Surgical Options

Although some children do not want surgery, it is important for parents to discuss the benefits of the reconstructions with them. All of the children that I have operated on have had very positive physical and psychological results.

There are generally 4 options for management of a microtia patient:

Option 1:

Technique employed by the Microtia-Congenital Ear Deformity Institute

Unilateral Microtia (One Side)

I usually start operating on a child at about 6 to 7 years of age. By this time, the child is usually large enough where there will be sufficient rib size to harvest an adequate rib graft. If the child is still small, I prefer to wait a year or so.

For example, if a very small 6 year old presents to the office, it is reasonable to wait until 7 or 8 years of age until there is sufficient rib growth. If on the other hand, a very large 5 year old presents to the office, I will begin reconstructions sooner due to adequate rib size.

The ideal time to begin the reconstruction is the summer before the first grade. By the time the child starts the first grade, at least two of the surgeries can be performed and the child now has the resemblance of an ear. Children tend to be made fun of during these early school years when they are not yet reconstructed.

Bilateral Microtia (both sides affected)

Although the ear reconstruction of patients with bilateral microtia were usually started at about 4 to 5 years of age, I now prefer to wait until the child is about 6 to 7 years of age.

It is very important to start the external ear reconstructions BEFORE the middle ear surgery. Once an attempt is made to open the canal prior to the external ear reconstruction, the elasticity of the "virgin" skin as well as the circulation is compromised.

Because these children are dependent on bone conduction hearing aids, the goal of starting earlier is to at least finish one ear. The canal may be drilled soon after the ear is reconstructed with the eventual goal of obtaining adequate hearing without the use of hearing aids.

In addition, there is not a normal ear to compare to. As a result, two relatively smaller ears will not be as noticeable as one asymmetric ear.

A CT scan of the temporal bones (ears) may obtained prior to the onset of the first microtia surgery. This will allow visualization of the anatomy of the outer, middle and inner ear. Usually, the first surgery will begin on the ear that has the more favorable anatomy for the eventual drilling of the canal (atresioplasty).

After the 1st stage is performed, the opposite ear's 1st stage is performed within 4 to 6 weeks. About 3 months are allowed to pass before proceeding to the next stage. In order to minimize surgeries, the different stages on each ear may now be combined. Both 2nd stage operations may be performed at the same time.

Advantage

• Very safe
• Has been the standard of microtia surgery for decades
• Excellent results

• Technically difficult
• Should be performed only by experienced microtia surgeons
• Requires chest incision

Option 2: No surgery

As long as the child has normal hearing on the good side, he/she should live a relatively normal life. There are adults with microtia that never had the reconstruction and are living normal lives. They have gotten used to the stares and the comments by other people and are at the point where it does not bother them. On the other hand, there are adults who have suffered emotionally because of the inability to adjust to the feeling of being different. This is usually compounded during the teenage years. In children, I feel that the reconstruction is extremely beneficial. It promotes self-confidence and self-esteem early in life. This, in turn, decreases the negative emotional impact that a non-reconstructed microtia patient may have.

Option 3: Ear Prosthetic

Advantage

• Avoids chest surgery
• May look very realistic
• May be of value for an older patient who does not want rib surgery or is at risk for a surgical procedure.

• Still requires surgery
• Screws are drilled on side of head and a bar is placed to hold the prosthetic ear
• If the child sweats, the prosthetic ear will not sweat; If the child gets a sunburn or a tan, the ear prosthetic will remain the same color and mismatch the normal skin
• The prosthetic ear is taken on & off every night during sleep for the rest of the childs life.
• The child will never feel like the ear is part of his/her body

Option 4: Ear Implant

Advantage

• Avoids a chest incision

• The scalp has to be divided above the ear to obtain a tissue flap in order to cover the implant
• A large scar may be noticeable above the ear because of the flap obtained to cover the implant
• There may be hair loss at the site of the incisions that may be very noticeable if the child has short hair
• The skin may look different because most of the implant is covered by skin from another part of the body (usually the opposite ear)