The Evolution of Microtia Surgery and Introduction of the Real Ear Reconstruction Technique

What is Microtia?

Microtia is the second most common deformity of the face. In plain language, microtia simply means “small ear”. While all children technically have small ears, those with microtia have ears that are disproportionally small for their heads or, in severe cases, are completely missing. Microtia varies widely in severity, to categorize each case a 4-point grading system is used where a higher grade indicates a more severe case, and a lower grade indicates a less severe case.

Grade 1: Patients with grade 1 microtia usually have a small ear with most of the typical anatomy present. The ear may not appear abnormal when seen in isolation, but the size deficit is obvious when compared to the patient’s unaffected ear. These patients or their parents sometimes choose to opt out of treatment since the deformity may not be too concerning, although reconstructive options may be available.

Grade 2: Patients with grade 2 microtia begin to have more obvious anatomical deficits. The fine details of the ear will not be clearly distinguishable, and the ear may have a squished or constricted appearance. Patients with grade 2 microtia are therefore often seen by reconstructive specialists early in life and can benefit greatly from ear reconstruction.

Grade 3: Patients with grade 3 microtia have pretty much none of the typical anatomical features of an ear and may have what is often described as a peanut shaped lump of skin with some cartilage where an ear would typically be found. Parents of patients with grade 3 microtia are almost always interested in learning about reconstructive options.

Grade 4: Finally, patients with grade 4 microtia have no ear at all, this is also referred to as anotia. These patients will often have no sign of an ear and sometime have a hairline that covers the skin where an ear would typically be positioned. Again, these patients are prime candidate for ear reconstruction since the missing ear is obvious.

Patients with grade 3 and grade 4 microtia have the most severe cases and therefore very often choose to undergo complete ear reconstruction. Evaluation by an ear reconstruction specialist is required to determine what treatment options are available to each individual patient.

What Treatment Options Exist?

Three major treatment options have been used to correct microtia in the past. The goal of all three options is the same, to create a functional and aesthetically appealing external ear. For patients with type 3 or type 4 microtia, an entirely new ear must be created, this is often referred to as complete ear reconstruction. In contrast, patients with type 2 microtia might undergo reconstruction of only specific anatomical features rather than the whole external ear. As far as complete ear reconstruction goes, the three major treatment options are as follows:

Prosthetic Ear: Prosthetic ears typically require the least extensive surgery. This option is less so reconstruction and more of a cover up. A small titanium anchor is surgically implanted onto the side of the head which holds the prosthetic in place. Well-made prosthetic ears can be extraordinarily lifelike and sit on the side of the head disguising the fact that an ear is missing. While this option can offer a very cosmetically appealing result, it is typically not the first treatment option recommended by ear reconstruction specialists. Prosthetics ears require significant upkeep, they need to be taken off before bed, they need to be cleaned regularly, they need to be replaced every 3 – 5 years, and they are not covered by insurance.

Exposure of Medpor construct

Medpor Reconstruction: Medpor reconstruction is performed using a material known as porous polyethylene, which can be thought of as a special medical grade plastic. This medical grade plastic is molded into an ear-like shape and covered by skin during a fairly length surgery. The result looks very similar to a natural ear, however, complications from this procedure tend can make it a less desirable option. The most common and most frustrating is known as “construct exposure”. Essentially, because the Medpor material is stiffer than real human cartilage, it tends to break through the skin that is covering it. Attempts have been made to reduce the frequency of this complication, but the inherent properties of the synthetic material have made reducing the rate of construct exposure difficult. Techniques used to reduce the rate of exposure can leave a patch of hair loss which is not a reasonable tradeoff for most patients.

The often-large chest incision that must be made to harvest rib cartilage from the patient.

Autologous Reconstruction: The current gold standard for complete ear reconstruction is autologous reconstruction. This is the oldest method used to treat microtia but has previously yielded the best results. Autologous reconstruction is accomplished in two stages. First, rib cartilage is harvested from the patient and used to create a cartilaginous framework that is implanted on the side of the head where the final ear will be positioned. At this point the new ear is flat against the head and is elevated off the head during the second stage surgery. These surgeries are typically done at least six months apart and yield a new ear that can be treated like a natural ear. The major downside of this surgery is, since rib cartilage must be harvested from the patient, it cannot be performed 8 – 10 years of age. Additionally, harvesting cartilage from the patient can lead to additional complications and typically causes pain after the surgery.

Currently, the limitations of current options can be very frustration to patients. Prosthetics require significant daily upkeep, Medpor reconstruction is prone to complications, and autologous reconstruction cannot be offer to patients until they are much older. Until very recently these were patient’s only options.

What is Real-Ear Reconstruction?

In early 2020, frustrated by the limitations of the current options, Dr. Bastidas set out to develop a better reconstructive option for patients with microtia. In August of 2020, Dr. Bastidas successfully performed the first Real-Ear reconstruction for a patient with type 3 microtia. Real-Ear Reconstruction combines many of the benefits and eliminates the major drawbacks of previously available reconstructive options. Real-Ear reconstruction uses real human cartilage instead of the synthetic material used in Medpor reconstruction. Unlike autologous reconstruction, Real-Ear reconstruction does not require painful and potentially disfiguring cartilage harvesting from the child’s rib cage. Instead, Real-Ear reconstruction uses a donor rib cartilage allograft. In the same way heart, lung, and liver transplants provide lifesaving treatment for patients in need, donated rib cartilage can be used to perform life changing reconstructive surgery. Unlike transplantation of other organs, using donor rib cartilage does not carry the risk of rejection because cartilage is not recognized as foreign by the body’s immune system. After all, rib cartilage is made of the same compounds in everyone: aggrecan, collagen, and hyaluronic acid. Real-Ear reconstruction uses the time-tested techniques of autologous reconstruction, and simply swaps out the patient’s own rib cartilage for off the shelf donor rib cartilage.

Our Experience with Real-Ear Reconstruction

Donor rib cartilage is received from MTF Biologics, a non-profit organization that processes donated bone, cartilage, and skin for use in reconstructive surgeries.

Over the two years following the first Real-Ear reconstruction, Dr. Bastidas has used this innovative approach to perform 15 ear reconstructions for patients with type 3 microtia. He has been able to offer this option to patients as young as 4 years old, which was previously unhear of with autologous reconstruction. When offered the option of Medpor reconstruction, autologous reconstruction, or Real-Ear reconstruction, parents consistently choose Real-Ear reconstruction for their children because of its advantages over traditional options.

Real-Ear reconstruction offers a less stressful experience for parents. Since rib cartilage does not have to be harvested and extensive dissections are not required, patients are only under general anesthesia for less than 90 minutes, compared to over 4 hours with the traditional options. Since Real-Ear reconstruction is also less invasive than traditional approaches, so patients can often go home on the day of surgery without the need for prescription narcotics to control pain.

While Real-Ear reconstruction is a relatively new treatment option for microtia, its benefits are clear and results in an improved treatment experience for both parents and patients. Patients are seeing results that are no different than autologous reconstruction without the downsides. The surgery is typically covered by insurance and serves as the latest breakthrough in ear reconstruction for microtia and anotia.

*Disclaimer: The information in this article is not medical advice and should not be used for the purposes of diagnosis or treatment. If you believe you or your loved one has any of the conditions described above, please consult a medical professional.