Navigating Microtia: Clear Answers for Confident Decisions

Microtia is found in children at birth and is usually an isolated condition. As of today, no real causes of Microtia (other than genetic syndromes involving approximately 5%) have been identified.

In some children, microtia occurs along with other facial abnormalities, such as hemifacial microsomia, which involves the underdevelopment of one side of the face, including the ear. In very rare cases, hemifacial microsomia can occur on both sides of the face at once.

Mothers often ask if they did anything during pregnancy that caused microtia. To date and to our knowledge, microtia is not caused by something that the mother did during pregnancy. So, it is important for parents not to feel guilty. Also, it is important to remember that through surgical advances, microtia can be successfully treated via a single procedure in the outpatient setting.

As far as I am concerned, the definition of a cosmetic procedure is improving something that is normal. The ear does not only have a cosmetic function but has also a functional aspect.

Reconstructing an ear helps:

• Restoring facial balance
• Improve hearing with either a BAHA or atrasiaplasty
• Helps with psychosocial integration as the patient grows older
• Makes wearing glasses easier
• If done before school age (5 years old), it can prevent harassment and bullying at school

Various anomalies can be detected by the ultrasound technician. Ultrasound technicians often focus on major organs, and external ears are not routinely checked during an ultrasound.

It may be easier to detect microtic ears with new high-definition 3D ultrasounds.

The traditional method of ear reconstruction has utilized an ear framework made from rib cartilage. Refinements of the cartilage procedure over the years have reduced the number of needed surgical stages.

However, the amount of required harvested cartilage has increased, pushing back the age of reconstruction until 10 years of age or older.

Reconstruction at an older age, and its usual multiple stages, have made microtia reconstruction with autologous cartilage a more arduous physical and psychological endeavor for both children and their parents.

If the final cosmetic result of the constructed ear is not ideal, the entire reconstructive journey can be disappointing.

The use of an alloplastic framework covered by a thin temporoparietal fascia flap offers several advantages over the traditional method of cartilage reconstruction.

Since ears reach 85% of adult size by 3.5 years, ear reconstruction can be performed at a younger age since the need for sufficient costal cartilage is not a factor.

Other advantages of a fascia-covered alloplastic framework over the traditional rib cartilage technique include minimal patient discomfort, a single outpatient procedure, and better ear definition and projection.

In order to evaluate a child for this life improving intervention, it has become necessary to perform CT scans of the temporal bone at a much earlier age than previously. Scans at 2.5 years are recommended. The CT scan will allow us to determine if your child is a candidate for Atresia repair but also, it allows us to rule out the presence of a Cholesteatoma.

Scan parameters are those used for standard temporal bone studies (1 mm cuts or less with bone windows, usually in a manipulable voxel format without contrast).

The surgery takes approximately 5 hours. Prior to starting the surgery, there is approximately a preparation phase lasting 1 hour. During this phase, anesthesia is being administered, we prepare the head, braid the hair if necessary, plan the surgery, make the surgical markings and prepare your child for the procedure.

Although it is a long surgery and it could seem painful, it is actually not. Patients tolerate it very well. It is done as an outpatient procedure and often, patients require only some minimal pain medications for the first 2 days after surgery. The surgery mostly involves skin and soft tissues. It does not involve muscle or bone and thus, the pain is relatively minimal.

No. PPE implants (and SUPOR™) are made of porous high-density biomaterial. This is a completely inert material and will not be rejected by the body.

Indeed, over the years various implants came on the market. MEDPOR™, OMNIPORE™ and SUPOR™ are the 3 most commonly used implants over time. These implants have been refined over the years to provide the best reconstruction. 3D designed SUPOR™ implants are the one we use now exclusively All implants have been refined over the years to provide the best reconstruction.

The first post-operative appointment occurs at post-op day #2 or #3. The absorptive dressing is removed during this appointment. If fluid is noticed beneath the scalp at that time, it can be easily drained percutaneously with a butterfly needle. The silicone ear splint is left in place for a total of two weeks post-operatively. During that period, the head should be kept dry and the patient should not sleep on the side of surgery to avoid pressure on the reconstructed ear.

For young children, parents should sleep with the child to make sure they do not inadvertently turn and sleep on the operated side.

At two weeks post-operatively, the silicone ear mold is removed and the ear and head are washed with shampoo in the office. Parents are shown how to wash it gently with their fingers on a daily basis. A new silicone ear mold is made for the patient to use at night for the following four months. A light coating of ointment is applied to the ear before applying the ear mold for the next week.

The third post-operative visit occurs after three weeks. Washing can now be done with a gauze pad to encourage removal of the dissolving chromic sutures. Parents are taught how to make the silicone ear mold, which will be worn every night for the following four months (parents are provided with the silicone mold packets). This helps to protect the ear, but more importantly, it helps to maintain the projection of the ear.

A fourth visit around week 4 ensures healing is on track as well. At that point, all sutures are removed. You’ll again be shown how to make replacement ear molds to continue nightly wear over the four-month period.

Patients are usually back to normal after the 2nd day after surgery. As long as the patient keeps the head dry while the mold is in place and avoids contact sports, there are no activity limitations. Often, our patients come from all over the world and stay for a few weeks in Los Angeles. They end up going roller blading by the beach, they go to the zoo, museums and take part of a lot of outdoor activities.

Since this surgery is performed as an outpatient procedure, it is often performed at a surgical center specialized in microtia reconstruction.

Those surgical centers are very experienced with treating patients with microtia and their care is second to none. If the patient has a genetic syndrome such as Treacher Collins Syndrome or other significant comorbidities such as cardiac or pulmonary problems, the surgery is performed at the Cedars Sinai Main Hospital.

Either at the surgery center or at the main hospital, we work closely with the same group of board-certified pediatric anesthesiologists who are part of the Cedars Sinai Anesthesia Group. Those pediatric anesthesiologists are very experienced and very comfortable treating patients with microtia. We work with them very regularly and they are very familiar with the SUPOR™ ear reconstruction procedure.

Complications most often occur within the first few weeks of surgery. They are rare however. The most common complication would be a small area of exposure of the implant. This means that the tissues in a small area did not survive and the implant is exposed. The rate of this complication is less than 4%. This complication is treated via small revision surgery aimed at covering the implant.

Other complications are rare and include infection, implant fracture and implant migration. Those complications are very rare and their rate is less than 1%.

Moreover, to maintain an adequate posterior sulcus, it is important to wear the silicone mold at night for the first 4 months. We have seen patients who have lost some ear projection because they were not compliant with wearing the mold at night in the first 4 months post-operatively.

Ideally, the patient should limit sports for the first few weeks following SUPOR™ ear reconstruction (4-6 weeks). Following that period, the patient is free to resume his/her regular activities, while wearing normal sport-specific protection.

If my child had previously a cartilage ear reconstruction for which a TPF flap was used, can a SUPOR™ ear reconstruction still be performed?

This is a very good question. In the rare circumstances that a TPF flap is not available (if it was harvested to cover a rib cartilage ear, or if the TPF vessels were injured from a prior surgery or if a SUPOR™ reconstruction was performed and failed), then an occipital fascia flap can be used to perform a SUPOR™ ear reconstruction. This occipital fascia flap is harvested from the back of the head and is used to cover the implant.

Thus, if a TPF flap is not available; it is still possible to perform a SUPOR™ ear reconstruction.

The main disadvantage of PPE implants is that they’re not flexible and do not bend like a normal ear. This is seen no matter what implant you use (MEDPOR™, OMNIPORE™, or SUPOR™).

One has to keep in mind that rib cartilage ear reconstruction does not bend either.

The other disadvantage of the PPE implant ear reconstruction is that if it is not secured properly, the ear can descend slightly from its original position (2-5mm). To prevent that, we used a soft tissue leash to suspend the ear at the appropriate position.

Dr. Tahiri specializes in microtia surgery for children. Patients from all over the USA and the world visit his Beverly Hills office to discuss microtia and surgical treatment.