The "pixie" ear deformity following face lift surgery revisited.

BACKGROUND: The "pixie" ear deformity can be recognized by its "stuck on" or "pulled" appearance, which is caused by the extrinsic pull of the medial cheek and jawline skin flaps at the earlobe attachment point, the otobasion inferius. The tension results in migration of the otobasion inferius from a posterior cephalad position to an anterior caudal position. Although this deformity has been described clinically, it has yet to be objectively defined. METHODS: Recently, the two components of the earlobe, the attached cephalic segment (intertragal to otobasion inferius distance) and the free caudal segment (otobasion inferius to subaurale distance), were shown to be essential in evaluating for earlobe ptosis and pseudoptosis. These two components can be used to designate an objective criterion for the pixie ear deformity. The deformity, as defined by the authors' parameters, was assessed in 44 patients who had undergone rhytidectomy. A simple and accurate surgical treatment is demonstrated by a cadaver dissection and a clinical case. RESULTS: The deformity can be defined as an increase in the attached cephalic segment (intertragal to otobasion inferius distance) and a decrease in the free caudal segment (otobasion inferius to subaurale distance) to 0 mm following rhytidectomy. The incidence of pixie ear deformity was 5.7 percent in the authors' series of patients. CONCLUSIONS: A medially based triangular excision over the attached cephalic segment is presented as a simple and accurate surgical treatment of pixie ear deformity. A more accurate and objective designation may allow for improved detection, avoidance, and treatment of this deformity.

Surgical design and algorithm for correction of earlobe ptosis and pseudoptosis deformity.

A previously described classification system for earlobe ptosis and criterion for earlobe pseudoptosis deformity was based on height measurements of the two earlobe components: the free caudal segment and the attached cephalic segment. The "ideal" ear lobule free caudal segment was found to be between 1 and 5 mm (grade I ptosis), and the "ideal" attached cephalic segment was 15 mm or less. Earlobe pseudoptosis was defined by an attached cephalic segment measuring greater than 15 mm. Previous studies revealed an association between the elongated free caudal segment and increasing patient age and between the elongated attached cephalic segment and rhytidectomy. Sixteen fresh cadaver earlobes were used to design surgical patterns that would differentially reduce the free caudal segment, the attached cephalic segment, or both. A horizontal, medially based triangular excision pattern was designed. Triangular excisions limited to the attached cephalic segment resulted in 98 +/- 5 percent reduction of excision height from the attached cephalic segment but also resulted in an unexpected 32 +/- 2 percent augmentation of the excision height in the free caudal segment. Triangular excisions limited to the free caudal segment resulted in 88 +/- 4 percent reduction of the excision height from the free caudal segment and negligible reduction of 4 +/- 4 percent of excision height in the cephalic attached segment. An algorithm for correction of earlobe ptosis and pseudoptosis was subsequently derived and implemented in a clinical case. The authors propose that surgical treatment of patients with pseudoptosis be dependent on the ptosis grade. If the ptosis is grade I (1 to 5 mm), then excision of only the attached cephalic segment is recommended. If the ptosis is grade II or higher (more than 5 mm), then a combined attached cephalic and free caudal segment excision is recommended. In cases of isolated ptosis grade II or higher without pseudoptosis, then excision location of only the free caudal segment is recommended. The above simple algorithm and surgical designs will enable plastic surgeons to differentially correct earlobe ptosis and pseudoptosis.

Effect of face lift on earlobe ptosis and pseudoptosis.

The authors have previously described a classification system for earlobe ptosis and established criteria for earlobe pseudoptosis. Earlobe heights were characterized on the basis of anatomic landmarks, including the intertragal notch, the otobasion inferius (the most caudal anterior attachment of the earlobe to the cheek skin), and the subaurale (the most caudal extension of the earlobe free margin). The classification system was derived from earlobe height preferences as determined by a survey of North American Caucasians and identified the ideal free caudal segment (otobasion inferius to subaurale distance) measuring 1 to 5 mm (grade I ptosis). Also, earlobe pseudoptosis was defined by an attached cephalic segment (intertragal notch to otobasion inferius distance) measuring greater than 15 mm. In this study, the authors evaluated the effects of standard face lift surgery on earlobe ptosis and pseudoptosis by comparing the preoperative and postoperative earlobe height measurements from life-size photographs of 44 patients who underwent rhytidectomy performed by the senior author. The postoperative attached cephalic segment (intertragal notch to otobasion inferius distance, 12.22 +/- 0.364 mm) increased over its preoperative attached cephalic segment (intertragal notch to otobasion inferius distance, 11.10 +/- 0.406 mm) (p = 0.041). The postoperative free caudal segment (otobasion inferius to subaurale distance, 6.32 +/- 0.438 mm) demonstrated only a trend toward decreased heights when compared with the preoperative free caudal segment (otobasion inferius to subaurale distance, 7.15 +/- 0.489 mm) (p = 0.210). The incidence of pseudoptosis, defined by an attached segment (intertragal notch to otobasion inferius distance) greater than 15 mm, increased from 12.3 percent of preoperative patient earlobes to 17.3 percent of postoperative patient earlobes. An ideal free caudal segment (otobasion inferius to subaurale distance), defined by a range of 1 to 5 mm, was observed in only 37.0 percent of postoperative earlobes versus 22.2 percent of preoperative earlobes. Significant increases in the attached cephalic segments (intertragal notch to otobasion inferius distance) following rhytidectomies correlated with increased incidence of earlobe pseudoptosis, as observed in 17.3 percent of postoperative patient earlobes. Because the free caudal segment was negligibly affected by rhytidectomy, a majority of earlobes (63.0 percent) demonstrated persistent nonoptimal free caudal segment heights (otobasion inferius to subaurale distance > 5 mm). Earlobe height changes can result from either age-related lobule ptosis (increase in free caudal segment) as previously described or in patients undergoing rhytidectomy (increase in attached cephalic segment). Therefore, ideal lobule distances along with the effects of aging and rhytidectomy surgery on the lobule should be discussed with patients who are seeking a more youthful facial appearance, so that the aging ear may be addressed concurrently with the aging face.

Incidence of earlobe ptosis and pseudoptosis in patients seeking facial rejuvenation surgery and effects of aging.

The authors have previously described a classification system for earlobe ptosis and have established a criterion for earlobe pseudoptosis. Earlobe heights were characterized based on anatomic landmarks, including the intertragal notch, the otobasion inferius (the most caudal anterior attachment of the earlobe to the cheek skin), and the subaurale (the most caudal extension of the earlobe free margin). The classification system was derived from earlobe height preferences as determined by a survey of North American Caucasians, and it identified the ideal free caudal lobule height range to measure 1 to 5 mm from otobasion inferius to subaurale (grade I ptosis). Also, earlobe pseudoptosis was defined by the attached cephalic lobule height measuring an intertragal notch to otobasion inferius distance greater than 15 mm. In this study, the preoperative earlobe height measurements of 44 patients seeking facial rejuvenation were evaluated. The average attached cephalic segment (intertragal notch to otobasion inferius distance) of patient earlobes measured 11.10 +/- 0.46 mm, and the average free caudal segment (otobasion inferius to subaurale distance) of patient earlobes measured 7.15 +/- 0.49 mm. Assessment of patient groups based on single-decade age differences demonstrated an increase in the free caudal segment (otobasion inferius to subaurale distance) with increasing age (p = 0.003). Assessment of patient groups based on single-decade age differences demonstrated no increase in the attached cephalic segment (intertragal notch to otobasion inferius distances) with increasing age (p = 0.281). When evaluating for the ideal otobasion inferius to subaurale distance, only 22.2 percent of earlobes demonstrated an ideal free caudal earlobe height (grade I ptosis). Moreover, pseudoptosis was detected in 12.3 percent of earlobes. Finally, a majority of earlobes demonstrated intrapatient variability, with only 16.2 percent of patients demonstrating identical attached cephalic segment (intertragal notch to otobasion inferius distances) and 37.8 percent demonstrating identical free caudal segment (otobasion inferius to subaurale distances) when compared with their contralateral ear. Plastic surgeons should be aware that a significant number of patients (77.8 percent of earlobes) may not possess an ideal free caudal segment and that 12.3 percent of earlobes may present with pseudoptosis. Therefore, earlobe height assessment should be an essential aspect of evaluation in patients desiring facial rejuvenation surgery. Evaluation of both ears should be performed independently due to intrapatient earlobe height variations. Finally, patients should be counseled with regard to the ideal earlobe parameters and aging patterns (stable attached cephalic segment versus increasing free caudal segment). With the natural progression of both facial rhytides and caudal segment earlobe ptosis (increasing free lobule segment) with increasing age, independent and accurate assessment of earlobe height is indicated so that the aging ear may be addressed concurrently with the aging face.

The aesthetic earlobe: classification of lobule ptosis on the basis of a survey of North American Caucasians.

North American Caucasian male subjects (n = 59) and female subjects (n = 72) were surveyed, to investigate earlobe height preferences that could serve as guidelines for aesthetic earlobe surgical procedures and reconstructions. Subjects were asked to rank their preferences for variously shaped earlobes in life-size-scaled sketched male and female profiles. Earlobe heights were varied on the basis of previously established anatomical landmarks, including the intertragal notch, the most caudal anterior attachment of the earlobe to the cheek skin (the otobasion inferius), and the most caudal extension of the earlobe-free margin (the subaurale). While the intertragal notch-to-otobasion inferius distance (range, 5 to 20 mm) and otobasion inferius-to-subaurale distance (range, 0 to 20 mm) varied, all other facial and ear anthropometric measurements were held constant. Each of the rank orders for the female and male facial profiles completed by the female and male subjects demonstrated statistical significance, as determined by one-way analysis of variance analysis of ranks (p < 0.001 for all four groups). No difference was noted between the two sexes' rank orders for either sex (p > 0.05). Therefore, analysis of the combined male and female preferences for each sex was completed with one-way analysis of variance analysis of ranks (p < 0.001 and p < 0.001) and a post hoc Dunn's test, to delineate significant preference differences between subgroups with respect to the intertragal notch-to-otobasion inferius and otobasion inferius-to-subaurale distances. Both female and male earlobe intertragal notch-to-otobasion inferius distances were preferred at either 5, 10, or 15 mm, more so than at 20 mm (p < 0.05 for all female and male comparisons). Furthermore, both female and male earlobe otobasion inferius-to-subaurale distances were preferred, in descending order, at 5 mm > 10 mm > 0 mm > 15 mm > 20 mm (p < 0.05 for all female and male comparisons). On the basis of the findings of this survey, the first classification of earlobe ptosis (based on otobasion inferius-to-subaurale distances), as well as a criterion for earlobe pseudoptosis (intertragal notch-to-otobasion inferius distance of greater than 15 mm), is presented. These findings suggest a role for independent assessment of the lobule length with respect to its anteriorly attached cephalad component (intertragal notch-to-otobasion inferius distance) and its free-margin caudal component (otobasion inferius-to-subaurale distance).

Implications for nasal recontouring: nasion position preferences as determined by a survey of white North Americans.

White North American men (n = 75) and women (n = 75) were surveyed to investigate gender specific preferences of nasion position, which may aid plastic surgeons in nasal shaping during rhinoplasty. The subjects were asked to rank preferences of various nasion positions from life-size, scaled, sketched male and female profiles. Nasion positions with regard to height (anterior projection) and level (vertical position) were altered, whereas all other facial and nasal anthropometric measurements were held constant. The nasion heights were drawn at 7, 10, and 13 mm anteriorly to the corneal plane, and the nasion levels were drawn at the supratarsal fold (ST), upper lid ciliary margin (CM), midpupil (MP), and lower limbus (LL). The rank selections made by the female and male subjects of both gender profiles demonstrated statistical significance, as demonstrated by one-way analysis of variance (ANOVA) of ranks (p < 0.001). Further analysis using a post-Dunn test was completed to delineate significant gender specific preferences for the aesthetic nasion level and height. Female nasion levels were preferred at CM or MP over LL or ST on the basis of female ranks, and at ST, CM, or MP over LL on the basis of male ranks (p < 0.05 for all comparisons). Additionally, female nasion heights were preferred at 10 mm > 13 mm > 7 mm anterior to the corneal plane on the basis of both female and male ranks (p < 0.05 for all comparisons). Male nasion levels were preferred at ST, CM, or MP over LL on the basis of both male and female ranks ( p < 0.05 for all comparisons). Male nasion heights were preferred at 10 mm > 13 mm > 7 mm anterior to the corneal plane by both male and female ranks (p < 0.05 for all comparisons). In summary, both the male and female subjects strongly disliked a low nasion height of 7 mm and a low nasion level placed at LL for both gender profiles. Both the male and female subjects were most particular concerning nasion height, preferring a 10-mm projection and strongly disliking a deeper 7-mm height for both male and female profiles. Both the male and female subjects were more tolerant of nasion level alterations. Whereas the male subjects tolerated nasion levels at ST, CM, or MP for either gender profile, the female subjects preferred only nasion levels at CM and MP for the female gender. Overall, these findings may lend support to recent trends in radix augmentation during rhinoplasty, especially among male patients.