Aesth Plast Surg (2013) 37:605–616
DOI 10.1007/s00266-013-0097-1
ORIGINAL ARTICLE
Progression of Growth in the External Ear from Birth
to Maturity: A 2-Year Follow-Up Study in India
Ruma Purkait
Received: 22 December 2012 / Accepted: 16 February 2013 / Published online: 22 March 2013
Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2013
Abstract
Background This study aimed to follow the growth
dynamics of auricular dimensions from birth to the age of
18 years. The norms of dimensions at different ages, the
peak growth period and the maturity age of the dimensions
are essential information to Physicians for early clinical
diagnosis or for deciding the optimal time for surgery to
correct abnormalities.
Methods For this study, 2,147 children belonging to central
Indian population were measured in at least three sequential
sessions. Eight dimensions including the physiognomic length
and width of the ear and its morphologic width; conchal
length, width, and depth; and lobular length and width were
measured using anthropometric technique. Three new
dimensions (tragal length and height and maximum width of
the antihelix) were introduced in the study. Three indices
(auricular, conchal, and lobular) also were derived.
Results Most dimensions exhibited very rapid growth
during the first 3–6 months of infancy and thereafter pro-
ceeded at a slow pace until adulthood. The smaller
dimensions (conchal depth, tragal height, and maximum
width of the antihelix) increased continuously throughout
the growth period. At birth, most of the dimensions were
52–76 % of their adult size, while tragal length and height
were less than half their adult size. Unlike the other
dimensions, the lobule length was smaller in males, prob-
ably due to the higher frequency of hypoplastic and bow-
shaped lobules among them. The width dimensions
matured earlier, at 5.6–11 years, whereas the maturity age
of lengths varied from 12 to 16 years.
R. Purkait (&)
Department of Anthropology, Dr. H. S. Gour Central University,
Saugor 470 003, Madhya Pradesh, India
e-mail: r.purkait@gmail.com
EXPERIMENTAL/SPECIAL TOPICS
Conclusions The data generated in the current study will be
useful to Physicians as a guideline in correcting auricular
deformity and in constructing age progression charts of the
external ear. Knowledge concerning the maturation age of the
ear will help law enforcement authorities in deciding when to
use it for establishing personal identification.
Level of Evidence III 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 Anthropometry  Ear linear dimensions
and index  Indian population  Maturation age 
Postnatal growth  Two-year follow-up study
Knowledge of normal auricular dimensions and growth
patterns are important in the diagnosis of varied congenital
malformations or syndromes. Trisomy 13 and 18 syndromes
as well as Noonan and Smith–Lemli–Opitz syndromes, for
example, are reportedly associated with low-set and
deformed ears. Down’s syndrome patients have smaller
auricles, whereas abnormal ear structure is associated with
Beckwith–Wiedermann syndrome [12].
An early recognition of abnormalities may prompt rel-
evant investigations. The dynamics of postnatal growth are
critical in planning the optimal time for surgical recon-
struction of the deformed or congenitally malformed
structure. Generally, physicians diagnose any abnormality
on the basis of their medical knowledge and expertise.
Population-specific normative data will aid them in their
diagnosis, enabling them to base it on objective and precise
information rather than their visual impression alone.
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606
Norms for any morphologic part of the body vary in
different ethnic groups including the dimensions of the
external ear. Detailed dynamics of growth in auricular
dimensions are available for Caucasians and other ethnic
groups including North Americans [1, 3], Turks [4], Ger-
mans [8], and Italian whites [10], but similar information
for Indian infants is limited (growth of ear length from
birth to 11 years [6] and the ear lobe [11]). The majority of
the reported studies are focused on growth pattern differ-
ences in various populations based on a few selected
parameters without considering the growth dynamics of
every part of the auricle, which actually prove useful to
Physicians and Surgeons for correcting deformities.
Moreover, many of these studies are based on cross-sec-
tional data giving us a crude and approximate estimate of
growth, because the subject is measured only once and
growth is calculated from age groups composed of differ-
ent subjects.
The current study was undertaken to fill the need for a
comprehensive study investigating this subject. During the
current study, the growth dynamics of various parts of the
external ear from birth to maturity were followed for a
period of 2 years using anthropometric technique.
Methods
Subjects
The study, conducted between 2009 and 2012 included
2,559 children and adolescent subjects ranging in age from
birth to 18 years. The data were collected from hospitals,
schools, and day care centers of central India. The subjects
belonged to middle-class families. Only normal, well-
nourished children without any craniofacial or auricular
abnormality or endocrine dysfunction were recruited as
subjects.
The complete growth period was categorized into age
groups of variable intervals. To facilitate close monitoring
of changes in the early years of life, the age groups were
categorized at close intervals (quarterly up to 2 years and
half yearly from 2 to 8 years) compared with the yearly
intervals used for older age groups. Because it was a fol-
low-up study, each subject was measured for a minimum of
three sessions in sequence. At the close of the study period,
19.2 % of the data belonging to subjects who had left the
study without completing the required measurement ses-
sions was rejected. Hence the current study was based on a
sample of 2,147 subjects (1,163 boys and 984 girls). Each
age group consisted of more than 50 subjects.
The study was approved by the University ethics com-
mittee and conformed to the guidelines set by the Indian
Council of Medical Research. Due consent was sought
123
Aesth Plast Surg (2013) 37:605–616
from the subjects and their parents before necessary mea-
surements were obtained.
Anthropometry
The measurements in singleton full-term newborns were taken
within 48 h after delivery and in the other age groups within a
week after the due date. The age of the children was confirmed
from the hospital or school record or birth certificate.
Data for all measurements were collected by a single
researcher. Three concurrent readings were obtained for
each measurement, and the average was taken for calcu-
lation. During the measurements, the head of the subject
was aligned in the Frankfurt horizontal (FH) plane.
To cover the complete morphology of the ear, 11 linear
dimensions were measured bilaterally. Data on the right ear
have been reported in this article. The physiognomic length of
the ear (PLE) (1 and 2 in Fig. 1a), physiognomic width (PWE)
(3 and 4 in Fig. 1a), the morphologic width (MWE) (5 and 6 in
Fig. 1a), the conchal length (CL) (7 and 8 in Fig. 1a), the
conchal width (CW) (9 and 10 in Fig. 1a), the conchal depth
(CD in Fig. 1b), the lobular length (LL) (2 and 8 in Fig. 1b),
the lobular width (LW) (11 and 12 in Fig. 1b), the tragal length
(TL) (8 and 9 in Fig. 1a), the tragal height (TH in Fig. 1b), and
the maximum width of antihelix (MWAH) (14 and 15 in
Fig. 1b) were measured with a sliding caliper (Dial caliper;
Mitutoyo Corporation, Kawasaki, Japan, accuracy 0.01 mm).
The aforementioned dimensions were incorporated into
indices for assessment of their proportion during growth
progression, for example:
1. Auricular index (AI) = PWE/PLE 9 100
2. Conchal index (CI) = CW/CL 9 100
3. Lobular index (LI) = LW/LL 9 100.
Measurements of PLE, PWE, MWE, LL and CW were
performed following definitions given by Knußmann [5]
whereas the auricular index was computed following
Martin and Saller [7], and the conchal index was computed
following Knußmann [5]. The remaining dimensions (i.e.,
CL, CD, LW, TL, TH and MWAH and the lobular index)
were defined by the author.
Conchal length was measured between the concha
superior and the incisura intertragica inferior (7 and 8 in
Fig. 1a), and CD measured between the plane joining the
protragion and the concha-antihelix margin to the deepest
point on the conchal floor (CD in Fig. 1b). The length of
the tragus was measured between the anterior auris pos-
terior and the incisura intertragica inferior (8 and 9 in
Fig. 1a), and the height of the tragus was measured by
joining a perpendicular line between the base of the tragus
and the protragion (13 in Fig. 1b). The lobular width was
measured between the lobule anterior and the lobule pos-
terior (11 and 12 in Fig. 1b). The maximum width of the
Aesth Plast Surg (2013) 37:605–616
Fig. 1 a The landmarks of the ear are as follows: 1 superaurale, 2
subaurale, 3 preaurale, 4 postaurale, 5 otobasion superius, 6 otobasion
inferius, 7 concha superior (the cross-over of the lower edge of the
anterior end of the crus antihelicus inferius and the posterior border of
the crus helicus), 8 incisura intertragica inferior (the deepest point in
the incisura intertragic notch), 9 incisura anterior auris posterior (the
most posterior point on the edge of the incisura anterior auris), 10 the
strongest antihelical curvature. b 11 lobule anterior (most anterior
point of the lobule located on the line attaching the ear to the cheek;
antihelix measured the largest separation of the scapha and
the concha-antihelix margin (14 and 15 in Fig. 1b).
Statistical Analysis
The age of maturation was determined according to the
method suggested by Farkas and Posnick [2]. Simple statistics
were analyzed using MS Excel [Microsoft Office Home and
Student 2007, MicrosoftÓ 2009 Microsoft Corporation
(India) Pvt. Ltd., New Delhi, India] and the SPSS 16 software
package (SPSS Inc., Chicago, IL) was used to derive the
regression equation and the age of maturation as follows:
Percentage increment of growth
Higher age value  lower age value of dimension  100
¼ :
Lower age value of dimension
Results
For both sexes, the mean values of all the dimensions show
a gradual increase in size from birth (Tables 1–4; Fig. 2a,
b). Except for LL, the dimensions are generally larger in
boys. Throughout the growth period, MWAH, CD and TH
607
the ear attachment line is drawn joining the otobasion superius and the
inferius; the point on this line just below the incisura intertragica
inferior level is the landmark), 12 lobule posterior (the most posterior
point on the margin of the lobule perpendicular to the lobule anterior),
13 protragion, 14 point on the concha–antihelix margin, 15 point on
the scapha. The arrow CD shows the distance from the deepest point
on the floor of the concha to the plane joining the protragion and
concha–antihelix margin
remain nearly similar in magnitude among both sexes. In
contrast to this, TL is larger in boys until the age 7.6 years,
when girls overtake and surpass boys.
All the dimensions exhibit very rapid growth during
infancy in both sexes. The increment is highest especially
during the first quarter of infancy in PLE, PWE, and MWE
(Table 1; Fig. 2a), whereas it extends until 6 months in CL,
CW, LL, and LW (Tables 2, 3; Fig. 2a).
The dimensions of small magnitude (CD, TH, and
MWAH) show continuous increments throughout the
growth period (Tables 2, 4; Fig. 2a, b). As shown in
Table 4 and Fig. 2b TL undergoes continuous rapid growth
until 4 years in boys and 8 years in girls. Except for CL
and LW, the increment in girls exhibits an edge over boys
in all parameters. In girls, CW undergoes nearly 1.5 times
more rapid increment than in boys (Table 2; Fig. 2a).
At birth, most of the dimensions are 52–66 % of their
size at the age of 18 years, whereas PWE, CW and CD are
70–76 % of their size, with TL and TH less than half their
adult size (Tables 1–4; Fig. 2a, b). By the age of 5 years,
the length dimensions have attained 82–89 % of the adult
size. It is interesting to note that at this age, the width
parameters (PWE, LW, CW, CD and MWAH) are nearer to
their adult size, especially in girls.
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608 Aesth Plast Surg (2013) 37:605–616

Table 1 Physiological length and width of ear and morphological width of ear statistics of subjects from birth to18 years in both sexes
Age (years) PLE PWE MWE
Male Female Male Female Male Female
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

NB 36.9 3.7 35.9 3.2 23.76 2.13 23.1 2.2 23.8 2.1 24.6 2.3
0.3 41.6 4.4 40.5 3.5 26.50 2.14 26.1 2.3 26.5 2.1 27.8 2.6
0.6 44.4 4.0 43.8 3.4 28.21 2.20 28.4 2.6 28.2 2.2 30.5 2.5
0.9 47.4 3.3 46.2 3.7 29.96 1.92 30.0 2.9 30.0 1.9 32.5 2.8
1.0 48.4 2.5 47.6 3.4 30.64 1.87 30.4 2.9 30.6 1.9 33.7 2.4
1.3 49.5 2.6 48.5 3.2 31.40 2.18 30.5 2.6 31.4 2.2 34.4 2.4
1.6 49.8 2.9 48.9 2.9 31.64 2.19 30.2 2.3 31.6 2.2 35.0 2.8
1.9 50.5 3.0 49.4 2.9 31.57 2.30 30.7 2.1 31.6 2.3 35.1 2.7
2.0 50.4 3.3 49.3 2.8 31.08 2.75 30.8 2.2 31.1 2.7 35.8 2.7
2.6 50.6 3.6 49.8 3.1 30.75 2.48 30.8 2.5 30.8 2.5 36.7 3.0
3 51.2 3.4 50.6 2.9 31.71 2.58 30.9 2.7 31.7 2.6 37.7 2.8
3.6 51.5 3.2 51.0 3.0 31.81 2.32 31.5 2.6 31.8 2.3 38.2 2.8
4 51.9 2.9 50.9 3.1 31.89 2.48 31.4 2.3 31.9 2.5 38.5 2.8
4.6 52.3 2.7 51.2 3.0 32.18 2.12 31.1 2.3 32.2 2.1 38.6 2.7
5 52.4 3.0 51.6 2.8 32.13 1.96 31.7 2.3 32.1 2.0 39.4 2.9
5.6 52.9 3.0 51.9 2.8 32.59 1.77 31.6 1.8 32.6 1.8 39.7 2.9
6 53.3 3.3 52.1 2.7 32.47 2.18 31.9 2.4 32.5 2.2 40.2 2.7
6.6 53.8 3.3 52.5 2.6 32.87 2.19 32.0a 2.2 32.9 2.2 40.5 2.4
7 54.2 3.6 52.9 2.4 33.04a 2.62 31.8 2.3 33.0 2.6 40.7 2.5
7.6 54.7 3.2 53.2 2.4 33.59 2.32 31.8 2.1 33.6 2.3 40.6 2.5
8 54.8 3.2 53.6 2.6 32.90 2.64 31.8 2.5 32.9 2.6 40.8 2.5
9 55.0 2.8 54.7 2.6 32.59 2.36 32.1 2.4 32.6 2.4 40.9 2.5
10 56.0 3.2 54.3 3.1 32.82 2.64 31.8 2.4 32.8 2.6 41.3 2.7
11 57.3 3.6 54.3 3.1 32.89 2.98 31.7 1.9 32.9 2.9 42.0 2.5
12 57.8 4.0 55.3 3.3 32.90 2.79 31.8 2.3 32.9 2.8 42.8 2.4
13 58.7 4.0 56.8a 3.5 33.74 2.65 32.2 2.3 33.7 2.6 43.7a 2.6
14 59.1a 4.0 56.7 3.5 33.83 2.74 32.3 2.5 33.8a 2.7 43.0 2.7
15 59.8 3.8 57.0 3.5 33.87 2.64 32.5 2.5 33.9 2.6 42.5 2.3
16 59.8 3.6 57.3 3.2 33.64 2.72 32.3 2.3 33.6 2.7 43.7 2.5
17 59.9 3.2 57.8 3.1 33.59 2.40 32.4 1.9 33.6 2.4 45.2 2.6
18 60.6 3.2 58.4 3.2 34.20 2.31 33.0 1.9 34.2 2.3 45.7 2.7
PLE physiologic length of the ear, PWE physiologic width, MWE morphologic width, SD standard deviation, NB new born
a
Maturation age

The maturity age varies for length and width dimensions
(Tables 1–4; Fig. 2a, b). As noted earlier, the width
dimensions are three-fourths of their adult size at birth,
which leads to attainment of early maturation. It may be
mentioned that the pace of growth is not much faster than
in length dimensions. The earliest maturity occurs with
CW, at the age of 5.6 years for girls and 6.6 years for boys.
The age for the maturity of the other width dimensions
varies from 6.6 to 11 years, with the maturity of length
dimensions following 4–5 years later. Like other width
parameters, CD has an early maturation, at 7 years for girls
and 9 years for boys. Most of the growth (92–99 %) is
completed by the maturity age.
The shape and proportion of the ear structures can be
judged from their index (Table 5; Fig. 2b). The concha, for
instance, is nearly rounded at birth, with equal length and
width dimensions (index 99 in boys and 103 in girls). With
the increase in length, the structure takes an oblong shape
(gradual fall in the index to 79 in boys and 77 in girls). A
similar trend is seen in the auricular index due to gradual
elongation of the ear with advancing age. The lobular index
exhibits a unique trend for boys. It varies from 140 to 153

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Aesth Plast Surg (2013) 37:605–616 609

Table 2 Conchal length, width, and depth statistics of the subjects from birth to the age of 18 years in both sexes
Age (years) CL CW CD
Male Female Male Female Male Female
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

NB 16.5 1.4 15.0 1.9 16.2 2.1 15.3 2.2 12.0 0.7 11.9 0.7
0.3 18.8 2.0 17.5 2.2 17.2 2.3 17.0 2.3 12.5 0.8 12.4 0.8
0.6 20.7 2.5 19.4 2.1 18.4 2.2 18.5 2.1 13.1 0.7 12.9 0.8
0.9 21.5 2.2 20.9 1.9 19.6 2.1 20.0 2.0 13.3 0.7 13.1 0.7
1.0 22.1 2.1 21.7 2.1 20.4 2.0 20.0 2.2 13.4 0.8 13.4 0.9
1.3 22.5 1.9 21.8 2.2 20.6 1.9 19.9 2.3 13.5 0.8 13.6 0.8
1.6 22.9 2.1 21.7 2.1 20.6 1.9 19.9 2.1 13.6 0.8 13.4 0.9
1.9 22.8 2.2 22.0 2.0 20.5 2.4 20.1 1.8 13.4 0.8 13.5 0.8
2.0 22.0 2.2 22.1 2.4 19.7 2.7 19.9 2.2 13.3 0.7 13.6 0.9
2.6 22.3 2.3 22.0 2.3 19.9 2.8 19.4 2.1 13.4 0.7 13.7 0.7
3 22.9 2.4 22.4 2.1 20.6 2.7 19.5 2.1 13.7 0.9 13.7 0.9
3.6 23.0 2.0 22.7 2.1 21.3 2.7 20.4 1.9 14.0 0.8 14.0 0.9
4 23.0 2.2 22.8 2.1 21.1 3.1 20.4 1.8 14.8 0.9 14.7 1.0
4.6 23.3 1.9 22.8 2.0 20.9 3.0 20.5 2.0 15.0 0.8 14.9 0.8
5 23.5 2.1 22.9 1.6 20.9 2.7 20.6 2.0 15.0 0.8 15.0 0.9
5.6 23.8 1.9 22.5 2.9 21.5 2.7 19.8a 2.0 15.0 0.8 15.0 0.8
6 23.6 2.2 22.7 2.6 21.0 3.0 19.2 2.3 15.0 0.8 14.9 1.1
6.6 24.1 2.1 22.8 2.3 20.7a 2.8 19.1 1.9 15.1 0.9 15.1 1.0
7 24.2 2.1 23.7 1.9 20.3 2.6 19.5 1.9 15.1 0.9 15.2a 1.2
7.6 24.4 2.2 23.7 1.8 20.3 2.6 19.2 2.1 14.9 1.6 15.1 1.2
8 24.0 2.3 23.6 2.1 20.0 2.4 19.1 1.4 15.2 1.0 15.1 1.2
9 24.1 2.4 24.1 2.4 21.0 2.3 19.7 1.5 15.4a 0.8 15.5 1.2
10 24.5 2.2 24.1 2.4 21.2 2.4 19.3 2.1 15.6 0.9 15.5 1.1
11 25.1 2.3 24.3 2.3 21.2 2.2 19.1 1.4 15.5 0.7 15.5 0.8
12 25.1 2.4 24.5 2.1 21.0 2.4 19.3 1.7 15.5 1.1 15.5 1.0
13 25.1 2.2 25.3a 1.8 21.4 2.4 19.4 1.4 15.5 0.9 15.6 0.9
14 26.4a 2.4 25.0 2.3 21.3 2.6 19.2 1.9 15.6 0.9 15.6 1.2
15 26.0 2.5 24.7 2.4 21.6 2.6 19.2 1.9 15.7 0.7 15.8 1.2
16 26.3 2.4 25.2 2.2 21.4 2.6 19.8 1.7 15.5 0.9 15.6 1.3
17 27.5 2.4 26.2 2.1 21.5 2.7 20.3 1.3 15.6 0.9 15.5 0.9
18 28.0 2.5 26.7 2.1 21.9 2.6 20.6 1.4 15.7 0.8 15.7 0.8
CL conchal length, CW conchal width, CD conchal depth, SD standard deviation, NB new born
a
Maturation age

throughout the growth period, whereas a consistent Discussion

decrease is witnessed among girls (146 to128) (Table 5).
Regression equations also were derived so that normal
ear dimensions can be estimated from age (Table 6).
Although all the dimensions except CW show a high
degree of correlation with age, LL gives the best estimates
in both sexes. The standard error of the estimate in the table
predicts the deviation of the estimated dimension from the
actual one. A low value indicates greater reliability in the
estimated dimension. The regression equation of CD will
give the best estimate of the dimension at any age.
Anthropometry is a useful tool for quantifying observations
of any morphologic structure. Auricular deformity, whether
structural or topographic, is associated with many con-
genital syndromes. An early clinical diagnosis can aid in a
timely management plan and an estimate of prognosis.
Microtia, macrotia, lop ear, Stahl’s ear, and other similar
structural deformities found among normal people can
cause psychological distress necessitating surgical inter-
vention. Knowledge of population-specific norms and

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610 Aesth Plast Surg (2013) 37:605–616

Table 3 Lobular length and width statistics of the subjects from birth attempts were made to record the changes occurring in the
to the age of 18 years in both sexes auricular region during the first 18 years of life.
Age (years) LL LW Although a significant effect of sex is found in the
magnitude of dimensions during the growth period, the
Male Female Male Female
pattern of growth is similar in both sexes. A comparison of
Mean SD Mean SD Mean SD Mean SD PLE in various ethnic groups (Table 7) demonstrated that
NB 9.9 1.3 10.2 1.1 14.7 2.3 14.7 1.7 Indian ears were shortest at most of the milestone ages,
0.3 11.3 1.2 11.6 1.4 16.9 2.2 16.8 1.9 although the mean ear length of Indian females was com-
0.6 12.2 1.2 13.0 1.6 18.2 2.0 17.7 1.9
parable with that of North Americans [3] and Italians [10].
0.9 12.8 1.1 13.6 1.7 19.5 1.7 18.6 1.8
At birth, German [8] infants have the largest ears, fol-
lowed by Turkey [4]. The ears of South Indian newborns
1.0 13.1 1.3 13.6 1.8 19.8 1.6 18.6 2.0
are the smallest [6]. At 1 year, the Indians in the current
1.3 13.5 1.4 13.7 1.6 20.0 1.5 19.3 1.9
study had the largest ears, attaining approximately 81 % of
1.6 13.5 1.2 13.9 1.5 20.3 1.5 19.5 1.8
adult size. North American and Turkish infants had ears
1.9 13.8 1.4 14.3 1.5 20.5 1.5 19.9 1.6
76 % of adult size during the first year.
2.0 13.5 1.5 14.2 1.9 20.3 1.9 19.9 1.7
The pace of growth and increment in size was similar in all
2.6 13.4 1.6 13.5 1.5 20.5 2.0 19.9 1.7
ethnic groups at the ages of 5 and 10 years. Most of the
3 13.9 1.6 13.7 1.6 21.0 1.8 20.0 1.8
increment in length occurred during the first year of life among
3.6 14.2 1.3 13.9 1.5 21.3 1.6 20.4 1.7
Indian infants (32 % increase among Indians in the current
4 14.3 1.3 14.1 1.4 21.2 1.7 20.3 1.6
study and 39 % among South Indians) and Turkish infants
4.6 14.5 1.3 14.5 1.2 21.6 1.6 20.8 1.6
(28 % increase), in contrast to the North Americans, who have
5 14.5 1.4 14.6 1.6 21.5 1.6 21.3 1.8
the most rapid growth between 2–3 years [3].
5.6 14.7 1.5 14.8 1.8 22.0 1.5 21.4 1.9 The age of maturation was earliest among Turks
6 14.6 1.5 14.4 1.7 22.0 1.7 21.0 1.9 (11 years in girls and 12 years in boys), followed by North
6.6 14.9 1.3 14.6 1.6 22.4 1.7 21.0 1.7 Americans 1 year later and by Indians 2 years later.
7 14.9 1.5 14.8 1.3 22.2 2.0 21.1 1.6 Lakshminarayana et al. [6] claimed that ear length stops
7.6 15.0 1.5 14.9 1.5 22.2 1.8 21.3 1.5 growing after 2 years of age, although their method of
8 14.7 1.7 14.6 1.7 21.9 1.8 21.3 1.7 determining the maturation age was not disclosed.
a
9 14.8 1.6 14.5 1.3 22.2 1.6 21.4 1.7 Infants generally have broad and round ears at birth, per-
10 15.3 1.5 15.2 1.4 22.3 1.5 21.4 1.8 haps because the ear attains more than 70 % of its adult width
11 15.8 1.6 15.8 1.6 23.1a 1.3 21.6 2.0 at birth. By the first year, the width increases further to more
12 15.7 1.5 16.1 1.4 22.7 1.4 21.8 1.8 than 90 % (94 % among North Americans and 91 % among
13 16.1 1.1 16.7a 1.3 23.0 1.2 22.0 1.4 Indians). After the infant spurt (increase *30 %; Table 1;
a
14 16.5 1.3 16.4 1.5 23.0 1.7 22.2 1.6 Fig. 2a), the ear continues to broaden at a moderate pace,
15 16.4 1.4 16.4 1.3 22.8 1.9 22.5 1.6 ultimately leading to early maturation. In one study, Indian
16 16.5 1.3 16.7 1.2 23.0 1.6 22.4 1.7 maturation time (6.6 years among girls and 7 years among
17 16.6 1.0 17.2 1.2 23.5 0.9 22.3 1.5 boys) conformed to that of North Americans [3]. The width
18 16.9 1.0 17.5 1.1 23.7 1.0 22.3 1.5 and pace of growth of the Indian ear was closer to those of
LL lobular length, LW lobular width, SD standard deviation, NB new
North Americans. Although Italians have broader ears, the
born increment pace was similar to that of Indians.
a
Maturation age Excessive concha depth may result in abnormal pro-
trusion of the ear, or an abnormally enlarged concha may
lead to macrotia. The deformities are associated with both
growth patterns of the ear would be useful for Surgeons normal and congenital syndromes. Hence, knowledge
enabling her or him to decide the dimension and the opti- concerning normal dimensions of the conchal part is
mal time for surgery. essential for reconstruction and rectification of a deformed
Unlike other parts of the world, India lacked compre- ear. Kalcioglu et al. [4] reported the growth of CW and CD
hensive data on the auricular growth patterns of normal among Turkish children. The dimension of Indian CW is
children. Initiating a step in this direction, the current study not comparable with Turkish CW because the landmark on
was conducted in central India, which encompasses the the medial part of the ear is not the same. Kalcioglu et al.
largest area and has the largest population compared with [4] measured it from the tragus as opposed to the anterior
other states. The study is the first of its kind to be con- auris posterior of the current study. Although the size was
ducted with a large sample of healthy children in which slightly larger in the current study, the infant spurt was

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Aesth Plast Surg (2013) 37:605–616 611

Table 4 Tragal length, height, and maximum width of antihelix statistics of the subjects from birth to the age of 18 years in both sexes
Age (years) TL TH MWAH
Male Female Male Female Male Female
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

NB 7.6 1.0 6.8 1.7 3.9 0.9 3.9 0.6 11.7 2.2 11.0 1.7
0.3 8.8 1.6 8.1 2.1 4.9 1.2 4.8 1.1 13.6 2.1 12.9 1.9
0.6 10.0 1.7 9.5 2.2 5.6 1.1 5.6 1.1 14.8 2.1 14.1 2.1
0.9 11.3 1.8 10.8 1.9 6.6 1.2 6.4 1.2 15.4 2.1 15.0 2.2
1.0 11.8 1.8 11.6 1.4 6.9 1.3 6.8 1.3 15.7 1.8 15.3 2.2
1.3 12.3 1.8 11.7 1.2 7.3 1.5 7.0 1.3 16.3 1.8 15.5 2.1
1.6 12.4 1.7 11.7 1.2 7.4 1.5 6.9 1.2 16.5 2.0 15.4 2.2
1.9 12.9 1.7 12.1 0.9 7.5 1.3 7.1 1.0 16.4 2.2 15.6 2.1
2.0 13.1 1.4 12.1 1.2 7.4 1.4 7.4 1.1 15.6 2.4 15.8 2.2
2.6 13.0 1.5 11.8 0.9 7.4 1.3 7.0 0.9 15.4 2.5 15.5 2.0
3 13.5 1.6 12.4 1.0 7.7 1.5 7.3 1.4 16.0 2.3 16.0 2.1
3.6 13.4 1.4 12.7 1.1 7.7 1.2 7.1 1.2 16.3 2.3 16.2 2.1
4 13.7 1.6 12.9 1.3 7.7 1.4 7.4 1.1 16.4 2.2 16.0 2.3
4.6 13.9 1.5 12.9 1.2 7.8 1.3 7.8 1.1 16.5 2.1 16.3 2.2
5 14.0 1.6 13.4 1.1 7.7 1.3 8.0 1.0 16.4 2.4 16.7 2.5
5.6 14.1 1.6 13.8 1.2 7.9 1.3 7.8 1.1 16.6 2.4 16.9 2.4
6 14.0 1.7 13.9 1.4 7.8 1.4 7.9 1.2 16.7 2.3 16.3 2.8
6.6 14.3 1.6 14.0 1.4 8.0 1.3 8.0 1.2 17.0 2.2 16.2 2.4
7 14.5 1.6 14.2 1.3 8.0 1.5 8.4a 1.3 17.1 2.4 16.2 2.1
7.6 14.8 1.5 14.2 1.3 8.1 1.5 8.1 1.5 17.2 2.4 16.9 2.1
8 14.7 1.6 14.9 1.1 7.6 1.7 7.6 1.6 17.0 2.3 16.7a 2.6
9 14.8 1.5 15.6 0.9 7.6 1.4 7.5 1.1 17.1 2.0 17.1 2.6
10 14.9 1.5 15.8 1.1 7.7 1.5 7.5 1.2 17.4a 2.2 16.8 2.3
11 15.3 1.5 15.6 1.0 7.8 1.4 7.6 0.9 17.4 2.1 16.7 1.6
12 15.5 1.6 16.1a 0.8 8.1 1.6 7.8 1.2 16.9 2.2 16.4 2.0
13 15.8a 1.6 16.3 0.7 8.4a 1.4 8.2 1.1 17.2 2.1 16.5 1.8
14 16.0 1.7 16.5 1.0 8.7 1.5 8.2 1.4 17.6 2.1 16.7 2.2
15 16.0 1.9 16.4 0.8 8.5 1.3 8.2 1.4 18.6 2.0 16.8 2.3
16 16.1 1.8 16.4 1.1 8.4 1.6 8.4 1.2 18.7 2.0 16.8 2.5
17 16.3 1.5 16.2 0.9 8.4 1.4 8.6 1.0 18.5 1.8 17.0 2.4
18 16.6 1.3 16.5 0.9 9.0 1.3 9.0 1.2 18.9 1.7 17.8 2.6
TL tragal length, TH tragal height, MWAH maximum width of antihelix, SD standard deviation, NB new born
a
Maturation age

most intense during the first 6 months in both populations
(Table 2; Fig. 2a). Niemitz et al. [8] observed that the
width does not increase much between ages 0–4 and
20–30 years among Germans. This may be due to the early
maturation of width. The maturity age is very early among
Turkish children [4] (6 months in girls and 1 year in boys)
compared with Indians.
Due to the variation in measuring CD, the data from Indians
and Turks are not comparable. Kalcioglu et al. [4] measured the
CD from the external auditory meatus to the tragus, whereas in
the current study, the distance from the deepest point on the
floor of the concha to the plane joining the protragion and
concha-antihelix margin was measured. The suggested meth-
odology reflects a better understanding of the depth of the
concha as the margin of the external auditory meatus generally
is set at a higher level than the deepest concha landmark. Except
for German children [8], no comparable data on CL are avail-
able, although details of its growth can be useful for recon-
struction. The length is comparable in both ethnic groups. Like
CW, the CL achieves a maximum increment during the
6 months after birth, which continues at a moderate pace until
maturity (Table 2; Fig. 2a). It matures at the same time as PLE.
Congenital earlobe defects vary from minor clefts to
complete absence. In normal people, the lobule may be

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612 Aesth Plast Surg (2013) 37:605–616

Fig. 2 a Distance curves for various dimensions of ear, concha and lobule. b Distance curves for dimensions of tragus, antihelix and indices. The
arrows point to the age of maturation in males and females

congenitally enlarged, torn, or enlarged due to the wearing
of heavy ear rings.
The LL presented a peculiar trend in the current study.
Unlike other auricular parameters, the dimension proved to
be smaller in boys than in girls during growth and in
adulthood. It is interesting to note that PLE is larger in boys
although its lobule is shorter (Table 3; Fig. 2a). The lob-
ular index in boys also does not exhibit a decreasing trend
but ranges from 140 to 153 during the growth period
(Table 5; Fig. 2b). The phenomena may be due to a more

123
Aesth Plast Surg (2013) 37:605–616
Fig. 2 continued
frequent occurrence of hypoplastic short bow-shaped lob-
ules among boys. The same trend was observed among
adults as well [9]. The maturity age also does not differ
from that for PLE. The size of the male ear lobe is larger
among Germans than it was in the study population.
Sharma et al. [11] followed the growth pattern of male
lobules from 1 to 20 years categorized in 5-year age
groups. The study was conducted in the northern part of
India. The lobule was longer than in central Indian males.
The LW is larger in males (Table 3; Fig. 2a). The largest
increase in size is during the 6 months after birth, leading to
earlier maturity than for its length. No comparable data on its
growth are available from populations other than North
613
Indians [11]. In all age groups, the central Indian earlobe was
much broader than that of North Indians.
Deformity of the antihelix in Stahl’s ear, macrotia, and
microtia, for instance, requires corrective surgery to create
a normal shape and dimensions to the auricle. Comparative
data are lacking on antihelical growth patterns and its
norms in any other population. Unlike other dimensions,
during the post-infant spurt, the growth proceeds at a
moderate rate, with frequent peaks (periods of high growth
rate) until the end (Table 4; Fig. 2b). This has led to early
maturation compared with most length dimensions. The
length and height of the tragus present a trend similar to
that of MWAH, high growth until the age of 6 months and
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614 Aesth Plast Surg (2013) 37:605–616

Table 5 Auricular index, conchal index, and lobular index statistics of the subjects from birth to the age of 18 years in both sexes
Age (years) AI CI LI
Male Female Male Female Male Female
Mean SD Mean SD Mean SD Mean SD Mean SD Mean SD

NB 64.8 6.6 64.5 7.0 98.8 13.8 102.8 15.8 149.9 28.7 146.3 23.6
0.3 64.1 6.8 64.7 6.4 92.0 15.0 98.0 14.9 150.9 23.3 146.4 23.5
0.6 63.9 6.2 65.1 6.3 90.2 15.0 96.2 14.1 150.6 20.4 138.4 21.6
0.9 63.5 5.0 65.3 7.0 91.8 12.8 96.1 12.2 153.0 17.1 138.3 20.3
1.0 63.4 4.4 64.0 6.0 92.4 10.8 92.4 9.9 152.8 16.8 138.8 21.4
1.3 63.6 4.8 62.9 5.2 92.1 9.6 92.0 10.9 149.8 15.6 142.3 18.3
1.6 63.8 4.9 61.9 4.6 90.3 9.9 92.4 11.0 151.3 15.1 141.8 18.5
1.9 62.7 4.7 62.3 4.5 90.5 10.6 91.8 9.4 149.3 16.0 140.8 17.5
2.0 61.8 5.2 62.5 4.2 90.3 12.6 90.7 10.4 152.0 18.0 142.6 21.8
2.6 61.1 4.7 61.7 4.9 90.4 12.8 88.3 9.1 154.1 20.2 149.3 18.9
3 62.0 4.7 61.1 4.7 90.4 12.5 87.2 10.1 152.5 17.4 147.3 14.0
3.6 61.8 4.3 62.0 4.2 93.1 12.8 89.9 10.2 151.5 14.8 147.2 14.1
4 61.5 4.6 61.8 3.8 92.0 13.4 89.7 9.4 148.5 13.4 145.0 14.3
4.6 61.5 4.5 61.1 4.3 89.8 12.1 90.5 10.0 150.1 15.7 144.5 16.0
5 61.3 3.9 61.5 4.3 89.2 11.2 90.1 10.1 149.0 15.5 145.2 18.6
5.6 61.7 3.8 61.0 3.9 90.8 11.1 89.5 14.2 150.1 15.6 146.5 17.9
6 61.0 4.2 60.9 4.0 89.0 11.7 85.8 13.3 152.2 16.7 148.1 16.1
6.6 61.2 3.8 60.7 3.7 86.1 11.0 84.9 12.2 150.8 14.4 144.6 14.8
7 61.0 4.2 60.2 4.0 84.4 10.7 82.4 7.7 150.3 15.3 143.5 13.0
7.6 61.2 3.3 59.9 3.8 83.2 10.0 81.2 7.9 148.9 15.4 143.7 14.7
8 60.1 4.2 59.3 4.3 83.8 11.2 81.3 8.0 151.0 17.4 147.1 16.8
9 59.1 4.4 58.3 3.7 88.2 11.8 83.2 10.9 151.3 16.8 147.8 16.0
10 58.7 4.4 58.7 3.5 86.8 10.8 80.5 10.3 147.7 15.3 142.1 16.9
11 57.6 3.7 58.5 3.3 84.8 9.4 79.4 8.4 147.1 15.4 137.5 17.9
12 57.1 4.0 57.7 3.7 84.0 10.5 79.2 8.3 145.5 13.6 136.6 14.5
13 57.6 4.1 56.8 3.3 85.4 10.8 76.9 7.3 143.5 11.9 132.4 11.7
14 57.3 4.3 56.9 3.9 81.3 11.3 77.5 8.2 140.5 11.8 136.8 13.2
15 56.8 4.4 57.1 4.5 83.7 13.5 78.3 9.4 139.8 12.5 137.6 12.9
16 56.3 4.2 56.3 4.1 82.0 11.9 78.9 9.2 140.3 11.8 134.5 13.5
17 56.1 3.9 56.1 3.3 78.5 10.8 77.8 7.5 142.0 10.3 130.2 12.3
18 56.5 3.5 56.6 3.5 78.7 10.3 77.3 7.2 140.9 10.4 128.2 12.2
AI auricular index, CI conchal index, LI lobular index, SD standard deviation, NB new born

moderate growth thereafter (Table 4; Fig. 2b). The TH
matures last among the 11 dimensions discussed.
The MWE refers to the attachment of the ear to the
face. Its variation in size and position on the face indi-
cates abnormality. Among North Americans [1], it
exhibited slow growth during the ages of 6 to 19 years,
registering an increase of 8 mm. Neimitz et al. [8]
reported that among German subjects, 40- and 35-mm
width for 0- to 4-year-old boys and girls increased
respectively to 49 and 44 mm at adulthood. The Indians
had a shorter attachment of the ear and did not exhibit
significant sexual dimorphism in magnitude as did the
Germans (Table 1; Fig. 2a).
The aforementioned discussion may lead to the con-
clusion that growth in most auricular dimensions proceeds
in two phases: a period of rapid growth rate lasting for
3–6 months after birth, followed by an average pace of
growth. In contrast, smaller dimensions (CD, MWAH, TH,
and TL) follow a different pattern, a continuous moderate
pace throughout the growth period.
The data are useful not only for Physicians diagnosing
abnormalities but also for Plastic Surgeons planning the
optimal time of surgery. The dimensions and their pro-
portions also can be useful for constructing child age
progression charts of the external ear, which are useful
during reconstruction of the face of missing children. Ear

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Aesth Plast Surg (2013) 37:605–616 615

Table 6 Linear regression equation: Pearson’s correlations between the age and ear dimensions and the standard error of estimate
Parameters Sex Value of Pearson’s Regression equation Standard error
correlation (r)* of estimate (mm)

PLE M 0.893 PLE = 46.78 ? 0.895*Age 2.501

F 0.862 PLE = 46.09 ? 0.796*Age 2.596
PWE M 0.718 PWE = 29.86 ? 0.293 Age 1.58
F 0.635 PWE = 29.43 ? 0.229 Age 1.549
MWE M 0.885 MWE = 32.69 ? 0.898*Age 2.629
F 0.868 MWE = 33.13 ? 0.793*Age 2.517
CL M 0.881 CL = 21.03 ? 0.374*Age 1.113
F 0.831 CL = 20.38 ? 0.36*Age 1.336
CW M 0.636 CW = 19.52 ? 0.145*Age 0.976
F 0.274 CW = 19.13 ? 0.053*Age 1.027
CD M 0.858 CD = 13.37 ? 0.173*Age 0.574
F 0.861 CD = 13.33 ? 0.175*Age 0.575
LL M 0.899 LL = 12.69 ? 0.261*Age 0.704
F 0.906 LL = 12.88 ? 0.259*Age 0.672
LW M 0.799 LW = 19.33 ? 0.288*Age 1.205
F 0.809 LW = 18.71 ? 0.262*Age 1.054
TL M 0.849 TL = 11.39 ? 0.351*Age 1.138
F 0.897 TL = 10.58 ? 0.436*Age 1.124
TH M 0.72 TH = 6.59 ? 0.139*Age 0.746
F 0.742 TH = 6.42 ? 0.145*Age 0.727
MWAH M 0.823 MWAH = 15.06 ? 0.22*Age 0.84
F 0.683 MWAH = 14.86 ? 0.167*Age 0.985
PLE physiognomic length of the ear, PWE physiognomic width, MWE morphologic width, CL conchal length, CW conchal width, CD conchal
depth, LL lobular length, LW lobular width, TL tragal length, TH tragal height, MWAH maximum width of antihelix
* All measurements exhibit significant correlation with age at p \ 0.05

Table 7 Comparative data on physiologic length of the ear at various ages in different populations
Populations Birth 1 year 5 years 10 years 18 years
M F M F M F M F M F

N. America – – 46.9 45.4 53.6 51.0 58.6 56.2 62.4 58.5

Turkey 37.2 38.4 47.8 47.3 54.3 53.7 61.3 58.0 64.5 60.3
Germany 47.0 47.0 – – – – – – 65.0 61.0
Italy – – – – 53.3 50.3 58.9 54.9 61.1 60.3
S. Indiaa 33.0 46.0 54.0 58.0 –
b
C. India 36.9 35.9 48.4 47.6 52.4 51.9 55.9 54.4 60.6 58.4
a
50th percentile value for combined data of males and females
b
Current study

Biometrics is an emerging technology for establishing the
identity of an individual. The knowledge of the age at
complete maturity of the ear will help law enforcement
authorities in deciding when to use it to establish personal
identification.
Acknowledgments The author is grateful to the subjects and their
parents for their cooperation during the study and to the Indian
Council of Medical Research, New Delhi for funding the study. The
author gratefully acknowledges the assistance of Ms. Ankita Asati
and Mr. Sandeep Prasad Daksha in preparing the manuscript.
Conflict of interest The author has no conflict of interest.
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