A surgical approach for earlobe keloid: keloid fillet flap

Earlobe keloid can form after cosmetic ear piercing, trauma, or burns, and it poses several difficulties in treatment and distinctive cosmetic implications. Treatment methods for earlobe keloids include both surgical and nonsurgical methods. After excision of the earlobe keloid, healing by secondary intention, primary suture, skin graft, or local flap has revealed some disadvantages. The authors approached this problem with a new excision and covering method. The surgery was performed under local anesthesia. Skin over the keloid was dissected from the keloid mass as a flap, which they termed a "keloid fillet flap," and the keloid mass was completely removed. Subcutaneous sutures were not used, and the keloid fillet flaps were closed with 6-0 nylon sutures after trimming. Other intraoperative or postoperative preventive procedures, such as steroid injection, pressure device, or irradiation, were not applied primarily. In the period from May of 1999 to October of 2000, nine earlobe keloids in eight patients were treated with this protocol. One patient had bilateral keloids. Of the eight patients, there were six women and two men, ranging in age from 21 to 61 years (mean age, 28.5 years). The causes of keloids were ear piercing in six cases and trauma in three cases. The largest lesion was 3 cm in its greatest dimension, and the smallest was 1.5 cm (mean, 2.3 cm). All flaps survived completely. There were four cases of recurrence. Seven cases, including two recurrences, showed good results. The authors believe the recurrence of earlobe keloid was closely related to the method for coverage of the defect after its surgical excision, and the "5 As and one B" (Asepsis, Atraumatic technique, Absence of raw surface, Avoidance of tension, Accurate approximation of wound margin, and complete Bleeding control) are important factors in reducing the recurrence rate of earlobe keloids in surgical excision. The authors' protocol is very effective in closing the defect after surgical excision of earlobe keloids and offers many advantages over other surgical approaches. The recurrence rate of earlobe keloid may be lower than in their results if other intraoperative and postoperative treatment procedures are combined with their protocol.     

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.     

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.     

Surgical techniques for a deep concha, a pseudomeatus, and high projection in congenital microtia

Some modified surgical techniques are described for constructing a deep conchal cavity and pseudomeatus and obtaining high auricular projection in congenital microtia. At the primary operation, a rather small portion of the microtic vestige is utilized for the lobule by switching, sparing the skin for the concha, with no free skin graft used. For higher projection of the auricle, three-dimensional transposition of a retroinfraauricular flap together with cartilage pieces underneath is applied to the cephaloauricular sulcus. A deep conchal cavity is constructed by further removal of the soft tissue there, transplantation of a cartilage for building a high posterior wall of the concha. The external meatus is successfully imitated by transplantation of a cone-shaped composite graft taken from the cymba of the opposite ear. The retroinfraauricular flap, the reconstruction of a deep concha, and the composite graft technique were successfully used in 55, 16, and 11 ears, respectively.     

Lower auricular malformations: their representation, correction, and embryologic correlation

Seventy-seven lower auricular malformations in 74 patients treated during the last 6 years were analyzed. Sixty cases (77.9 percent) were of malformations involving the earlobe; 54 cases involved the earlobe alone, and 6 cases were of complex deformities involving the earlobe and adjacent helix and/or tragus. Cleft earlobe was the most common lower auricular malformation (49 cases, 63.6 percent); four subtypes and their corrective methods are described. Cases of complex earlobe malformations, corrected by fabricated costal cartilage and expanded skin flap, are presented. A question mark ear (5 cases, 6.5 percent), a malformation with an ectopic anthelical fold (5 cases, 6.5 percent), and a malformation with a lower conchal stria (5 cases, 6.5 percent) are considered to be major lower auricular malformations. An attempt has been made to correlate the presented malformations with the embryologic-fetal development of the auricle. It is suggested that "clefting" ear malformations such as the cleft earlobe, the question mark ear, and the ectopic anthelical fold deformity may provide clues to understanding the embryologic-fetal development of the human auricle. It appears that hillocks 1 and 6 produce the earlobe and that hillock 4 or 5 produces the anthelix or helix.     

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.     

Long-term survival of a free split-thickness skin graft on a large seroma

A free skin graft about 12 cm in diameter transplanted after excision of a Bowen's carcinoma on the back totally survived for a long period on seroma and was confirmed to have revascularization from the host skin margin. Repeated evacuations of the fluid and subsequent pressure dressings failed to cause adherence of the graft to the bed, even on the thirty-ninth postoperative day. Histologic examination of the graft and the bed revealed partial epithelialization on the face-to-face surfaces, to which no adherence was attributed. The incomprehensible phenomenon in this unusual clinical case evokes a new interest in the mechanism of free skin graft survival, particularly in the phase of serum imbibition.     

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).     

Leave the fat, skip the bolster: thinking outside the box in lower third nasal reconstruction

Defects of the lower third of the nose often present especially challenging reconstructive dilemmas. The surrounding skin to match is often thick, sebaceous, and sun damaged, none of which characterizes the historically ideal periauricular donor skin for grafting. The surrounding nasal skin is quite stiff, precluding very small local flaps. To avoid the "misplaced patch" appearance of most classic full-thickness grafts to this area or the depressed scar of an elliptical excision, many surgeons turn to larger local or regional flaps. These provide not only skin color and texture match but also the necessary several millimeters of subcutaneous fat necessary for proper tip aesthetics. Many defects of the lower third are small, making many surgeons reluctant to employ these larger flaps with their long scars and potential to twist or distort delicate tip or ala anatomy. The author has sought a means to transport skin and subcutaneous fat for lower third nasal defects outside of flaps. On the basis of the superiority of nasolabial fold scars and a vast positive experience in the literature utilizing skin and fat composite grafts with no bolsters, the author applied these techniques to 33 lower third nasal defects in 29 patients. Of 33 grafts varying in size from 4 mm circular to 17 mm x 16 mm and retaining 1 to 5 mm of fat, no grafts were lost. Four grafts developed a 30 percent area or less of central necrosis resulting in localized depression. Three of these four grafts were in active smokers and the fourth graft was in a former smoker. Aside from these four grafts and one with considerable excess fat early in the series, contour was good to excellent. Hypopigmentation is still common but improves with time. Easily performed composite grafts effectively carry the necessary fat for aesthetic reconstruction and do not risk long scars on the nose and twisting of the tip and ala that can result from flaps. Revisions are infrequent and extremely simple when indicated.     

Lymphedema of the eyelids

Lymphedema of the eyelids is a relatively rare condition whose main effect is to obstruct vision, and it is unsightly. We present 3 cases in which the edema was treated by excision and skin grafting of the eyelid, with satisfactory functional and cosmetic results. It is suggested that a split-skin graft be used for the upper eyelid and a full-thickenss graft for the lower eyelid. The lower eyelid skin can be "de-fatted" and used as a graft, but in the more severe cases we suggest a postauricular skin graft be used.     

A challenge to the undefeated nasolabial folds

Previous attempts to improve the nasolabial folds have been disappointing. By extending the face lift skin dissection to the nasolabial fold and up onto the malar prominence, reducing the fat of this fold by excision, and applying direct posterior retraction to the freed facial skin, rather dramatic improvement in the nasolabial folds have been achieved. This is a preliminary report with a follow-up of 8 months or less.     

Facial resurfacing in xeroderma pigmentosum with monoblock full-thickness skin graft

A case of xeroderma pigmentosum with multiple skin tumors on the face that was treated with total excision and replacement of face skin except the eyelids with a monoblock full-thickness abdominal skin graft is reported. The quality and tumor-free features of the monoblock full-thickness skin graft in xeroderma pigmentosum are indicated. Despite the increased morbidity of the donor region, the radical surgical approach advocated here has improved the prognosis in the case reported.     

Free tongue composite graft for correction of a vermilion defect

A case report of hemangioma of the vermilion border treated with excision and free composite tongue graft is presented. A technique of lip reconstruction utilizing a composite tongue graft in one step has been described. It constitutes an improvement over the tongue pedicle flap technique, which has been hitherto used and requires two stages. The indications and limitations of the technique have been discussed.     

Morphometry of the adult human earlobe: a study of 547 subjects and clinical application

The purpose of this study was to define the factors that influence earlobe length and to establish a standard for adult earlobe length by sex and age. The study sample consisted of 547 adult subjects older than 20 years of age. A randomized, prospective design was used. Patients with malignancies, previous surgery or trauma to the earlobe, or congenital earlobe anomalies were excluded. The following variables were studied: sex; age; ethnic origin; skin complexion; height, weight, and body mass index; and piercing. Pearson's correlation, analysis of variance, t test, and multiple regression analysis were used for the statistical analysis. There were 383 women (70 percent) and 164 men (30 percent) aged 20 to 80 years. The average length of the left earlobe was 1.97 cm (SD, 0.42 cm), and that of the right earlobe, 2.01 cm (SD, 0.42 cm) (p < 0.0001). A post hoc test revealed a statistically significant difference among the three age groups (20 to 40 years, 40 to 60 years, and >60 years) in both men and women. Pendulous earlobes were significantly longer and less symmetrical than nonpendulous ones by t test. In men, nonpierced left earlobes were longer than pierced lobes; in women, there was no significant difference between pierced and nonpierced ears. Pearson's correlation tests for weight, height, and body mass index showed that only weight had a significant effect on earlobe length, and only in women. Analysis of variance for ethnic origin and skin color revealed a longer left earlobe in Ashkenazi and Sephardic Jews compared with Ethiopian, Asian, and American Jews and Arabs and a short earlobe in blacks compared with dark and fair-skinned people. On multiple regression analysis, sex and age were the only factors that contributed to earlobe length. A table of average earlobe length by age was formulated on the basis of the authors' findings. These data, together with the knowledge that earlobe length changes little in women over 40, that earlobes are not symmetrical, and that right and left nonpendulous earlobes are symmetrical in individual patients and shorter than pendulous earlobes, can assist the plastic surgeon in deciding on the proper time for loboplasty. The preferable technique is creating a nonpendulous earlobe to minimize the chances of further elongation with time.     

The focal differentiation of pigment cells.

A study has been made of the normal development and of the regeneration after excision of the groups of large pigment cells which form the spotted skin pattern of the gecko Eublepharis macularius, together with the effects of neonatal graft transplantation on this pattern. The results all indicate strongly that such groups of specialized pigment cells are not clones but the product of an induction process. This is then compared with the neural reflex mechanism by which the skin pattern of Chamaeoleo dilepis is formed.     

Short-scar face lift with extended SMAS platysma dissection and lifting and limited skin undermining

In the past 8 years, short-scar cervicofacial rhytidectomy has been used with great success and a high level of patient satisfaction. The operation involves limited incisions in the sideburn and preauricular areas, extending just around the fold of the ear lobule. Extensive undermining of the superficial musculoaponeurotic system (SMAS)/platysma is performed, and lifting of the face and neck is performed mainly at this level. Skin undermining is kept to a minimum, eliminating the need for extended incisions to reduce dog-ears. The preservation of fibrous bands between the skin and the SMAS/platysma unit is an important factor in making such an operation practical and is the reason why the skin incisions can be kept short. Dissection of large areas of skin and separation of the skin from the underlying SMAS necessitate larger incisions. The operation is safe, speedy, less traumatic, and well tolerated among patients at high risk, such as smokers. The risks of complications are also reduced with this operation.     

Precision in breast reduction

Precision in the design and performance of a breast reduction can be enhanced by careful formulation of the criteria. The breast cone should incline about 15 degrees medialward. The intersection of the midshoulder (anterior iliac) spine line with the inframammary fold offers a reference point for horizontal localization of the nipple. The nipple-suprasternal notch length, the diameter of the areola, and the nipple-inframammary fold length are determined by the height of the patient and the size of the brassiere cup. On this basis, a table for breast reduction can be drawn up that gives these dimensions for a given height and size of brassiere cup. Other important factors include the stretch direction of the skin and the course of the nerve to the nipple. A distinction is made between radial segment conization and anterior tangential conization. Criteria and measurements were incorporated into a technique comprising anterior tangential excision of glandular tissue and limited inferior radial segment excision of skin.     

Presuturing--a new technique for closing large skin defects: clinical and experimental studies

We have developed a new technique termed presuturing for aiding in the closure of large skin defects which may have otherwise required a skin graft or flap. This technique is based on biomechanical properties of skin (creep, stress relaxation) which allow skin to stretch beyond its inherent extensibility. Presuturing is performed under local anesthesia and consists of plicating intact skin over the area of planned excision the night prior to operation. Experimental studies in a pig model showed the decrease in force required to close a standard-sized wound to be 40.1 percent less than control (p less than 0.001). Fourteen patients who underwent wide excision of skin lesions had their wounds presutured. All but one wound could be closed primarily without undermining. Presuturing seems to be an easy and clinically useful technique in aiding the primary closure of large defects.     

What is the appropriate management of tissue extravasation by antitumor agents?

Review of 175 patients sustaining extravasation of an antitumor agent showed that most (89 percent) can be managed immediately with intermittent application of ice (15 minutes four times daily for 3 days) and close wound observation. We consider pain, usually associated with varying degrees of skin involvement, to be the only indication for surgery. Such a procedure should consist of wide, three-dimensional excision of all involved tissue, temporary coverage with a biologic dressing, and simultaneous harvesting and storage of a split-thickness skin graft. Once the wound is clean, delayed application of the graft is performed (usually at 2 to 3 days). Not only will this result in immediate pain relief and provide safe wound coverage, but it also will not interrupt the patient's chemotherapy schedule. Most patients were able to be restarted on their chemotherapy shortly after surgery, and none demonstrated a "recall phenomenon."     

A morphometric study of the external ear: age- and sex-related differences

The human ear is a defining feature of the face. Its subtle structures convey signs of age and sex that are unmistakable yet not easily defined. With analysis of normative cross-sectional data, this study explored anatomic and aesthetic differences in the ear between men and women, as well as changes in ear morphology with age. A total of 123 volunteers were randomly selected for this study. The cohort consisted of 89 women ages 19 to 65 years (median age, 42 years) and 34 men ages 18 to 61 years (median age, 35 years). The average total ear height across the entire cohort for both left and right ears was 6.30 cm, average lobular height was 1.88 cm, and average lobular width was 1.96 cm. As expected based on head size, significant sex-related differences were noted in the distance from the lateral palpebral commissure to both the helical root and insertion of the lobule. Measured distances in both vectors were approximately 4.6 percent longer in men than in women. Similarly, the height of the pinna was significantly larger in men than in women by approximately 6.5 percent. The average height and width of the lobule, however, were nearly identical in men and women. Analysis of age-related data showed a significant difference in the total ear height between the subpopulations; however, this difference was not significant after the lobular height was subtracted from total ear height, suggesting that the lobule was the only ear structure that changed significantly with age. In addition, lobular width decreased significantly with age. This study establishes normative data for ear morphology and clearly demonstrates the changes in earlobe morphology that occur with advancing age.