Anatomy of the Earlobe
Understanding the anatomy of the earlobe is important so that the appropriate approach to the treatment of aesthetic imperfections can be determined.
The external ear consists of the auricle—also known as the pinna—and the ear canal. The auricle, which is the visible part of the ear, is made of several components including the helix, antihelix, tragus, antitragus, and the lobule. These structures are mainly composed of cartilage covered by skin. The earlobe, on the other hand, is made of tough areolar and adipose connective tissues. This is why the earlobes are softer and less elastic compared to the rest of the auricle. There are 2 main types of earlobes differentiated by their appearance: where the lower lobe is not attached to the side of the cheek and where the lower lobe is connected.
Treatment for earlobe concerns can only be conducted successfully if the blood vessels and nervous systems present in the earlobes are properly understood by the physicians. This is to ensure that the earlobe will continue to have blood supply and sensation. The earlobes are rich in blood supply to maintain warmth of the area.1 The 3 branches of the external carotid artery that supply blood to the earlobes are the occipital artery, posterior auricular artery and the anterior auricular branch of superficial temporal artery.1 The veins also run alongside each artery.
There are 4 sensory nerves in the earlobe: the great auricular nerve, the auriculotemporal nerve, the lesser occipital nerve, and the auricular branch of vagus nerve.1
Common earlobe concerns
There are several common concerns that patients have when it comes to their ears. As the ears are essential to the facial aesthetic, keloid scarring, enlarged piercing holes, and split earlobes can affect self-esteem.
- Split Earlobe:
As the name suggests, this imperfection is usually caused by wearing heavy earrings. Over time, the post or hook of the earring will cut through the delicate skin of the pierced earlobe. This concern can be caused or exacerbated if patients wear heavy earrings to bed, as the earring can catch as the patient moves throughout the night. Damage can also be caused if the earring catches on a hairbrush or comb while brushing the hair. There are 2 types of split earlobes: A complete split earlobe, when the piercing is completely torn, and an incomplete split earlobe, when the piercing is only slightly torn.
- Enlarged Piercing Hole: Victoria Pitts, a Queen’s College assistant professor of sociology, stated that ear stretching—a type of body modification—gained popularity in the 1980s with the rise of the body art movement.2 The process of deliberately enlarging ear piercing holes by placing is known as “gauging.” This involves expanding the piercing hole in sizes from 1mm up to more than 2cm. While it can be possible to gradually reduce the size of the piercing hole naturally, over-stretched piercing holes may not be able to revert to a more natural state.3
- Keloid Scarring: For some people, the body may react to ear piercings by forming a raised scar. The wound healing process happens in 3 consecutive phases: The inflammatory phase, the proliferative phase, and the remodeling phase. An aberrant healing process results in hypertrophic and keloid scars, which may impact patients’ self-esteem.
Prior to treatment, the severity of the earlobe imperfections must be gauged. A complete medical checkup and aesthetic assessment will ensure that the best treatment option is chosen for the patient.
Split Earlobe Repair: A split earlobe can be repaired with or without reconstructing the piercing hole.4,5 Some health care practitioners prefer to repair without reconstructing the hole. The patient should wait a minimum of 6 months to pierce the ear again. The new piercing should be done at either 2mm medial or lateral to the scar to reduce the risk of splitting the earlobe again.
Alternatively, physicians can also choose to restore the split earlobe using either a straight line or a broken line of repair. Though the straight-line repair is simple, the final result may not be aesthetically pleasing as the scar tends to contract and a notch at the free border appears. The broken line repair technique, such as Z-plasty, is a preferable alternative. This technique, which repairs the wound in a Z shape, prevents the scar from shrinking.
To repair an incomplete split ear, the L-plasty is optimal. Cutting the split around the edge and stitching it can cause the earlobe to become elongated.
Earlobe Reduction: The earlobe tissue can be removed by excising the earlobe, as it will not leave a notch or scar on the free border. To do this, physicians must discuss the patient’s preferred earlobe size, which you can mark using a white marker. A line must be drawn from the tragus to the white mark level and a second line must be drawn from the tragus to the lateral end of the white mark. The length between the lines must be measured and a triangle must be drawn on the second line. Ensure that the size of the triangle base is the same as the length of the first and second lines. The marked earlobe can then be excised before joining the first and second lines with deep dermal and vertical mattress stitches.
Enlarged Ear-Piercing Hole Repair: Very large hole piercings can be corrected using the Y-plasty6 technique, while large hole piercings can be treated with the L-plasty method—depending on the amount of earlobe tissue available. Patients who want to get rid of small ear-piercing holes will be treated via elliptical excision.
Prior to the procedure, assess the patient’s medical history (e.g. underlying medical conditions and medications and supplements taken) to ensure that the procedure is completed with very little risk of complications. The procedure is then conducted in an out-patient theatre while the patient is under local anesthesia.
- Before starting the procedure, inject about 2ml of a local anesthetic agent into the sub-dermal layer of the junction between the earlobe and the cheek, and from the lowest end of the junction up to the intertragic notch. It may make it easier to use a scalpel if you infiltrate the earlobe with an anesthetic solution without epinephrine until it becomes firm and pale. However, using an Iris scissors may prove to be difficult in this instance.
- For L-plasty technique, the lines of excision must be drawn on the highest point of either side of the cleft before the edges start curving in gently. Otherwise, a groove along the repair line will appear like a split earlobe with a notched border.
- For both L-plasty and Y-plasty, the areas that were marked will be excised from the free border to the apex of the cleft of the earlobe using a scalpel or Iris scissors. Physicians must ensure that the back of the earlobes are cut to the same shape as the front. Afterwards, the flap can then be inserted accurately from the anterior aspect. Any discrepancy that may arise will be transferred to the posterior aspect to ensure that there is no irregularity in the free border of the earlobe.
- The front and the back of the earlobe will then be stitched with non-absorbable sutures using the vertical mattress technique. Physicians must use the vertical mattress technique to prevent the scar rolling inwards while healing, as this will only make it seem more visible.7
Several important precautions must be taken to ensure that the procedure is carried out successfully while avoiding any major complications.
- Physicians must ensure that the earlobe is completely cut through according to the desired shape by checking the back of the earlobe before they start stitching the wound.
- Since the stitches can be loosened from stress or pressure applied to the area, physicians must advise their patients to protect the treated earlobe from potentially harmful activities (e.g. any contact sports, sleeping on their sides, etc.) that may cause pulling of the ear.
- Physicians should ensure that both the earlobes share a similar shape by measuring the markings and establishing that the earlobes are of the same angle and length. As for earlobe reduction, both the ears must be marked to ensure similar results. It is very important for you to advise your patients that the earlobes may not necessarily look exactly alike following procedure. The outcomes of the procedure depend of the amount of earlobe tissue available.
- Some of the commonly reported side effects are bruising, bleeding, and blood clots. So, the stitches must be tightened properly to reduce the severity of those secondary reactions. Besides that, patients should also avoid taking blood thinning medications before the procedure.
- Triamcinolone (TCN), a type of synthetic corticosteroid, may trigger the release of Immunoglobulin E (IgE) antibodies, resulting in type 1 anaphylactic reaction. The allergens identified in TCN could be steroid, carboxymethyl cellulose (CMC),8 and/or succinate.9 The patient’s medical history, particularly their history of previous allergic attacks, must be reviewed thoroughly before the procedure.
- Another side effect of the earlobe treatment is scarring, which can occur in patients with V-VI skin types. Those with a history of keloid or hypertrophic scarring must be advised of their risk of developing scars on the treated earlobes.
- Should the patient develop an infection, they must avoid touching the affected areas. Besides that, it is advised that the infected areas do not come into contact with water for the first 2 to 3 days. Patients are advised to wash their hair before their procedure and avoid washing their hair altogether for 2 to 3 days following surgery.
Patients seeking to repair earlobe imperfections can be treated with several techniques, depending on the condition of the earlobe. While split earlobe can be repaired with the L-plasty technique, earlobe reduction and repair of large piercing holes are best treated with Y-plasty technique. The techniques provide optimal results with a greatly reduced risk of complications.
Reena A Bhatt, ‘Eat anatomy’, Medscape, 2016. http://emedicine.medscape.com/ article/1948907-overview#a2
Pitts V, ‘In the Flesh: The Cultural Politics of Body Modification’, 2003.
Chiummariello, S, Iera M et al., ‘L-Specular plasty versus Double round plasty: Two new techniques for earlobe repair’, Aesthetic Plastic Surgery, 2011, 35, pp. 398-401 https://www. ncbi.nlm.nih.gov /pubmed/? term=L-specula+plasty
Boo-Chai K, The cleft ear lobe’, Plastic and Reconstructive Surgery, 1961, 31, pp. 337-338. https://www.ncbi.nlm.nih.gov/pubmed/?term=The+cleft+earlobe+Boo-chai
Argamaso RV, ‘The Lap-joint principle in the repair of the cleft earlobe’, British Journal of Plastic Surgery, 1978, 31, pp. 337-8. https://www.ncbi.nlm.nih.gov/ pubmed/?term= The+Lapjoint+ principle+in+the+ repair+of+the+cleft+earlobe
Yabe T & Muraok M, ‘Double opposing V-Y hinge flap’, Annals of Plastic Surgery, 2003, 51, pp. 641-2. https://www.ncbi.nlm.nih.gov/ pubmed/14646668
Silvia Mandello Carvalhaes & Andy Petroianu et al., ‘Assesment of the treatment of earlobe keloids with triamcinolone injections, surgical resection, and local pressure’, Revista do Colegio Brasileiro de Cirurgioes, 2015, 42, http://www.scielo.br/scielo.php?script=sci_ arttext&pid=S0100-69912015000200009& lng=en&nrm=iso& tlng=en
Linares HA & Larson DL et al., ‘Historical notes on the use of pressure in the treatment of hypertrophic scars or keloids’, Burns, 1993, 19, pp. 17-21. https://www.ncbi.nlm.nih.gov/ pubmed/8435111
Patterson DL & Yunginger JW et al., ‘Anaphylaxis induced by carboxymethylcellulose component of injectable triamcinolone’, Annals of Allergy Asthma & Immunology, 1995, 74, pp. 163-6. https://www.ncbi.nlm.nih.gov/pubmed/?term=Anaphylaxis+induced+by+ carboxymethylcellulose+ component+of+injectable+triamcinolone