What is it?
Ear reconstruction is performed for children that are missing enough tissue from the ears that it needs to be replaced in some way to make the ears appear normal. This is typically seen in patients with microtia (including syndromes such as hemifacial microsomia and Goldenhar syndrome), severely constricted ears, or after trauma. There are three main options available for ear reconstruction: cartilage reconstruction, medpor reconstruction, and prosthetics. We offer all of these options, but each has their own unique advantages and disadvantages. Regardless of the type of external ear reconstruction you choose, your child will likely need some type of intervention for their hearing as well. This will be determined by the ENT specialist. In some instances, an ear canal can be reconstructed, and this will have to be coordinated with the external ear surgery. Otherwise, your child will need some type of hearing aid. Sometimes these are implanted in the skull and can be coordinated with the ear reconstruction.
The oldest and most traditional form of ear reconstruction uses cartilage from the patient’s own body to create an ear. The reconstruction is generally performed in 2-3 different surgeries or more. At the first surgery, cartilage from 2-3 ribs is removed from the chest. The cartilage is then carved into a shape that resembles an ear. This cartilage framework is then placed beneath the skin of the side of the head and is allowed to heal. This may cause an issue for patients that have a very low hairline (hemifacial microsomia) because hair may grow on the surface of the ear which will later need to be removed. 1-2 more operations are generally needed to move the earlobe into its proper position, tweak the shape of the ear, and place skin grafts behind the new ear so that it projects away from the head. It is possible to obtain good results with this method. However, it does require multiple procedures, necessitates removing part of your child’s ribs, which can cause pain and additional scarring, and never projects away from the head as much as a normal ear. Additionally, the surgery is typically not performed until your child is 8-10 years old because the ribs need to be large enough to be used to make the ear.
The newer procedure, and one that we generally prefer is called medpor reconstruction. Medpor is a synthetic substance made from porous polyethelene that has been used in ear reconstruction very successfully since the 1990s. It is 100% biocompatible and non-reactive in the body and is used by craniofacial surgeons for implants all over the facial skeleton. Its properties allow the bodies tissues to grow into the implant, making it stronger, more incorporated into the body, and more resistant to infection. The implants come in pre-formed pieces that we customize and shape on the day of surgery to match the size, shape, and projection of your child’s normal ear. Once the ear is healed, it tends to have a more normal shape and projection than a cartilage ear. One of the main advantages of using medpor, is that excellent results can generally be achieved in just one surgery, rather than the 3 or more required for cartilage reconstruction. Occasionally, small revisions may be necessary. Additionally, the surgery can be performed much earlier since it doesn’t rely on the body’s own tissues. It can be done as early as age 4. At this time, the ear is about 80% its adult size. We are able to create a slightly larger ear that should have longevity and match your child’s adult ear without needing further surgery. Recovery is generally easier for your child at this age, and it is before they have started school, which helps prevent problems with self-esteem and teasing. The procedure also has the advantage of avoiding unnecessary scarring and pain on the chest. The reconstruction is generally quite sturdy, but the medpor can fracture if traumatized.
During surgery, a portion of your child’s hair will need to be shaved on the side of the reconstruction. We then take careful measurements to make sure that the ear will be similar in appearance and location to the other side. We shape the medpor as needed, and this will become the new framework of the ear, taking place of the cartilage. An incision is made in the hairline as well as at the location of the new ear. We then create what is called a “temporo-parietal fascia flap”. Underneath the scalp, there is a layer of tough thin pliable tissue called the temporoparietal fascia which has a robust blood supply. We are able to lift up this tissue and rotate it to the position of the new ear, where it makes the perfect covering for the medpor. The medpor is then completely enclosed by the flap and sutured into place. The flap will bring a blood supply to the area and gradually grow into the implant. It is what allows us to have the ear project away from the head during the first operation. The implant and flap are then covered with skin. We use whatever skin is in the area, as well as parts of your child’s remnant ear. Additional skin grafts are also needed, which we usually obtain from behind the opposite ear and the groin. These areas heal well, with an almost imperceptible scar. All of the skin and grafts are sewn very carefully into place. If your child has an earlobe, this is also moved to the correct position. Drains are used to allow the tissues to form tightly around the new shape of the ear. A special foam-like splint is then placed over the ear to protect it and is sutured in place.
The splint will be removed in the office in 10-14 days. You should plan on spending one night in the hospital, and the drains will be removed the next day before you go home. We will also give you a special compression hairband for your child to wear to help protect the ear. Once the splint is removed, the ear will look very swollen, and it will take several months for this to go down. As more swelling subsides, the detail and shape of the ear will gradually become more defined. Sometimes the hair follicles become “shocked” from the surgery, and may fall out. This will be temporary, and the hair will slowly grow back over several months. Since the medpor is a foreign body, it is possible for it to get infected. If this should happen, the medpor may need to be removed or exchanged. However, this is something that can also happen with a cartilage reconstruction. To recap, we prefer medpor reconstruction because it can be performed at a younger age, generally only requires one surgery, tends to look more realistic, and saves your child from the pain and scarring of harvesting rib.
The third form of ear reconstruction uses an ear prosthesis. This can be an excellent option depending on you and your child’s goals. An ear prosthesis is made of silicone by a specialist called an anaplastologist. A prosthesis looks extremely realistic, often more realistic than what we can ever achieve with cartilage or medpor. It can be made to almost exactly match the other normal ear. It is held in place by special glue or magnets which are implanted into the skull. However, the ear is not part of the body, so it will have to be removed and cleaned and is generally not worn during sports. Methods of attachment are excellent, but it is possible for the ear to fall off. The ear will also need to be replaced throughout your child’s lifetime. If you wish to avoid significant scarring or surgery for your child, or if your child is not a candidate for another type of reconstruction due to medical problems or lack of tissue, a prosthetic is a great option. However, if you prefer an ear that is a part of your child, and does not need specific daily care than medpor or cartilage reconstruction is a better choice.