Earlobe Rejuvenation and Repair

Richard K. Green

BACKGROUND

Ear piercing is an extremely common form of body modification, and repair of a torn earlobe is a frequent cause for patients to seek surgical intervention of the earlobe. Earlobe tear may be due to chronic stretching due to gravitational pull on the earlobe by heavy earrings or by abrupt traumatic avulsion of the earring through the earlobe. The increased popularity of gauging earlobes over the last few decades has led to a unique challenge of earlobe repair and tissue reduction. In this chapter, earlobe deformity repair is discussed, as well as approaches to earlobe volume depletion. Finally, keloids of the earlobe are a common complication of ear piercing and may be challenging to resolve owing to frequent recurrence after excision.

REPAIR OF EARLOBE TEARS AND DEFORMITIES

PRESENTATION

Patients present with an enlarged piercing, a linear stretched piercing, a completely split earlobe or a dramatically enlarged piercing due to gradual intentional stretching, or gauging of the earlobe.

DIAGNOSIS

Clinical Diagnosis

Enlarged piercings and tears in the lobe present in 4 different ways, and each requires a different approach for surgical correction. Type I tears are only slightly enlarged and may no longer hold an earring in place properly. One generally sees little if any distortion of earlobe shape. Type II tears show greater enlargement and will no longer hold a post earring. Some distortion or lengthening of the lobe may be noted. Type III tears extend completely through the base of the lobe and have usually resulted from trauma. Type IV tears include gross enlargement as seen with dilation of the lobe with gauges. Just as with tissue expansion elsewhere in the body, the lobe is not merely stretched out. There exists an abnormal excess of earlobe tissue that will need to be removed during the course of the repair.¹

Subtypes

Type I
Type II
Type III
Type IV

Differential Diagnosis

Congenital earlobe cleft
Disrupted piercing due to allergic contact dermatitis
Enlarged piercing space secondary to keloid

TREATMENT

The vast majority of earlobe tears are repaired surgically with excellent results (Algorithm 15.1.1). However, there are a few reports of nonsurgical repair or laser-assisted repair, which is briefly discussed here. A successful earlobe repair will restore a smooth contour to the anterior surface of the lobe while maintaining a gentle curve at its base. Scars on the ear generally heal well, and a fine line will typically appear less conspicuous than a divot or depression. It is preferable to suture the anterior surface of the lobe as carefully as possible before proceeding to the posterior surface as any posterior scar is not easily seen. One can avoid marks along the scar from sutures by removing them at 1 week.² The patient will also benefit from the massage of silicone gel into the scar twice a day for up to 3 months following suture removal.³

Cosmetic

Trichloroacetic Acid

De Mendonca and colleagues reported the use of high-concentration trichloroacetic acid (TCA) 90% solution to the inside edges of the cleft until frost, followed by occlusion. This creates a contact dermatitis leading to scarring and readhesion of the sides of the cleft. Thirty-two patients were treated with this noninvasive technique with complete readhesion in all patients. Multiple treatment applications were needed to achieve this result, on average 3.8 treatments were necessary. Complications included erythema, edema, and irritation. Hyperpigmentation was seen as a later complication, which resolved.⁴

ALGORITHM 15.1.1 Treatment options for earlobe tears. (Courtesy of Macrene Alexiades, MD, PhD.)

FIGURE 15.1.1 A type I tear is excised and repaired primarily.

Laser

Er:YAG Laser-Assisted Surgical Closure. The use of Er:YAG laser in earlobe cleft deepithelialization was reported by Herbich in 2002 as a technique to allow for surgical closure of the cleft while minimizing the earlobe notch, which is a common adverse effect of surgical interventions. In this report, a 31-year-old patient with incomplete earlobe cleft was treated with Er:YAG laser to deepithelialize the cleft, followed by surgical closure with favorable outcome.⁵

CO₂ Laser Enhancement of Surgical Closure. Ravanfar and Alster presented a case series of 10 patients with torn earlobes. One group had previously received surgical reconstruction but had undesirable results who were treated with CO₂ laser, and the other group had simple linear closure with concomitant CO₂ laser. Outcomes were assessed to be very good to excellent at 6 and 12 months after treatment. The use of CO₂ laser in this clinical scenario leads to reduction in earlobe tissue bulk, minimizes scar appearance, and reduces risk of earlobe notching.⁶

Dermabrasion-Assisted Surgical Closure. To minimize the amount of tissue required to be removed before surgical repair, which may lead to alteration on overall earlobe shape, Ashique and colleagues report the use of dermabrasion to deepithelialize the inner borders of an earlobe cleft, followed by surgical closure. The cosmetic outcome was favorable, with minimal scar.⁷

Surgical

Type I Earlobe Tears

These smaller defects respond very well to excision and primary closure. One must keep in mind that the hole in the lobe is an epithelialized cylinder or tract extending from anterior to posterior. This must be completely excised to avoid cyst formation. An 18-gauge needle and a hollow skin biopsy punch aid greatly in this excision. After anesthetizing the skin with 1% lidocaine with epinephrine buffered with sodium bicarbonate (10 parts lidocaine solution to 1 part sodium bicarbonate), the ear is prepped with povidone iodine. The 18-gauge needle is passed from posterior to anterior through the piercing without cutting skin. A skin biopsy punch with a diameter 1 mm larger than the hole to be excised is passed over the guide needle from anterior to posterior with a gentle twisting motion. This removes the entirety of the epithelialized tract as the needle is withdrawn. The anterior and posterior wounds are then closed with 5-0 nylon suture, and a dressing is applied. Remove the nylon sutures at 1 week to avoid suture marks (Figure 15.1.1). Excise additional small piercings on the earlobe, helix,
or tragus in the same fashion as just described, usually with a 2-mm punch. Patients will find the look of the resulting scars very satisfactory after several months.

FIGURE 15.1.2 This earlobe had a large type II tear, which was repaired primarily. This resulted in an elongated appearance to the lobe.

Type II Earlobe Tears

These lesions vary in size and shape relative to the dimensions of the earlobe, and direct excision with primary closure may result in an unsatisfying, elongated appearance (Figure 15.1.2). After anesthetizing the earlobe as noted earlier, the physician will use a number 11 blade scalpel to excise an inner ring of skin from the earlobe defect. The freshened wound edges are then approximated without suture in various directions (eg, 12:00-6:00 or 3:00-9:00) to estimate the best direction for closure. If no option produces a smooth shape to the lobe without an elongated appearance, then a portion of the inferior skin is removed with the number 11 blade to allow for a more aesthetic closure. If possible, removal of this skin excess at the lobe-cheek junction preserves the contour inferiorly. 5-0 Monocryl for the subcutaneous tissue and 5-0 nylon for the skin complete the closure (Figure 15.1.3). In a larger, near-complete tear, remove the small skin bridge connecting the 2 halves of the earlobe, as this atrophic skin serves no useful purpose (Figure 15.1.4). This converts a partial tear into a complete one, and the lobe is then repaired as discussed in the next paragraph.

FIGURE 15.1.3 Primary closure of a type II repair at 1 week.

FIGURE 15.1.4 A small skin bridge was divided inadvertently by the patient. This conveniently facilitated the repair.

Type III Earlobe Tears

Complete tears of the earlobe are generally oriented vertically and may be single or multiple. Often they have resulted from an earring becoming caught in a sweater or grabbed by a child. After local anesthesia and iodine skin preparation, a number 11 blade scalpel is used to excise a V-shaped wedge of skin from the inside of the tear. Again, one should temporarily approximate the wound edges to ensure that the repair will result in a satisfactory shape. If not, further excision is performed before closing the wound edges with 5-0 Monocryl for the subcutaneous tissue and 5-0 nylon for the skin (Figure 15.1.5). This repair necessarily disrupts the natural inferior contour of the lobe. As scars tend to contract with time, a slight eversion of the skin edges at the most inferior portion of the lobe may help to prevent a small notch at the base of the lobe. About 2 or 3 horizontal mattress sutures at this location will provide the needed eversion. When repairing 2 adjacent tears, consider shortening the narrow bit of intervening skin to create 1 scar at the base of the lobe instead of 2 (Figure 15.1.6). One must always warn the patient that they may require a small revision in the future to help smooth the earlobe contour.

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