Introduction

Physicians have addressed concerns about the signs of aging on the face, chest, neck, and hands, but maintaining the youthful appearance of earlobes is often overlooked. Unaddressed discordance between the rejuvenated face and aged earlobes becomes increasingly obvious. Over time, the effects of gravity and the volume loss that occurs with aging contribute to the elongated appearance of the earlobe. This can be exacerbated by the wearing of long, heavy earrings. Photoaging changes are also frequently seen on the earlobe. Earlobe restoration is frequently needed in patients who have facelifts and desire earlobes that match their new, younger looking features. The popularity and improvement in techniques of facial rejuvenation have drawn new attention to aging earlobes and produced a higher demand for earlobe rejuvenation procedures that can restore volume, minimize sagging, and renew texture and color.

Anatomy and classification of earlobes

The earlobe is composed of tough areolar and adipose connective tissues and lacks the firmness and elasticity of the rest of the pinna. Earlobes have a tendency to elongate slightly with age. The surgery literature places an emphasis on repairing the elongated earlobe to complement the youthful face after a rhytidectomy. As early as 1972, Loeb recognized the potential need for earlobe rejuvenation. He described the distance between the intertragal notch and the otobasion inferius (the anterior implantation of the earlobe to the cheek skin) as a parameter requiring evaluation (Fig. 24.1). In his observations, he noted a range of 1–2.5 cm between the intertragal notch and the otobasion inferius (attached anterior segment; Fig. 24.1) and advocated correction when this distance exceeded 2.0 cm. A large study by Azaria et al (2003), which focused on the anatomy of the earlobe, used a line of balance through the long axis of the ear and measured the earlobe length based on the distance from the intertragic notch to the caudal tip (Fig. 24.2). The study consisted of 547 adult subjects ranging in age from 20 to 80 years. The subjects included 383 women (70%) and 164 men (30%). The average length of the left earlobe was 1.97 cm and that of the right earlobe 2.01 cm. From the data, the earlobes are naturally found to be slightly asymmetrical, which becomes clinically relevant so that the practitioner carefully assesses the size of each earlobe prior to treatment. Another study suggested that a complete assessment of earlobe height requires accounting for the entire lobule length as designated by its two components: the attached cephalic segment (the intertragal notch to otobasion inferius distance as described by Loeb), as well as its free caudal segment, which is the otobasion inferius to subaurale distance (see Fig. 24.1). Both measurements can be taken into consideration; however, it is more common to measure the earlobe length from the intertragal notch to the subaurale.

Figure 24.1 The anatomical landmarks of the intertragal notch (I), otobasion inferius (O), and subaurale (S) are labeled. Earlobe height parameters are defined with respect to the attached cephalic segment (I to O segment) and the free caudal segment (O to S segment).

Figure 24.2 Measurement technique of earlobes: line of balance (line A) and earlobe length (line B).

The shape of the earlobe is normally smooth but occasionally exhibits creases. Creased earlobes are associated with genetic disorders, including Beckwith–Wiedemann syndrome. Recently, diagonal earlobe creases have been associated with an increased risk of heart attack and coronary heart disease. However, since earlobes become more creased over time and heart disease is more common among the elderly, age may account for the findings linking heart attack risk to earlobe creases. The earlobe shape can be classified as being attached or unattached (Fig. 24.3). The unattached earlobe is controlled by a dominant gene, while the attached earlobe is inherited in a recessive pattern. Patients with the attached pattern have a lesser tendency to experience elongation.

Figure 24.3 Anatomical shape of earlobes: (A) unattached and (B) attached.

Use of fillers for earlobe rejuvenation

Fillers used for soft tissue augmentation are becoming increasingly popular to restore volume loss in the earlobes. These include hyaluronic acid derivatives such as Restylane (Medicis Aesthetics Inc, Scottsdale, AZ), Juvéderm (Allergan Inc, Irvine, CA), and Juvéderm Ultra (Allergan Inc, Irvine, CA). Longer lasting fillers such as calcium hydroxylapatite (Radiesse, Merz Aesthetics, San Mateo, CA) and poly-l-lactic acid (Sculptra, Valeant Pharmaceuticals, Bridgewater, NJ) also can be used; however, their use has not been reported in the literature.

Since the earlobe is a small area and often needs great volumes, it is easier to use larger needles that allow the gel to flow faster and also result in less resistance to the procedure. One method described is to use topical anesthesia prior to the injection, remove the anesthesia with an antiseptic, and then use a 27-gauge -inch (1.25 cm) needle for the injections. The author recommends placing the needle into the mid-dermis at a 30–45° angle to fill the earlobe. The suggested techniques include a series of small injections or a threading technique where the needle is withdrawn as the hyaluronic acid is injected. After the injection, the earlobe can be gently massaged to evenly distribute the product.

Pearl 3

Fillers, especially hyaluronic acid products, can be injected directly into the earlobe to correct the volume loss.

Another technique is to cleanse the area with an antiseptic solution and then apply ice for approximately 1 minute to decrease the blood flow and for the anesthetic effect. The author describes grasping the earlobe firmly between the thumb and the index finger then slowly injecting small droplets of hyaluronic acid (Restylane or Juvéderm Ultra) in a circular pattern around the piercing hole. This method will tighten the diameter of the hole and then move outward to fill the entire lobule. After injecting, firm pressure should be maintained for about 1 minute to minimize bruising and edema.

In our experience, topical anesthesia is not usually necessary, especially with the use of hyaluronic acid formulations that contain anesthesia. Needle gauge is up to the injector’s preference. We use between 27- and 30-gauge needles depending on the product selected, the patient, the earlobe, and the injector. The injection can be made from the inferior pole of the earlobe as a depot injection and then massaged into place (Fig. 24.4). The exact volume depends on the amount of volume loss. We have found that use of hyaluronic acid in the earlobes tends to last longer than its placement in the face.

Figure 24.4 Injection technique using Restylane^®-L (Medicis Aesthetics Inc, Scottsdale, AZ) to restore volume from the inferior aspect of the earlobe in a patient who has previously had earlobe repair surgery.

As with other soft tissue augmentation, there is a risk of bruising, swelling, prolonged erythema, and need for repeat injections to maintain results. Owing to the earlobe’s rich vascularity, the lobule can appear red and edematous for a prolonged period of time. Patients can resume wearing earrings immediately after the procedure and the earlobe can be reassessed after 2 weeks to address the potential need for more product.

In addition to soft tissue augmentation, other methods can be used to rejuvenate the earlobe. Little has been written on earlobe photoaging, but wrinkling and discoloration of the earlobes are frequently seen with aging. The skin of the earlobes is forgiving and responds to laser and light devices that are often used for retexturing and for treating dyschromia. Q-switched lasers and intense pulsed light treatments are highly effective for sun-induced earlobe discoloration. Laser resurfacing with non-ablative and ablative fractional laser devices is highly effective in improving earlobe texture.

Conclusion

There is an increasing emphasis on earlobe rejuvenation to address volume loss and sagging in order to maintain a youthful appearance. Earlobes can be corrected through surgical intervention, but also with fillers that are commonly used for soft tissue augmentation, such as hyaluronic acid. This appears to be a well-tolerated procedure that can reverse the signs of aging.