Introduction

“I’m Dr. Elizabeth Kerner, and welcome to Plain Talk About Plastic Surgery, your source for all things related to plastic surgery operations, procedures, and interesting history.

Thank you for joining me for Episode Two, which is about “The Surprising Mysteries of the Earlobe.” 

We’re going to learn about the types of earlobe problems that would bring a patient to a plastic surgeon, the types of procedures that can be done on an earlobe, interesting tidbits about the history and lore of the earlobe, and the anatomy. 

Let’s get started.

What is the Earlobe Actually Made of?

First, let’s start with a little anatomy about the earlobe.  The earlobe is just a little dangly piece of flesh that hangs off the cartilaginous structure of the ear.  It is tissue that is covered by skin and has a very robust blood supply. 

Why does it exist?  Nobody actually really knows.  Most things that are attached to the skeleton of the body have a function; such as the nose, allowing you to smell, the eyes to see, the ears to hear.

Some scientists have theorized that the earlobe provides warmth because of the blood supply to the cartilage. I think it’s awfully small to provide any warmth, any substantial warmth, to the large cartilaginous structure.  Others have hypothesized that perhaps it helps to balance us when we walk and hold our head.  I also think it’s awfully small to provide any kind of a balance structure to the head, which is quite large in proportion to the rest of the body. 

As far as I can tell, its only purpose seems to be for support of body ornamentation. And throughout history that really seems to have been the earlobe’s function, which is to have earrings put into it.

Cosmetic Surgery and the Earlobe

So why would a plastic surgeon be concerned about the earlobe?  We see lots and lots of earlobe problems, with the most common being the torn, or split earlobe.  This occurs when a woman, or man, is wearing an earring that is too heavy for the size of the earlobe, and it eventually pulls through creating what is called the clefted earlobe, or the split earlobe. 

This can happen over time from a heavy earring or can occur more as an accident when a child pulls on an earring, or the earring gets caught on hair, or pulled down by the telephone.  I would say, this is the most common reason that women and men present to my office; which is to have repair of that torn piece of their lower earlobe. 

Also, earring holes can be placed too low and then the weight of the earring will pull through causing a cleft.  Of course in more recent times, use of the gauge earring has caused its own set of problems.  A gauge hearing is basically a cylinder that is put into the earlobe hole to gradually enlarge it until there’s quite a large opening in the earlobe.  It has been adapted really from the Maasai tribe in Kenya. 

I think this is a very unusual form of cultural appropriation for Americans, but in the Massai, the enlarged earlobe hole is considered a sign of beauty.

What other reasons do people call plastic surgeons and ask for procedures on their earlobe?  As we get older, earlobes begin to become a little more fleshy and elongated so that they can look out of proportion to the face.  This is commonly known as the ‘aging earlobe’. 

You can have a ‘pixy’ earlobe where your ear is attached more to the cheek; and I’ll talk a little bit more about that later because there are some studies about whether you have an attached or an unattached earlobe, and what it might mean. 

Some people develop keloids, or abnormal scarring in their earlobe from ear piercing.  You can have a folded upper earlobe with an abnormality of the earlobe as well.  That’s called a ‘lop ear’. 

Of course there can be skin cancers on the ear which are most common in men because they tend to wear ball caps and the ears are not as protected. 

And then a very serious type of ear problem would be microtia, and that’s a genetic condition where the ear just doesn’t develop.  That’s a very complicated and involved operation to create a new cartilaginous structure and cover it with skin and have it look like an ear.  Very few people in the country do microtia repair, and the results have become quite astounding, now that they’re beginning to culture cartilage in the laboratory to create the scaffold for the ear.

Aging and the Size of Our Ears

Most of us recognize that as we get older, or men get older, it seems like their ears get a lot bigger.  There have actually been some studies to try and scientifically corroborate this observation that most people have.  I know certainly looking at some older men you think, “Oh my gosh, those ears are just gigantic compared to their head.”

There has been some scientific research done looking at this phenomenon of the enlarging ear and men as they get older.  Surprisingly, they found that men really only had a 5% to 6% increase in the height of the ear.

In their study, they found that the length of the lobule stayed the same, but the width decreased.  And t was felt that perhaps it was gravity that was causing the cartilage to lengthen.  However, cartilage doesn’t really respond to gravity that way, otherwise, our nose would be tipped down to our chin by the time we were 80 years old.

So, I don’t really find that that study might be quite as reliable as it should be.  But their final conclusion was, over 50 years, men would gain about a half inch length on their total height of their ear.  Women get the same increase in the ear, it’s just not as noticeable because we tend to cover it with our hair or we have earrings on, so you just don’t see it as much.

Abnormalities of the Ear

I would say the most famous example of a long ear would be that of Buddha.  If you look at sculptures or paintings, pictures of Buddha, he’s always represented as having a pretty long ear, mostly because the lobule is quite long. 

Buddha is considered to be The Compassionate One and some scholars theorize that he’s depicted this way because with big, long ears, he’s able to hear all the sounds of the world.

In Buddhism, if a person has a long ear, it is considered quite auspicious.  It is indicative that you have wisdom and compassion, which is quite odd for us Western people, because big years in the Western world, oftentimes will get you taunted and called things like ‘Dumbo.’ 

Just a different way of looking at ears.

Well back to Buddha.  When he was young, before he became an ascetic, he was quite wealthy, and men in those days displayed their wealth through ear jewelry, so they would wear very heavy gold earrings and that was emblematic of their social status and how rich they were.

And so most people theorize that because he wore such big heavy gold earrings, as a very rich young man, that this stretched out his earlobes. 

And then once he renounced his wealth and became The Buddha, he still had elongated stretched earlobes, and this was just incorporated into all of the depictions of The Buddha.

Pixie ears are another kind of interesting abnormality of the ear.  You can have an attached earlobe which is when the earlobe doesn’t have much of a dangle to it.  So the whole bottom part of the lobule is attached to the cheek; and you can have an unattached earlobe. 

And if you go online, there’s all kinds of websites that look at celebrities and famous people and say whether they’re attached or unattached.  It was thought in the past that this was actually a genetic factor, but that’s been thoroughly rebuked or debunked and it really has nothing to do with anything. 

In plastic surgery, Pixie ears are usually an unfortunate occurrence from a facelift.  We do try when you’re doing a facelift to make the ear unattached so it has a nice little separation from the cheek. 

Sometimes with a facelift though, too much of the ear lobule will be sewn down to the cheek, and it gives what we call a pixie ear deformity.  That can be corrected relatively easy in the office just by cutting around the bottom and re-suturing it up at a little higher level.

Keloids and the Overgrowth of Scar Tissue

Keloids of the earlobe are when a person develops thick scar tissue where a piercing was.  This can occur either in the lobule, which is fleshy, which is most common; or it can occur up into the cartilage, now that cartilage piercings are more common. 

Keloids are just a huge issue and we’ll deal with that in another podcast in more detail.  Keloids are difficult to treat.  They are considered a tumor of scar. 

We don’t really know why people develop them.  You can get keloids in your earlobe and not have keloids elsewhere.  You can develop keloids on other parts of your body and they can be deforming and debilitating. 

For the earlobe, we tend to treat these first with steroid injections. The steroids will help the collagen to flatten out, and then compression earrings, which are basically screw on earrings that you would wear for an extended period of time. 

When a patient comes in and has a large keloid, so it looks like a bump on the ear, or I’ve seen them as large as even a grapefruit that’s hanging off of the earlobe, then those have to be cut out. 

When you cut a keloid out or remove it from tissue, there’s about a 50% chance that it will recur.  So if we have to surgically remove a keloid, we would immediately, or as soon as you’re healed and can tolerate it, have you wear a compression earring to help prevent this from coming back. 

If keloids are really terribly bad, also radiation can be done to that tissue, which will help to prevent the keloid from reforming.  Of course when you radiate an area, the issue would be in 20 years are you going to develop a cancer in that area?  So radiation is usually just reserved for those quite severe cases of keloid formation. 

I do encourage my patients that have keloids that have been treated in their ear, not to re-pierce because that’s almost a 100% certainty that that keloid is going to reform.

When I was in Uganda on a mission trip I saw massively huge keloids on the ear; incorporating the back of the ear, the cartilage of the ear, the lobule of the year, the neck, and of course other parts of the body. 

In many of those instances to adequately treat the keloid, we would have to remove all of the skin and then skin graft the ear.  It doesn’t look quite as normal, but surprisingly, with a skin graft, most of the time the ear will heal well, look relatively normal, and the keyboard won’t recur.

For most Americans, because we have access to good health care, I don’t tend to see keloids of that size or require that extreme of an operation such as a skin graft to treat them.  Usually just steroid injections, excision if they’re noticeable or dangly keloids, and then compression earrings.

Skin Cancer of the Ears

Skin cancer is quite common along the ear, especially along the outside rim, because it’s exposed to sun and men of course tend to wear ball caps and that just doesn’t give good coverage over the ears. 

If you really want to try and protect your ears from developing skin cancer, you should wear a larger wide brimmed hat, especially one that’s got an SPF protection.  There is a company called “Solumbra” that offers excellent hats with FDA-approved SPF protection. 

I have nothing to do with the company but they’ve been around for a long time and are a good source for sun protection clothing.

The procedures and operations to correct or to remove a skin cancer along the ear and to reconstruct it are as varied as the number of skin cancers that one sees.  Small ones can just be done in the office. Larger ones may require rearrangement of both the cartilage and the skin to close the defect.  And really large ones may require a piece of tissue from elsewhere. 

Either a graft, or what’s called a flap where tissue is connected to the skin behind the ear to provide coverage over the cartilage frame.  In severe cases of skin cancer it is sometimes necessary to remove portions of the year, which is always sad because it’s such a noticeable deformity. 

It is possible to have a prosthetic ear made in severe skin cancers.  The medical artists that do that are really nothing short of wizards, because these ears look quite normal, and unless you get up close, you really wouldn’t notice that it’s not a real ear. 

I would have to say seeing skin cancer in the lobule of the ear would be the least common area.  A skin cancer there I think would just be taken out by a wedge excision where we just take the wedge of skin which includes the skin cancer, and then close it up so you just have a little smaller earlobe that remains. 

Elongated Earlobes

This is also about what we do when someone comes in and complains of the aging earlobe or the elongated flabby earlobe.  In these cases extra tissue can be taken out in the earlobe either through the middle portion of the earlobe like taking a pie wedge out or along the edge, where we try and hide the scar. 

Decision of what sort of procedure would be done to fix the aging earlobe is mostly made looking at the ear, and where the redundancy is, and how it can be corrected with the least visible amount of scarring. 

The good news for that is most scars on the earlobe heal very well.  And with a little bit of time, especially ones that are either the wedge removal, where the scar is put right at the junction of the cheek, or is along the edge of the lobule – give it about nine to 12 months and it’ll be pretty hard to find that scar.

Famous Earlobes

I think that Carol Burnett has had a facelift, at least I’m pretty positive, but I often wondered if they had to do something to her earlobe.  As you will recall, she’s the one that would always pull on her earlobe. 

I can’t remember if it was right or left, as a little, “Hi, Mom, I’m here.  I love ya.”  She’s probably one of the more famous celebrities known for their earlobes. 

Vincent van Gogh is another famous person in history who’s known for his ears because he cut off part of his earlobe. Most of the paintings show that the bandage is on just the bottom part of the lobe, consistent with him having chopped off just a little bit at the bottom.

However, documents surfaced about 20 years ago from supposedly the doctor who treated his ear injury. And at that time, the doctor wrote that he had cut off the majority of the ear and only left a little bit of the earlobe behind. Now this is interesting because history since then says he just cut off a little bit of the earlobe.

And why would Vincent van Gogh to this?

Well, he was known to have major depression issues. His good friend, the painter Paul Gauguin, had come to Paris. And at some point after his arrival, Vincent brought up the idea of creating an artist colony in Arles where they were staying.

I hope I have not butchered Arles, and I’m not even going to try and say “Vincent van Gogh” the way the Dutch do, because it sounds like you’re spitting up a cat or something.

By any way of looking at it Vince’s mental health was tenuous. When Gauguin told Van Gogh he didn’t want to be part of the dream to start the artists colony, a terrible fight erupted and Gauguin packed his belongings and moved out of the famous little yellow house.

In his depression and despair, Van Gogh took a knife and cut off a portion of his ear. And to make it even more bizarre, he took the severed portion of the ear, wrapped it in paper, and took it down to the local brothel where he presented it to an 18 year old young woman named Gabrielle. She was a farmer’s daughter who was working there as a maid.

Other accounts say that he took it to the brothel and asked for a prostitute named Rachel to whom he gave his ear bit.

Either way, it’s quite odd.

The paintings that show the bandage on Van Gogh’s ear, when I look at them as a surgeon, show me that they’re on his right ear, because, of course, that’s what you see. But evidently, when a painter does a self portrait he automatically reverses it. So when you’re looking at it, it’s how he would be painting it in the mirror, and that’s his left ear.

I did not know that that’s how self paintings are done. I just assumed the artists would naturally flip it around.

You can get mirrors nowadays, that are called true mirrors, that will allow you paint a self portrait just the way other people will see you so it automatically flips your projection left to right.

In plastic surgery this is kind of interesting because in facelifts there are lots of studies to show that when you put two right sides of the face together and two left sides of the face together such as are often done in facelift studies, the person doesn’t look anything like themselves. This is a good way to point out to your potential facelift patient that they have significant asymmetries between the right and the left side of the face.

According to art historians, Van Gogh’s painting is consistent with him having cut off part of his left ear, I suppose we’ll never really know whether it was most of the ear or just a little bit of lobule but based on the doctor’s letter I would side with most likely he cut off the majority of his ear, and he just painted it the way he saw it in the mirror.

The oldest known human with a known elongated earlobe is Ötzi the Iceman.  He’s a frozen mummy who was found from 3,300 BC, I think, in the Scandinavian countries. 

He has very long earlobes and nobody has any idea why he would have long earlobes.  He certainly does not have earrings in and there’s no piercing.  So that will just remain a mystery I suspect forever and ever.

Frank’s Sign – An Amazing Link to a Serious Condition

And the last little medical tidbit I’ll give you about the earlobe is called ‘Frank’s Sign’ .  It is a known fact that when a patient presents and has a crease in their earlobe that they are at a higher risk of having coronary artery blockage.  This is named after a physician, Dr. Frank (Sanders T. Frank, MD) in 1973. 

There have been multiple studies that show that there is actually an association between a crease in the earlobe and heart disease.  It is a true correlation, it’s not just a chance finding, and nobody really knows why. 

They think maybe it’s that with coronary artery disease, there’s less blood flow out to the distant portions of the body like your fingertips and toes, and of course, the earlobe would be quite distant from the heart, and that that would cause it to crease because of damage to the blood supply.

This was historically felt to be associated with the death of Emperor Hadrian.  The bust of Hadrian, in multiple museums shows that he has a very clear earlobe crease.

Famous people right now that have it, I was just looking online.  George Bush has an earlobe crease, but you can also get an earlobe crease if your earlobe just gets kind of fleshy and dangly.  So I’m not quite sure how the cardiologists distinguish between the two. 

I did speak with a few cardiologists and they said, “Oh, yes, we look for Frank sign and that’s just one of those little telltale signs that you should probably do an angiogram on someone to see if they have underlying coronary artery disease.”

Who would have thought that the humble earlobe could be a predictor of heart disease? 

Cleft Earlobes

Lastly, I’ll talk about the cleft earlobe, which is what I see the most.  Usually it’s a woman she’ll come in and say, my earring tore through my earlobe and now I have a “V”.  Sometimes the cleft, or the hole, for the earring is just elongated what we call an ‘elongated cleft’. 

I fix those in the office.  We just numb the earlobe by putting a shot in and then the edges of the cleft, which are now skin, have to be cut off and then the earlobe is just sewn back together.  Depending on where the earring hole is, I normally will place a new earring hole so it’s not right on the scar tissue, because scar tissue is weaker and when you put an earring right above it, it will tend to pull back through again. 

Stitches surprisingly have to be in about 10 to 11 days because it takes the earlobe a little bit longer to heal.  Again, I think not as great a blood supply as say, your face which is got abundant blood supply; and the scar usually heals quite beautifully.

This is an extraordinarily common little procedure that’s done in the office.  Sometimes insurance will cover it because it is actually a repair of a laceration but it’s easy to do.  And we do ask if you’re having a cleft earlobe repaired that you bring in a very small stud earring, like a three millimeter little ball, because if you put a heavy earring on it’s going to interfere with the stitches healing on the earlobe.

Conclusion

So that’s about all that I have for you about the humble earlobe.

You can go to my website www.DrKerner.com/podcasts for other episodes and upcoming episodes, or you can subscribe to our newsletter to know when a new episode is available. And this is also on YouTube.

Thank you very much for listening to Plain Talk About Plastic Surgery. Have a great day and don’t forget to use your sunblock.”