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