Single-field reconstruction of congenital longitudinal cleft earlobes using large Z-plasty and dermofat grafting

Youngjin Kim; Jun Park; Sang Yoon Kang; Jin Sik Burm

doi:10.7181/acfs.2025.0114

Abstract

Congenital longitudinal cleft earlobes (CLCEs) present a ginkgo leaf–shaped malformation with combined skin and soft-tissue deficiency along the inferior margin. No previous method has addressed both deficiencies while preserving earlobe length and contour. We introduce a simple, single-field procedure that combines a large, single Z-plasty for complete skin preservation with dermofat grafting for volumetric restoration. A Z-plasty was designed on the cleft-side skin, with the central limb placed along the cleft valley and the opposing limbs aligned with the anterior and posterior ridges of both lobules. After elevating both triangular flaps and fully releasing the contracted fibrotic tissue at the cleft base, a compact, dense dermofat graft harvested from the ipsilateral mastoid area was inserted into the inferior marginal defect and anchored to prevent superior migration. The Z-plasty flaps were then transposed and closed without skin sacrifice. Postoperatively, the superior portion of the earlobe was compressed to prevent graft displacement. At 16–32 months of follow-up, all reconstructed earlobes maintained stable volume and natural contour without horizontal or vertical shortening. This combined technique provides a reliable, tissue-preserving, and cosmetically favorable option for correcting CLCEs, effectively resolving both skin and soft-tissue deficiencies within a single operative field.

Keywords: Cleft / Congenital abnormalities / Ear auricle / Reconstruction

Abbreviations

CCE

congenital cleft earlobe

CLCE

congenital longitudinal cleft earlobe

INTRODUCTION

The earlobe consists of two structurally distinct components: a plump, smoothly curved inferior portion and a thin, flat, or basin-like concave superior portion, both devoid of cartilage. Congenital cleft earlobes (CCEs) are the most common malformations of the lower third of the auricle [1]. The deformities result from abnormal fusion of the auricular hillocks of the first and second branchial arch during embryonic development [2]. Consequently, the cleft corresponds to the junction of the maldeveloped auricular hillocks which leads to skin and soft tissue deficiency, curved cleft margins, and asymmetry of the two lobules on both sides of the cleft. The common goals of congenital cleft repair include achieving adequate volume and size of the inferior portion without soft-tissue deficiency and restoring smooth marginal curvature.

Among several types of CCEs, congenital longitudinal cleft earlobe (CLCEs), also called simple CCEs, appear to be the most common [3]. Various surgical techniques have been described for their correction [4-11]; however, no standard guideline exists to consistently achieve the reconstructive goals. In particular, no previous method has addressed the volume deficiency of the earlobe created by the cleft. To overcome these limitations, we devised a new surgical approach that incorporates Z-plasty for skin preservation and lengthening with dermofat grafting to restore soft-tissue bulk along the earlobe margin.

IDEA

Correction of CLCEs was performed in six patients (four girls and two boys; age range, 22–34 months; four left and two right ears) from January 2018 to December 2022. In four patients, an accessory auricle was presented at the cleft. The longitudinal cleft was found at the anterior area of the earlobe rim in four patients and at the posterior area in two patients. The postoperative follow-up period ranged from 16 to 32 months.

A large Z-plasty was designed to create a substantial triangular flap on each cleft side of both lobules, enabling maximal skin preservation and lengthening (Fig. 1A). First, the lowest protruding points of both lobules were identified, and a straight line was drawn between them along the inferior margin of each lobule to serve as the longitudinal axis of the Z-plasty. The central limb of the Z-plasty was positioned along the cleft valley, with one limb along the posterior ridge of the larger lobule and the other along the anterior ridge of the smaller lobule. This design yielded an anteriorly based triangular flap on the cleft side of the larger lobule and a posteriorly based triangular flap on the cleft side of the smaller lobule.

Following local anesthesia, full-thickness skin incisions were performed along the Z-plasty design. Both triangular flaps were elevated by uniform subcutaneous dissection, preserving the subdermal plexus (Fig. 1B). The contracted fibrotic bands at the cleft base were completely released in both vertical and horizontal directions.

After estimating the soft-tissue deficiency of the earlobe, a dermofat graft was harvested from the ipsilateral mastoid area anterior to the hairline, and the donor site was closed primarily. The graft was trimmed into a croissant or diamond shape and placed at the soft-tissue defect along the earlobe margin (Fig. 1C). Both poles of the graft were anchored to the subcutaneous tissue of the two lobules to prevent superior migration. The Zplasty flaps were transposed and closed with 6-0 Vicryl suture for the dermis and 7-0 nylon for the skin. After evaluating the soft-tissue volume and marginal curvature of the earlobe rim, additional small pieces of the dermofat graft were inserted into residual deficient areas through the marginal wound as needed, followed by final skin closure (Fig. 1D).

The wound was covered with thin gauze. The superior concave portion of the earlobe was compressed with a thick bolster dressing to prevent superior displacement of the dermofat graft. Skin sutures were removed on postoperative day 7, and the incision lines were splinted with surgical paper tapes (Steri-Strip; 3M). Compression of the superior portion was continued for 3–4 weeks to maintain the bulk of the inferior margin and the concavity of the superior portion.

DISCUSSION

The characteristic feature of longitudinal CCEs is the ginkgoleaf-shaped defect of the earlobe, particularly in the inferior portion. The two principal problems in correcting these deformities are the skin and soft-tissue deficiencies of the inferior portion. However, no previous surgical technique has ad-dressed both issues simultaneously.

The skin on each cleft side of the lobules represents valuable tissue for increasing the lengths of both horizontal and vertical dimensions of the earlobe; therefore, its preservation is crucial. Nonetheless, many previously described techniques sacrifice skin on the cleft sides [4-11], resulting in postoperative shortening of the reconstructed earlobe. Qing et al. [12] introduced a skin preservation technique using diametric hinge flaps on both lobules, but this method did not address the soft-tissue deficiency, leaving inadequate bulk of the inferior portion. To restore soft-tissue volume, Lee et al. [8] used two flip-over deepithelialized flaps, which caused reduction in the earlobe length. Thacoor and Bulstrode [11] used conchal cartilage grafts for volume restoration, but this resulted in a stiffer earlobe. Hence, no previous approach has successfully corrected both the skin and soft-tissue deficiencies simultaneously.

Our method uses a single large Z-plasty to preserve all cleftside skin from both lobules and to cover the inferior portion using two large triangular skin flaps, thus preventing postoperative shortening. The fundamental concept is that the anteriorly based flap from the larger lobule covers the anterior surface of the smaller lobule, whereas the posteriorly based skin flap from the smaller lobule covers the posterior surface of the larger lobule.

Despite total skin preservation, the soft-tissue deficiency of the earlobe margin remains inevitable because of the ginkgoleaf-shaped defect, which can result in flat or unnatural marginal contour. To address this problem, we used a dermofat graft harvested from the ipsilateral mastoid region for volume augmentation. The mastoid skin and soft tissue are compact and dense, with a rich subdermal plexus [13], in contrast to the supraclavicular or groin donor sites. The mastoid dermofat graft offers several advantages: it can be easily harvested within the same operation field, can be trimmed into the desired shape, maintains its contour because of moderate rigidity, and shows excellent viability with minimal postoperative volume loss. It provides satisfactory plumpness and curvature of the inferior margin and can also be applied effectively to other variants, especially the defective type.

This technique is simple, reproducible, and performed entirely within the same operative field. It preserves skin, restores soft-tissue volume, and maintains the natural bulkiness of the earlobe. In all six patients, we achieved plump earlobes with a smooth contour and inconspicuous scars (Fig. 2). During follow-up, the inferior portion remained bulky, the superior portion remained thin, and no horizontal or vertical shortening occurred.

In conclusion, this method represents a unique option for correcting longitudinal CCEs, as it simultaneously addresses both skin and soft-tissue deficiencies within a single operative field, leading to superior cosmetic outcomes without complications.

Notes

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Ethical approval

The study was approved by the Institutional Review Board of Kyung Hee University Hospital (IRB No. KHUH 2025-12-027).

Patient consent

Written informed consent for publication and the use of images was obtained from the parents or legal guardians of all pediatric patients.

Author contributions

Conceptualization: Youngjin Kim, Jun Park, Sang Yoon Kang, Jin Sik Burm. Data curation: Youngjin Kim, Jin Sik Burm. Formal analysis: Jin Sik Burm. Methodology: Youngjin Kim, Jun Park, Sang Yoon Kang, Jin Sik Burm. Project administration; Visualization: Jin Sik Burm. Writing–original draft: Youngjin Kim. Writing–review & editing: Youngjin Kim, Jun Park, Sang Yoon Kang, Jin Sik Burm. Investigation: Youngjin Kim. Validation: Jun Park, Sang Yoon Kang. All authors read and approved the final manuscript.

Fig. 1.

A 34-month-old girl with a congenital longitudinal cleft earlobe. (A) Design of a large Z-plasty without skin sacrifice. (B) Elevation of bilateral triangular skin flaps. (C) Placement of a dermofat graft into the soft-tissue defect along the earlobe margin. (D) Transposition of the flaps and final skin closure.

Fig. 2.

Clinical cases of longitudinal cleft earlobe. Anterior cleft in a 34-month-old girl: (A) preoperative photograph and (B) postoperative photograph at 24 months. Posterior cleft in a 24-month-old girl: (C) preoperative photograph and (D) postoperative photograph at 32 months.

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