Microtia / Anotia Reconstruction Surgery

Type I microtia can often be reconstructed with otoplasty. Type II requires a reconstruction of the upper half of the pinna. Type III and type IV require complete ear reconstruction.

Ear reconstruction options include a prosthesis, a silicone or polyethylene plastic framework covered by living tissue, or living cartilaginous framework covered by living tissue.

Prosthetic Ears

Prosthetic ears can look very natural and can nicely match the contralateral ear when fabricated by a skilled technician. They attach to the patient’s head with either adhesive tape or osseointegrated implants. Problems encountered with prosthetic ears include falling off at inopportune time leading to embarrassing situations and further psychosocial withdrawal, and significant lifetime cost. Prosthetic ears are made out of latex rubber, they can become oxidized and split and crack with time (similar to the rubber on your automotive tires) requiring a new prosthetic be made very few years. Over the lifetime of the patient this can create a significant financial burden (frequently the first prosthesis can be covered by an insurance plan but usually the latter additional prostheses are paid for by the patient out of pocket). It is Dr. Griffiths’ opinion that prosthetic ear reconstruction is primarily suited to a less active senior patient who is usually missing an ear because of skin cancer or trauma.

What is the advantage of using MEDPOR™

To reconstruct an external ear surgically, a framework material must be selected that can withstand the contractile forces of the overlying skin and fascia. The two most widely used options include polyethelene-plastic (MEDPOR™) or the patient’s own living cartilage.

The MEDPOR™ auricular prosthesis has been around since the mid 1990’s. It has been used worldwide for microtia reconstruction. Advantages include lower operating room time, avoidance of chest incision, ease of use, and the ability to be used by less experienced surgeons who do not have the artistic ability to carve ear framework out of cartilage. The primary disadvantage of the MEDPOR™ implant is that it is a foreign material. If at any time during the lifetime of that patient there is a laceration on the ear exposing the framework, then there is a great risk for having the underlying framework becoming infected requiring complete removal. The plastic framework can also break causing a tear in the skin with subsequent infection and ear loss. Secondary reconstructive operations can be very costly with limited options given the primary skin grafts, skin flaps and fascia flaps were used with the first ear reconstruction. We all know that children can be children and that lacerations on the ear can occur. Another disadvantage of the MEDPOR™ polyethylene plastic framework is that it comes in one size and shape. If you carefully study ears you will notice a significant variation in size, shape, and projection.

Microtia reconstruction using autogenous chest cartilage as a framework

Dr. Griffiths prefers to use a patient’s own autogenous cartilage for fabrication of an ear framework. Dr. Griffiths harvests a portion of the chest cartilage from the sixth, seventh and eighth ribs. The cartilage pieces that are then artistically and meticulously sewn together then carved into a framework. Measurements are made so that the reconstructed ear framework has the same height, length, curvature and projection of the contralateral normal ear.

This is a photograph of a patient with left sided grade III microtia. Please look carefully at the two different mirror image views of the framework that Dr. Griffiths made for this boy. Notice how closely the details match his normal ear.

Critics of using chest cartilage as an ear framework often site the scar and chest discomfort following surgery as disadvantages of this technique. Dr. Griffiths uses an incision that is usually less than 6 cm to harvest the cartilage. He closes the incision with the finest plastic surgical technique to make the scar difficult to see in most patients, To reduce postoperative pain, he uses a special marcaine pump for several days after surgery that slowly delivers a local anesthetic directly to the rib graft harvest site though a micro-thin tube. Click here to learn more about the onQ pump

What tissue does Dr. Griffiths use to cover the ear framework?

The ear framework needs to be covered with vascularized tissue. This can be accomplished with a three-stage procedure championed by Dr. Brent, a two-stage procedure championed by Dr. Nagata, or a novel one-stage procedure performed by Dr. Griffiths.

In a three-stage operation the ear framework is carved and inserted underneath a pocket of skin at the desired site under the microtic ear. It needs to heal in this position for approximately six months so that it can obtain its own blood supply. The second stage involves rotation of the ear lobule and creation of a tragus and external ear canal. The third stage involves lifting the ear away from the scalp and utilizing a skin graft to cover the back of the ear. It is during this third phase that an extra cartilage graft is often added behind the ear framework to enhance its projection.

In a two-stage procedure the ear framework is inserted and the ear lobe lobule rotated during the first operation. During the second operation, the framework is elevated and skin grafts are used to cover the back of the ear. Some surgeons incorporate the aid of a tissue expander to stretch the overlying skin prior to inserting the framework for a three stage reconstruction. Tissue expansion does involve multiple visits to the physician’s office to inflate the tissue expander before the second operation when the ear framework is created and placed.

The three-stage and two-stage techniques are wonderful options for reconstruction of the microtic ear. Dr. Griffiths used these techniques over the first half of his career, carefully honing his technique in order to perform the most perfect reconstruction possible. He honors and respects the wonderful contributions made by these two masters of plastic surgery. These two techniques however have two main disadvantages, cost and time. As medical costs have risen in the past decade (particularly hospital fees), multiple operations create extra financial burden on the patient and families. If the patient lives out of state not only are travel costs higher but multiple surgeries require greater time away from home which can impact school and parent work schedules.

Dr. Griffiths has developed a one-stage reconstruction where he also rotates the ear lobule, creates the tragus and the external portions of the external auditory canal at the same time. This one-stage technique can significantly limit overall medical costs and is preferred by patients and families, particularly those who have to travel great distances for their operation.

The one-stage procedure performed by Dr. Griffiths involves the use of a thin vascularized membrane underneath the scalp on the lateral forehead and temporal regions to cover the carved cartilage framework. This thin membrane is called the temporoparietal fascia (TP fascia flap).

This diagram shows the superficial temporal artery and vein and the thin membrane that is fed by these arteries (TP fascia).

Once this vascularized membrane is harvested it can be wrapped around the ear framework to provide a complete vascular covering. Dr. Griffiths utilizes a limited incision access to harvest this flap so that the scars are carefully concealed around the ear. The fascia flap is then covered with a skin graft. Skin grafts are carefully chosen to provide the best texture and color match to the skin of the contralateral ear.

Another advantage Dr. Griffiths one stage technique is that the reconstructed ear has feeling (from the sensory nerves that come from the fascia under the skin grafts). This sensory input helps the patient avoid injuring his ear in the future. The 2 and 3-stage procedures produce ears that are insensate (numb).

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