Cosmetic A Morphometric Study of the External Ear: Age- and Sex-Related Differences Michael J. Brucker, M.D., Jagruti Patel, M.D., and Patrick K. Sullivan, M.D. Providenc, Ri The human ear is a defining feature of the subile structures convey signs of age and sex ¢ unmistakable yet not easily defined. With analysis of nor this study explored anatomic ar between men and women, as well as changes in ear norphology with age. A total of 123 volunteers were randomly selected for this study. The cohort consisted of 89 women years (median age, 42 years) and 34 men years (median age, 85 years), The average total eat across the entire cohort for both left and right cars was 6.30 em, average lobular height was 1.88 em, and average lobular width was 1.6 em. Asexpected based on head size significant sex-related differences were noted in the dis- tance from the lateral palpebral commissure to both the helical root and insertion of the lobule, Measured dis. tances in both vectors were approximately 4.6. percent longer in men than in women. Similarly, the height of the pina was significantly larger in men than in women by approximately 6.5 percent. The average height and width of the lobule, however, were nearly identica id women, Analysis of age-related data showed a significant difference in the total ear height between the subpopt- lations; however, this diffe gnificant after the lobular height was subtracted from total ear height, suggesting that the lobule was the only ear structure that changed significantly with age. In addition, lobular width decreased significantly with age. This study establishes normative data for ear morphology and clearly demon. strates the changes in earlobe morphology that occur with advancing age. (Plast. Reconstr, Surg. 112: 647, 2003.) The human ear is a defining feature of the face and an important key in the natural, har monious, aesthetically pleasing face. Its subtle structures convey signs of age and sex that are unmistakable yet not easily defined. A plastic surgeon can look at an ear and know that it is not youthful, yet cannot easily correct this problem because data regarding the parame- ters of a normal youthful ear are not currently From the Department of Pasi Surgery, Brown Medical School and Rhexle [sland Hospital, Received for publication June 3, 2 DOE: 10,1097/01.PRS.0000070979,20079.1F available. Many authors have detailed the anat- omy of the external ear," and Brent and oth- ers have exhaustively and brilliantly described proper form and placement in ear reconstrue- tion.'-* However, very little has been described to guide the surgeon in rejuvenation of the ear. Tolleth’s heavily referenced work describing the proportions of the normal ear, the position of the ear, and the varied shape of the ear and earlobe was published in 1978." His article pro- vided general proportions as surgical guides; however, their derivation was based on the au- thor’s artistic perception, Though certainly a helpful contribution, his assessme most entirely subjective. The current report describes the aesthetic proportions of the human ear based on nor- mative crosssectional data. Within these data, we demonstrate anatomic and aesthetic differ. ences between men and women, as well as changes in car morphology with age. The «: conveys as much info: non age and sex as other defining features of the face. It should be treated as such by the aesthetic plastic surgeon when desiring optimal facial rejuvenation that also does not inappropriately masculinize or feminize. With the appropriate normative dat we hope to better define the approach to ¢: rejuvenation. SUBJECTS AND MetHoDs A total of 123 volunteers were randomly se~ lected for this study. All volunteers were ployees of Rhode Island Hospital or affiliated with the Department of Plastic Surgery at Rhode Island Hospital. Age and sex of eachvolunteer were recorded. The cohort consisted of 89 women ages 19 to 65 years (median age 42 years) and 2 (median Standardized measurements of each ear in- cluded total ear height, lobular height, lobular width, distance from the lateral palpebral com- missure to the root of the helix, and distance from the lateral palpebral commissure to the Total car height was men ages 18 to 61 years insertion of the lobule measured as the distance from the caudal-most projection of the lobule to the cephalic most projection of the helix. Lobular height was measured as the distance from the caudal-most projection of the lobule to the base of the tragal notch. Lobular width was measured as the horizontal width of the lobule at the mid- point of the lobular height, All measurements were taken using a standard pinch caliper by a single investigator. Figures | and 2 show € ples of these measurements Digital photographs of all 246 ears were ob- tained using a Nikon 990 digital camera (Ni- kon, Tokyo, Japan). Photographs were taken with the volunteer in the standard lateral posi tion, at a distance of 1m, with the camera lens set at approximately 105-mm focal length. Dig: ital images were then archived and analyzed using Mirror Professional software (Canfield Scientific, Fairfield, N. J.). Using the Mirror software, the axis of the pinna was defined as a line that incorporates the midpoint curvature of the antitragus and evenly bisects the pinna. The axis of the lobule was defined as a line from the caudal-most projection of the lobule through the same point on the antitragus. The angle of the lobule relative to the pinna was defined as the acute angle created by the in: tersection of the two axes Statistical analysis of sex-related differences was performed using the test with a two-tailed distribution and a 95 percent confidence inter- val. Analysis of age-related changes was per- formed using both analysis of variance and the Pearson test for linear correlation. RESULTS, Combined data from all 246 ears are de- picted in Table I. The average total car height across the entire cohort for both left and right cars was 6.30 cm and the average lobular height was 1.88 cm, fora lobular height to total car height ratio of 29.8 percent. The average lobular width was 1.96 em. The average height of the pina, calculated by subtracting the lob: PLASTIC AND RECONSTRUCTIVE SURGERY Fic, 1. Cal andl total ear height. and the insertion of the lobule ular height from the total ear height, was 4.43 Table [also lists data classi sex. As expected based on head size sexcrelated differences were noted in the dis tance from the lateral palpebral commissure to both the helical root and insertion of the lob- ule, Measured distances for men were approx: imately 4.6 percent longer in both veetors com: pared with women. Similarly, the height of the nificantly larger in men than in pinna was si women by approximately 6.5 percent. The erage height and width of the lobule, however were nearly identical between men and women, Average lobular height was 1.89 cm for men and 1.87 cm for women, whereas average lobular width was 1.95 cm for men and 1.97 forVol. 112, No, 2 / EXTERNAL EAR MORPHOLOGY 649 TABLE 1 Combined Sex- and Age-Related External Ear Measurements ‘Overall a 18 448 Men os 19 454 Women 8 187 sae Age Te80yean 586178 S20 430 SI yean 11062788 S10 441 4665 yearn 78643190. 835 447 For analysis of age-related changes in ear anatomy, the cohort was divided into three subgroups. The age ranges of 18 to 30 years (group 1), 31 to 45 years (group 2), and 46 to 65 years (group 3) were arbitrarily selected based on overall age distribution within the cohort. A significant difference was noted in the total ear height, which increased from 6.17 cm in group 1 to 6.45 cm in group 3. When the lobular height was subtracted from the total ear height, however, statistical significance was lost. The calculated height of the pinna was 4.39 cm in group 1, 4.41 cm in group 2, and 4.47 cm in group 3, suggesting that the lobule was the only ear structure that changed signif icantly with age. In fact, the lobule increased in height from 1.78 cm in group I to 1.99 em in group 3 while the width decreased from 2.10 cm in group 1 to 1.91 cm in group 3. When the data were broken down further to analyze age- related changes in ear anatomy based on sex: only lobular width in men failed to reach sta- tistical differences across the age groups. Lob- ular height increased significantly with age in both men and women, and lobular width de- creased significantly with age in women only ‘The angle between the axis of the pinna and the axis of the lobule was quite variable across the entire cohort. An average value of 8.9 de- grees posterior to the axis of the pinna was calculated with a standard deviation of 6.5 de- grees. No significant difference was found in any of the data subgroups Discussion ‘The ear is an important and underrecog- nized defining feature of the face. Its shape conveys information about age and sex that is clear yet difficult to characterize. We have tempted to break down the basic aesthetic pro- portions of the ear and lobule in a broad cross- sectional study. The data generated from this study were both predictable and unexpected. One of the more thorough discussions of normal ear morphology as it relates to the rhytidectomy patient was by McKinney and col leagues in 1993.!” Their study specifically ad- dressed the treatment of the ear and earlobe in aesthetic surgery. Using measurement para eters similar to those used in the current study, they obtained data in 100 “normal” volunteers and found a mean ear height of 6.5 cm and a mean lobule height of 1.8 cm. These values correlate well with our data. However, they did not find a significant correlation between lobe height and aging, and no comparisons between male and female volunteers were reported. It is unclear why the results of McKinney et al.!” are disparate from our own. One possibil ity could be their method of calculation, which involved linear correlation between age and the ratio of earlobe height to total ear height, We calculated statistical significance by com- paring age groupings and lobular height When our data were analyzed for linear cor lation between age and lobular height, we found a statistically significant coefficient of 0.25. Another possibility would be if MeKinney etal, only measured one ear from each volun- teer; however, their methods with regard to this point are unclear. Nonetheless, if only the right ear from each volunteer is analyzed, the correlation coefficient remains statistically nificant at 0.18. When our data were analyzed with regard to sex of the volunteers, we uncovered some ve interesting similarities. Our data clearly suggest that earlobe size does not vary significantly be- tween men and women. While total ¢650 larger in men, ¢: Jobe height and width were ly identical between the men and women our cohort, Additionally, when these data were analyzed for age and sex changes, we found a consistent and statistically significant increase in earlobe height for both men and. women. A majority of women and none of the men had pierced earlobes in our cohort, sug~ gesting that the inerease in earlobe height with age is not entirely due to the weight effects of earrings. Lengthening of the earlobe is more likely an unavoidable result of the cess. Figure 3 shows a schematic of the phologic changes of the ¢ . In aesthetic earlobe reshaping, the ulti- mate goal is to achieve a more youthful ap- pearance. We therefore draw upon data col- lected for the youngest subgroup of our PLASTIC AND RECONSTRUCTIVE SURGERY, August 2003 cohort as our aesthetic standard, The aver- age youthful earlobe is approximately 1.8 em long and 2 cm wide at its midpoint. In gen- eral, the earlobe is gently curved from the distal extent of the helix toward the base of the lobule. In the case of the detached lob- ule, the shape of the earlobe then takes a circular turn and inserts slightly posterior to the anterior projection of the tragus. A heightto-width ratio of approximately 90 percent aids in creating the preoperative markings. Figure 3 shows a typical rhytidec- tomy patient with significantly elongated ear- lobes contributing to an aged appearance. This patient underwent endoscopic brow lift, composite rhytidectomy, and earlobe reshap- ing. The method used for earlobe reshaping is shown in the preoperative markings in Fic, signif ‘operative planning (center Preoperative (ie!) and Lyear postoperative (vgh) images of a patient with lobes who requested facial rejuvenation. (Belo) Preoperative (lf) nd postoperative (right) images of a different patientVol. 112, No, 2/ EXTERNAL FAR MORPHOLOGY Figure 3. The caudal projection of the lobule is excised as shown with a slightly greater amount of skin taken posteriorly, which con- ceals the closure along the posterior aspect of the lobular borde Many authors have discussed the impor- tance of proper earlobe placement in the rhytidectomy patient. Considerations such as ear morphology, flap tension, and contraction from healing must be taken into account to ensure an acceptable end result, Several authors have recommended specific parameters for inset of the earlobe during thytidectomy. Their application in varying clinical situations, however, can often be quite subjective. In light of this, we at- tempted to quantify the normal position of the earlobe in relation to the upper two- thirds of the ear. Similar to Tolleth,! we defined the main axis of the ear to be the line passing through the midpoint curvature of the antitragus and evenly bisecting the pinna. The axis of the lobule incorporates the same antitragal point and passes through the caudal-most projection of the earlobe on lateral view. While our results did not reach statistical significance, the trend is clearly toward the retrograde shift of the lobule from the upper two-thirds of the ear. Earlobes that insert anterior to the main axis of the ear tend to give a reclined appearance to the ear as a whole. When this look is recreated in the rhytidectomy patient, the end result is an undesirable pixy ear deformity. Our current 651 practice is to inset the earlobe in a more ce- phalic position at a 20legree axis, which is posterior to the 9-degree axis norm described in this report. The natural tendency is for the inset to migrate anterior and caudal with wound contraction. With proper placement, however, the final position of the earlobe should remain posterior to the main axis of the ear. ConcLusions We believe that the data obtained in this study have generated some very useful pa- rameters for car morphology, particularly the relation of ear and earlobe morphology to advancing age. Few surgeons would dis- agree with the notion that elongated ear- lobes are an undesirable result of aging. What we lacked were the data to describe both the age-related change and the youthful mean. As depicted in Figure 4, the normal lobule clearly changes from a short and wide structure in youth to one that is long and narrow. There are, however, many individu- als who have large earlobes as one of their individual characteristics. When these ear- lobes become even larger with aging, a much more noticeable problem emerges. These are the patients in whom earlobe contouring is particularly indicated. We have now gained the parameters necessary to reshape and re- juvenate the ear. Fic, 4, Changesin easlobe shape with advancing age (Leftto righ). The helixis identical in all three depictions, with progressive lengthening and narrowing of the lobule652 1 Patrick K. Sullivan, M.D. Brown Medical School Department of Plastic Surgery Rhode Island Hospital 2 Dudley Street, Suite 450 Providence, RL. 02905 cosmetic@drsullivan.com REFERENCES Brent, B. Reconstruction of the auricle. In J. G. M Carthy (Ed.), Plastic Surge: The Face, Vol. 8: Philadel Saunders, 1900. Pp, 2095-2152 as, LG. Anthropometry of the normal and defec- tive ear. Clin, Plast. Surg. 17: 213, 1990, as, L. G., Posnick, J. C., and Hreczko, T. M. Ans Urepometric growth study of the ear. Cleft Palate Craniofac. J. 2 324, 1992, Brent, B Auricular repair with autog _grafis:Two decades of exper Reconstr. Surg, 90: 955, 1992, snouts rib cartilage sce with 600 eases. Plas PLASTIC AND RECONSTRUCTIVE SURGERY, August 2003, 5, Bre 1B, Technical advances in ear reconstruction with autogenous rib cartilage grafts: Personal experience with 1200 cases. Plast. Reconstr. 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