J Oral Maxillofac Surg
78:1666-1668, 2020
Surgeons Beware: The Preauricular
Crease Is an Indicator of Coronary
Artery Atherosclerosis as well as an
Anatomic Landmark
Arthur H. Friedlander, DMD,*
Paulo H. Couto-Souza, DDS, MSc, PhD,y and Soraya A. Berti-Couto, DDS, MSc, PhDz
This year, while perusing Angiology, an interdisci-
plinary academic peer-reviewed journal that publishes
research findings relative to the diagnosis and treat-
ment of vascular disease, we were captivated by a
report describing how the presence of a preauricular
crease (PAC) served as an indicator of the complexity
and severity of angiographically documented stenotic
coronary artery lesions among a cohort of patients
admitted to the hospital for acute coronary syn-
drome.1 This observation has very important patient
care implications given that myocardial infarction
(MI) is the number 1 cause of death among older
men in Brazil and the United States and specifically
because almost half of such deceased individuals had
an occult form of coronary artery atherosclerotic dis-
ease, without prodromal signs, symptoms, and tradi-
tional risk factors. Unfortunately, most health care
providers are unaware of the negative cardiovascular
implications of the PAC and therefore do not act
accordingly.
Recognition of the presence and clinical implica-
tions of a PAC (Fig 1) or anterior tragal crease (ATC)
is most opportune for members of our specialty
when performing the maxillofacial component of the
physical examination during the presurgical risk-
*Associate Chief of Staff, Director of Graduate Medical Education,
and Accreditation Council for Graduate Medical Education
Designated Institutional Official, Veterans Affairs Greater Los
Angeles Healthcare System; Professor-in-Residence, Oral & School of Life Sciences, Department of Dentistry, Pontifı́cia Universi-
Maxillofacial Surgery, University of California at Los Angeles Dental
School; and Director, Quality Assurance, Hospital Dental Service,
Ronald Reagan University of California at Los Angeles Medical
Center, Los Angeles, CA.
yOral Radiologist and Full Professor, School of Life Sciences,
Department of Dentistry, Pontifical Catholic University of Paran
a,
Curitiba, Brazil.
zStomatologist and Associate Professor, School of Life Sciences,
Department of Dentistry, Pontifical Catholic University of Paran
a,
Curitiba, Brazil.
1666
assessment process. The PAC is familiar to members
of our profession as an anatomic landmark used to
safely develop skin flaps with minimal risk of transect-
ing the facial nerve branches when accessing the
temporomandibular joint and performing a rhytidec-
tomy. The crease is easily identifiable, appearing as
one or more vertical grooves in the facial skin close
to the tragus. The pathophysiological mechanisms
for what might appear to be the dubious association
between the PAC and ischemic heart disease has
been explicated by a group of international anato-
mists.2 These scientists have concluded that when
the maxillary artery (a branch of the external carotid
arising within the substance of the parotid gland) is
affected by the systemic atherosclerotic process, the
consequent plaque buildup within the vessel lumen
and concomitant wall distension displace the parotid
gland superficially and the tragus downward, thereby
creating a PAC.
Of note, the authors of the aforementioned angiog-
raphy study commented on the fact that among the pa-
tients with severe coronary artery stenotic lesions, the
PAC was very frequently seen simultaneously with a di-
agonal earlobe crease (DELC) (Fig 2)1—a dermato-
logic sign that also has been validated as a ‘‘risk
Conflict of Interest Disclosures: None of the authors have any
relevant financial relationship(s) with a commercial interest.
Address correspondence and reprint requests to Dr Couto-Souza:
dade Cat

olica do Paran
a, Imaculada Conceic~ao, 1155, Prado Velho,
80215-901, Curitiba (PR), Brazil; e-mail: couto.s@pucpr.br
Received May 15 2020
Accepted May 15 2020
Ó 2020 American Association of Oral and Maxillofacial Surgeons
0278-2391/20/30557-7
https://doi.org/10.1016/j.joms.2020.05.032
FRIEDLANDER, COUTO-SOUZA, AND BERTI-COUTO
FIGURE 1. Preauricular creases (white arrows).
Friedlander, Couto-Souza, and Berti-Couto. Preauricular Crease
and Atherosclerosis. J Oral Maxillofac Surg 2020.
indicator’’ of the presence, extent, and severity of
ischemic heart disease3 and the subject of a recent
publication of ours.4 In our study, we described how
a cohort of oral and maxillofacial surgery patients
with calcified carotid artery plaque (CCAP) on their
panoramic images (PIs; similarly a validated risk indica-
tor of near-term MI)5 were significantly more likely to
evidence DELCs than those without imaged ather-
omas. Thus, given the conglomeration of prior
research findings, we informally observed the preaur-
icular area in 15 consecutive male patients older
than 55 years who attended our dental school’s oral
and maxillofacial surgery clinic and showed CCAP on
their PI. We noted that 13 of the 15 individuals evi-
denced a bilateral PAC and that 1 of the other 2 per-
sons manifested a unilateral PAC. For the sake of
completeness, among these same 15 individuals, we
also visualized the earlobe for the presence or absence
of a DELC. We can report that 11 of these patients evi-
denced bilateral DELC and 1 showed a unilateral
DELC. Thus, it appears as if the PAC or ATC is slightly
more sensitive than the DELC in identifying atheroscle-
rotic disease. This latter determination is made in con-
cert with the work of other investigators who have
similarly denoted that the PAC is somewhat more sen-
1667
FIGURE 2. Presence of both preauricular (white arrows) and diag-
onal earlobe (black arrows) creases.
Friedlander, Couto-Souza, and Berti-Couto. Preauricular Crease
and Atherosclerosis. J Oral Maxillofac Surg 2020.
sitive than the DELC as an indicator of atherosclerotic
disease.1 At this juncture, it also is critical to empha-
size that carotid plaque seen on a PI often heralds
near-term MI because of advanced atherosclerotic dis-
ease in the coronary vessels.5
Therefore, we believe that it is reasonable to recom-
mend that the oral and maxillofacial surgeon examines
both the preauricular facial area and the earlobes for
creases when conducting the maxillofacial component
of the presurgical physical examination, as well as
analyze accompanying imaging studies for the presence
of calcified atheromas. When positive findings are
encountered, we suggest that the surgeon consider noti-
fying the patient’s primary care physician of the pres-
ence of these validated risk indicators of a future MI so
that preventive therapeutic regimens can be instituted,
if not already in place. Of note, a formal research project
evaluating the association between CCAP on PIs and the
PAC is currently being planned for implementation in
the United States and will encompass a mixed-gender
cohort that is age and ethnically diverse.
The subject of this article is uniquely relevant to
members of our profession because it documents for
the first time in the medical-dental literature an associ-
ation between CCAP and the PAC and how easily this
potentially life-saving determination can be
1668
accomplished during the routine aspects of care that
we provide, namely maxillofacial clinical examina-
tions and the interpretation of accompanying imaging
studies. This article also shows that the presence of
the PAC or ATC is a slightly more sensitive risk indica-
tor of atherosclerotic disease than is the DELC, a surro-
gate marker that has been around for almost 50 years
and whose validity has been substantiated by
numerous clinical studies.3-5
References
1. Kul S, Konus AH, Dursun I, et al: Anterior tragal crease is associ-
ated with SYNTAX score in non-ST-segment elevation myocardial
PREAURICULAR CREASE AND ATHEROSCLEROSIS
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pointer: Anatomy and its importance as a landmark in surgical
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2019
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