The goal of corrective ear surgery is to restore balance to the face and shift unwanted attention away from prominent or misshapen ears. With fears about teasing at school, parents are often keen to have their children’s ears operated on at an early age. However, a child’s opinion, consent and cooperation are essential to a successful and satisfying cosmetic outcome. For this reason, many surgeons prefer to wait until a child is older to perform ear surgery.
There are two type of conditions that affect a persons ears:
Congenital :Conditions that people are born with
- Prominent ear
- Other ear deformations
Acquired :Those that develop later in life due to accident or infection.
- Cauliflower ears (post traumatic/surgery)
- Infection of the ears
- Skin cancer of the ear
Microtia, translated from the Greek, means ‘little ear’, and is the medical word used to describe small or absent ears in newborn babies. Affecting one in 6,000 live births worldwide, microtia can appear in isolation or as a feature of other syndromes, such as hemifacial microsomia or Treacher-Collins syndrome.
Microtia usually affects one ear only, although in 10% of cases both ears are involved. The root cause of the problem is thought to relate to an interruption of the blood supply to the affected area about eight weeks after a baby’s conception. Hearing is often impaired on the affected side due to the ear canal being underdeveloped, although a hearing aid is only usually needed in cases of bilateral microtia.
Microtia Treatment options
There are three main reconstructive options available to patients with microtia. The first is autologous ear reconstruction, which means reconstruction using the patient’s own tissue. The second option involves utilising a prosthetic framework covered or buried under the patient’s own skin. The third option is to use an external prosthesis crafted to match the opposite ear and fitted to the side of the head.
Autologous Cartilage Reconstruction
The gold standard technique for autologous ear reconstruction is a rib cartilage graft; a surgical intervention that is usually carried out in two or three stages under general anaesthetic. The first stage of surgery is conducted when the child is between 7-10 years, when there is sufficient volume of cartilage in the chest area.
The rib cartilage is harvested via a small incision at the side of the chest. The operation lasts between 4-5 hours. Once removed, the pieces of cartilage are carved and joined together to create a framework replicating a new ear. Based on a map of the patient’s other ear, the framework is as close as possible to a mirror image of the opposite ear. The new ear structure is buried under the skin at the side of the head. Occasionally if the skin is scarred or the hairline is very low the ear maybe covered by a flap of fascia from under the scalp and a split skin graft.
Past attempts to reconstruct the ear with cartilage from from mothers or human donors have yielded poor results. More recently scientists have created ears made of engineered cartilage in laboratory mice. Although promising this technology does not work in humans as the cartilage is too soft.
The newly constructed ear initially lies flush against the patient’s head.At a second stage the ear is lifted to achieve a normal projection. This procedure takes from 3 to 5 hours and involves inserting a wedge of cartilage behind the ear with fascial flaps and skin grafts used to cover the exposed surfaces.
Sometimes a third operation is required to refine the results or to perform additional procedures such as piercing the lobe or correcting prominence of the opposite ear. Occasionally a course of laser treatment maybe required if there are a few hairs growing on the ear.
Patients undergoing the first stage of autologous ear reconstruction need to be kept in hospital for 1-3 days. Very small suction drains help to stick the skin onto the new ear. These are removed after four or five days. Skin stitches are removed after a week.
It takes several months for the swelling to settle but the shape of the new ear will be apparent to all at an early stage. A week after the second operation, the skin graft will need to be checked. Patients should avoid all sporting activity for three months, but should rest assured that long-term satisfactory outcomes can be expected following autologous ear reconstruction.
Buried Prosthetic Reconstruction
Rather than using cartilage from the chest some surgeons utilise frameworks made of hard porous material or even silicone. This is buried under the skin or a fascial flap and skin graft in much the same way as the cartilage framework. The reconstruction can be completed in one stage.
The final option is to wear an external prosthesis on top of the skin. A skilled prosthetist can create a very realistic ear using silicone. These external prosthesis maybe secured with special glue or alternatively, patients can opt for a more permanent bone-anchored prosthesis. This type of false ear is secured via two or three small titanium implants which are embedded into the bone at the side of the head over the course of two operations.
The First Consultation
During the consultation, your needs desires and expectations from the surgery will be discussed in detail.It is very important that you share your expectations for the outcome from this operation. You will be explained the different options available to you, the procedure itself, and its potential risks and limitations. It is important for you to provide complete information about your past medical history, drug allergies, previous surgeries, and medications that you currently take.
Even if only one ear needs correction, surgery may sometimes still be recommended on both ears to achieve the most natural, symmetrical appearance.
General guidelines prior to Ear Reconstruction
Patients have to follow certain instructions prior to their Ear Reconstruction Surgery.
- Detailed Ear examination
- Exact measurements of opposite Ear and Facial dimensions
- Pre-Operative Photographs for medical records
- Pre-operative Anaesthetic assessment for fitness for surgery
- Agreement to proceed with the surgery by signing an informed Consent Form
- Obtain laboratory testing or a medical evaluation
- Take certain medications or adjust your current medications
- Stop smoking well in advance of surgery
- Avoid taking aspirin, anti-inflammatory drugs and herbal supplements as they can increase bleeding.
The Operative Procedure
Ear Reconstruction surgery is performed in a major hospital under general anaesthetic for your comfort. The attending Anaesthetist will explain the type and risks of the particular form of anaesthesia for your operation.
Autologous reconstruction is widely regarded as the gold standard in Microtia surgery. Since the patient’s own tissue is used the new reconstructed ear is very much a part of their body. It is robust and will heal if injured and there is minimal chance of infection or ulceration in later life. Ear reconstruction using rib cartilage is however regarded as a highly skilled procedure and patients are advised only to have this surgery in a centre of excellence.
Silicon /Porex Implant
The main advantage of ear reconstruction using a buried plastic or silicone prosthesis is that there is no second operative site. Thus one avoids a cut on the chest and the use of rib cartilage. This also means that the surgery can be performed at a younger age. However the long term risk of the silicone extruding though the skin makes this technique less popular worldwide.
The use of an external prosthetic ears is well known and is a relatively safe procedure although the small titanium anchors can become infected. However, there can be difficulties finding a good skin-colour match and patients often report a sense of being incomplete arising from the daily removal of a false ear. Significant psychological adjustments are often required as patients incorporate the prosthesis into their lives.
There will be some discomfort following an otoplasty, and in some cases, patients may experience bleeding, bruising, infection and scarring. Very occasionally a corrected ear may drift back out, requiring a second operation. However, the operation is usually very successful, with 90-95% of patients happy with the outcome.
Most ear-trauma injuries are caused by biting, but some are also due to sharp lacerations. Attempts to replant ears in an emergency environment often yield poor results. Following a surgical ‘tidy up’, the damaged area is left to heal, and is then reconstructed using the same surgical methods described above for the treatment of microtia.
Acute swelling of the ear following trauma is usually due to a collection of blood clot (haematoma) under the skin. This is best dealt with as an emergency by surgical drainage. In neglected cases the blood can become calcified leading to a thickened so called ‘cauliflower ear’. Such deformity is common in boxers and rugby players. It is recommended that patients finish their sporting careers before seeking treatment. Treatment usually requires elevating the skin from the front of the ear and thinning the calcified thickened tissue to recreate the ear shape.
Piercing of the cartilaginous part of the ear can result in late infection and loss of ear structure. This may then necessitate ear reconstruction with rib cartilage.
Skin cancer of the ear is usually treated by surgical excision and reconstruction, as described in the head and neck cancer section of this website.
The ears are one of the first parts of the body to reach adult size. When the ear projects excessively it can be regarded as prominent. Around 2% of the population suffers from prominent ears.In prominent ears the usual folds of cartilage that give the ear its shape are missing or underdeveloped at birth. Prominent ear correction (otoplasty) recreates these folds in order to pin the ears back.
Most cases of prominent ears, become a problem in early childhood, often relating to teasing at school. Surgery for prominent ears is not undertaken until the child is old enough to understand what the surgery involves. At this stage the child is more likely to be cooperative. In addition one must consider that not all adults with prominent ears wish them to be corrected. Therefore if one operates on children prior to the acquisition of understanding a proportion will have been subjected to unnecessary surgery. For this reason, and because ear cartilage is often soft in the early years, operations for prominent ears are rarely performed on children under the age of five.
Cryptotia means ‘buried ear’. This is a relatively rare deformation in which the groove behind the ear is not fully formed. This is aesthetically displeasing and can cause difficulties in wearing glasses. This condition can occasionally be corrected using splints but more commonly is corrected surgically around the age of 5.
A variety of other ear deformations such as ‘Stahls’ ear and constricted ears are well recognise entities which maybe corrected by splintageotoplasty or ear reconstruction.
Splintage is a simple, safe and non-invasive procedure for the correction of prominent ears. The cartilage in a baby’s ear is very soft and malleable, and can be moulded with the use of splints. Splints are fitted into the outer groove of the ear and fixed by strips of tape, with the ear then taped to the side of the head using a broad strip of tape. The pressure of the splint corrects the tendency of the ear to stick out, while maintaining the proper contours of the ear. To be effective, splints can be required for as little as two weeks in newborn babies, or for up to four months in babies aged six months or over.
Otoplasty is the term used to describe the surgical correction of prominent ears. The surgery is carried out when the child’s ears are fully grown, which is usually around the age of eight.
The surgery is done under general anaesthetic for children, and local anaesthetic if it is an adult.
During the operation, a cut is made in the groove behind the ear. This incision exposes the cartilage, the ear maybe set back by scoring the front surface to weaken the cartilage, removing a small piece of the cartilage bowl (concha) or by inserting some stitches at the back of the ear to reshape or to rotate it closer to the head. Once this is done, the skin is closed with a stitch and a protective bandage or head garment is usually applied which is removed between 2nd-5th day.
Stitches are removed around 7 days later. It is advisable to wear a headband at night and while playing sport for six weeks. Young patients can return to school after a week, and can resume all normal physical activities after six weeks. They will usually have follow-up appointments at one week and about three months after the operation.