Age to Begin Surgical Ear Repair

he age at which an auricular construction should begin is governed by both psychological and physical considerations. Since the body image concept usually begins forming around the age of four or five years [65], it would be ideal to begin construction before the child enters school, and before he/she is psychologically traumatized by his/her peers' cruel ridicule. However, surgery should be postponed until rib growth provides substantial cartilage to permit a quality framework fabrication, which is rarely before the age of six.

In my experience with interviewing and evaluating over 2,500 microtias from age one-month to sixty-two years, the patients and/or their families consistently stated that their psychological disturbances rarely began before age seven, and usually became overt from ages seven to ten. Hence, in general, I prefer to delay the initial cartilage graft until the patient is six years old, when there is usually sufficient rib cartilage for the repair. At age six, the normal ear has grown to within 6-7 mm. of its full vertical height [45], which permits one to construct an ear that will have reasonably constant symmetry with the opposite normal ear. Tanzer has demonstrated comparable increases in vertical height in both normal and reconstructed ears over 10- to 16-year periods, but the roles played in this growth by soft tissues and by cartilage have not been determined [101]. In my own patients, I have likewise found that most surgically constructed ears have grown, and many of these have not only kept up with the little residual growth in the opposite, normal ear but have slightly overgrown (see Fig. 7). I have found none to have either shrunk, softened, or lost its detail. With all this in mind, I conclude that one should try to match the opposite side during the preoperative planning session. Certainly there is no reason to construct the ear larger, as some investigators have thought, and, in fact, I now usually make the framework several millimeters smaller in the youngest patients, in whom I expect the new ear to slightly outgrow the opposite side. 

This interesting concept is explained by the following facts:

Because ears are 85 percent grown by age six, young children appear to have very large ears. Obviously, the chest is not 85 percent grown by that age, so rib cartilage has a greater growth potential than the residual, 15 percent growth left in the opposite, normal ear. Just because the rib cartilage is carved into an ear shape doesn't make the actual tissue into ear tissue. It still retains the growth potential of the original tissue source, i.e., rib, and I now take this into account during my planning of the new ear.

If the patient is small for his/her age and/or the opposite, normal ear is large, then I find it prudent to postpone the surgery for several years.

Fig. 7 - Growth of the surgically constructed ear

7a - Eight-year-old girl with right microtia. 7b - The result, two years after surgery. 7c - Appearance eight years later. From age 10 to 18, the new ear has grown from 5.1 to 5.6 centimeters, a gain of 8.9 percent.
7d - The opposite, normal ear at age 10. 7e - The normal ear at age 18. During the same 8-year span, the normal ear grew from 5.5 to 5.8 centimeters, a gain of 5.2 percent.  

From Brent, B.: Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases. Plastic & Reconstructive Surgery, 90: 355, 1992, with permission.