Microtia / Total Ear Reconstruction | Rib cartilage, implants and prostheses

Rib cartilage is autogenous: costochondral cartilage is harvested, sculpted into an ear shape and implanted, usually in staged procedures. A synthetic implant avoids rib harvest, chest asymmetry and discomfort, can allow earlier reconstruction and maintains its shape over time. Implant exposure and fracture concerns have been reduced by covering the implant with vascularized fascia and careful technique. Both approaches still need a suitable soft-tissue cover; rib cartilage may be preferred when autogenous tissue is desired, while synthetic frameworks may be considered when rib cartilage is unavailable or harvest is undesirable. The choice depends on age, anatomy, hairline, scarring and surgeon experience; no single framework is right for every patient after careful assessment.

Microtia reconstruction can use rib cartilage, an implant framework or a prosthesis. A prosthetic ear avoids a chest-wall donor site and can be matched to the other ear, but it is not living tissue. The comparison notes daily placement and periodic replacement, and that it prevents future reconstruction. Prosthetics can look very real and may be worn with adhesive or a surgically implanted anchor system. They are a good option when reconstruction is not possible or has not succeeded. In children, operative reconstruction is often preferred on psychological grounds, while in older patients surgical risks may sometimes outweigh possible advantages. The choice also depends on surgeon and patient preference when surrounding soft tissue is adequate.

Age and body size matter because the surgeon must harvest enough cartilage to build an ear matching the other side. The amount needed depends on the technique used. Some surgeons look for a chest diameter of at least 60 cm or a lower thoracic circumference of at least 64 cm, while one author found about 45 to 47 inches of height adequate if the normal ear is not too large. If a child is too small or the normal ear is large, surgery may be delayed. Some surgeons prefer to wait until about 9 or 10 years. Cartilage can also become stiffer and more calcified with age, so reconstruction is usually planned before late adolescence.

The first stage creates the shaped cartilage framework and skin cover. The second stage, usually about six months later, releases the reconstructed ear through an incision near the rim down to the fascia and lifts the framework to the bowl of the ear . A cartilage block kept in a chest skin pocket is carved and fixed to support projection toward the opposite ear. A fascial flap covers the cartilage block and back surface. If projection is already at least 80% of normal, elevation may not be insisted upon; the decision is left to the patient. This is a trade-off: accepting a second operation for better projection and symmetry.

In microtia reconstruction, the cartilage framework has no blood supply of its own, so its covering must bring blood supply. Residual microtic and mastoid skin may cover only part of the lateral surface; additional full-thickness skin may come from the contralateral postauricular area, or from the inner upper arm or supraclavicular area in bilateral cases. Temporal fascia with a split-thickness scalp graft can cover the framework, including part of its posterior surface in some cases. Scalp grafts may contract more and can form inclusion cysts even after hair removal, and may need careful follow-up. The trade-off is accepting donor-site scarring and possible color or texture mismatch for durable coverage.

The surgeon compares the vestige's height with the normal ear, notes the ear axis roughly parallel to the nasal profile, and records the distance from the lateral canthus to the helical root. These measurements are transferred to the affected side, and the reversed pattern is traced about 6 mm below the lobule. In bilateral microtia, facial proportions and the lobule landmark guide size and position. Severe hemifacial microsomia makes matching harder because facial heights and depth differ. Errors in size, position or orientation are important complications. The ear should lie between the eyebrow and base of the nasal columella, inclined somewhat parallel to the nasal dorsum, about 5 to 6 cm from the lateral orbital canthus.

Bilateral microtia is not simply two separate one-sided cases. Children with both ears affected have conductive hearing loss on both sides, so early bone-conduction hearing support matters for speech and language development. Bilateral cases also more often have associated syndromes and jaw underdevelopment that can affect sleep and intubation. Reconstruction may use rib cartilage or an alloplastic framework; porous polyethylene is described as ideal in bilateral disease because it allows earlier atresia repair and fewer operations. Most surgeons reconstruct each ear at a different time, and simultaneous bilateral alloplastic reconstruction is avoided because of operative time and pressure on the new ears during sleep. A minimum of four months is advised between the first and second ear.

Microtia often occurs with aural atresia, causing conductive hearing loss on the affected side; bilateral cases are functionally deaf and need bone-conduction hearing support. Middle-ear surgery is generally reserved for bilateral microtia and done after auricular reconstruction. In selected unilateral cases, it should be planned after external reconstruction is complete to avoid further complicating these procedures. Canal, eardrum and ossicle reconstruction may be possible depending on aplasia, but for most patients results do not justify it; creating a canal can affect appearance and needs lifelong cleaning by an otolaryngologist. Thus hearing support and any later canal surgery are sequenced around staged outer-ear reconstruction with careful individualized planning and follow-up as appropriate rather than performed first.

Secondary cases are often among the most difficult reconstructions. Scarring around the ear greatly increases surgical complexity, and skin potential guides whether local skin, tissue expansion or fascial flaps can cover a new framework. Infection can damage cartilage integration, and severe infection may lead to framework absorption. A new complete framework usually requires costal cartilage from the other side; adult cartilage may be firmer and harder to carve. Scars from prior canal surgery can compromise anterior blood flow. Burns or trauma in the area can make local healing less predictable and may distort the result. A prosthesis should always be discussed before secondary reconstruction because results may not match primary cases.