Surgical Treatment of Microtia

What is Microtia?

Microtia is defined as a congenital condition characterized by small size, deformity, or absence of the auricle (earlobe). It can be unilateral or bilateral. In most patients, it is unilateral. It occurs in 1 in 6000-8000 births. Its cause depends on many factors. Some infections (rubella) and some medications (thalidomide) are effective in its development.

Normally, the ear consists of three structures: the outer, middle, and inner ear. The failure of the outer ear to develop is called ‘microtia’.

Does Microtia Cause Deafness?

In most patients, the external auditory canal is also absent; it is closed. Since the auricle and external auditory canal develop from the same structures in the womb, individuals with microtia usually lack an external auditory canal. When the external auditory canal is absent, hearing is reduced in the ear on that side. The ear on the normal side usually hears normally. Hearing is very difficult for those with bilateral closed auditory canals.

In individuals without an external auditory canal, the structures in the middle ear (eardrum, middle ear ossicles; malleus, incus, stapes) are also underdeveloped. The lack of development in these structures also impairs hearing.

Except in rare cases, there are no problems in the inner ear.

What Should a Family Do If Their Baby/Child Has Microtia?

1. Families with a baby with microtia should first plan an examination to assess their hearing function. Babies with impaired hearing will likely have impaired speech later in life. An audiogram, a hearing test, should be performed immediately after birth.

2. In babies with bilateral microtia, bone conduction hearing aids are needed to address hearing problems. This aid is initiated within a few months of birth. Surgical intervention necessary for hearing correction is postponed until after augmentation (ear reconstruction).

3. The child should be monitored at regular intervals for hearing and speech development. Efforts should be made to protect the health of the healthy ear.

4. The affected ear should be evaluated with a 3D CT scan.

5. A plastic surgeon’s examination and follow-up should be provided.

6. The child should receive speech therapy from a speech therapist.

7- When the time comes, ear auricle surgery should be planned first. If necessary, external auditory canal and middle ear surgery are performed later.

Why is Microtia Surgery Performed?

The aim of microtia surgery is to create a small, misshapen, or absent ear auricle. External auditory canal or inner ear surgery is not performed with this operation.

At What Age is Microtia Surgery Performed?

Surgical treatment is generally performed after the age of 5, during preschool or school age. At the age of 5, the human ear has reached a size close to that of an adult. Furthermore, in surgery performed at this age, it is easier to create ear cartilage using rib cartilage that has reached sufficient development. Surgery performed before school age is extremely important for the child’s psychosocial development.

It has also been shown that in microtia surgeries performed between the ages of 2-5, the created ear cartilage develops along with the child.

Some publications state that ear reconstructions performed after the age of 10 are more successful in terms of appearance.

What is Microtia Surgery Like?

Correcting microtia is not a single surgery. Depending on the surgical technique used, 2, 3, or 4 surgical sessions may be required for those with no earlobe at all.

Microtia surgeries are performed under general anesthesia, with specific intervals between surgeries.

The ideal goal of microtia surgeries is to create an ear by shaping cartilage taken from the ribs.

In the first session, cartilage taken from the patient’s own ribs is shaped using various sutures to create a normal ear framework. Then, a subcutaneous socket is created in the area where the ear is missing, and the ear skeleton (mold) is placed there. In this session, the earlobe can be shifted to its proper location.

The second session is performed a few months after the first. The aim is to create the back of the ear tissue attached to the skull. The ear mold placed in the first session is separated from the skull slightly, with skin tissue in front of it. A thin skin graft (patch) taken from the groin is also transplanted here to create the back of the ear.

In subsequent surgical sessions, earlobe reconstruction (if none exists), earlobe correction (if present), creation of a protrusion in front of the ear canal, and correction of ear canal depressions can be performed. These corrections can be done in the first two surgical sessions, depending on the patient and the surgical technique. Three or four surgical sessions may also be necessary.

What are the Surgical Procedures for Patients with Skin Tissue Problems?

In some patients, due to various previous surgeries, burns, or congenital deformities, there may not be sufficient healthy skin tissue in the area where ear tissue reconstruction is needed. In this case, different techniques may need to be included in the classic surgical method sequence.

In some patients, balloon (tissue expander) application is performed in the ear area to increase the amount of skin tissue in the region.

In some patients, the ‘temporoparietal fascia’ tissue, a thin membrane located under the skin of the skull, is used as a cartilage covering. A skin graft from the groin is then placed on top of this membrane tissue.

Are there other methods besides using rib cartilage in microtia surgery?

In microtia surgical treatment, using the patient’s own cartilage is always a less risky solution. Alternatively, ear cartilage frameworks can be created with ready-made prostheses without touching the ribs. Ear reconstruction surgery with these prostheses is similar to multi-session ear surgery using the patient’s own ribs. The difference is that the patient’s ribs are not touched.

In surgery with prostheses, the risk of infection, protrusion through the skin, and surgical failure is higher.

Is Non-Surgical Microtia Treatment Possible?

If no surgical solution is possible and surgery is not desired, artificial ears, which are entirely prosthetic, can be used by gluing them on.

Is Microtia Only Congenital?

No. A portion or all of the auricle may be missing after various degrees of trauma such as cuts and tears, after ear cancer surgery, or after burns. Microtias formed in this way can also be corrected surgically.

In Which Cases Is Middle Ear Surgery Performed?

In microtia, complete deafness is usually not observed because the inner ear is normal. Children generally communicate well and their speech is normal. Therefore, middle ear surgery is not frequently performed. Middle ear surgery is generally performed in patients with bilateral microtia and severe hearing problems, and the timing should be delayed until the outer ear is reconstructed. Rarely, middle ear surgery is performed in patients with unilateral microtia. However, the outer ear must be reconstructed first. Otherwise, the tissues used to reconstruct the outer ear may be damaged, making the reconstruction very difficult.