Mr David T Gault
Consultant Plastic Surgeon
Ear Reconstruction
London Centre for Ear ReconstructionThe correction of serious ear deformity (microtia, cryptotia and total or partial ear loss through trauma, failed surgery or cancer) is an exacting task. Mr Gault no longer works within the NHS but his work is recognised by a number of PCT’s as eligible for NHS funding. Your GP should be able to advise you of your options under the Patient Choice scheme.
The lack of an ear, or part of it, is a significant deformity, and the psychological effects should not be underestimated. In some, particularly teenagers, concern over a deformed ear lies at the root of serious behaviour problems. Lack of an ear is also a disability - the ear supports glasses, sunglasses, blue-tooth headsets and headphones.
Some are born without one or both ears, a condition known as microtia. Others lose their ear, or part of it, in later life. 73% of this group result predictably from bites, road traffic accidents, shootings and burns. More surprisingly, most of the rest come from failed surgery to set back prominent ears, and from infected piercings.
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Surgery for ear loss
Some patients do not wish to have the defect reconstructed. For the rest, there are now two reconstructive options - to have the ear rebuilt from their own tissues (autogenous ear reconstruction) or to have a prosthetic or false ear anchored to the bone of the side of the head by titanium (Branemark) fixtures.
Autogenous ear reconstruction
If the tissues have not been further damaged by previous attempts at reconstruction, it is possible in some cases to fashion a completely new ear in two operations six months apart. The first stage takes between four and five hours. Under general anaesthetic, a replacement ear framework is carved from costal cartilage taken from the ribcage and inserted into a pocket made beneath the skin on the side of the head. If one ear is present, it is used as a model for the new one.
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 template framework |
The material used for the framework, known as costal cartilage, joins the ribs to the breastbone. It is white in colour, and usually fairly easy to carve. If an entire ear is missing, it is assembled from several carved components, one for the rim, one for the main part of the ear, and separate pieces to resemble the individual ridges and valleys that make a realistic ear shape. Using special suction drains, the skin is sucked onto the framework to allow the ear shape to show through. This leaves an ear shape which lies flat against the side of the head, under the skin. Over a period of several months, the skin nestles into the framework and the detail becomes established. Six or so months later, at the second stage, the ear is released from the side of the head to make the groove behind the ear.
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Complex Autogenous Reconstruction
For tissues which have been damaged by trauma or previous attempts at reconstruction, it is sometimes necessary to first increase the amount of skin cover by inserting a tissue expander before the first stage, or by raising a temporoparietal fascial flap using tissue under the scalp at the time of the first stage surgery. This patient underwent TP flap reconstruction to rescue failed attempts to reconstruct a childhood dog bite.
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This patient underwent tissue expansion after a bite injury
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After extensive surgery in his own country, this patient required a TP flap but a successful outcome was still achieved.
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Although the cartilage used is a little stiffer than the opposite normal ear, most people prefer the autogenous technique. As results improve, it is unusual to choose a prosthesis unless the local tissues are so badly damaged that there is no other option, and it is not uncommon for patients who were originally offered only the prosthetic option to undergo autogenous reconstruction at a later date.
Once the advice was to cover the defect with long hair, or simply learn to live with it. A new “real” ear is now a realistic option.
Prosthetic ear reconstruction
The prosthetic technique also requires two stages, again both under general anaesthetic. The first involves removal of any ear remnant and the placement of two or three small titanium implants into the bone on the side of the head. These metal fixtures become firmly embedded into the bone and at a second stage, metal “abutments” are attached to the implants.
Once all has healed, extensions can be attached to the abutments and a false ear can be attached, in turn, either by a system of clips or magnets. A good prosthesis will last approximately eighteen months before it requires replacement. It should generally be removed at night so that the ear and the area around the abutments can be very carefully cleaned. Granulation tissue can build up around the abutments, and is a particular problem for those who normally live in hot countries.
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 prosthetic ear |
Prosthetic reconstruction is preferred when the tissues or the blood supply at the site of the missing ear have been very badly damaged, either by trauma, disease or by previous surgery. Costs of regular prosthesis replacement (£1000 - £2500) can be prohibitive, however. It is not uncommon for patients who were originally offered only the prosthetic option to undergo autogenous reconstruction at a later date.
Relevant publications
Harris P, Ladhani K, Das Gupta R and Gault DT. (1999)
Reconstruction of Acquired Subtotal Ear Defects with Autogenous Costal Cartilage.
British Journal of Plastic Surgery 52: 268-275.
Gault DT. (1998)
Ear Reconstruction : Pitfalls and Tips
Face 6: 15-16
Chana JS, Grobbelaar AO and Gault DT (1998)
Tissue expansion: a useful adjunct to auricular reconstruction
Face 6: 65-68
Cicchetti S, Skillman J and Gault D
Piercing the upper ear: a simple infection, a difficult reconstruction
British Journal of Plastic Surgery 2002, 55, 194-197
Gault DT
Reconstruction of the ear - a chapter for Principles and Practice of Head and Neck Oncology
Editors Peter Rhys Evans, Patrick Gullane & Paul Montgomery. Martin Dunitz 2003
Winner for George Davey Howells Memorial Prize for most distinguished published contribution to the advancement of Otolaryngology during the preceding five year
Beckett KS and Gault D
Operating in an eczematous surgical field; Don’t be rash, delay surgery to avoid infective complications
Accepted by the British Journal of Plastic Surgery 2006
Gault DT
Total Reconstruction of the Pinna - a chapter for Scott Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold
Horlock N, Vogelin E, Bradbury ET, Grobbelaar AO, Gault DT
Psychosocial outcome of patients after ear reconstruction - a retrospective study of 62 patients.
Annals of Plastic Surgery 54: (5): 517-524 2005