Microtia is a congenital condition where the external ear is underdeveloped, affecting approximately one in every 5,000 to 8,000 births. The decision to pursue reconstruction is driven by the goal of creating a more typical ear appearance to improve facial symmetry. Surgical and non-surgical options are available to construct or replace the external ear. These procedures can have a significant impact on an individual’s self-perception and social interactions.
What is Microtia and Why Consider Reconstruction?
Microtia is classified into four grades reflecting the ear’s underdevelopment. Grade I involves minor abnormalities, while Grade II presents as a small ear with many recognizable structures. Grade III appears as a small, peanut-shaped remnant of tissue, and the most severe form is Grade IV, or anotia—the complete absence of the external ear. The condition can be unilateral, affecting one ear, or bilateral, affecting both, and is more common in males.
While appearance is a primary concern, reconstruction is often linked to psychosocial factors. Creating a more typical-looking ear can help with self-esteem, particularly as children enter school age and become more aware of physical differences. The goal is to construct an ear that balances with other facial features, reducing unwanted attention.
The absence of a well-formed external ear is frequently associated with aural atresia, the absence of the ear canal. This condition leads to conductive hearing loss because sound cannot efficiently travel to the inner ear. While reconstruction focuses on the external structure, it is considered alongside plans for hearing management.
Surgical Reconstruction Techniques Explained
Two main surgical approaches create a new ear: autologous reconstruction with rib cartilage and alloplastic reconstruction with a synthetic implant. In autologous reconstruction, surgeons harvest the patient’s own rib cartilage. They sculpt it into a three-dimensional framework mimicking a natural ear and place it under the skin on the side of the head.
Using the patient’s own tissue is an advantage, as the cartilage becomes a living part of the body and lasts a lifetime. However, this technique requires a chest scar and carries risks like pain and potential chest wall contour changes. The procedure is performed on older children to ensure the rib cage has developed enough to provide sufficient cartilage.
Alloplastic reconstruction uses a prefabricated porous polyethylene implant, like Medpor. This synthetic framework has interconnected pores allowing the patient’s tissue to grow into it over time. The implant is surgically positioned, covered with a tissue flap from the scalp, and then with skin grafts to create the ear structure.
A benefit of this method is avoiding a chest incision, resulting in less pain and a quicker recovery. It can also be performed at a younger age since it does not depend on rib cartilage growth. Downsides include a lifelong risk of the implant becoming exposed through the skin from trauma or infection.
The Reconstruction Timeline and Stages
The timing and staging of reconstruction differ between the two surgical methods. Autologous reconstruction using rib cartilage begins when a child is between six and ten years old. This age ensures the rib cartilage is large enough to create an adult-sized ear framework and that the child is mature enough to participate in postoperative care.
This method is a multi-stage process, requiring two to four separate surgeries spaced several months apart. The first stage involves harvesting the rib cartilage, sculpting the ear framework, and embedding it beneath the skin. Subsequent stages refine the ear’s appearance by lifting it from the head for projection, repositioning the earlobe, and constructing the tragus.
In contrast, reconstruction with an alloplastic implant can be completed in fewer stages, sometimes in a single surgery. This procedure can be performed on children as young as three because it does not rely on the patient’s cartilage growth. During the surgery, the implant is placed and covered with a tissue flap and skin grafts, with minor refinements possibly performed later.
Managing Hearing and Non-Surgical Alternatives
Microtia is often accompanied by conductive hearing loss from aural atresia, where the ear canal is absent. Early audiological assessment is important to determine the extent of hearing loss, especially in bilateral cases, to support language development. The most common solution is a bone conduction hearing device, which transmits sound vibrations through the skull directly to the inner ear.
These hearing systems can be worn on a soft headband for infants. Later, a small titanium implant can be surgically placed in the bone behind the ear, to which a sound processor attaches in a system known as a Bone Anchored Hearing Aid (BAHA). A separate surgical procedure called canalplasty can sometimes be performed to open the ear canal.
For individuals who wish to avoid surgery, a non-surgical alternative is a custom-made prosthetic ear. An anaplastologist crafts a realistic silicone ear colored and shaped to match the patient’s other ear. These prosthetics can be attached daily with a medical-grade adhesive.
Another attachment method uses surgically placed titanium implants, similar to those for hearing aids, allowing the prosthetic ear to snap on securely. This option avoids the risks of major reconstruction but requires daily care. The prosthesis may also need to be replaced every few years and can be detached.