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Dr. Yang Explains... Pixie Ears

Dr. Yang Explains... Pixie Ears

Postby MillenniumFPS » Tue Nov 20, 2007 2:42 pm

Dr. Yang Explains... Pixie Ears: What are they? How do you fix it?

What is a Pixie Ear?
A Pixie Ear is a specific term for a pulled down earlobe from a facelift. The earlobe is pulled down from its original position, from over-removal of skin or from relaxation or release of the SMAS/platysma (tough muscular/connective tissue that supports the face and necklift results). The over-excision of skin is the obvious reason for pixie ears; however, if you look carefully at the original position of the ears after a facelift, many times the earlobes are in a good position. Later on after the initial tightness of the face and necklift loosens up, the earlobes begin to migrate downwards. At the same time the incisions behind the ear which may have been flat initially begin to thicken and form cord-like scars behind the ears.

What does it look like?
Image
This earlobe is moderatedly pixied. In a very severe pixie ear, the earlobe and jawline can form an almost continuous line. You can see in this example how it does not form a line, but if the earlobe were pulled down another 1/2" it would look that way.

Let's look at the shape of a normal ear.
Image
Notice that the ear lobe is set back from the long axis of the ear about 15 degrees.

Now let's look an average facelift incision and earlobe placement.
Image
The part that I like is that the tragus itself maintained some of it's "roundness" and is not flattened like some of the examples that I showed in my other post Dr. Yang Explains... Pre- vs. Post- Tragal Incisions. The part that I don't like and is not a fault of the surgeon, but of the technique itself. The incision behind the cartilage (post-tragal incision) causes a loss of the "little dip" in front of this cartilage (face lift specialists have special technique to try to maintain this "dip". If you look at my prior post, some people naturally have a flatter ear cartilage (tragus) so the lack of a "little dip" is not apparent. However if the cartilage sticks out more, the lack of the "dip" becomes more apparent. The earlobe is slightly pulled down, but would not be considered a pixie ear, in fact it would be considered par for the course. The last thing I want to point out is that the skin on the ear itself is different from the skin on the face. Look closely at the left photo. The skin on the ear is like baby skin with a slight peach fuzz on it. The skin on the face has larger pores and is visibly different from the ear skin, in face you can see a transition of the skin about 1/8" from the front of the ear.

Compare that to one of my facelift incisions.
Image
I have tried different facelift techniques, which also cause the same problems as seen in the pixie ear example. However, but understanding why this happens, I have changed my technique to consistently get the result you see above, by avoiding the "snap-back" phenomenon which I have observed in my earlier facelift patients. This is related to lifting the neck (neck-lift) from behind rather than repositioning and reshaping the front of the neck.

The "snap-back" phenomenon also may explain why people get pixie ears and also why most people who have had facelifts have a thicker scars behind the ears relative to in front of the ears. (Why some FL scars in front and some behind ears?)

Let's look at the other ear of the same patient which does have a pixie ear (Uneven earlobes.)
Image

Was the ear intentionally pulled down?
Image
No, look at the photo on the right. The surgeon did set back the earlobe about 15 degrees, but why did this happen?

Now that we look at the same photo again, we can see that the surgeon did not remove too much skin, and also set back the earlobe about 15 degrees. The part that was not anticipated is the "snap-back" or rebound effect in which the neck muscle fibers try to return to its natural position thus pulling the skin of the neck, as well as the earlobe down and forward with it.
Image

How do you fix it?

Now that we understand what caused it, we do not want to repeat the same mistakes caused it in the beginning. For example, some people get both pixie ears and bad scarring behind the ears with all types of facelifts, however, if the same technique is used and even more skin is removed, the same thing will happen, except even worse!

The simplest repair of the pixie ear is called a V-Y advancement.
Image
Image Credit: http://www.maitrise-orthop.com/corpusma ... r_us.shtml

ImageImage
The incision is performed around the earlobe and the earlobe attachments are freed up and pushed upwards toward the base of the ear. The open part of the incision where the pixie was is then sewn together which creates a short scar below the earlobe. The visible scar below the earlobe is the drawback of this type of repair, it is also the simplest, and should not take more than 15-20 minutes to perform.

The second method which is my preferred method to repair the pixie ear is by first performing a proper corset platysmaplasty necklift and freeing up the entire neck skin. Since most of the skin was already removed, most likely very little to no additional skin would be removed other than the thin white scar that we see at the base of the earlobe. The skin is then pulled up behind the ear which allows the base of the earlobe to be lifted up without creating a scar under the earlobe. The drawback of this procedure is that it requires a full necklift procedure to be performed instead of a small scar revision.

ImageImage

Why are the earlobes uneven?
Since a facelift and necklift is a two sided operation, both sides are not tightened simultaneously. The first side is tightened as much as possible, and the skin is trimmed and sewn closed before the second side is begun. Usually the muscle is tightened a more on the first side as well as more skin removed from the first side than the second side. I suspect that if one earlobe is lower, it would be the first side of the facelift that was performed.

I will post a follow-up explanation of why Pixie ears occur in relation to the type of necklift along with why thickened scars behind the ear occur in relation to the type of necklift.

Dr. Yang Explains... Why necks fall after a face/necklift, Pixie ears, and Thickened scars behind the ears

Best,

Dr. Yang

www.GeorgeYangMD.com
www.Twitter.com/GeorgeYangMD
www.Facebook.com/GeorgeYangMD
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My online posts are not a substitute for a physician evaluation and examination and should not be considered as medical advice.

Private inquiries: info@nycface.com
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Postby barbara741 » Mon Nov 26, 2007 1:55 am

those are great picturee..hope they help someone.
had millennium lift.DR.GEORGE YANG 3/12/07.

http://www.makemeheal.com/pictures/view ... bumid=2797
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Postby traci46 » Mon Nov 26, 2007 11:25 am

I had a Pixie Ear repair in 2003 by another plastic surgeon who had done repair on another woman's ears, whom I met. They looked just great, after the repair, but now, at 4+ yrs. later, they seem to be "pixied" again. I am distraught at this happening after paying more for this to be corrected. Luckily I wear my hair in a way that covers them, but it's the idea of it all that really bothers me.
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Postby YourOwnChoice » Tue Nov 27, 2007 7:25 am

I have made this a "sticky note" as it is excellent information for ones researching.
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Postby atlanti » Tue Dec 04, 2007 8:10 am

Dr Yang

Do you have a percentage figure on the "snapback" phenomenon and if so, at what stage does it usually occur?
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Percentage figure for "snapback" phenomenon

Postby MillenniumFPS » Mon Dec 10, 2007 2:45 pm

Hi atlanti,

Sorry about the delay. I tend to skip the Stickies section, unless I get an email notifying me that there has been a new posting to this thread.

I don't know the percentages for the snapback phenomenon, but I personally believe that it is higher than we think. In order to define what we mean by falling, we need to define three things that people want to improve: 1. Turkey neck (central fat ?muscle bands), 2. muscle bands, 3. double chin (lots of fat under the chin). If a patient has one of these three issues, I believe that the "snap-back" will happen to all three cases, assuming no liposuction or platysmaplasty is performed. I'm sure we could find several plastic surgeons to dispute this, so please take what I say with a grain of salt. These are my opinions only.

Liposuction under the chin/neck
If liposuction is performed under the chin, the liposuction itself is what is "lifting" the neck, and creating a nice profile contour as seen in several of examples on MMH, one example that comes to mind is Gayla's facelift with under chin liposuction. Does it work? Yes, for the right diagnosis. Why does it work? The liposuction treats the extra fat, and the face/necklift treats the extra skin. So to any dermatologist and cosmetic surgeon who is venturing into facelift surgery, it seems like an easy procedure.

It does seem easy, until they start uncovering the platysmal bands which can make the neck look worse than before the liposuction. Also, within a few years after the liposuction under the there may be early formation of muscle bands, because most of the fat that covered the front edge of the platysma muscles has been liposuctioned away. The early formation of muscle bands. Postoperative platysmal band deformity. A pitfall of submental liposuction F. M. Kamer and J. J. Minoli http://archotol.amaassn.org/cgi/content ... /119/2/193

If this bothers the patient they end up needing a platysmaplasty, possibly a full necklift anyway. So, no matter how I try to avoid treating the neck muscles, I end up having to do them either now or later. So, I choose to perform them with their main procedure, so that they only need to have one recovery.

Treating platysmal bands from behind the ears: Early Returns, Later Returns

Early Returns
If the SMAS/platysma in the neck is folded up (SMAS plication) to behind the ear, it does give an immediate improvement to the neck. In fact, if the surgeon does not "grab" the actual platysma, but some fat in the area, the neck does not improve when the surgeon is pulling/lifting. So plicating the platysma behind the ears does seem to hold up the neck, but in my experience for about 6-8 weeks and this is with using permanent sutures. When I have performed my own touch-up necklifts and I check on the previous permanent sutures, they are loose and not holding anything up. I no longer use permanent sutures because it is actually your own collagen and scar tissue which will hold up the facelift not the permanent sutures. Why are "new" minifacelifts still being invented pulling from the sides with permanent sutures? They may not have done enough facelifts or followed them long enough to realize that it is not working. Is the Millennium Lift a mini-facelift? No, by definition if a full necklift is performed with the facelift it becomes a "traditional facelift," but it can be performed under local anesthesia like a mini-lift, so this makes it more accessible for people who are afraid of undergoing general anesthesia or even twilight for their facelift.

Later Returns
If the platysma is identified and lifted up in a "deep-plane" fashion, this creates more scar tissue or "glue" which can hold up the lift much longer. I don't have any statistics for this type of necklift, but I believe TwinL had a more extensive type of SMAS lift and her muscle bands (platysmal band) were improved for 6 months before they reappeared. Since it lasted beyond the 2 month mark, I assume that the platysma work was more extensive, but no lipo or formal platysmaplasty was performed. Will some necks hold up this this type of necklift? Most likely, but I don't have any percentages for this technique. We would have to find a plastic surgeon who does not believe in platysmaplasties and ask that surgeon.

Best,

Dr. Yang

www.GeorgeYangMD.com
www.Twitter.com/GeorgeYangMD
www.Facebook.com/GeorgeYangMD
Google+

My online posts are not a substitute for a physician evaluation and examination and should not be considered as medical advice.

Private inquiries: info@nycface.com
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Postby atlanti » Tue Dec 11, 2007 5:52 am

Thank you - this is very informative and educational. Would you also be able to give an opinion on Baker's lift - since he is such an experienced and successful surgeon I wondered how his lift holds up!
Many thanks
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Postby Elaine » Sat Dec 22, 2007 4:35 pm

Pixie ears are not a bad thing. Not everyone who has pixie ears has had surgery. I was born with them and I rather prefer the look on me. I am happy that it did not change much from the fl. It's all what one is used to and of course, beauty is in the eye of the beholder..
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Attached Earlobes are not Pixie Earlobes

Postby MillenniumFPS » Sat Jan 12, 2008 8:16 am

Hi Everybody,

I want to clarify the difference between attached earlobes and pixie ears. If you have attached earlobes, that is not the same thing as a pixie ear. Attached earlobes look fine, but pixie ears do not. This is not an eye of the beholder thing, ask any facelift patient who ended up with a pixie ear(s).

In my prior posts, I did not discuss the two types of earlobes.
Image
_Attached Earlobe_ | _Free (Detached) Earlobe

I found a survey regarding attached earlobes when looking for a photo example. This survey was performed at a high school as part of a biology project. They posted their results on the internet. Although the sample size was small, the ratio of Free earlobes to Attached earlobes was 2 to 1. Link to the study: http://www.jbhs.k12.nf.ca/biology/EARS.HTM

Earlobe reductions are performed for women who have large detached/hanging earlobes, and they wish to have smaller more attached earlobes. This can be performed at the same time as a facelift. I do have a couple of patients who I have performed this procedure with their facelift, but I do not have their permission to show their photos on the internet.

Pixie Ears are not Attached Earlobes
A pixie ear is a specific earlobe deformity related to facelifts. Both an attached or a hanging earlobe can become "pixied." The worst case pixie ears look like the earlobe blends in with the jawline.
Image
Image Credit: http://www.otohns.net/images

You can see how this may have some resemblance to the an elf or a pixie
Image

Although the earlobe is not attached to the jawline you can see how the elongated line along the lower part of the ear make the top part of the ear appear pointier, because the ear is out of balance.Note in this man wearing the pixie ear attachment, actually has attached earlobes. Notice how his ear lobe is not on the same plane as his jawline as in the above example of a facelift pixie ear. Attached earlobes don't have the stigma of having had a facelift.

Whether an attached earlobe looks better than a free earlobe is a "beauty is in the eye of the beholder" thing. God made your ears the way they are. As a facelift surgeon, I don't want to change that, my job is to put things back the way that I found them.

Hopefully this helps to clarify things more.

Best,

Dr. Yang

www.GeorgeYangMD.com
www.Twitter.com/GeorgeYangMD
www.Facebook.com/GeorgeYangMD
Google+

My online posts are not a substitute for a physician evaluation and examination and should not be considered as medical advice.

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Postby Elaine » Sat Jan 12, 2008 11:13 am

Thank you Dr Yang for an accurate definition of pixie ears. I have been told my whole life (I am 60) that I have "cute pixie ears", I can correct the general public next time I am offered that compliment.

Having said that I still believe that beauty is in the eye of the beholder. Due to a poor job in stitching up the outer corners of my eyes following a fat transfer under eye, one eye is small and almond shaped the other large and round. Yet all the the cyber friends I have made on this board (and there are dozens of them) who I have sent my photo to, do not see the problem. Yet when I update my business photo every single photographer I go to, every I doctor I have been to sees this immediately.

I know I am attractive but the eye thing is huge to me and was a huge emotional struggle to overcome. I am a happy spirit and project that, perhaps that is why my cyber buddies from this board study my picture and can't see the problem that is very real. They all tell me I am beautiful and can't see what I am talking about. They, I believe are drawn to my smile.

So I will stick to the belief that indeed, beauty is in the eye of the beholder. I have heard that you are an excellent surgeon, and with all due respect, I send my warmest alohas.
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Postby traci46 » Sat Jan 12, 2008 11:15 am

Your explanation is so great. After my ears became "pixied" I looked everywhere for an explanation at the time, and found almost nothing. My dr. even asked me why I didn't liked pixie ears. Who wants to look lke their earrings are alomst on their cheeks - not the lobes since there is no serparation? The dr. who corrected them used the VY Advancement, which did correct them, but now,after almost 5 yrs, they have become semi-pixied again..not to the point where I cannot tolerate them, but it still is not what I desire. However, I shall live with them, as am quite used to them now. Thank you for this in depth explanation. You do such great service for everybody.
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Postby herself » Sat Jan 12, 2008 6:31 pm

Great article! My earlobes used to be gigantic and when they got smaller after my lift, I was a bit freaked out. Now that things have settled in, they look fine. After viewing those photos, I am very relieved to see that my doc really knew what he was doing. I don't have that funny angle thing going on at all.
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platysmaplasty,

Postby Pleasehelp » Tue Nov 25, 2008 4:06 pm

I have been reading your posts and boy have I learned a lot about neck lifts. I am in need of a platysmaplasty. I have three questions. First, what are the chances of the bands pulling apart again? Second, is there a chance of pixie ears with a full neck lift? And, are incisions made in front and back of the ears?
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