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The Prominent Antihelix and Helix—The Myth of the ‘Overcorrected’ Ear in Otoplasty

Shokrollahi, Kayvan FRCS(Plast)*; Manning, Steven MRCS; Sadri, Amir MRCS; Molajo, Adeyinka MRCS§; Lineaweaver, William MD

doi: 10.1097/SAP.0000000000000441
Research Papers
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Background Classic teaching of ear anatomy in the context of otoplasty states that if the antihelical fold is more prominent than the helical fold after surgery then the ear is “overcorrected.” We set out to explore the role of the antihelix in normal ear anatomy, its relevance to aesthetic perceptions of the ear, and a snapshot of its incidence in nonoperated ears.

Methods To readily identify junior staff in our department, their color photographs, names, and contact details are posted on every ward. Using digital methods, we cropped the left ear out of the source images, making them unidentifiable. Clinical and nonclinical staff in our unit were asked to choose their favorite and their least favorite ears based on their aesthetic appeal. Responses were tabulated and the 2 most popular ears were compared.

Results The preferred ear did not conform to the traditional dogma because it had a prominent antihelix and was statistically significant when compared to other choices. We also noted that a prominent antihelix is common among the general population and among colleagues within the department, and hence “normal.” Also interesting was that the helix of the ear chosen as the most aesthetic was also the ear where the helix was almost touching the side of the head.

Conclusions We found that when judging the aesthetic nature of the “virgin ear, antihelical fold prominence did not appear to be a negative attribute. Indeed, we noted that a prominent antihelix was a common attribute, and we conclude that this was a normal variant without undue negative aesthetic stigma. A surgically corrected ear should not necessarily be regarded as a poor outcome simply on the basis of antihelical prominence. Furthermore, we postulate that patients who have a prominent antihelix might be part of a spectrum of individuals who might have had the subtype of prominent ears featuring a deep conchal bowl. Finally, although not tested directly, it appears that we do not have an idea of our own ear shape, as none of the participants was able to recognize their own ear from the photographs.

From the *Department of Plastic Surgery, St Helen’s and Knowlsey NHS Fountation Trust, Liverpool; †Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, Wales; ‡Department of Plastic Surgery, Chelsea & Westminster Hospital, London; §Department of Plastic Surgery, Wythenshaw Hosipital, Manchester, UK; and ∥Joseph M. Still Burn and Reconstructive Center, Jackson, MS.

Received July 9, 2014, and accepted for publication, after revision, December 16, 2014.

Conflicts of interest and sources of funding: none declared.

Reprints: Amir Sadri, MRCS, Mersey Regional Burns & Plastic Surgery Unit, Whiston Hospital, Warrington Road, Liverpool, L35 5DR, United Kingdom. E-mail: amir@hotmail.co.uk.

Otoplasty is a common procedure, and a number of different techniques are used to achieve correction of helical projection and create a natural antihelical fold.1–6 Goals of corrective surgery were set out in 1968 by McDowell,7 who recommended that the corrected ear should appear as if no surgery had been undertaken, that the most lateral part of the helix should lie between 1.7 and 2.0 cm from the head, and that the helical rim should project lateral to the antihelix when viewed from the front.

Observation informs us that enormous variation of ear morphology exists in the general population. Frequently, individuals with aesthetically pleasing ears that are not classically prominent or otherwise abnormal possess antihelical folds that are more prominent (i.e., more lateral) than the helical folds. Thus, many individuals therefore possess an “overcorrected” ear as defined by McDowell. The question thus arises, if this anatomical variation occurs commonly, does the so-called overcorrection actually matter?

We undertook a simple study looking at the ears of the doctors working in our department to ascertain the frequency of a prominent antihelix and to investigate others’ perception of these ear shapes by looking at nonoperated ears and ranking them in order of aesthetic preference.

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METHODS

All new junior surgeons in the department have their photographs taken on arrival. These photographs are then posted on all wards and clinics to facilitate identification and accessibility due to rapid turnaround. We digitally cropped copies of this photographic series to produce a single page showing enlarged and nonidentifiable images of the right ear of each surgeon (Fig. 1). It is important to note that all photographs are taken by the same photographer at the same angle and in the same position. These images were allocated a number (1 to 11). Members of medical, nursing and clerical staff in the unit were then asked to look at these ears and rank them in order of preference. We also asked a staff in a general surgical unit of a district general hospital to perform the exercise. No further information was provided, such as whether these were patients, or whether they had undergone surgery. Interestingly, it was apparent during the exercise that participants appeared to assume that these were postoperative photographs of patients following otoplasty. Furthermore, none of the medical staff who took part in the assessment recognized their own (or colleagues’) ears in the series.

FIGURE 1

FIGURE 1

We also inspected the ears of all surgeons of all grades in the department to assess how many individuals had a prominent antihelix.

A point scoring system was developed to cross compare ears, the “aesthetic score”. Five points were awarded for a first choice vote, 3 points for a second choice, and 1 point for a third choice vote.

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RESULTS

The junior surgeons’ ears are shown in Figure 2, and of these, 2 (18%) had a prominent antihelix as highlighted by the arrows.

FIGURE 2

FIGURE 2

Of all surgeons of all grades in the department (31), 7 had prominent antihelices (22.5%).

Fifty-nine staff members responded to our request to take part in choosing the most appealing ear. The distribution of responses is shown in Figure 3.

FIGURE 3

FIGURE 3

Ear 6, with a prominent antihelix, was the most popular choice receiving 15 first-choice votes. Ear 2 attracted the next most first-choice votes. Figure 4 shows the distribution of first choice votes across all responders.

FIGURE 4

FIGURE 4

We broke down the responses further to isolate responses from plastic surgeons to see if they were skewed, but the choices reflected that of other participants (Fig. 5).

FIGURE 5

FIGURE 5

We also analyzed how many times each ear was voted 11th choice, that is, least aesthetically pleasing (Fig. 6). Ear 4 received the most number of votes (41) and was deemed the least aesthetically pleasing ear, as it also received the least number (1) of first-choice votes.

FIGURE 6

FIGURE 6

Aesthetic scores for each ear are shown in Figure 6. Again, ear 6 scored the highest points with 102. Ear 4 scored the least number of aesthetic points. This is in keeping with voting patterns shown in earlier figures (Fig. 7).

FIGURE 7

FIGURE 7

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DISCUSSION

From our results, the most popular ears were 6, followed by number 2. Ear number 6 is an interesting first choice because this ear anatomy is contrary to McDowells description of an “aesthetically corrected” ear because the antihelical fold is prominent beyond the helix and would classically be described as “over-corrected”—yet as a “virgin” ear, has not been surgically corrected.

We believe that this modest data and analysis illustrates the point sufficiently—that an ear that McDowell would have described as overcorrected can be more aesthetically pleasing than one which would conform to his principles.

From this study, a prominent antihelix has not been shown to be a negative aesthetic attribute in itself, and could even be attractive. Furthermore, approximately one quarter of surgeons in the department over and above the ones in the analysis had some element of antihelical prominence. Subjectively, it seemed that when judging aesthetics of an ear, individuals selected their preference based upon several factors including smooth outline. Beauty of ears clearly remains in the eye of the beholder, as some ears had almost equal numbers of positive votes as negative ones. This suggests that there is unlikely to be a single ear that is universally appealing or unattractive. The implication is that antihelical fold prominence after otoplasty is not as negative an outcome as previously suggested, especially in light of its relative frequency in the general population—from which our surgical department is a reasonably representative sample. Studying the “average passer-by”, one will often encounter this anatomical variation after. An interesting observation during the course of this study was that individuals did not appear to have an inherent concept of their own ear shape because none of the individuals recognized their own ears from the photographs. Also worthy of note was the occasional comment from plastic surgical assessors: “that ear is overcorrected,” when in fact, no surgery had been undertaken.

We speculate that had nonoperated ears with a prominent antihelix not undergone normal embryological development in terms of chondral folding, they might have become the subgroup of prominent ears with the characteristic pattern of a “deep conchal bowl.” The extrapolation is that patients with deep conchae are most likely to have prominent antihelices after surgical correction using suture techniques, and that such a result after surgery could simply reflect their “normal” ear anatomy if embryological development had been complete.

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CONCLUSION

As a profession, we are sometimes indoctrinated by rules of optimal aesthetics, and these concepts have tended to change over the years especially in terms of facial aesthetics. Most surgeons would agree that the triad of prominent antihelix with an acute antihelical angle and a helical rim close to the side of the head are likely to be unsatisfactory. However, we challenge the mantra that an end result in aesthetic otoplasty is suboptimal if the antihelix is simply more prominent than the helix. Although this should by no means be the primary aim of the operation, if an aesthetically pleasing result is obtained with some degree of antihelical prominence traditionally described as “overcorrection”, and with an acceptable helical position not too close to the side of the head or angulated posteriorly, then this ear is within the normal spectrum of anatomical variation. A surgically corrected ear should not be regarded as a poor outcome simply on the basis of antihelical prominence.

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REFERENCES

1. Mustarde JC. The correction of prominent ears using simple mattress sutures. Br J Plast Surg. 1963;16:170–8.
2. Furnas DW. Correction of prominent ears by conchamastoid sutures. Plast Reconstr Surg. 1968;42:189–93.
3. Horlock N, Misra A, Gault DT. The postauricular fascial flap as an adjunct to Mustarde and Furnas type otoplasty. Plast Reconstr Surg. 2001;108:1487–90; discussion 1491.
4. Chongchet V. A method of antihelix reconstruction. Br J Plast Surg. 1963;16:268–72.
5. Stenström SJ. Simple operation for prominent ears. Acta Otolaryngol. 1966:Suppl 224:393+.
6. Shokrollahi K, Cooper MA, Hiew LY. A new strategy for Otoplasty. J Plast Reconstr Aesthet Surg. 2009;62:774–81.
7. McDowell AJ. Goals in otoplasty for protruding ears. Plast Reconstr Surg. 1968;41:17.
Keywords:

otoplasty; pinnaplasty; antihelical fold

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