Microtia is a congenital malformation that consists of an alteration in the development of the pinna, also known as ear. Most of the time we do not know the cause that provokes it and it is almost never a hereditary problem. The manner of presentation is very variable, affecting mostly males and is most frequently unilateral.
Although microtia literally means “small ear” it is not the most frequent way of presentation. In fact, the malformation of the ear is usually so severe that we can hardly identify any of its structures. Of all the possible presentations, the most frequent is the so-called lobular microtia because in this case we can recognize the lobe.
Microtia is not simply an aesthetic problem as it is associated with many other malformations. Most often it coexists with the so-called aural atresia, that is, an alteration in the development of the external ear and the eardrum box, causing a variable degree of deafness. It is also relatively frequent that the same side of the face has a deficit in its development (hemifacial microsomia), so in addition to having a smaller face, it can also have alterations in mastication when the jaw is severely affected or even present some form of paralysis if the motor nerve of the face is affected. Rarely, microtia may be associated with other major malformations that may affect the skull or other organs of the body. Therefore, any child born with a microtia should undergo a comprehensive physical examination to identify and rule out these associated problems.
In essence, the ear is a three-dimensional structure that is formed by a cartilage skeleton of elastic consistency surrounded both front and back by a very thin skin. Whenever possible, we plastic surgeons recommend autologous reconstruction, that is, one in which we use the person’s own tissues.
The first surgery consists of building a new skeleton for our ear using rib cartilage. Although it is stiffer than native ear cartilage, it is the only one that is present in sufficient quantity to be able to make our framework, usually from the age of 10 years old. Several fragments corresponding to ribs 6, 7, 8 and 9 are harvested through an incision in the lower rib ridge. Outside the patient, and taking the other ear as a mold, the various pieces will be carved and assembled together to achieve a three-dimensional structure that resembles as closely as possible to the ear we want.
The last part of the surgery consists of implanting our framework under the skin in the auricular area, for which the malformed parts of the embryonic cartilage must be previously removed. At the end of the surgery we will be able to recognize the reliefs of the new ear through the skin, although it is literally buried under it.
If everything goes well, after 6 months we will perform the second surgical intervention which consists of separating the ear from the head and giving it the appropriate forward projection, recreating the so-called retroauricular groove. In general, this involves trimming the contour of the ear and placing a new piece of cartilage that acts as a wedge that lifts and pushes our structure forward. The posterior aspect of our new ear must be covered with a final covering of new tissues taken from the patient from the surrounding area, such as fascia from the temporal region and skin taken from the scalp.
When for some reason the patient’s own tissues cannot be used to reconstruct the ear, the so-called alloplastic reconstruction, that is to say, one that uses synthetic materials, will be chosen. One possibility is to replace the rib cartilage with a synthetic material such as polyethylene and cover it with the patient’s own tissues (partial alloplastic reconstruction). And another radically different option is to use an external silicone prosthesis manufactured in an orthopedic clinic and that will be placed in the auricular area either by means of an adhesive or, what is more stable, through osseointegrated metallic implants (total alloplastic reconstruction).
Recovery after the microtia operation How is the post-operative period?
Auricular reconstruction operations are performed under general anesthesia and hospitalization.
The first operation is the most complicated, it lasts about 6 hours in the operating room and involves up to 4 days of hospitalization. During the immediate postoperative period the main complaints of the patient are discomfort at the costal level with movements and deep breathing, requiring up to 1 month for full recovery. On the other hand, discomfort in the auricular area is minor. It is very important that the patient does not support the reconstructed area to sleep and that he/she avoids crowds and contact sports during the first weeks to avoid possible blows in the area. The application of sunscreen on the scars will prevent pigmentation.
The second surgery usually lasts about 4 hours and requires 2 days of hospitalization. Compared to the first one, it is much less painful, although it has a longer healing period. Indeed, the area from which the skin graft is extracted remains as an open wound that can take up to 2 weeks to heal. The most stressful thing for the patient is to wear the ear covered during all this time until it can be fully exposed.
Results of an ear reconstruction
The main problem derived from microtia, considered as an isolated entity, is the one related to body image, i.e. self-esteem. Patients usually have avoidance behaviors trying to camouflage their problem either by special hairstyles, either by a cap, headbands, etc… In addition, these problems can be increased by comments from schoolmates when they start their school years. Avoidance behaviors can alter their personal and social relationships and even their school performance.
Ear reconstruction removes the stigma of the malformation. The child will already have 2 ears and, although the results are not always perfect since the reconstructed ear is more rigid and its reliefs are coarser, I have to say that I do not know any child who has had an ear reconstruction who is not happy with the results.