Background: Surgical reconstruction of the earlobe after gauge ear piercing can be challenging especially in cases of large defects. Objective: By performing a systematic review of the current literature, we aimed to identify available surgical approaches for earlobe reconstruction after gauge piercing and provide a surgical classification system with regard to defect size. Methods: A literature review was performed including MEDLINE and PubMed databases to identify articles describing reconstruction after stretched earlobe piercing. Articles referring to traumatic, congenital, and acquired cleft deformities were excluded. Surgical techniques were summarized and categorized with regard to different defect sizes. Drawings of each method were performed. Results: A total of 17 different surgical approaches were found and described. Based on the authors' descriptions of each technique, a classification system for small to medium, large, and extralarge defects was established and special benefits of each method were highlighted. Conclusion: A simple classification of available techniques for stretched earlobe reconstruction with regard to defect size might help physicians to choose the appropriate surgical management especially in cases of large defects.