Table 1. Table 1. Definition of Pseudoptosis/Ptosis and Distribution in our Patient Cohort Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Classification of pseudoptosis/ptosis following the scientific literature16 and distribution within our patient cohort preoperatively and 12 months postoperatively after SMAS facelift. Ptosis grade I/II was defined as an ideal postoperative outcome. I, intertragal notch; O, otobasion inferius; S subaurale. View Large Table 1. Definition of Pseudoptosis/Ptosis and Distribution in our Patient Cohort Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Definition of pseudoptosis Pseudoptosis in our patient cohort (n = 210) Incident I-O distance Preoperative (n) One-year postoperative (n) Negative <15 mm 175 (88.1%) 208 (99%) Positive >15 mm 25 (11.9%) → in 13 patients (12 in both earlobes; 1 unilateral earlobe) 2 (1%) → in 1 patient (1 in both earlobes) Definition of ptosis Ptosis in our patient cohort (n = 210) Ptosis grade O-S distance Preoperative (n) One-year postoperative (n) 0 0 mm 20 (9.5%) 0 (0%) 1 (ideal) 1-5 mm 66 (31.4%) 184 (87.6%) 2 (ideal) 6-10 mm 74 (35.2%) 26 (12.4%) 3 11-15 mm 50 (23.8%) 0 (0%) 4 16-20 mm 0 (0%) 0 (0%) 5 >20 mm 0 (0%) 0 (0%) Unaesthetic result (not ptosis grade I/II) 70 (33.3%) → in 37 patients (33 in both earlobes; 4 unilateral earlobes) 0 (0%) → in 0 patients Classification of pseudoptosis/ptosis following the scientific literature16 and distribution within our patient cohort preoperatively and 12 months postoperatively after SMAS facelift. Ptosis grade I/II was defined as an ideal postoperative outcome. I, intertragal notch; O, otobasion inferius; S subaurale. View Large Statistical Analysis The data collection and primary statistical analysis were performed with Microsoft Excel (Microsoft Corporation, Redmond, WA), and an independent t test was applied. Statistical significance was defined as a P-value of <0.05. RESULTS The median age of the patient cohort at the time of surgery was 54 years (SD: 9.0; standard error [SE]: 0.88; range, 37-75 years) with a gender distribution of 95 female (90.5%) and 10 male patients (9.5%) (origin: Caucasian). Only the patients with a minimum of 12 months of follow-up time were included in the study (median follow up, 16 months; range, 12-30 months). The patients were followed up after one week, two weeks, one month, three months, six months, and one year postoperatively and then annually or if complications occurred. Two major complications were detected during the follow-up period—an apraxia of the mandibular branch of the facial nerve, which was resolved after three months, and a postoperative hematoma requiring surgical revision. This resulted in a 1.9% major complication rate (2/105) among our study cohort. One patient developed a bilateral pseudoptosis of 19 mm, which was counted as a minor complication (1% [2/210]). No cases of ptosis grades 0, III, or IV were detected after surgery (Table 1). A statistically significant correlation was shown for the reduction in the age-related enlargement of the earlobe (P > 0.05). The median preoperative and one-year follow-up measurements of the I-O distance (pseudoptosis) and O-S distance (ptosis), as well as the measurements of auricular displacement, are shown in Table 2. The free earlobe pedicle (O-S distance) was intraoperatively enlarged in 54 cases (right side: 24; left side: 30), reduced in 142 cases (right side: 73; left side: 69), and unchanged in size compared to the preoperative measurements in 14 cases (right side: 8; left side: 6) (n = 210). Furthermore, the authors did not detect any change of the lobule axis in their patient cohort. Table 2. Detailed Information About Preoperative and 1-Year Postoperative Patient Data Concerning Pseudoptosis, Ptosis, and Auricular Displacement Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Statistical analysis (t test) of patient data in our cohort showed no statistical significance for auricular displacement in a comparison of preoperative and postoperative MAD measurements (P > 0.05). Statistical significance was observed for the reduction of the age-related enlargement of the earlobe (P > 0.05). Any change in MAD angle measurement >5° was defined as postoperative auricular displacement. I, intertragal notch; MAD, auricular displacement; O, otobasion inferius; S, subaurale; SD, standard deviation; SE, standard error. View Large Table 2. Detailed Information About Preoperative and 1-Year Postoperative Patient Data Concerning Pseudoptosis, Ptosis, and Auricular Displacement Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Right earlobe (n = 105) Left earlobe (n = 105) Left + right earlobe (n = 210) Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement Preoperative measurement One-year postoperative measurement I-O distance (pseudoptosis) Incidents (n > 15mm) 13 1 12 1 25 2 Median 10.62 mm 9.3 mm 10.68 mm 9.4 mm 10.52 mm 9.25 mm SD 4.31 2.83 4.4 2.84 4.27 2.78 SE 0.42 0.27 0.43 0.28 0.42 0.27 Range 5-25 mm 5-19 mm 5-26 mm 5-19 mm 5-25.5 mm 5-19 mm t test 0.01 (P < 0.05) 0.01 (P < 0.05) 0.01 (P < 0.05) O-S distance (ptosis) Incidents (n = not grade I/II) 34 0 36 0 70 0 Median 6.3 mm 3.82 mm 6.14 mm 3.78 mm 6.29 3.77 SD 3.87 1.53 3.84 1.55 3.85 1.52 SE 0.38 0.15 0.38 0.15 0.38 0.15 Range 0-14 mm 2-9 mm 0-13 mm 1-9 mm 0-13 mm 1.5-7.5 mm t test 0.00 (P < 0.05) 0.00 (P < 0.05) 0.00 (P < 0.05) Auricular displacement (MAD > 5°) Median 79.75° 79.16° 79.15° 79.7° 79.16° SD 9.02 8.47 8.86 8.44 8.93 8.39 SE 0.88 0.83 0.86 0.82 0.87 0.82 Range 63-98° 64-95° 63-99° 62-95° 63-98.5 63-95 Maximum auricular displacement (preoperative vs. postoperative) 8° 9° 6.5° t test 0.63 (P > 0.05) 0.67 (P > 0.05) 0.65 (P > 0.05) Statistical analysis (t test) of patient data in our cohort showed no statistical significance for auricular displacement in a comparison of preoperative and postoperative MAD measurements (P > 0.05). Statistical significance was observed for the reduction of the age-related enlargement of the earlobe (P > 0.05). Any change in MAD angle measurement >5° was defined as postoperative auricular displacement. I, intertragal notch; MAD, auricular displacement; O, otobasion inferius; S, subaurale; SD, standard deviation; SE, standard error. View Large Only three patients presented a postoperative auricular displacement greater than five degrees (1× bilateral; 2× unilateral; 2% minor complication rate (4/210)). Detailed information is given in Table 3. No statistically significant differences in auricular displacement incidents could be detected in the comparison between preoperative and one-year postoperative results (P > 0.05). Table 3. Overview of Patients with Auricular Displacement Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Four cases of auricular displacement were found in a total of 210 operated ears (3/105 patients). The largest MAD angle change was 8°. Auricular displacement is defined as an MAD change greater than 5°. MAD, auricular displacement. View Large Table 3. Overview of Patients with Auricular Displacement Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Right ear Left ear Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Preoperative measurement One-year postoperative measurement Maximum MAD (preoperative vs. postoperative) Patient details Auricular displacement defined as MAD angle change >5° 85° 78° 7° 85° 79° 6° Same patient with both ears 74° 66° 8° 87° 80° 7° Two different patients with one left and one right ear Four cases of auricular displacement were found in a total of 210 operated ears (3/105 patients). The largest MAD angle change was 8°. Auricular displacement is defined as an MAD change greater than 5°. MAD, auricular displacement. View Large One patient showed a mild hypertrophic scarring of the retroauricular fold and the postauricular hairline incision on both sides, resulting in a 1% minor complication rate (2/210). The overall rate of minor complications—meaning a deviation from the desired aesthetic outcome—was 4% (8/210). Two representative cases are shown in Figures 14 and 15. Figure 14. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative (B) right lateral views of a 60-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 6 mm; otobasion inferius–subaurale (O-S) distance both sides: 11 mm; measurement of the auricular displacement (MAD): 63° right side/64° left side; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 6 mm; MAD: 67° right/68° left side (≤5° = no auricular displacement). Figure 14. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative (B) right lateral views of a 60-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 6 mm; otobasion inferius–subaurale (O-S) distance both sides: 11 mm; measurement of the auricular displacement (MAD): 63° right side/64° left side; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 6 mm; MAD: 67° right/68° left side (≤5° = no auricular displacement). Figure 15. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative right lateral views of a 65-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 13 mm; otobasion inferius–subaurale (O-S) distance both sides: 3 mm; MAD: 68° bilateral; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 5 mm; measurement of the auricular displacement (MAD): 71° bilateral (≤5° = no auricular displacement). Figure 15. View largeDownload slide Aesthetic outcome after superficial muscularaponeurotic system (SMAS) facelift surgery using the posterior earlobe rotation flap (PERF) and a concha-mastoid suspension suture (CMSS) technique. (A) Preoperative and (B) 12-month postoperative right lateral views of a 65-year-old Caucasian woman who underwent rhytidectomy with the PERF and CMSS technique in our clinic. Preoperative intertragal notch–otobasion inferius (I-O) distance both sides: 13 mm; otobasion inferius–subaurale (O-S) distance both sides: 3 mm; MAD: 68° bilateral; postoperative I-O distance both sides: 11 mm; O-S distance both sides: 5 mm; measurement of the auricular displacement (MAD): 71° bilateral (≤5° = no auricular displacement). DISCUSSION The understanding of the anatomy of the ear/earlobe and its surrounding ligamentous structures is fundamental to achieving a natural and aesthetically pleasing outcome after rhytidectomy. Normally, the ear is positioned with the superior helical rim and the superior orbital rim in alignment. Its long axis is defined as a line passing through the most superior point on the helix to the most caudal portion of the lobule.2 It is approximately 50% to 60% as wide as it is high, with a median overall length of 6.5 to 7.5 cm, inclining approximately 20 degrees and protruding approximately 1.5 to 2.0 cm outward from the lateral orbital rim.3 The vectors of the traction forces following rhytidectomy may rotate the ear around the external auditory canal, resulting in an unnatural position and contour of the ear.6 Ear and earlobe distortions are unpleasant complications after facelift surgery. Several methods to prevent earlobe deformity following rhytidectomy are described in the current literature,5-14 along with other techniques for earlobe reduction.15-18 Thus far, no standard procedure has been described to simultaneously prevent auricular displacement and earlobe distortion after rhytidectomy. Van Putte et al developed a technique to correct earlobe ptosis.19 Several publications focus on correcting the so-called pixie ear deformity following facelift surgery,5,20-26 while other techniques target earlobe reconstruction and earlobe augmentation.27,28 In 1973, Lindgren et al described a technique using a large postauricular advancement of the skin flap to prevent direct traction on the earlobe.29 This technique has the disadvantage of enlarging the earlobe itself and, therefore, is less suited for the majority of patients already having an age-related enlargement of the earlobe. Stark et al described a technique based on the complete detachment of the earlobe up to the cartilaginous base; followed by the direct closure of the anterior and posterior edges of the detachment area at the earlobe base.29 This technique always shortens the earlobe and is, therefore, not suited for already small earlobes; furthermore, it often creates an unnatural and wedge-shaped appearance of the earlobe. The average length of the earlobe increases during the natural aging process.19 Previous studies show a correlation between an increase in the patient’s age and the elongation of the free caudal segment as well as a connection between the elongation of the attached cephalic segment and previous rhytidectomy.16 A classification based on a survey published by Mowlavi et al on the appearance and shape of an aesthetically pleasing earlobe showed that an I-to-O distance greater than 15 mm is considered unattractive by both sexes (classified as pseudoptosis) and that an O-to-S distance of 1 to 10 mm (classified as ptosis grades I and II) is considered to be more attractive than ptosis grades 0, III, or IV.4 These proven correlations and the aesthetic expectations of our patients should be considered when performing a facelift procedure. The PERF technique is based on a retroauricular advancement-rotation flap, which allows the redefining of the position of the new otobasion inferius and, therefore, gives complete control of the aesthetic relation between the attached cephalic segment and the free caudal segment. Additionally, this method offers the option to reduce or enlarge the earlobe in size and tailor the desired shape and the length of the earlobe by choosing different flap sizes. Also, the relation between free pedicle and the fixed part of the earlobe can be tailored as desired. The lobule axis, which is set to be around 15 degrees posterior to the body of the ear axis,2 is not changed by this procedure and therefore intends to stay the same. Moreover, the results of our study indicate that our novel surgical approach may help to prevent traction-induced earlobe deformities such as the pixie ear. The pixie ear deformity is a well-known complication arising after rhytidectomy. It is characterized by an increase in the length of the attached cephalic segment (I-to-O distance) and a decrease in the length of the free caudal segment (O-to-S distance) to 0 mm.9 The deformity, which occurs when the earlobe is pulled along its longitudinal axis, can be easily recognized.7 As a result, the attached cephalic segment will lengthen, causing pseudoptosis.19 Common causes of the pixie ear deformity are traction forces due to excessive facial skin flap resection or failure to anchor the facial skin flap at Loré’s fascia at the otobasion inferius.6 In our patient cohort, two cases of pixie ear deformity (pseudoptosis) occurred during the 12-month follow-up period (1%) compared to a published incidence rate of 5.7% in patients receiving rhytidectomies.5 Apart from its use to redirect tension forces from the skin flap and to correct or prevent a pixie ear deformity, the authors use the flap routinely for earlobe shape modifications—either within a reduction or augmentation of the earlobe for a more natural outcome. If no earlobe modification is desired or needed, the PERF flap is not routinely necessary within a properly vectored facelift. The authors strongly believe that the use of the CMSS technique is a useful recommendation to minimize the possible distortion of the natural position of the ear caused by traction forces on the fascia periauricular (Loré). Comparing the data from our study with the current scientific literature, the PERF and CMSS combination technique achieves a more consistent cosmetic outcome regarding an aesthetically pleasing earlobe shape and size. In our study cohort, ptosis grade I was predominant (88%), followed by ptosis grade II (12%) and only two cases of pseudoptosis; the data published by Mowlavi et al show ptosis grade 0 in 7.5%, ptosis grade I in 37%, ptosis grade II in 37%, and ptosis grade III in 18.5% of patients after facelift surgery.30 We showed that the combined use of the described CMSS technique minimizes the occurrence of auricular displacement and rotation after SMAS facelifts by counterbalancing the tractional forces, which could occur during scarring, SMAS, and skin flap contraction. A retrospective metastudy by Brink et al analyzing preoperative and postoperative photographs in 12 facelift articles proves that auricular displacement is present in varying degrees in up to 62% of patients receiving facelift surgery and is postulated to be present in up to 90% as a true incidence.2 Within our patient cohort, no statistically significant auricular displacement was present (P > 0.05), showing a significantly reduced occurrence of postoperative auricular displacement in comparison to the scientific literature. Additionally, the surgeon can perform an individualized correction of age-related earlobe enlargement during rhytidectomy by using this technique in a reconstructive manner. Notably, a size reduction of the earlobe correlates with a more youthful overall facial appearance.30 This correlation should be discussed with every patient planning to have a facelift procedure, and adequate correction of existing age-related deformations should be planned to achieve a harmonious aesthetic outcome. Since 2005, approximately 75% of all rhytidectomy patients operated upon in our clinic have had additional earlobe reduction procedures. In our study cohort, no cases of hypertrophic scarring occurred within the area of the otobasion inferius or the inferior auricular base. However, one patient suffered from mild bilateral hypertrophic scarring of the retroauricular fold and the postauricular hairline incision (1%). No objective incidence rates for hypertrophic scarring within the periauricular region after rhytidectomy could be found in the scientific literature. Additional prospective studies regarding the general incidence of periauricular hypertrophic scarring after rhytidectomy would be needed for a comparison of our data with those of other techniques. Skin flap tension and retraction are mainly responsible for the pixie ear deformity—apart from other factors, such as wrong anchoring or scar retraction. This means that even with a tension-free closure of the dermal skin flap, skin and/or scar retraction after SMAS lifting are not always predictable. The CMSS technique, which may prevent movement of the ear as a whole unit in reference to the position on the skull (due to SMAS tension forces transferred to the periauricular fascia), is a useful tool for this purpose. Furthermore, the authors use the PERF technique in most cases to sculpt the earlobe and to prevent potential earlobe distortion, but the recommended utilization can be as well applied for correction purposes. Due to a proper anchoring/fixation of the SMAS, most of the retraction forces can be eliminated. Nevertheless, the authors believe that postoperative SMAS shrinking and scarring can be transposed to the ear itself (via Loré′s fascia)—resulting in auricular displacement. The retroauricular area is a preferred skin harvest location for various procedures due to its easy access, excellent quality of skin, and very thin skin layer.31 In our patient cohort the authors did not see any length retraction of the harvested flap. Due to the good properties of the dermis within the retroauricular sulcus, secondary retraction of the flap is according to this neglectable. Our work focuses on achieving a better postoperative earlobe shape in primary facelift surgeries. However, to date, the authors have used the technique successfully in many cases to correct earlobe deformities in secondary or tertiary rhytidectomy cases; therefore, a follow-up publication will address this topic. The authors believe that the techniques shown in this study present a useful and novel approach for the correction and prevention of the pixie ear deformity and therefore enhance the armamentarium of facial plastic surgeons. As aesthetically unpleasant results after facelifts are still common in daily practice due to the wide proliferation of facial rejuvenation procedures among treatment providers outside the surgical core specialties, the authors would like to contribute, with this study, toward the development of an effective treatment alternative for these cases. The results of this study and the resulting recommended use of the technique could only be shown on Caucasian skin and within a predominantly female study group; hence, further studies may be needed to prove the effectiveness in other skin types. CONCLUSIONS Our publication contributes toward minimizing the occurrence of postoperative auricular deformities by introducing a simple and effective technique combining the PERF and CMSS procedures. This method avoids the inherent disadvantages of the existing techniques and can be combined with any given SMAS facelift procedure. This novel technique grants the surgeon complete control over the aesthetic relation between the attached cephalic segment and the free caudal segment. Furthermore, the surgeon has the possibility to use this technique in a reconstructive approach to reduce or enlarge the earlobe in size by choosing the dimension of the flap to tailor the desired shape and length of the earlobe. In combination with the concha-mastoid suspension suture, this technique stabilizes the natural position of the ear, leading to significantly less auricular displacement and a reduced incidence of ear/earlobe deformities and hypertrophic scarring after rhytidectomy. The results of our study indicate that the technique may also help to prevent traction-induced earlobe deformities such as the pixie ear and, therefore, should be considered a valuable addition to any SMAS facelift procedure. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Wan D , Small KH , Barton FE . Face lift . Plast Reconstr Surg . 2015 ; 136 ( 5 ): 676e - 689e . Google Scholar CrossRef Search ADS PubMed 2. Brink RR . Auricular displacement with rhytidectomy . Plast Reconstr Surg . 2001 ; 108 ( 3 ): 743 - 752 . Google Scholar CrossRef Search ADS PubMed 3. Tolleth H . Artistic anatomy, dimensions, and proportions of the external ear . 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Aesthetic Surgery JournalOxford University Press

Published: Apr 9, 2018

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