Microtia Treatment

What are the options for microtia treatment and repair?

Reconstruction of the outer ear malformation cannot be done right after birth. Until the reconstruction can be done, patients and families must cope with the abnormality. This can be difficult; talking about issues that arise can really help you and your family not feel embarrassed or ashamed.

What are reconstructive options for Microtia?

1. Rib Cartilage Graft Surgical Reconstruction

Rib Cartilage Graft Surgical Reconstruction is a reliable technique that has been around since the 1920’s. It usually involves two to four separate surgeries done under anesthesia separated by several months to allow for healing between each stage. There are several different rib cartilage graft reconstruction techniques. All involve taking rib cartilage from the chest during the 1st stage and carefully sculpting it into a framework that is shaped like an ear. This framework is then implanted in a skin pocket underneath the scalp on the skull where the new ear will be located. The newly created cartilage framework becomes part of the patient’s live tissue, and is incorporated after 3 to 4 months, at which point the second stage of the surgery is performed.

In the 2nd stage, incisions are made behind the ear to release the ear from the scalp skin, and the cartilage framework is lifted up to give it adequate projection. A skin graft is then used to help cover the backside of the newly lifted ear. Sometimes, additional minor stages are performed to improve the shape of the ear, the appearance of scars, or project the ear even further.

Although some surgeons consider doing rib cartilage graft reconstruction in patients as young as 5 to 6 years of age, a much better and more detailed 3-dimensional reconstruction can be achieved at 8 to 10 years of age, when there is a thicker, more robust rib cartilage to use from the chest.

If reconstruction of ear canal atresia is also desired, and if your child is a candidate for this surgery, it must be performed after the external ear has been completed, because the 1st stage of rib cartilage graft implantation depends upon the skin overlying the cartilage to have good blood supply that has not been compromised by any previous surgical incisions in the region.

• Advantages of rib graft reconstruction:
  The main advantage of rib graft reconstruction is that the cartilage tissue used for the reconstruction is from the child’s own body, decreasing the risk that the body rejects the implant. Rib cartilage is proven to resist trauma and contact sports are permitted without extra protection or restriction. Ears constructed by this method retain their form and should last a lifetime.
• Disadvantages of rib graft reconstruction:
  Disadvantages include pain from the rib harvest site at the time of the initial surgery that goes away when the child is healed. There will be a scar and a risk of a small deformity in the chest at the place where the cartilage was removed. Reconstructed rib graft ears will be slightly stiffer than the biological ear since the rib graft cartilage is thicker and stronger than ear cartilage. At times, the initial healing of the reconstructed graft can be unpredictable.

2. MedPor Graft Surgical Reconstruction

Medpor graft surgery uses a synthetic pre-made porous polyethylene framework, eliminating the need for harvesting rib cartilage. The implant is covered with tissue from the scalp. This can be achieved with just one surgery and can be performed as early as three years of age.

If reconstruction of ear canal atresia is also desired, and if your child is a candidate for this surgery, it can be performed before the external reconstruction utilizing Medpor.

• Advantages of MedPor grafts
  The advantage of this technique is that it requires only one stage and theoretically can be done at an earlier age in comparison to rib cartilage reconstruction. It also does not require a donor site and eliminates the pain and healing from this site. The MedPor implant typically has less variability in the cosmetic outcome.
• Disadvantages of MedPor graft
  This technique is a technically challenging surgery that most microtia surgeons do not perform. It requires a well-vascularized temporalis muscle fascia flap for the implant to successfully heal, and even then, a Medpor implant never becomes a living part of the body like a cartilage graft. Minor trauma occurring in the future can cause an opening, increasing the risk of infections, exposing part of the Medpor implant, and ultimately resulting in complete extrusion and loss of the ear implant. Another problem with Medpor reconstructions is that they are covered completely with unfeeling skin graft, and without feeling, they are more likely to sustain trauma un-noticed by the patient, leading to potential extrusion and loss of implant. This risk is life-long for the patient. At this stage, it is not known how long Medpor ears can last without failing. Due to these significant concerns, we do not perform Medpor reconstructions at Stanford.

3. Prosthetics

With a good anaplastologist (specialist who creates prosthetics), a prosthetic ear can be made to look very real. A prosthetic ear can be worn by either adhesive or by being attached to an implanted anchor system to allow a secure fit (which requires a minor surgery to place).

• Advantages of ear prosthetics
  An ear prosthetic can look cosmetically excellent and mirror the opposite ear. They are made with materials that feel similar to skin, and can be an excellent option if other options have failed. Prosthetics attached with an implanted abutment still allow for patients to swim and bathe with a prosthetic. It is a much less painful surgery and can be done in one stage.
• Disadvantages of ear prosthetics
  Many people have a difficult time coping with the idea of a prosthetic ear that comes on and off in comparison to a reconstructed ear that is formally part of the body. Some patients have difficulty with medical grade glue or an implanted anchor system. The implanted anchor can have a risk of a skin infection around the anchor. Prostheses do wear down over time and need to be replaced, and can sometimes can fall off.

4. The “Do Nothing” Option

Some individuals opt to not have any reconstruction and to leave the microtia ear the way it is. Some people adjust to it, sometimes keeping their hair long so the deformity is not immediately obvious. Families that are uncomfortable with the reconstructive options do not have to rush into the decision, because the surgery is actually easier when the child is older, due to more cartilage graft available to make a framework. Additionally, an older child may be more mature to deal with surgery and the recovery from surgery. Most patients who complete their reconstructions are very satisfied, and less self conscious when meeting people for the first time. As microtia surgeons, we know we have succeeded when patients come into their clinic visit with their hair cut very short, or their hair tied back in a pony tail or bun to show off their new ear.