Long-Term Results

his material reviews my personal thirty year experience of operating and managing my first 1,000 microtia patients, and discusses pertinent information I have gleaned from a long-term survey of these patients via a comprehensive questionnaire.

Because many of my patients are scattered throughout the world, obtaining long-term information is somewhat difficult. However, of the 1,000 congenital microtia patients that I surveyed, 508 (50.8 percent) responded [26]. This volume of cases provides substantial information from which to derive valid and worthwhile conclusions regarding the benefits of ear reconstruction.

Follow-up ranged from one to 17 years, with an average follow-up of 7.7 years (see Fig. 25). The following information is derived from these surveyed patients.

Figure 25. Long-term stability of ears constructed with autogenous rib cartilage grafts.

Figure 25a
25a) Eight-year-old girl with microtia, shown preoperatively; then at one, four, and twelve years postoperatively.
Figure 26b
(25b) Thirteen-year-old patient shown preoperatively; at one year, ten years, and twenty-five years postoperatively
Figure 25f
(25c) Six-year-old girl with microtia shown at one year and 21 years postoperatively.
Figure 25g
(25d) Six-year-old with microtia, shown at one, six, 22, and 28 years postoperatively.
Fig25h
(25e) Seven-year-old girl with microtia, shown at 2 years and 17 years postoperatively.
Fig25i
(25f) Teenager with microtia variation, shown one year and 16 years postoperatively.
Figure 25j
(25g) Nine-year-old boy with microtia, shown 2 years and 30 years postoperatively.
Figure 25c
(25h) Six-year-old girl, shown preoperatively; then at one year and at eight years postoperatively. Ear growth is particularly obvious in this patient.
Figure 25d
(25i) Eight-year-old boy with microtia shown at two, eight, and 18 years postoperatively.
Figure 25e
(25j) Six-year-old girl with microtia shown at two, twelve, and 18 years postoperatively.

 

Durability of Constructed Auricle

The survey disclosed that ears constructed from autogenous tissues withstand trauma remarkably well and retain their form over the years. In spite of more than 70 reports of major trauma to surgically constructed ears, all healed without incidence. These traumatic episodes included severe blows from soccer kicks, baseballs, and hockey pucks; abrasive injuries from football tackles and wrestling matches; insect bites and bee stings; and even a dog bite. The survey showed no instances of softening or shrinkage of the cartilaginous frameworks; there were only four reports of decreased definition (1.5 percent). These were all described as a "blunting" of the ear's details after the elevation and grafting procedure, a phenomenon that I always observe in the early postoperative course, but one that usually completely resolves as the swelling subsides. There were two cases in which the helical rim had flattened. On several occasions, wire sutures became exposed and had to be extracted. Years ago this prompted me to change my framework sutures to clear nylon.

Psychological and Emotional Benefit

The impact of microtic deformity on patient and family sequentially becomes greater as the child enters school, approaches adolescence, and reaches adulthood.

Emotional Impact of Unrepaired Microtia
Rated by Patient and Family. Authorís Series of 1,000 Cases.
Age (years) Severe Moderate Mild
5-10 18.6 % 46.2 % 35.2 %
11-14 16.3 % 61.2 % 22.5 %
15-20 26.7 % 60.0 % 13.3 %
21-62 44.1 % 41.2 % 14.7 %

Before 10 years of age, 64.8 percent of families rated the deformity's impact as "moderate" to "severe," whereas this figure jumped to 77.6 percent in ages 10-14, and 86.7 percent in patients over 15. In ages 6-10, where 35.2 percent of families rated the impact as being only "mild," these same families often stated that the full impact had not yet been realized and that they sought surgery "not to solve a current problem but to prevent a future, anticipated crisis" as their child grew older.

In families where the deformity's impact was rated "moderate" to "severe," the psychological and emotional relief attained after the surgical repair was also rated high. Relief was attained in 100 percent of patients in all age groups when the deformity's impact had been rated "severe;" and the emotional improvement was graded "significant" in 86.6 percent of these families and "somewhat" in the other 13.4 percent. When the microtias' impact was rated as being only "moderate," 78.4 percent of families still reported the emotional relief as being "significant," except in ages 15-20, where 76.9 percent deemed the benefit to be "somewhat" (see Table 5). Perhaps this reflects the "picky," critical nature of adolescents, or suggests that these patients had become resolved to their deformity or psychologically "numbed" to peer criticism.

The emotional benefits of the surgical repair were further reflected in the patients' activities. In the youngest age group, operated before age ten, 42.1 percent of parents found their children to be "more outgoing." The 10-14 year age range was most impressive of all, in that 62.5 percent were more willing to socialize and participate in sports after their surgical repair; and 20.0 percent had even improved their school grades. In ages 15-20, 37.5 percent were more outgoing, 26.1 percent more social and sports oriented, and 20.0 percent improved scholastically. After age 20, 64.0 percent of the patients ranked themselves as more outgoing, and 50.0 percent felt that they were "more social."

Table 5 - Emotional Relief by Microtia Repair
Author's Series of 1,000 Microtia Patients
Deformity Impact: Severe Moderate Mild
Relief by Repair signif some unch signif some unch signif some unch
Age 91.8% 8.2% 0.0% 79.3% 20.7% 0.0% 52.7% 43.0% 4.3%
  75.0% 25.0% 0.0% 76.7% 23.3% 0.0% 36.4% 54.5% 9.1%
  66.7% 33.3% 0.0% 15.4% 76.9% 7.7% 0.0% 75.0% 25.0%
  87.5% 12.5% 0.0% 72.7% 27.3% 0.0% 0.0% 100.0% 0.0%

Evaluation of Result by Patients and their Parents

When parents or patients graded themselves as having been "severely impacted" by the original microtic deformity, 100.0 percent of patients in all age groups were pleased with the result and were glad that they had had the surgical repair. In all these cases, the parents confirmed patient responses. For those who considered themselves "moderately disturbed" by their defect and were operated on by age 14, 95.5 percent were glad they had had the surgery and 4.5 percent were "undecided." In this same group, 97.6 percent of the parents were pleased with the outcome. Whereas all of the "moderately" impacted patients over 20 years of age were pleased, only 83.3 percent of the 15-20 year olds were totally satisfied; the rest were "undecided."

Of the families who ranked the original deformity's impact as "mild," but elected to have the repair completed before age 10 to avert any future emotional problems, 98.2 percent were satisfied with the surgical outcome.

Regarding the chest donor site, the survey indicated that 63.6 percent of patients found it of no concern, and 35.1 percent rated the scar and/or contour as "noticeable, but worth the trade-off." Of the 1.3 percent who were concerned about the appearance of the chest region, all had been operated on by the age of nine.

As a "final analysis," the survey asked each patient if he/she allowed his/her ears to be exposed without concern for hairstyle during routine social and sporting activities. With the exception of ages 15-20, 94.5 percent of all patients responded "yes" to "I carry on with a normal life without giving the ear a thought, whereas the microtic ear and its exposure used to be a concern at all times." In contrast, 14.3 percent of the 15-20 year age group still concerned themselves with hairstyle and ear exposure. Again, this probably reflects critical expectations and identity development during adolescence.

Portions of this Web site's text and illustrations are reprinted with permission from Brent, B.: "Auricular repair with autogenous rib cartilage grafts: Two decades of experience with 600 cases." Plastic & Reconstructive Surgery, 90:355-374, 1992.