Purpose <p>To compare the efficacy and safety of acellular dermal matrix (ADM) insertion with traditional fascia-anchoring sutures for managing dead space and improving aesthetic outcomes following preauricular fistulectomy.</p> Methods <p>A retrospective review was conducted on 135 ears that underwent preauricular fistulectomy performed by a single surgeon between September 2020 and December 2024. The patients were divided into two sequential cohorts: fascia-anchoring suture (<i>n</i> = 52) and ADM insertion (<i>n</i> = 83) groups. Operation time, complications (seroma and hematoma), recurrence rates, and aesthetic satisfaction (5-point Likert scale) were analyzed and compared as surgical outcomes.</p> Results <p>Demographic characteristics and excised specimen dimensions were comparable between the groups. The ADM insertion group demonstrated significantly higher aesthetic satisfaction scores (3.96 ± 0.82) compared with the fascia-anchoring suture group (3.21 ± 0.87; <i>p</i> &lt; 0.001). Importantly, the proportion of patients reporting satisfaction (score ≥ 4) was significantly higher in the ADM group (69.9% vs. 36.5%; <i>p</i> &lt; 0.001). The incidence of postoperative seroma or hematoma and operation time did not differ significantly between the groups. No recurrences were observed in either group, despite preoperative inflammation being present in approximately 40% of the patients in both groups.</p> Conclusion <p>ADM insertion is a safe and effective alternative for managing soft tissue defects after preauricular fistulectomy. Compared with fascia-anchoring sutures, ADM insertion provides significantly improved patient-reported aesthetic satisfaction without increasing complication risks, making it a valuable option for patients with substantial defects.</p>