Integration of Outer-and Middle-Ear Surgeriesor optimal function and aesthetics in bilateral microtia, one must plan to integrate surgical procedures so that one does not compromise the other (see Fig. 24). In these cases, the auricular construction should precede the middle-ear surgery because, once an attempt is made to "open" the ear, chances of obtaining a satisfactory auricular repair are severely compromised because the invaluable virgin skin has been scarred.
Figure 24 - "Team Approach" to bilateral microtia.
|24a) Construction of auricle by author. (24b) Otologic surgeon now proceeds: Constructed auricle is lifted from bed, bony canal is drilled, and the middle ear repair is completed. Next, intervening soft tissues will be removed to exteriorize the canal. (24c) The completed repair achieved by this "team approach" of plastic surgeon and otologic surgeon.|
Patients with both ears involved are staged so as to minimize the number of operations. In bilateral microtia, I cartilage graft each side as separate operations, because each side of the chest contains sufficient cartilage for only one good ear framework. Simultaneous bilateral reconstruction would necessitate bilateral chest wounds with attendant discomfort and respiratory distress. Furthermore, the first auricular repair might be jeopardized upon turning the head to do the second side. For these reasons, I prefer to do the first stage of each ear on separate occasions.
Following the first rib graft operation, the second side can be done safely as early as six weeks. Then, after a waiting period of two to three months, both earlobes can be positioned during one surgery. Then three more months are allowed to lapse. The two ears are lifted from the head with skin grafts during separate procedures, separated by a minimum of three months. With this timing, the two ears can be constructed in just five operations within a reasonable time frame. If tragus constructions are to be done, they both can be performed later on at a single surgery (see Fig. 24).
Figure 24, continued.
|(24d) Preoperative views of the same bilateral microtia
patient. (24e) Bilateral results of the external and
middle ear "team repair."
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.
|(24f) Preoperative views of 6-year-old boy with bilateral
(24g) Results of the “team repair.” Both external ears have been constructed with rib cartilage grafts; the right surgically-created canal is visible. The left canal surgery is planned in several months time.
(24h) The final result, shown 6 years postoperatively. The boy
no longer needs hearing aids, and excels at numerous contact sports