Other Surgical Stages

TIo allow for proper healing, a minimum of several months is allowed between the staged surgeries. This extra time allows for swelling to subside, circulation to improve, and for the tissues to settle down. There is no such thing as waiting too long between surgical stages, and it wouldn't even matter if one waited years! Basically, I like to have at least two months between the first and second operations, then three months between the others. In certain instances, I will wait even longer between stages to ensure optimal condition of tissues.

Transposition of the Ear Lobe: Technical Aspects

The ear will also look unusual until the second stage, when the earlobe tissue is repositioned and any remnants of unusable ear tissue are removed. This is when young patients truly understand and appreciate the surgical plan, as the structure really begins to look like an ear.

Although it is technically possible to transpose the earlobe while simultaneously placing the framework, this combination imposes risks to tissue circulation and increases the likelihood of complications. I find it safer and far more accurate to transpose the lobule secondarily [13]. This can be accomplished on an outpatient basis several months after the cartilage framework is placed at the first procedure.

Figure 18. Earlobe transposition.

Figure 18 - Earlobe transposition

Patient with healed repair.
Fig 18f

18a) Simplified drawing of the procedure. The earlobe has been shifted as a flap of tissue with circulation maintained through its base. The operation demonstrated in patient: (18b) The original microtic ear. The lower portion of the vestige represents the earlobe. (18c) The healed ear several months after insertion of carved rib cartilage framework. (18d) The earlobe has been mobilized as a tissue flap, and it is still attached so that circulation will flow through its base. (18e) The earlobe has been transposed into position and "spliced" upon the previously constructed ear; unusable tissues have been removed and all wounds closed with sutures. (18f) The same patient several months later, demonstrating the healed 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.

Most patients born with microtia have an earlobe that is fairly normal but is displaced. If present, the lobe is always too far forward and usually too high (when compared to the opposite side). At the second phase of surgery, the earlobe is moved into position and "spliced" into place upon the previously constructed ear "foundation" (see Fig. 18). Although this is a very detailed technical operation involving many little stitches, it is very minor for the patient. There is no discomfort with this procedure. However, the procedure is performed in the hospital and under general anesthesia, unless the patient is an older teenager or adult, in which case local anesthesia is optional (although most teenagers prefer to be put to sleep).

Hospital Course and Postoperative Care

Including anesthetic time, the procedure lasts about two hours. For this procedure, the patient leaves the hospital the same day, and sutures are removed one week later. It is ideal to leave the stitches in for six to eight days. Earlier removal could result in wound disruption, and later removal might leave permanent stitch marks. Patients who live nearby return to my office for suture removal. My out-of-town patients prefer to drive or fly home and have their local physician remove the stitches one week later.

Wound Care and Activities

Children usually stay out of school for a week, although they certainly could return earlier. However, most kids don't want questions asked and might be teased about the bandages. With this operation, sports and swimming are discouraged for about two-and-a-half to three weeks. Hair can be washed at seven to ten days postoperatively, and hair dryers can be used at about three weeks. Again, I encourage patients to try not to sleep on the ear for one month.

The Elevations or "Lifting" Procedure: Technical Aspects

After the first two stages, the structure has an ear-like contour, but still looks somewhat two-dimensional, like an ear-beneath-the-skin (because that's exactly what it is). The third procedure separates the ear from the head with a skin graft, defining the back edge of the ear by producing a space behind it (see Fig. 19).

Figure 19. Separating the surgically constructed ear from the head with skin graft.

Figure 19. Separating the surgically constructed ear from the head with skin graft.
(Inset: Appearance of a surgically constructed ear after two stages. Note that the new auricle still looks two-dimensional, like an ear beneath the skin). An incision is made around the surgically constructed ear, and the auricle is sharply elevated from its tissue bed. A skin graft is sutured to the raw area which has been created on the ear's undersurface and bed beneath it. Long silk sutures are tied with light pressure over a dressing to prevent blood clots from accumulating under the skin graft, which would prevent its "take." This dressing is left in place for a week.

I obtain the skin graft by removing an ellipse of skin from the lower abdominal region. The abdominal wound is repaired by closing it directly with sutures (see Fig. 20).

This surgery lasts about two hours, and I often keep the patient in the hospital overnight. There is very little discomfort from this surgery, and this is easily managed by oral medications for a few days.

Figure 20. Donor site of skin graft.

Figure 20

The backside of the new ear is lined with a full-thickness skin graft which is harvested from the lower abdominal region. This site is stitched closed directly, resulting in a linear, straight scar.

Postoperative Course

Wound Care and Activities

Of all stages of the ear repair, the new ear is probably most delicate and vulnerable after this surgery, and should be treated carefully for the next four to six weeks.

Once the head dressing is removed, I encourage the patient and family to keep the skin graft on the back of the ear lubricated with a film of antibiotic ointment for three to four weeks.

Although it is all right if a little water gets on the ear soon after the dressing is taken off, it is probably wise to avoid prolonged soaking of the ear during the first several weeks of hair washing. This time the hair dryer should be avoided for six to eight weeks. Most sports can begin at four weeks, but swimming should probably be avoided for six weeks. One should be particularly cautious about heavy sun exposure for the first two months after this procedure. This is a non-issue for patients with long hair. However, if the patient has short hair or will be exposing the ear to the sun for prolonged periods of time, a wide-brimmed hat and/or good sun blocking agent should be applied to the ear. The latter is a very good idea during strong sun exposure for six months.

Tragus Construction & Achieving Frontal Symmetry

This surgery is meant to create the small flap-like tragus in front of the ear, but, more importantly, scoop out the tissues beneath it to mimic a canal, and improve symmetry from the front view. An actual canal is not created, but if the constructed tragus heals favorably, a light striking it from the front will throw a shadow behind it which can look quite like an opening.

To create the tragus, two small grafts are borrowed from the opposite ear (if the patient was born with both ears affected, then this procedure obviously cannot be done and I use another technique). The main graft is a crescent of composite tissue (skin and cartilage) taken from the concha (bowl in the ear's center). This is the same tissue one removes and discards when patients with protruding ears have an otoplasty (ear "pin-back"). When building a tragus, this usually-discarded tissue instead is used as "building material" (see Fig. 21). A small skin graft is also taken from behind the opposite ear and the wound is closed with dissolvable sutures.

Figure 21. Tragus construction and conchal excavation.

Figure 21. Tragus construction and conchal excavation.

Harvested from the opposite, normal ear's conchal region, a composite graft of skin and cartilage is placed under a thin J-shaped flap to create the tragus. Before surfacing the floor of the tragus region with a full-thickness skin graft (harvested from behind the opposite ear), extraneous soft tissues are excised to deepen the region.

Because surgically-constructed ears rarely protrude as far as the opposite, normal ear, this operation is a "two-for-one" procedure, as removing the grafts from one ear and switching them to the other tends to equalize the two ears' projections and give better frontal (head-on) symmetry (see Fig. 22). Upon healing, it is usually difficult to see scars and tell that anything has been removed from the normal ear. If the surgically-constructed ear and the normal ear have equal projections before the tragus construction is undertaken, a modified technique is used in removing the grafts so as to prevent the normal ear from being "pinned back."

Figure 22. Result of tragus construction.

Figure 22. Result of tragus construction.
Figure 22. Result of tragus construction.
22a 22b
Figure 22. Result of tragus construction. Figure 22. Result of tragus construction.
22c 22d
22a) Nine-year-old boy with microtia. (22b) Appearance of surgically constructed ear. Note illusion of "canal" created by shadow cast underneath the constructed tragus. (22c) Frontal appearance before surgery. (22d) Appearance after construction of new ear and setback of opposite, normal ear (facilitated by its repair when grafts were harvested for creating the new tragus). Notice symmetry of projection of both ears achieved by this procedure.

From Brent, B.: Total auricular construction with sculpted costal cartilage. In B. Brent (Ed.),The Artistry of Reconstructive Surgery, St. Louis, 1987, The C.V. Mosby Co., pp. 113-127.

This surgery takes about three hours, and is performed on an out-patient basis. There is minimal discomfort where the grafts have been taken from the normal ear, but this is gone by the morning. This discomfort is easily controlled with oral medications.

Again, stitches are removed after one week, after which the grafts of the newly constructed tragus are lubricated with ointment for several weeks. Sports and swimming are restricted until one month postoperatively, and hair dryers are disallowed for one month.