Mr David T Gault
Consultant Plastic Surgeon
Microtia
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.
Microtia, the absence at birth, of an ear, affects about 1 in 6000 children. In one in ten microtia cases, both baby’s ears will be affected. The problem that results in microtia occurs in the womb about 8 weeks after the baby is conceived. The most likely cause is an interruption of the blood supply to the area which will form the ear. Microtia is sometimes seen as an isolated problem or sometimes as part of a syndrome such as Goldenhar syndrome, hemifacial microsomia or Treacher Collins syndrome.
In most cases there is a small fold of skin at the site where the ear should be, rather like a misplaced ear lobe. Sometimes there is little tissue present at all.
 microtia |
 microtia |
There is usually hearing loss on the affected side as the middle ear is underdeveloped. If only one side is affected, then a hearing aid is not normally needed. When the condition affects both sides, however, treatment to improve the hearing is important. If bone-anchored hearing aids are to be used, it is very important that the aids are properly positioned so as not to compromise the tissues for autogenous ear reconstruction.
 before |
 after |
Surgery
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 fixtures.
Autogenous Reconstruction
If the tissues have not been damaged by previous attempts at reconstruction, it is possible to fashion a completely new ear in two operations six months apart. The first stage, under general anaesthetic, 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. Scarring on the chest and the thigh (from which a skin graft may be taken at the second stage) is minimal.
 chest scar |
 donor site on thigh for skin graft |
If one ear is present, it is used as a model for the new one. 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.
 template |
 template framework |
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. The back of the ear is resurfaced using grafts and flaps harvested locally. Second stage surgery takes almost two hours.
 before |
 after the first stage |
The ideal age for microtia surgery is over the age of 9 but if the patient is being teased, or if there are other pressures to have the reconstruction carried out a little earlier, it is possible to proceed, although the costal cartilage used to carve the replacement ear is not so plentiful and the result is sometimes not as good.
 before |
 after |
 before |
 after |
Complex Autogenous Reconstruction (more)
For tissues which have been damaged, 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 at the time of the first stage surgery. Some patients are referred after failed attempts at reconstruction and these are especially challenging. In some of these, a bone anchored prosthesis is the only option. It is very important to resist attempts at surgery to improve the appearance of the ear or scalp area before definitive reconstruction, as the blood supply to the new ear can be irreparably damaged and the results compromised.
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.
 before |
 after |
Relevant publications
Gault DT. (1998)
Ear Reconstruction : Pitfalls and Tips
Face 6: 15-16
Gault DT and Rothera M
Management of Congenital Deformities of the External and Middle Ear - a chapter for Scott Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold
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
Gault DT
Total Reconstruction of the Pinna - a chapter for Scott Brown’s Otorhinolaryngology, Head and Neck Surgery, 7th Edition Arnold
Chana JS, Grobbelaar AO and Gault DT (1998)
Tissue expansion: a useful adjunct to auricular reconstruction
Face 6: 65-68
Gault D. (1999)
Reconstruction for microtia.
Journal of Laryngology and Otology Supplement no 23. Vol 113, page 27.
Botma M, Aymat A, Gault D, Albert D
Rib graft reconstruction vs Osseointegrated prosthesis for microtia: A significant change in patient preference.
Clinical Otolaryngology. 2001, 26, 274-277
Lawson K, Waterhouse N, Gault DT, Calvert ML, Botma M, Ng T.
Is hemifacial microsomia linked to multiple maternities?
British Journal of Plastic Surgery 2002 55, 474-478
Sabbagh W and Gault D
Location, location, location
Journal of Laryngology and Otology; 2004 118: 738-740
Bajaj Y, Wyatt M, Gault D, Bailey M, Albert DM
How we do it: BAHA positioning in patients with microtia requiring auricular reconstruction
Clinical Otolaryngology 2005 30: 468-471.
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