Anatomy of the Ear
The outer ear is a composite complex of cartilage and skin comprised of 3 critical elements – the helixantihelix – fossa triangularis complex, the conchal bowl, and the lobule. Other external anatomical landmarks include the tragus, antitragus, intertragic notch, and tubercle of Darwin. The anatomical divisions of the ear have embryological origins, based on the first (mandibular) and second (hyoid) branchial arches. The major difference between the ear of a newborn child and the adult ear is that the cartilage is more malleable and soft in the neonate; by adulthood, the ear’s cartilage becomes stiffer and more calcified and surgically more difficult to sculpt.
The ear achieves about 85% of its adult size by age 3 to 4 years. Ear width reaches its mature size in boys at 7 years and in girls at 6 years, while ear length matures in boys at 13 to 15 years and in girls at 12 to 14 years. The ear has several proportions or “canons” that are common in the normal ear—as originally described by Da Vinci in his descriptions of normal facial aesthetics. Some of these canons include:
- The width of the ear is about half the height.
- The ear’s height is generally equal to the distance between the lateral margin of the ipsilateral orbital rim and the root of the ear.
- The ear inclines posteriorly about 20 degrees off the vertical axis.
The arterial supply to the external ear is from branches of the external carotid artery, specifically, the posterior auricular and the superficial temporal arteries. The primary innervation to the external ear consists of the great auricular nerve and the auriculotemporal nerve. Other sensory nerve branches to the ear include the lesser occipital, vagus, and glossopharyngeal nerves.
Ear Deformity and the Constricted Ear
An Ear Deformity of any type can bring about social anxiety and may make children vulnerable to teasing. Regardless of the origin of the ear deformity, these ear conditions can be surgically corrected. These procedures do not alter the patient’s hearing, but they may improve not only appearance but self-confidence as well.
The “Constricted Ear” applies to a spectrum of deformities where the helical rim is wrinkled, very tight or folded over (Lop Ear Deformity). The term “Constricted Ear” is best described as a purse-string closure of the ear that takes into account the protrusion of the ear (Cup Ear) and downward folding of the upper helix giving a drooping appearance (Lop Ear). Other ear deformities or malformations occur in a variety of conditions. Some patients are born with absent ears or “buds” where the ear is not fully formed (Microbial). Painful ear deformities also transpire as a direct result of trauma (e.g. car wreck or dog bite) or torn earlobes.
Formation of the ear during development is a complex choreography of moving skin and adjacent soft tissue to give rise to the different parts of the ear. If this process is interrupted, various differences in ear shape can occur, with the most severe being Microtia (absence of the ear and possibly the ear canal), to mild folding differences of the ear. The “fold” of hard, raised cartilage that gives shape to the upper portion of the ear does not form in all people. This is known as “Lop Ear Deformity,” and it is inherited. The missing fold can cause the ear to stick out or flop down.
Ears that protrude more than 2 cm from the side of the head are considered prominent. In most people this is caused by improper formation of the anti-helical fold, which causes the helix stick out. Additionally, most people with protruding ears have a deep conchal fossa that pushes the entire ear away from the side of the head.
Ear Deformity Treatment
There are minimally invasive and surgical options available to correct deformities of the Constricted Ear.
As early as 1984 Plastic Surgeons determined that the cartilage of newborn ears is extremely malleable due to maternal estrogen, and deformed ears can be easily molded into a normal shape during infancy. After several weeks to months, the cartilage stiffens and maintains its new shape.
This technique has been applied to a variety of congenital ear deformities, including Lop Ear Deformity, with an exceptional outcome. If ear molding begins early enough (ideally in the first week of life), surgery can often be avoided. Results are less successful if treatment is delayed longer than 3 weeks as maternal estrogen levels fall to normal by 6 weeks of age.
Ear molding is a treatment option that is available to our patients if they are referred to us early enough while their ears are still soft. Using a combination of a commercially available ear molding system and orthodontic molding materials, non-operative correction of protruding ears is possible.
Surgical Correction – Otoplasty
For ears that are already protruding or drooping and too stiff for molding, surgical correction is an option. It may be preferable to wait until about age 6, when ears are almost fully grown. This coincides with the age when children typically begin to receive teasing from their peers, which provides additional incentive for them to undergo surgery. Otoplasty Surgery is usually performed through an incision behind the ears.
Correction of the Constricted Ear must include a comprehensive approach and follow these general principles:
- Less is more so do as little as needed to achieve an acceptable result. Each deformity correction does not require dissection of cartilage and soft tiddues.
- The main goal should be symmetry.
- A symmetrical appearance of the vertical height and position will create a good outcome. Intra-auricular anatomy us then secondary to vertical height of the ear.
- Flexibility in surgical correction is a must as no ear deformity is exactly the same.
The most common deformity that leads people to pursue Ear Plastic Surgery is Protrusion, where the ear protrudes too much from the side of the head. The height is normal and with simple adjustments, the Plastic Surgeon can fold and push the ear to a normal position. A combination of cartilage scoring and suturing is often used to create an antihelical fold. Additional sutures on the back of the conchal cartilage bring the entire ear closer to the side of the head. Although anesthesia is needed, the operation is done on an outpatient basis.
This anomaly is usually the result of a combination of four anatomical issues. Unless these issues are thoroughly examined, understood and corrected, the end-result of Ear Plastic Surgery will be inadequate.
- First, the main ear fold (AKA antihelical fold) is flattened. Bending the protruding ear at the antihelix leads to an improvement of the auricle’s position. This congenital issue is almost always found in prominent ears.
- Second, the ear bowl (AKA concha) is rather large adding to the auricular prominence. When the ear is folded appropriately at the antihelix and it still appears prominent, it is typically caused by the enlarged concha.
- Third, the angle between the top of the ear and the side of the head (AKA temporo-helical angle) is rounded. This feature is caused by the direction the ear cartilage (AKA helix) takes as it exits from the side of the head.
- Fourth, the earlobe is too prominent. As a pendulant structure that does only contain skin and a tiny amount of fatty tissue (but no cartilage), it is commonly protruding adding to the overall look of the prominent ear.
A second deformity that leads patients to Ear Plastic Surgery is known as Lop Ear Deformity or Lidding. The upper third of the ear includes a deficiency of the scapha, superior crus and fossa triangularis that results in a downward fold of the upper helix as well as reduced natural vertical height of the ear. The helical rim is folded onto itself.
Surgical correction of the Lop Ear often includes two steps. The first step involves skin incision and cartilage excision. The second step includes use of a cartilage flap. In moderate deformities, only the first step of correction may be required.
Some infants are born without an ear canal and hearing can be restored with a bone-anchored hearing aid or it can be surgically opened, and the outer ear reshaped to look like the other ear. Individuals born without an ear (Microtia), or lose an ear due to injury, can have an artificial ear surgically attached for cosmetic reasons. These are custom formed to match the patient’s other ear. Alternatively, rib cartilage or a biomedical implant, in addition to the patient’s own soft tissue, can be used to construct a new ear.
Please note, heath insurance companies deem Otoplasty Cosmetic Surgery, and therefore they will often not cover any fees incurred for this surgery.