Dr. Thorne has experience with all types of ear reconstruction. A summary of the alternatives and their relative advantages and disadvantages will be presented below as well as Dr. Thorne’s recommendations for what age to perform each procedures.
The alternatives for ear reconstruction for microtia fall into three categories:
Tracings are made of the normal ear and used to determine the size and shape of the cartilage pieces to harvest from the patient's chest.
Individual pieces of cartilage are sutured together to create the framework.
Undersurface of framework. Additional pieces have been added to stabilize and project the tragus as well as to augment the posterior wall of the concha.
A prosthesis is a plastic ear that is worn on the surface of the skin. It can look quite life-like from a distance. The disadvantage is that it has to be held in place. Glue adhesives are time consuming, messy and are not practical for sports and activities where sweating occurs. From a practical point of view, children refuse to wear them and tend to leave them in the drawer or lose them on the school bus. In addition, prostheses have to be taken off every night and put on every morning and are a daily reminder to the patient that he/she is deficient in some fashion. In our practice, prostheses are almost always reserved for elderly patients who lose an ear, or part of an ear, from trauma or cancer. They can occasionally be used in children as a salvage procedure when all other techniques have failed.
This type of ear reconstruction has a long history. The first artificial frameworks were made of silicone rubber. The most recent artificial framework is made of porous polyethylene, called Medpor. This hard plastic material is pre-made by the manufacturer. It can be modified slightly by the surgeon for an individual case and is covered with a combination of the normal skin on the side of the head, a layer of tissue from the scalp called the temporoparietal fascia, and a skin graft. The advantage is that it can be performed by surgeons unfamiliar with carving cartilage. The disadvantage is that the material is very hard and some patients complain of discomfort when they lie on it and if injured, is more prone to serious complications than the patient’s own cartilage. Proponents say that it avoids a chest incision, which is true, but the incisions that are used in the scalp and behind the other ear can be more disfiguring than a chest incision. I tend to reserve it for cases where patients specifically request it or where cartilage has already been removed from the chest and there are limited alternatives.
As mentioned in other parts of this site, my preference is to use a framework from the patient’s own rib cartilage covered with the patient’s own skin. The advantages are that the color and texture are preferable to Medpor techniques, the reconstruction is less likely to have a framework exposure or infection over the life of the patient and it is the most lifelike. The disadvantages are that in a very thing patient dent may be visible in the chest where the cartilage was removed and this technique requires the most experience and skill of all the techniques mentioned above. My rationale is this: If the surgeon can carve a framework out of cartilage that is of similar shape to a normal ear, wouldn’t you rather have native cartilage in your child’s head for decades than a hard plastic material?
This is an important question, which has undergone evolution. Up until about a decade ago, surgical reconstruction of the outer ear was recommended beginning at the age of approximately six years. As surgical techniques have improved, however, it has become clear that a better quality, more detailed, ear reconstruction is possible when the surgery is delayed to after the age of 8-10 years. When first told that the reconstruction is not recommended for a few additional years, some parents are disappointed. We have never seen, however, a child suffer psychological distress because of delaying the reconstruction. Remember, the child will have this ear for about 90 years, hopefully, and we want it to be as ideal as possible.
Dr. Thorne’s technique requires two stages separated by approximately 6 months. The framework is placed at the first stage. After this stage the ear will be visible and complete but it will be stuck down to the head. Six months later the reconstructed ear is elevated so that it projects off the head and the sulcus behind the ear is created with a skin graft. This two stage approach doesn’t mean that an additional touch up procedure is never performed. Occasionally there are scars or irregularities that can be improved with a third procedure some years later.
Dr. Thorne is the Editor-in-Chief and the author of several chapters in Grabb and Smith's PLASTIC SURGERY, 7th Edition.
Ear Construction Chapter in PDF