title: The Existence of a Natural Plica at the Anatomical Base of the Antihelix and its Surgical Importance to Address Protruding Ears: An Anatomicosurgical Study.
abstract: BACKGROUND
  Protruding ears represent the main abnormality of the external ear, which has required numerous anatomic and surgical studies. Most studies give attention to the absence of the antihelix as the anatomic defect responsible for the clinical deformity of the lateral aspect of the ear that leads to its anteversion. The reason for this study is the controversial origin of the fold of the antihelix within the auricle framework, a field of interest for aesthetic otoplasty. The current study examined the medial surface of the cartilaginous ear frame from cadaver specimens with right morphology to investigate the starting point of the fold of the antihelix. This allowed for verification of a natural plica at the anatomic base of this antihelical fold, which to date has not had its topography described morphologically. It is acknowledged that relevant literature makes no reference to this innominate natural plica at the origin of the antihelix, whose anatomic and surgical importance is related in this report. This study aimed to show that the existence of a natural plica at the base of the antihelix in ear framing represents a landmark between normal and protruding ear morphology.
  
  
  METHODS
  For 8 years, 118 ears were carefully investigated within rigid ethical principles based on a thorough review of the pertinent literature. The study investigated 16 selected cadaver specimens and 102 protruding ears dissected by the senior author including 49 bilateral cases (26 males and 23 females) and 4 unilateral cases (2 males and 2 females). Bifacial anthropometric measurements by calipers were used for documentation.
  
  
  RESULTS
  A natural plica at the base of the antihelix was found in all cadaver ears selected with right morphology, whereas it was totally absent in every surgically treated protruding ear irrespective of color, gender, age, or ethnic origin. Ambilateral measures of the antihelix eminence certify the study object in normal specimens as well as its lack in abnormal ones.
  
  
  CONCLUSIONS
  Technical and topographic knowledge that a natural plica exists at the anatomic base of the antihelix is a valuable key point in recognizing the normal external ear. In addition, the making of a natural plica is the first and most effective factor in the reconstruction of the antihelical fold and its absolute absence results in the pathologic condition for protruding ears.
  
  
  METHODS
  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 A3 online Instructions to Authors. http://www.springer.com/00266 .
authors.affiliation: Division of Plastic Surgery at Santa Casa General Hospital, Campo Grande, MS, Brazil. miguelmar@hotmail.com.br.|Marques Interclínicas, Av Afonso Pena 3504, Suite 126, Campo Grande, MS, 79002-075, Brazil. miguelmar@hotmail.com.br.
authors.forename: Miguel Marques
authors.initials: MM
authors.lastname: Oliveira
authors.affiliation: Campo Grande Clinic General Hospital, Campo Grande, MS, Brazil.
authors.forename: Daniel Sousa Marques
authors.initials: DS
authors.lastname: Oliveira
authors.affiliation: Division of Plastic Surgery at Santa Casa General Hospital, Campo Grande, MS, Brazil.|Marques Interclínicas, Av Afonso Pena 3504, Suite 126, Campo Grande, MS, 79002-075, Brazil.
authors.forename: Gustavo Sousa Marques
authors.initials: GS
authors.lastname: Oliveira
mesh_terms: D000293:Adolescent; D000328:Adult; D002102:Cadaver; D002508:Cephalometry; D002648:Child; D002675:Child, Preschool; D054644:Ear Auricle / Q000033:anatomy & histology* / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D013506:Otologic Surgical Procedures / Q000379:methods*; D019651:Plastic Surgery Procedures / Q000379:methods*; D055815:Young Adult
keywords: Aesthetic otoplasty; Ear cartilage; Ear framework; External ear anatomy; Fold of the antihelix; Protruding ears