Avoiding the "pixie-ear" deformity following face lift surgery by differential insetting and secondary intention healing.

[BACKGROUND] The "pixie-ear" deformity has been described by its "stuck-on" or "pulled" appearance, due to the extrinsic pull of the cheek and jawline skin flaps on the earlobe attachment point (O), the otobasion inferius. The tension results in migration of the earlobe attachment point from a posterior cephalad position to an anterior caudal position. Recently, the 2 components of the earlobe, the attached cephalic segment (I to O distance) and the free caudal segment (O to S distance), have been defined.

[OBJECTIVE] We describe a novel technique involving differential insetting of the cheek and jawline skin flaps to the earlobe and secondary intention healing to create an aesthetically pleasing cephalic attached segment.

[METHODS] Rhytidectomy was performed using an extended superficial muscular aponeurotic system (SMAS) technique along with jawline undermining. The earlobe soft-tissue-retaining ligaments to the mastoid were released to the level of the new otobasion inferius to creat a cephalic attached segment less than 1.5 cm, which allowed the caudal free segment to approximate 0.5 cm. Whereas the cephalic segment was directly repaired, the free caudal segment anterior and posterior skin flaps were not reapproximated and were to heal by secondary intention.

[RESULTS] In a series of 20 consecutive patients, excellent aesthetic results were obtained using this approach without healing complications, hypertrophic scarring, or "pixie-ear" deformity.

[CONCLUSIONS] Our approach for cheek and jawline skin flap fixation to the earlobe eliminates any vector of pull on the free caudal segment of the earlobe and, consequently, any potential for "pixie-ear" formation. We advocate allowing the free caudal segment to heal by secondary intention, which results in the medial edge of the free caudal earlobe attaining a curved and blunt-edged appearance that is aesthetically superior to primary repair.