SCIENTIFIC FORUM
Avoiding the “Pixie-Ear” Deformity Following
Face Lift Surgery by Differential Insetting and
Secondary Intention Healing
Arian Mowlavi, MD; and Mo Zakhireh, MD
Dr. Mowlavi is in private practice in Laguna Beach, CA. Dr. Zakhireh is in private practice in Rancho Mirage, CA.
Background: The “pixie-ear” deformity has been described by its “stuck-on” or “pulled” appearance, due to the extrinsic pull
of the cheek and jawline skin flaps on the earlobe attachment point (O), the otobasion inferius. The tension results in migration
of the earlobe attachment point from a posterior cephalad position to an anterior caudal position. Recently, the 2 components of
the earlobe, the attached cephalic segment (I to O distance) and the free caudal segment (O to S distance), have been defined.
Objective: We describe a novel technique involving differential insetting of the cheek and jawline skin flaps to the earlobe and
secondary intention healing to create an aesthetically pleasing cephalic attached segment.
Methods: Rhytidectomy was performed using an extended superficial muscular aponeurotic system (SMAS) technique along
with jawline undermining. The earlobe soft-tissue–retaining ligaments to the mastoid were released to the level of the new otobasion inferius to creat a cephalic attached segment less than 1.5 cm, which allowed the caudal free segment to approximate 0.5
cm. Whereas the cephalic segment was directly repaired, the free caudal segment anterior and posterior skin flaps were not
reapproximated and were to heal by secondary intention.
Results: In a series of 20 consecutive patients, excellent aesthetic results were obtained using this approach without healing
complications, hypertrophic scarring, or “pixie-ear” deformity.
Conclusions: Our approach for cheek and jawline skin flap fixation to the earlobe eliminates any vector of pull on the free caudal segment of the earlobe and, consequently, any potential for “pixie-ear” formation. We advocate allowing the free caudal
segment to heal by secondary intention, which results in the medial edge of the free caudal earlobe attaining a curved and bluntedged appearance that is aesthetically superior to primary repair. (Aesthetic Surg J 2005;25:467-470.)
T
he earlobe can be described using 2 components:
the attached cephalic segment delineated by the
intertragal (I) to obasion inferius (O) height, and
the free caudal segment delineated by the otobasion
inferius (O) to subaurale (S) height (Figure 1). 1
Furthermore, the ideal aesthetic earlobe has been defined
by a free caudal segment measuring 1 to 5 mm and the
attached cephalic segment measuring <15 mm.1 The
2-component earlobe analysis offers significant insight
into earlobe dynamics.2 Increasing patient age has been
associated with elongation of the free caudal segment (O
to S distance).3 In contrast, elongation of the attached
cephalic segment (I to O distance) has been observed in
patients following rhytidectomy procedures.4
The “pixie-ear” deformity has been described by its
“stuck-on” or “pulled” appearance, caused by the extrinsic
pull of the cheek and jawline skin flaps at the earlobe
attachment point, the otobasion inferius (O), following
AESTHETIC
rhytidectomy. The resulting tension results in migration of
the earlobe attachment point (O) from a posterior cephalad
position to an anterior caudal position. The “pixie-ear”
deformity has been defined by an enlarging attached
cephalic segment and a decrease in free caudal segment
down to 0 mm (Figure 2).5 Using this definition, the incidence of “pixie-ear” deformity was determined to be
5.7 % of patients undergoing face lift surgery.5 We present
a novel approach to avoiding the “pixie-ear” deformity.
This technique was performed in 20 consecutive patients
with excellent aesthetic results and no healing complications, hypertrophic scarring, or “pixie-ear” deformity.
Technique
Rhytidectomy was performed using an extended
superficial muscular aponeurotic system (SMAS) technique, along with jawline undermining. During insetting
of the cheek and jawline skin flaps, the earlobe soft-tis-
SURGERY
JOURNAL
~
SEPTEMBER/OCTOBER
2005
467
SCIENTIFIC FORUM
Figure 1. The anatomic landmarks of the intertragal notch (I), otobasion inferius (O), and subaurale (S). Earlobe height parameters are
defined with respect to the attached cephalic component, I to O distance, and the free margin caudal component, O to S distance. Modified
from Mowlavi et al,4 with permission.
Figure 2. The “pixie-ear” deformity using the 2 components of the earlobe following rhytidectomy. This deformity is characterized by an
increase in the attached cephalic segment (I to O distance) and a
decrease in the free caudal segment (O to S distance) equal to 0 mm.
A
B
C
D
Figure 3. Intraoperative illustrations before (A) and immediately following (B) rhytidectomy, demonstrating the differential insetting of the attached
cephalic and free caudal segment. Close-up illustrations (C and D) demonstrate the reapproximated attached cephalic segment (≈1.0 cm) but avoidance
of primary repair of the caudal free segment (≈0.5 cm).
468
Aesthetic
Surgery
Journal
~
September/October
2005
Volume 25, Number 5
SCIENTIFIC FORUM
A
B
Figure 4. A, Preoperative view of a 42-year-old patient. B, Postoperative view at 6 months following extended SMAS rhytidectomy with jawline
undermining demonstrates lack of hypertrophic scarring or “pixie-ear” deformity.
A
B
Figure 5. A, Preoperative view of a 72-year-old patient. B, Postoperative view at 6-months following extended SMAS rhytidectomy with jawline
undermining and blepharoplasty shows lack of hypertrophic scarring or “pixie-ear” deformity.
A
B
Figure 6. A, Preoperative view of a 67-year-old patient. B, Postoperativeview at 9 months following extended SMAS rhytidectomy with jawline undermining and blepharoplasty shows lack of hypertrophic scarring or “pixie-ear” deformity.
Avoiding the “Pixie-Ear” Deformity Following
Face Lift Surgery by Differential Insetting and
Secondary Intention Healing
AESTHETIC
SURGERY
JOURNAL
~
September/October
2005
469
SCIENTIFIC FORUM
sue–retaining ligaments to the mastoid fascia were
released to the level of the new otobasion inferius (O).
This point was selected to create a cephalic attached segment (I to O distance) less than 1.5 cm. This height distance was specified to allow the caudal free segment (O
to S distance) to approximate 0.5 cm. The cheek and
jawline skin flap was then secured to the mastoid fascia
at the crutch of this dissection using a horizontal mattress
suture with 5-0 nylon suture. Despite repair of the
attached cephalic segment earlobe to the cheek skin flap,
the free caudal segment was not fixed; instead, the skin
incision at the junction of the anterior and posterior earlobe skin flaps was allowed to heal by secondary intention (Figure 3).
Conclusion
The approach for cheek and jawline skin flap fixation
to the earlobe that we describe lacks any vector of pull
on the free caudal segment of the earlobe, thereby eliminating any potential for “pixie-ear” formation. We advocate allowing the free caudal segment to heal by secondary intention rather than by primary repair, because
primary repair of this segment would result in an unnatural sharp edge and a sharp caudal point at the subaurale
(S). By allowing for secondary contraction, the medial
edge of the free caudal earlobe attains a curved and
blunt-edged appearance that is aesthetically superior to
primary repair. ■
References
Results
Postoperative assessment of earlobes, with a maximum follow-up of 1 year, demonstrated no secondary
deformity of the 2 components. The maximum change in
segment heights was 10%. Changes in segment heights
demonstrated a trend toward an increased attached
cephalic segment and a decreased free caudal segment.
All patients demonstrated excellent aesthetic outcomes
with no healing difficulties, hypertrophic scarring, or
“pixie-ear” deformity (Figures 4 through 6).
Discussion
Tension vectors intrinsic to rhytidectomy procedures
result in a migration of the earlobe attachment point
(O) from a posterior cephalad position to an anterior
caudal position when compared to the perpendicular
line referenced from the FHP and passing through the
intertragal notch. This has influenced previous clinicians to advocate placement of the lobule more cephalad and dorsal to compensate for the caudal and ventral
migration of the lobule.6,7 In addition, evaluation of the
postrhytidectomy ear should also take into account
anterior rotation, downward vertical movement, and
distortion of the concha.8-10
We have previously advocated treatment of “pixieear” deformity with a medially based triangular excision
located over the attached cephalic segment.11 This excision design resulted in a 90% reduction of excision
height from the attached cephalic segment, as well as a
30% increase in excision height augmentation of the free
caudal segment. In this study, we present a novel
approach to avoidance of the “pixie-ear” deformity that
improves on our previously described procedure by eliminating a horizontal incision scar.
470
Aesthetic
Surgery
Journal
~
1. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. The aesthetic earlobe: classification of lobule ptosis based on survey of North American
Caucasians. Plast Reconstr Surg 2003;112:266-272.
2. Mowlavi A, Meldrum DG, Wilhelmi BJ. Earlobe morphology delineated by
two components: the attached cephalic segment and the free caudal
segment process. Plast d Reconstre Surg 2004;113:1075-1076.
3. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Incidence of earlobe ptosis
and pseudoptosis in patients seeking facial rejuvenation surgery and
effects of aging. Plast Reconstr Surg 2004;113:712-717.
4. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. Effect of facelift on earlobe
ptosis and pseudoptosis. Plast Reconstr Surg 2004;114:888-891.
5. Mowlavi A, Meldrum DG, Wilhelmi BJ, et al. The “pixie” ear deformity
following facelift surgery revisited. Plast Reconstr Surg 2005;115:11651171.
6. McKinney P, Giese S, Placik O. Management of the ear in rhytidectomy.
Plast Reconstr Surg 1993;92:858.
7. Hoefflin SM, Rubin AM, Cleveland C. Simple repair of a pixie earlobe.
Plast Reconstr Surg 2001;107:1623.
8. Lewin M. The eave skin flap for helical reconstruction. In: Strauch B,
Vasconez L, Hall-Findlay E, eds. Grabb’s Encyclopedia of Flaps. Boston:
Little, Brown and Co.;1990:298-300.
9. Connell BF. Neck contour deformities. The art, engineering, anatomic
diagnosis, architectural planning, and aesthetics of surgical correction.
Clin Plast Surg 1987;14:683-692.
10. Connell BF, Gaon A. Surgical correction of aesthetic contour problems
of the neck. Clin Plast Surg 1983;10:491-505.
11. Mowlavi A, Kalkanis J, Meldrum, et al. Surgical design and algorithm for
correction of earlobe ptosis and pseudoptosis deformity. Plast Reconstr
Surg 2005;115:290-295.
Accepted for publication June 24, 2005.
Reprint requests: Mo Zakhireh, MD, The Plastic Surgery Institute, 71-874
Sahara Road, Rancho Mirage, CA 92270.
Copyright © 2005 by The American Society for Aesthetic Plastic Surgery, Inc.
1090-820X/$30.00
doi:10.1016/j.asj.2005.07.010
September/October
2005
Volume 25, Number 5