2017 modabber-ear-aps

ORIGINAL ARTICLE FACIAL SURGERY
Three-Dimensional Analysis of the Ear Morphology
Ali Modabber1 • Helmut Galster1 • Florian Peters1 • Stephan Christian Mo¨hlhenrich1 •
Kristian Kniha1 • Matthias Knobe2 • Frank Ho¨lzle1 • Alireza Ghassemi1
Received: 20 August 2017 / Accepted: 2 November 2017
Ó Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery 2017
Abstract
Background For surgical treatment of the face, detailed
surgical planning is necessary to avoid later unaesthetic
results. Most of the studies in the literature concentrate on
the ears’ anatomy during childhood and adolescence.
Nearly no study evaluates the anatomy of ears of people
aged 50 or older. It was our aim to measure and evaluate
the ear’s anatomy in Caucasians between the ages of 21
and 65.
Methods Three-dimensional scans of 240 volunteers were
taken. The subjects were divided into groups of males and
females and each of them into three groups by age (21–35,
36–50, 51–65). Landmarks were placed in these scans.
Distances, relations and angles between them were
recorded.
Results The distance between the subaurale and superau-
rale significantly increases (p 0.001) during the aging
process in males and females. Also, the width of the ear,
measured between the preaurale and postaurale, signifi-
cantly increased (p = 0.007) with advancing age. When
the length of the ear is divided into four parts by anatom-
ical landmarks, it extended the most in the lower quadrant
with increasing subject age.
Conclusion The ear of Caucasians does not stop changing
its shape during adulthood. Even after the body has stopped
growing, the ear still does. With the measured values in this
study, it should be possible for the surgeon to plan the
operation in advance and achieve satisfactory aesthetic
outcomes.
Level of Evidence V This journal requires that authors
assign a level of evidence to each article. For a full
description of these Evidence-Based Medicine ratings,
please refer to the Table of Contents or the online
Instructions to Authors www.springer.com/00266.
Keywords Ear morphology Á Facial scanning Á Three-
dimensional
Introduction
Since antiquity, humans have assessed facial proportions as
the basis for attractiveness [1]. These studies investigate
facial morphology with regard to ethnic variations [2], age
differences [3], gender differences [4] and characteristics
of attractiveness. Some studies described attractiveness as:
averageness [5, 6], sexual dimorphism [7], the appearance
of childlikeness [8] and symmetry [9]. All studies in this
field reported specific standard values of different ages and
ethnic groups. Such data are useful for surgeons to recon-
struct facial proportions and to achieve aesthetic results in
regular clinical practice.
Surgeons rely on personal experience for aesthetic
results. Whereas, nearby structures or symmetry may help
in orientation during the operation, there are not always
natural contours on which to rely. In that case, it is
important to be aware of certain distances and angles of
particular facial parts. Detailed therapy planning is
required to determine what operation and transplantation
methods and materials fit the best; for example, proper
placement of the incision line without destroying the
& Ali Modabber
amodabber@ukaachen.de
1
Department of Oral, Maxillofacial and Facial Plastic Surgery,
RWTH Aachen University Hospital, Pauwelsstr. 30, 52074
Aachen, Germany
2
Department of Orthopaedic Trauma, RWTH Aachen
University Hospital, Aachen, Germany
123
Aesth Plast Surg
https://doi.org/10.1007/s00266-017-1027-4

natural proportions, and the use of the incision line to
conceal prospective scars to make it look natural [10].
Surgeons do not only need this knowledge for average
patients, but also for patients of different ages and gender.
Because certain parts of the ear undergo various changes
during a lifetime, the surgeon has to account for such
variations to provide a suitable treatment for patients of
varying ages [3]. Most existing publications concentrated
on morphological changes during childhood and adoles-
cence and extended to about 18 years [11]. Abundant
measurements and norms have been reported for people
aged 18–35 [2, 12]. However, the progress of morpholog-
ical changes in adult ears is fragmentarily documented. To
facilitate individual treatment planning for various ages,
age-dependent standard values are strongly needed [3]. For
example, following the norms of a mid-20s person, on
which most of the available standard values are based, may
look artificial in a 50-year-old.
Calculated standard values are essential for diverse
surgical adult treatments. The ear undergoes surgical
treatment for various reasons including: tumor therapy,
trauma therapy, bite wounds and use of the cartilage for
other reconstructions. Besides that, the ear is the subject of
aesthetic-plastic interventions.
In view of these observations, the purpose of this study
was to supply anthropometric data on the ears of Caucasian
subjects using a modern measurement technique.
Materials and Methods
After institutional approval and informed consent, we
divided 240 volunteers (120 female and 120 male Cau-
casians) into six groups of 40 subjects each. The groups
consisted of three female subgroups: F1 (age 21–35), F2
(age 36–50), F3 (age 51–65) and three male subgroups: M1
(age 21–35), M2 (age 36–50), M3 (age 51–65). All vol-
unteers were scanned with FaceScan3D (FaceScan3D; 3D-
Shape GmbH, Erlangen, Germany). The acquired 3D data
were imported into OnyxCeph version 3.2.45 (Image
Instruments, Chemnitz, Germany). Facial landmarks were
set to the volunteers’ 3D scans and the software calculated
distances, angles and proportions.
Exclusion criteria for the study were: prior injuries or
operative treatments of the ears, wearing earrings, and non-
Caucasian subjects.
FaceScan3D
FaceScan3D is an optical 3D scanner for acquiring a digital
surface scan of the human face. The structured light tech-
nique is used to acquire 3D surface information. No
physical contact or ionizing radiation is employed. To
acquire this information, the scanner utilizes two black and
white cameras, a commercial digital SLR camera and an
LCD projector, as well as two professional flashes. A
mirror configuration surrounds a volunteer’s face permit-
ting a 180° panoramic record to be taken in one single shot.
One recording takes 800 ms. As stated in the technical data
provided by 3D-Shape, FaceScan3D has a precision of
0.1 mm. A commercial personal computer controls the
scanner. This computer uses Slim3D software (3D-Shape
GmbH, Erlangen, Germany) for post-processing raw data
acquired by the cameras. Finally, a 3D model consisting of
triangles with texture information is exported as a Wave-
front Object (.obj) file with its texture information stored in
a Joint Photographic Experts Group File Interchange For-
mat (.jpg) and a Material Template Library file (.mtl) file.
The mean error in measuring distances using this method is
1.17 mm [13]. Each volunteer was scanned similarly:
seated inside the mirror construction and aligned with the
crosshairs projected by FaceScan3D. Subjects were
instructed to relax their face and look towards the scanning
unit.
Scan Analysis
The facial datasets were imported into commercially
available orthognathic planning software (OnyxCeph ver-
sion 3.2.45). Using this software, distances, angles and
proportions were measured. Ultimately, for adequate
orthognathic therapy, measurement parameters can be set
by the user. Points necessary for planned facial analysis
were patched into this software. All distances, angles and
proportions between these landmarks were calculated
automatically.
The landmarks to optimally show extensions and pro-
portionality of the ear were selected. A clearly definable
position of the landmark, typically a point of strong con-
vexity or concavity, was required. The definitions of the
landmarks (Table 1) were described previously by Swen-
nen et al. and Sforza et al. [14, 15].
The angle between SupAu–SubAu and PreAu–PostAu
could not be measured in the three-dimensional view
because the points did not have an intersection in common.
Thus, reference planes were constructed. These were the
Camper projection plane, defined by the two Tragion points
and Subnasale, as well as the sagittal plane, vertically
positioned on the Camper projection plane meeting Sub-
nasale, and the midpoint between the two Tragion points.
SupAu–SubAu and PreAu–PostAu were projected per-
pendicularly on the sagittal plane and the measurement of
the angle between them taken within that plane.
Chosen measuring points for the lateral ear are shown in
Fig. 1. Figure 2 shows the measured relation.
Aesth Plast Surg
123

Statistical Analysis
First, we averaged the values of a total of 480 ears for each
volunteer and the resulting 240 datasets were statistically
analyzed with Prism GraphPad Version 6 (GraphPad
Software, Inc. La Jolla USA). The data were checked for
normality using the D’Agostino-Pearson normality test in
omnibus K2 variant. The data were normally distributed.
For statistical analysis between the male and female
groups, a t test was used. For analysis between groups of
different ages, a one-way ANOVA analysis of variance
was performed. The level of significance was set to
p B 0.05. All data were expressed as mean values ± s-
tandard deviation.
Fig. 1 Measuring points ear lateral Fig. 2 Four quadrants of the ear
Table 1 Definitions and abbreviations of chosen landmarks
Abbreviation Landmark Definition
Tra Tragion Point at the upper margin of the tragus
SupAu Superaurale Most cranial point of the ear
SubAu Subaurale Most caudal point of the ear
PreAu Preaurale Most ventral point of the ear
PostAu Postaurale Most dorsal point of the ear
Osup Otobasion superius Cranial point of the attachment of the ear to the cheek
Oinf Otobasion inferius Caudal point of the attachment of the ear to the cheek
Ia Incisura anterior Point of highest concavity at the anterior notch between the cranial origin of the helix and the tragion
ITra Incisura intertragica Point of highest concavity on the inner helix between tragion and antitragion
Aesth Plast Surg
123

Results
Ear Lateral
Table 2 shows measured values for SubAu–SupAu and
associated p values. With increasing age, the distance
between superaurale and subaurale increased significantly
in males and females (p 0.001) with increasing age.
Figure 3 demonstrates the increase of the distance between
superaurale and subaurale.
Table 3 illustrates the results of the other measured
distances. Also, the distances increase with advancing
age—in particular, the distance between preaurale and
postaurale is age-dependent. All values are significantly
higher for men than for woman. The angle between the
distances SubAu–SupAu and PreAu–PostAu does not
show a correlation with the aging process, but shows a
significant dependence on gender. The difference between
men and women in the relation Ia–Itra: Osup–Oinf is sta-
tistically significant also.
Four Quadrants of the Ear
As shown in Fig. 2, the ear was divided into four distances
by anatomical tissue points. Distances between them are
shown in Table 4 for the different groups. Because the
distances between superaurale, L1, L2 and L3 show a
slight dependence on age, the largest increase during
adulthood takes place in the distance L3–Subaurale. This
increase is significant. Figure 4 demonstrates the increase
of the distance between L3 and SubAu.
Using the anatomical tissue landmarks to divide the ear
into four parts, the percentage distribution for both genders
is as shown in Fig. 5. The lengths between the selected
tissue landmarks in Fig. 5 are expressed as part of the total
length.
Discussion
The techniques of anthropometry include: classical mea-
surements using a spreading caliper, two-dimensional
photographs, laser-scanning, cephalometry, computed
tomography, magnetic resonance tomography and three-
dimensional surface imaging based on passive or active
triangulation [12, 16–20]. Regarding anthropometrical
surface measurements, the triangulation systems are
advantageous. This is because performing the investigation
that way only needs a few minutes—mainly for positioning
the volunteer. Moreover, taking the three-dimensional
photograph requires less than 1 s. Additionally, the vol-
unteer is not exposed to ionizing radiation throughout the
Table2MeasuredvaluesforthedistancebetweenSubAu–SupAuandassociatedpvalues
EarlateralM1M2M3F1F2F3MFAll
SubAu–SupAu(mm)62.72±3.6666.15±3.6068.19±4.0458.85±3.0261.65±4.4063.08±4.3665.68±3.7761.19±3.9363.44±3.85
pvalue0.0010.0010.001
Aesth Plast Surg
123

investigation [13, 19, 21]. Optical three-dimensional face
scans are used in craniofacial surgery for diagnostics and
therapy planning—customarily in addition to common
techniques such as radiographs. Furthermore, they can be
applied as a control tool during operations and postoper-
atively in the context of follow-ups of surgical interven-
tions [22–24]. The accuracy of modern optical 3D scanners
is sufficient for this medical purpose [13, 21, 25]. In con-
trast, many of the existing measurements—and especially
those with a larger number of Caucasian test persons and
landmarks—were performed with outdated techniques, e.g.
measuring with a spreading caliper [2, 3, 12]. Nowadays,
superior techniques like the above-mentioned triangulation
systems are available [13, 19].
Another shortcoming in the existing literature is that the
overwhelming majority of existing studies concentrate on
measurements over the entire face [2, 12, 26, 27], whereas
only few focus on specific parts of the face, e.g. the ear
[28, 29]. So far, the benefit to surgical interventions that
usually take place in limited facial areas, e.g. the upper lip
or nose is small. Concerning the selection of volunteers,
prior investigations used mainly younger adult volunteers,
mostly between 18 and 35 years [2, 12, 17]. In contrast, the
morbidity and thus the necessity of reconstructive inter-
ventions, grow with increasing age. Hence, the surgeon
should perform an aesthetic facial reconstruction consid-
ering the actual age of the patient. However, gathering
information for natural proportions of older adults is
difficult.
The shape of the ear of each human being is asym-
metric, but there is no accordance in the literature of how
the asymmetry exactly occurs, e.g. that the right ear would
always be 3% bigger than the left ear [12, 15]. In the
present study the mean values of right and left ear were
used due this knowledge and to give a database of average
ears for different ages and gender.
As a result of these observations, the aim of the present
study was to create a database of measurements of the ear
as a part of the face, which can impact various surgical
Table3Measuredvaluesforthedistancebetweenlandmarksonthelateralearandassociatedpvalues
EarlateralM1M2M3F1F2F3MFAll
PreAu–PostAu(mm)32.66±3.2734.06±2.8236.34±2.8331.61±2.5733.08±2.7833.82±2.2734.35±2.9732.84±2.5433.60±2.76
pvalue0.0070.0020.007
Tra–PostAu(mm)37.94±2.6938.19±2.8238.93±2.9734.20±2.5934.78±3.0236.01±2.9538.35±2.8334.99±2.8536.67±2.84
pvalue0.1860.0250.001
Osup–Oinf(mm)46.27±4.1149.51±5.2648.50±3.703.71±3.3344.14±3.8045.58±4.8648.10±4.3644.48±4.0046.29±4.18
pvalue0.0090.0940.001
Ia–ITra(mm)17.86±1.2417.77±1.1818.75±1.5816.05±1.1516.29±1.5916.54±1.3518.13±1.3316.29±1.3617.21±1.35
pvalue0.0020.2930.001
(SubAu-
SupAu)-(PreAu-
PostAu)(°)
79.98±6.7680.67±6.8878.63±6.2976.56±7.6777.89±7.0178.70±6.8179.76±6.7677.72±7.1778.74±6.90
pvalue0.3440.3840.025
Ia–ITra:Osup–Oinf(%)38.6035.8938.6636.7136.9036.2937.6936.6337.16
pvalue0.0040.7890.016
Fig. 3 Increase of distance between SubAu and SupAu in different
groups depending on gender
Aesth Plast Surg
123

treatments. Therefore, one of the main goals was to acquire
a homogenous collection of volunteers from the age of
21–65 to simplify individual therapy planning for people of
varying ages.
Another consideration involves the lateral part of the ear
during photography—mainly using the mirror construction
of FaceScan3D. A difficulty for three-dimensional pho-
tography for longhaired volunteers, was to get a clear view
of each part of the ear. If it was not possible to place the
hair behind the ear, then a surgical cap was used. There
was the possibility that hair or the surgical cap affected the
cranial part of the ear by slight pressure. However, the
potential effect on the final results was negligible because
the calculated height and width of the ear correlated with
the results in other studies [15, 28].
Because the selected landmarks are used for orientation
during surgical interventions, they must therefore be
clearly definable in the three-dimensional photography as
well as in real life. The landmarks Tra, SupAu, SubAu,
PreAu and PostAu were frequently used in previous studies
[15, 28] and thus are readily compared with the current
study. Thus, the age-dependent increasing distances and
gender-dependent variations for certain parts of the ear can
be confirmed. Conversely, the landmarks, Ia, ITra, Osup
and Oinf, have not been commonly used in the literature.
Therefore, they provide new findings to the anthropometry
of the external ear.
Table4Measuredvaluesfortheeardividedinquartersandassociatedpvalues
QuadrantsofearM1M2M3F1F2F3MFAll
SupAu–L1(mm)12.88±2.5812.56±2.0112.90±2.2411.70±1.8312.66±2.3912.81±2.5112.78±2.2712.39±2.2412.58±2.26
pvalue0.7420.0510.217
L1–L2(mm)18.27±2.5819.91±2.4820.04±2.2917.46±1.7617.38±2.4217.22±2.5319.41±2.4517.35±2.2418.38±2.35
pvalue0.0220.8880.001
L2–L3(mm)16.94±1.3216.95±1.2817.76±1.4815.11±1.2015.31±1.6515.58±1.4917.22±1.3615.33±1.4516.28±1.40
pvalue0.0070.4040.001
L3–SubAu(mm)14.63±2.4916.63±2.7417.49±2.6814.58±1.7216.29±2.4817.47±2.5816.25±2.6416.11±2.2616.18±2.45
pvalue0.0010.0010.592
Fig. 4 Increase of distance between L3 and SubAu in different
groups depending on gender
Fig. 5 Distribution of length in the four quadrants of the ear in both
genders
Aesth Plast Surg
123

Some difficulties occurred while positioning the outer
landmarks of the ear, e.g. Osup and PreAu sometimes
appear to lie almost at the same position. This is caused by
the convexity of the ventral area of the ear and varies
between subjects. Also, for SupAu and PostAu, it was
difficult to clearly define the point of highest convexity.
Therefore, correct positioning of the subject during the
scan was important.
All lateral ear measurements (Fig. 1), showed a signif-
icant dependence on gender. All measured values were
higher in men than in women. Remarkably, the relation
between Ia–Itra and Osup–Oinf in every age and gender
was slightly lower than the golden section with a signifi-
cant difference between men and women. Some dis-
tances—especially SupAu–SubAu and PreAu–PostAu—
showed a significant relation to the volunteer’s age. The
measured values not only showed an increase of the ver-
tical height of the ear with greater age, but also the main
reason for this increase was noted in the lowest quadrant of
the ear, which grows the most. The dependence of this part
on age demonstrated significance for both sexes. A reason
for this may be that the earlobe only consists of skin, fat
and connective tissue and—in contrast to other parts of the
ear—does not contain any cartilage. Therefore, the higher
elasticity of the tissue together with gravity could be the
reason for the growth change during adulthood.
Symmetry of the ears is important for facial aesthetics.
From a surgical standpoint, a defect of one-fourth of the ear
permits direct closure without a creating an aesthetic
catastrophe. For this investigation, we divided the ear into
four parts of equal height [30]. It is unclear whether a
division of the ear by distance or by landmarks into four
parts is more practical in surgery. The present study forms
the basis for such considerations. To get four parts of
almost the same height, the following anatomical land-
marks were used in the investigation: superaurale, incisura
anterior, tragion, incisura intertragica, subaurale. When the
distances between these landmarks were compared to the
total length of the ear, rounded values from cranial to
caudal of 20, 30, 25 and 25% were detectable. Only the
cranial half of the ear differed from the classical metrical
division.
In total, the measured values for males and females in an
expansive age range should be helpful for planning resec-
tions of the ear and the subsequent reconstruction.
Compliance with Ethical Standards
Conflict of interest The authors declare that they have no conflict of
interest to disclose.
Ethical Approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
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