CME

Microtia Reconstruction
Gordon H. Wilkes, M.D.
Joshua Wong, M.D., M.Sc.
Regan Guilfoyle, M.D.
Edmonton, Alberta, Canada
Learning Objectives: After reviewing this article, the participant should be
able to understand: 1. The epidemiology and genetics of microtia. 2. Refine-
ments in surgical technique for microtia. 3. Outcomes of treatment. 4. Chal-
lenges in treatment selection, hearing restoration, surgical training, and tissue
engineering.
Summary: Microtia reconstruction is both challenging and controversial. Our
understanding of the epidemiology and genetics of microtia is improving. Sur-
gical techniques continue to evolve, with better results. Treatment selection
continues to be controversial. There are strong proponents for reconstruction
with costal cartilage, Medpor or a prosthesis. More realistic models for teach-
ing surgeons how to do the procedures are becoming available. Our approach
to hearing rehabilitation is changing. Better solutions using percutaneous and
implantable devices are under evaluation to help both unilateral and bilateral
microtia patients. Tissue engineering will offer some exciting new treatment
possibilities in the future.  (Plast. Reconstr. Surg. 134: 464e, 2014.)

E
ar reconstruction continues to be chal-
lenging and not without controversy.
There have been several CME and review
articles published in this Journal and others,
beginning with the excellent two-part series by
Drs. Beahm and Walton in 2002.1–9 This series in
particular gives an in-depth overview of the field
of ear reconstruction at the time, and much is
still very relevant. When used with this over-
view, together they provide an excellent under-
standing of the classic surgical techniques and
their evolution. The goal of this CME article
is to attempt to minimize repetition and pres-
ent complementary new information. Most ref-
erences have been published since 2005. This
article in conjunction with these other reviews
will give the reader an up-to-date understanding
of the field of ear reconstruction and its areas of
controversy.
EPIDEMIOLOGY AND GENETICS OF
MICROTIA
The cause and wide variation in prevalence
(0.83 to 17.4 per 10,000 births) is still poorly
understood.10 There is evidence for significant
genetic and environmental contributions to
microtia. There are more than 18 different
microtia-associated syndromes with single-gene
or chromosomal aberrations; however, there is
no causal genetic mutation confirmed to date
(Table 1). Mendelian inheritance is more com-
mon in syndromic and familial cases. Multifac-
torial or polygenic causes are more probable
in sporadic cases. Microtia and oculoauriculo-
vertebral spectrum share variable phenotypic
expression, asymmetric facial involvement,
right-side preponderance, male predilection,
familial occurrence, microtia, tags, and pits.
Craniofacial or hemifacial microsomia and
Goldenhar syndrome are included in this
spectrum. There are no accepted minimal
diagnostic criteria for oculoauriculovertebral
spectrum. Microtia and oculoauriculoverte-
bral spectrum should each be considered a
separate entity. Current hypotheses for micro-
tia include (1) neural crest cell disturbance,
(2) vascular disruption by means of several
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

From the Institute for Reconstructive Sciences in Medicine,

Covenant Health Group, Faculty of Medicine and Dentistry,
Misericordia Community Hospital.
Received for publication September 18, 2013; accepted May
28, 2014.
Copyright © 2014 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000000526
Related Video content is available for this ar-
ticle. The videos can be found under the “Re-
lated Videos” section of the full-text article, or,
for Ovid users, using the URL citations pub-
lished in the article.

464e www.PRSJournal.com
Volume 134, Number 3 • Microtia Reconstruction

Table 1.  Human Disorders with Microtia (Except Chromosomopathies)*

Syndrome Microtia (%)† Genes Identified
Bixler (hypertelorism-microtia-clefting) 100 —
Bosley-Salih-Alorainy 33 HOXA1
Branchiooculofacial 20 TFAP2A
Branchiootic 80–90 EYA1, SIX1
Branchiootorenal 30–60 EYA1, SIX5
CHARGE Reported CHD7, SEMA3E
Congenital deafness, inner ear agenesis, microtia, and microdontia 100 FGF3‡
Craniofacial microsomia 65 —
Fraser Reported FRAS1, FREM2
Kabuki 80 MLL2
Klippel-Feil Reported GDF6
Lacrimoauriculodentodigital 20 FGFR2, FGFR3, FGF10
Mandibulofacial dysostosis 100 HOXD
Meier-Gorlin (ear-patella-short stature) 100 ORC1, ORC4, ORC6, CDT1, CDC6
Microtia, hearing impairment, and cleft palate 100 HOXA2
Miller 100 DHODH
Nager 80 —
Oculoauricular 100 HMX1
Pallister Hall Reported GLI3
Townes-Brocks 20 SALL1
Treacher Collins 60–80 TCOF1
Wildervanck (cervicooculoacoustic) Reported
*Reprinted with permission from Luquetti DV, Heike CL, Hing AV, Cunningham ML, Cox TC. Microtia: Epidemiology and genetics. Am J Med
Genet Part A 2012;158:124–139.
†Gorlin RJ, Cohen MM, Hennekam RCM. Syndromes of the Head and Neck. Oxford, NY: Oxford University Press; 2001.
‡Hemizygosity: only inner ear anomalies.

Table 2.  Risk Factors for Microtia Reported in the SURGICAL TECHNIQUE FOR MICROTIA
Literature*
First-Stage Modifications
General Surgical creation of a three-dimensional cos-
 Male sex
 Low birthweight tal cartilage ear framework has traditionally been
 First parity considered the most challenging part of ear
 High parity reconstruction.11–15 Classically, Brent harvested
 Multiple births
 Maternal acute illnesses contralateral rib cartilage in an extraperichon-
 Maternal type 1 diabetes drial plane. Nagata and Firmin both harvest carti-
 Maternal use of medications lage from the ipsilateral chest. Nagata harvests in
 Advanced paternal age
 Advanced maternal age a completely subperichondrial plane and Firmin
 Low maternal education leaves the posterior perichondrium intact. Inad-
 Maternal exposure to altitude vertent pleural tear and chest wall deformity are
 Maternal residence in an urban area
 Maternal residence in a rural area less likely if perichondrium is left intact. Some sur-
 Maternal exposure to air pollution geons feel there is better adherence of soft tissues
Race/ethnicity to the framework if some perichondrium is left
 Native ethnicity
 Hispanic ethnicity behind following carving; however, Nagata has not
 Ecuadorian found this to be a problem. Modifications of the
 Chilean Brent and Nagata techniques particularly involv-
 Asian
 Philippine ing the tragal and conchal bowl regions continue
 Pacific Islander to be reported. Included are three videos of cos-
Teratogens
 Retinoic acid tal cartilage ear framework creation. (See Video,
 Thalidomide Supplemental Digital Content 1, which displays
 Alcohol the fabrication of the three-dimensional costal car-
 Mycophenolate mofetil
tilage frame for microtia. This video is available in
*Used with permission from Luquetti DV, Heike CL, Hing AV, Cun-
ningham ML, Cox TC. Microtia: Epidemiology and genetics. Am J the “Related Videos” section of the full-text article
Med Genet Part A 2012;158:124–139. on PRSJournal.com or, for Ovid users, at http://
links.lww.com/PRS/B55. See Video, Supplemen-
different mechanisms, and (3) altitude. There tal Digital Content 2, which demonstrates how
are a multitude of potential risk factors for the to carve an autologous rib cartilage. This video
development of microtia (Table 2). is available in the “Related Videos” section of the

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 Plastic and Reconstructive Surgery • September 2014

Video 1. Supplemental Digital Content 1, which displays the fabrica-

tion of the three-dimensional costal cartilage frame for microtia, is avail-
able in the “Related Videos” section of the full-text article on PRSJournal.
com or, for Ovid users, at http://links.lww.com/PRS/B55. Courtesy of S.
Nagata, ©Nagata Microtia & Reconstructive Plastic Surgery Clinic.

Video 2. Supplemental Digital Content 2, which demonstrates how

to carve an autologous rib cartilage, is available in the “Related Vid-
eos” section of the full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B56. Courtesy of F. Firmin.

Video 3. Supplemental Digital Content 3, which shows the first

stage in total auricular reconstruction, is available in the “Related
Videos” section of the full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B57. Courtesy of R. Zhang.

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Volume 134, Number 3 • Microtia Reconstruction
full-text article on PRSJournal.com or, for Ovid
users, at http://links.lww.com/PRS/B56. See Video,
Supplemental Digital Content 3, which shows the
first stage in total auricular reconstruction. This
video is available in the “Related Videos” section
of the full-text article on PRSJournal.com or, for
Ovid users, at http://links.lww.com/PRS/B57.)
Nagata adds an extra piece of cartilage under
the framework to deepen the conchal bowl. Firmin
adds an extra piece she calls the “surelevation” to
give more stability and projection to the root of
the helix and tragus. Chin et al.16 place an “extra
cartilaginous cube” under the reconstructed tra-
gus to give better projection and stability. They
add a piece of cartilage to reconstruct the anti-
helix only if the thickness of the cartilage block is
less than 5 mm. More recently, however, greater
emphasis has been given to soft-tissue manage-
ment to optimize the aesthetic result. Both Firmin
and Marchac17 and Park16 provide an algorithm to
help with the soft-tissue management of microtia.
It has been shown that the subcutaneous pedicle
in Nagata’s W flaps does increase the vascularity
and decrease skin flap necrosis18,19 (Fig. 1). A gap
is needed between the tip of the tragus and crus
helicis in the carved framework to allow rotation
around the pedicle during framework placement
if the pedicle is left intact.
Fig. 1. Lobule-type microtia marked for Nagata-type reconstruc-
tion. Circle indicates where the subcutaneous pedicle of tissue is
left for circulation to the W-type flaps.
Creation of a Postauricular Sulcus
Successful elevation of the ear framework and
creation of a postauricular sulcus continues to be
a challenge. Past approaches have included ele-
vation and placement of a split-thickness or full-
thickness graft only. Addition of a surgical stent
to maintain projection has been used. The results
were variable and often poor. New refinements
appear to be beneficial, including adding a car-
tilage, bone, or alloplastic buttress.20–22 Alloplastic
materials include bone cement and a hydroxyapa-
tite ceramic. During elevation, Brent and Nagata
leave some soft tissues on the elevated cartilage.
Firmin exposes the entire posterior surface of the
framework during elevation, leaving no soft tis-
sues restraining the projection except for the pos-
terior wall of the concha. The buttress requires
vascularized coverage. Flaps described include a
postauricular fascial flap, a temporoparietal fas-
cial flap, and a superficial musculoaponeurotic
system (SMAS) advancement flap. The flap from
the mastoid is thicker than a temporoparietal fas-
cial flap and most commonly covers just the but-
tress. The temporoparietal fascial flap can cover
the complete raw surface of the posterior ear but
is more involved to elevate. Endoscopic harvest
has been reported, with fewer alopecia issues.23
Three different techniques of sulcus construc-
tion in microtia repair using a temporoparietal
fascial flap, a retroauricular fascial flap from the
mastoid region, and an SMAS advancement flap
were compared, with no significant difference in
outcome at 3 months. All included a cartilage but-
tress.24 The authors found the SMAS flap safe and
easy to perform, and the procedure resulted in no
secondary defects. It can be used for combined
auricle and middle ear reconstructions, leaving
the temporoparietal fascial flap available for com-
plicated or revision cases. Rotation and advance-
ment flaps have been described.25 The technique
described by Chen et al. involves elevating a thin
split-thickness skin graft from hair-bearing scalp
in continuity with the full-thickness skin posterior
to the ear to cover the temporoparietal fascial flap
and avoid some visible scarring.26 Primary graft
healing is essential in all techniques to prevent sec-
ondary wound contraction and loss of projection.
Harvesting the Rib and Chest Wall Deformity
Critics of autogenous reconstruction cite chest
wall deformity as a major drawback. Although still
an issue, it appears to be less of a problem. Cer-
tainly, rib harvest including the perichondrium
can result in chest wall deformity.27,28 Brent has
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 Plastic and Reconstructive Surgery • September 2014
advocated leaving a rim of sixth costal cartilage
in situ to mitigate against this. Further steps are
being taken intraoperatively to lessen the possible
adverse effect of harvesting rib cartilage.29 Fir-
min recommends leaving the posterior perichon-
drium intact, stating that the “deformation at the
donor site is minimal.” Kawanabe and Nagata30,31
leave the complete perichondrial sleeve intact and
fill it or a Vicryl (Ethicon, Inc., Somerville, N.J.)
sleeve with diced pieces of leftover cartilage. In a
series of 273 patients, they reported no chest wall
deformity. They also demonstrated regeneration
of cartilage for future use. Siegert and Magritz32
described reducing chest wall morbidity by using
patient-controlled analgesia for pain and a two-
stage approach to hide the scar in the inframam-
mary fold and to provide a full-thickness skin graft
in women, and minimizing chest wall deformity
by leaving perichondrium intact posteriorly and
placing cartilage pieces in an absorbable sleeve to
make “new” regenerated ribs.
Soft-Tissue Expanders
The use of soft-tissue expanders in ear recon-
struction can be helpful.33,34 The rationale is to
attempt to provide complete skin coverage of a
framework with no need for a fascial flap or skin
graft. This approach provides thin skin with good
color match. Barring a complication during expan-
sion, the circulation is reasonable, as the skin
has been delayed. Flaps can be designed in the
expanded skin to provide coverage both anteriorly
and in the posterior sulcus. Dealing with the cap-
sule around the soft-tissue expander is controver-
sial. It can be removed judiciously in areas if it is too
thick or would affect adherence to the underlying
structures. It is safest to leave it attached to any flaps
created in the expanded skin. Soft-tissue expanders
have also been used to expand under a temporo-
parietal fascial flap and scalp skin graft to provide
coverage in challenging cases of anotia, failed autog-
enous reconstructions, and posttraumatic cases.
This has included both ipsilateral pedicled and
Table 3.  Causes of Skin Necrosis Using Soft-Tissue
Expanders in Ear Reconstruction*
Wrong expander choice
Valve placed over bony prominence
Fold in STE
Overinjection
Scarring in the area
Poor incision placement
STE, soft-tissue expanders.
*From Jing C, Hong-Xing Z. Partial necrosis of expanding postau-
ricular flaps during auricle reconstruction: Risk factors and effective
management. Plast Reconstr Surg. 2007;119:1759–1766.
468e
contralateral free vascularized temporoparietal fas-
cial flaps. The potential for complications including
skin necrosis and the added surgical stage are the
major concerns with the use of soft-tissue expanders
in ear reconstruction.35-37 Many complications are
preventable with proper planning (Table 3). Higher
rates of skin necrosis in acquired versus congenital
cases have been reported. Expanding scarred skin
provides inadequate skin in both quality and quan-
tity for the delicate needs of ear reconstruction and
should be discouraged.
OUTCOMES
There is no commonly accepted means of
assessing outcomes in ear reconstruction. Per-
ceived results as judged by the patient, family,
surgeon, and other observer can be quite differ-
ent. The psychological outcome of treatment is as
important as the patient’s overall recovery.
Microtia patients have been found to have a
high prevalence of mood disorders, in particular,
depression, interpersonal/social difficulties, and
hostility/aggression.38 The child usually discovers
they are different around the age of 3 or 4 years.
The age of surgical intervention must be balanced
against the potential for a good aesthetic reconstruc-
tion, as a poor result may have a long-term adverse
psychological effect on self-esteem. The earlier the
child is made aware of the deformation, the lower
the prevalence of psychological disorders.
A standardized assessment tool (Glasgow Ben-
efit Inventory) measuring health-related quality
of life and a surgical outcome questionnaire have
been effectively applied to ear reconstruction.
Soukup et al. showed a significant improvement
in health-related quality of life following autog-
enous ear reconstruction (Level of Evidence:
­Therapeutic, IV).39 The Glasgow Benefit Inven-
tory demonstrated the greatest impact helping
patients improve social interaction and relation-
ships. Microtia with a syndrome had higher scores
than isolated microtia. Age at the time of surgery
had no effect. Chest scar color was more concern-
ing than chest wall deformity. All had some form of
successful chest wall reconstruction. Surprisingly,
the surgeons and age-matched patients gave lower
scores than the patients and parents. This contra-
dicts opinions held by many skeptics that surgeons
overestimate the quality of their results. Overall,
there was a strong correlation between Glasgow
Benefit Inventory and the surgical outcome
scores. This study identifies where to improve the
most to achieve greater health-related quality-of-
life benefits. Others have shown similar results
Volume 134, Number 3 • Microtia Reconstruction
in both retrospective and prospective studies.40–42
Approximately 70 percent of patients felt the ear
became part of the body image and the chest scar
was acceptable. Interestingly, they revealed no dif-
ference in lifestyle and self-consciousness between
autogenous and prosthetic treatment patients.
Braun et al. used the Glasgow Benefit Inven-
tory, the Glasgow Children’s Benefit Inventory,
and a questionnaire to study a group of patients
who underwent reconstruction with porous poly-
ethylene (Medpor; Porex Surgical, Inc., Newnan,
Ga.) (Level of Evidence: Therapeutic, IV).43 There
was again a high satisfaction rate with the aesthet-
ics in 73 percent of adults and 85 percent of chil-
dren. The Glasgow Benefit Inventory was elevated
(21.2), indicating improvement in health-related
quality of life, but was not as high as in the autog-
enous group (48.1).
The results of various autogenous techniques
have recently been published by several authors.44–46
Although overall satisfaction is reported as high,
there are certainly weaknesses in the methods of
evaluation. When performed properly in an appro-
priate patient by an experienced surgeon, a satis-
factory, stable ear reconstruction is possible in the
majority of cases. Probably more important than
the specific technique is the overall experience of
the surgeon using an acceptable technique. Critics
of autogenous reconstruction argue that the results
published by the leaders in the field are only the
best results and are not necessarily obtainable by
other surgeons performing smaller volumes.
Controversy still surrounds the outcomes of a
porous polyethylene alloplastic framework. Rein-
isch and Lewin published their series of 786 ear
reconstructions from 1991 to 2008.47 Complica-
tions decreased when complete coverage of the
framework with a temporoparietal fascial flap was
used. A subgroup of 41 temporoparietal fascial flap
patients with 12 years’ follow-up had a 2.7 percent
fracture rate and a 7.3 percent exposure rate. Braun
et al. presented their 65 temporoparietal fascial flap
patients with a porous polyethylene framework.48
Twenty-eight patients (43.1 percent) had one or
more revision operations, mainly for minor correc-
tions. Only one required a major revision opera-
tion with partial explantation and reimplantation
of porous polyethylene. Others have also reported
success with porous polyethylene frameworks.49,50
Osseointegrated prosthetic ear reconstruc-
tion has also demonstrated high levels of success
and patient satisfaction.51,52 Psychologically, the
prosthesis becomes part of the body image in the
majority of patients. Issues regarding prosthetic
shape, color, means of attachment, and long-term
implant stability are minimal. The major disad-
vantages of the osseointegrated approach are
intermittent, usually mild, chronic soft-tissue
problems; the need for continued maintenance;
and repeated prosthetic reconstruction every 2
to 5 years. The implant failure rate in nonirradi-
ated mastoid bone is low (2 percent), and loss of
an implant does not necessarily mean inability to
wear the prosthesis. The majority of patients (97
percent) were satisfied. Despite the soft-tissue
problems, 94 percent would do it again and 97
percent would recommend it to other patients.
TREATMENT SELECTION
Controversies remain regarding appropriate
treatment selection for patients with major ear
deformities. These include choice of framework
(either costal cartilage or Medpor), surgical tech-
nique, or type of reconstruction (osseointegrated
prosthetic or autogenous). Although we all have
treatment biases, providing informed consent
requires up-to-date knowledge of the various
approaches and their appropriateness in a variety
of clinical situations (Table 4).
Autogenous
Although most surgeons would agree that a
successful autogenous ear reconstruction is ideal,
critics would argue that currently the aesthetic
results are very inconsistent and often poor. Con-
tinued refinements in surgical techniques have
resulted in better ear reconstructions (Fig. 2).
The results are becoming more consistent and
Table 4.  Indications for Specific Techniques in Ear
Reconstruction
Autogenous
 Microtia
 Lower third intact
 Patient preference
 Less compliant patient
 In compromised area if TPFF available
Osseoprosthetic
 Severe local trauma and scarring
 Thermal injury
 After oncologic resection
 After radiotherapy
 Poor autogenous result
 Patient preference
 Poor operative risk
PPE framework
 Patient preference
 Calcified costal cartilage
 Patient does not want rib harvested
 Microtia (controversial)
 In compromised area if TPFF available
TPFF, temporoparietal fascial flap; PPE, porous polyethylene.
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 Plastic and Reconstructive Surgery • September 2014

ear. Proponents tout several advantages.47,49,50 A

less controversial indication for the use of a porous
polyethylene framework is the well-informed adult
who does not want costal cartilage harvested or in
whom it is too calcified and who does not want a
prosthesis.

Osseointegrated Auricular Prosthetic

Reconstruction
Many plastic surgeons have difficulty under-
standing the role of this modality. Osseointe-
grated auricular prosthetic reconstruction is

Fig. 2. Successful reconstruction of lobule type microtia using a

Nagata-type technique.

Table 5.  Advantages of Specific Techniques in Ear

Reconstruction
Autogenous
 Uses your own tissues
 Long-term stability
 No ongoing care
 Can use in less compliant patient Fig. 3. Major soft-tissue injury including traumatic ear loss fol-
Osseoprosthetic lowing a motor vehicle accident.
 Outpatient, straightforward surgery
 Useful in elderly or medically compromised patients
(can perform under local anesthesia)
 Can use in severely compromised tissues
 Good for tumor surveillance
 Prosthesis very realistic
PPE framework
 No chest morbidity
 Microtia reconstruction at younger age
 Framework shape relatively consistent
PPE, porous polyethylene.

reproducible. Surgeons are more aware of the

need for appropriate training and mentorship
and a sufficient case volume to achieve consistent
high-quality reconstructions. Most reconstructions
currently performed are variations of the Brent or
Nagata technique. Although they involve more
complicated frameworks, Nagata-type procedures
are becoming much more common (Table 5).

Porous Polyethylene Framework (Medpor)

The role of porous polyethylene frameworks
in our treatment selection remains controversial.
There remains reluctance by many to use an allo- Fig. 4. The same patient following soft-tissue expansion of the
plastic framework in an exposed area such as the cheek and temple and osseointegrated ear prosthesis.

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Volume 134, Number 3 • Microtia Reconstruction

Table 6.  Disadvantages of Specific Techniques in Ear

Reconstruction
Autogenous
 Variability of aesthetic result
 More surgical stages
 Longer surgical procedures
 Chest wall morbidity
 Steep learning curve
Osseoprosthetic
 Intermittent soft-tissues problems
 Long-term maintenance
 Prosthetic remakes every 2–5 yr
 Ongoing cost
 Can compromise future autogenous options
 Need compliant patient
PPE framework
 Uses temporoparietal fascial flap
 Long-term risk of alloplastic implant exposure or loss
 Compromise any future autogenous options
PPE, porous polyethylene.

Table 7.  Patient Satisfaction after Different Types of

Ear Reconstruction
Fig. 5. Failed autogenous ear reconstruction after over 10 surgi-
cal procedures. Satisfaction Would You Do It
Rate (%) Again? (%)
Autogenous
 Zhang 89
 Brent 90
 Siegert 82 90
 Kristiansen 95
Osseointegrated prosthetic
 Korus et al. 97 94
 Younis et al. 60 70
Medpor
 Braun et al.
   Pediatric patients 85 90
   Adult patients 73 87

of microtia, it is our opinion that a reasonable

Fig. 6. The same patient has successfully worn an osseointe-
grated ear prosthesis for 24 years.
complementary to other approaches and pro-
vides a reasonable alternative in many cases with
poor autogenous options (Figs. 3 and 4) or a
poor autogenous result (Figs. 5 and 6). The use
of an adhesive-retained prosthesis should not be
considered a trial for an osseointegrated auricu-
lar prosthetic. Stability, positioning, skin break-
down, and confidence issues are completely
different when using adhesives. Although some
surgeons consider osseointegrated auricular
prosthetic reconstruction a primary treatment
autogenous result is a superior long-term treat-
ment choice (Table 6).
The onus is on the reconstructive surgeon
to consistently provide a reasonable result with
minimal morbidity and a high satisfaction rate
(Table 7). As all these approaches can produce
a satisfied patient, appropriate treatment selec-
tion and informed consent are some of the more
important issues facing the surgeon in dealing
with patients with major ear deformities. It is our
experience that when all the options are pre-
sented, patients decide quickly how to proceed
and very rarely change their mind.
HEARING RESTORATION IN THE
MANAGEMENT OF MICROTIA
The treatment of microtia should ideally involve
reconstruction of the external ear and the resto-
ration of normal hearing. Hearing impairment

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 Plastic and Reconstructive Surgery • September 2014
Table 8.  Deleterious Effects of Untreated Unilateral
Hearing Loss*
Poorer language scores or delayed language development
Increased rates of grade failure (22–35%)
Increased need for educational assistance (12–41%)
Increased behavioral issues in the classroom
*From Lieu JE. Speech-language and educational consequences of
unilateral hearing loss in children. Arch Otolaryngol Head Neck Surg.
2004;130:524–530; and Lieu JE, Tye-Murray N, Karzon RK, Piccirillo
JF. Unilateral hearing loss is associated with worse speech-language
scores in children. Pediatrics 2010;125:e1348–e1355.
conceptually impairs a variety of social, cognitive,
and developmental domains (Table 8). Hearing
impairment in microtia is related to abnormali-
ties of the external auditory canal, tympanic mem-
brane, and middle ear. Attempts to reconstruct
these structures have been fraught with difficul-
ties such as frequent restenosis, infection, possible
facial nerve injury, and scarring at the future site
for auricular reconstruction.53 Hearing improve-
ment has been variable and often poor. For these
reasons, traditional thinking has been that further
intervention is not necessary in unilateral microtia
if there is normal hearing in the other ear. Yeakley
and Jahrsdoerfer developed a computed tomo-
graphic grading system to predict patients with
the most favorable hearing outcome from surgical
intervention.54 Their results have proven difficult
to replicate by most otologists. Also, comparative
studies have shown that reconstructive middle ear
surgery often requires the addition of an air-con-
duction hearing aid for hearing to be as good as
that of a bone-anchored hearing aid alone.55 Sieg-
ert56 describes reconstruction of an ear canal and
tympanic membrane as part of a three-stage micro-
tia reconstruction. At the first stage, remnants of
elastic auricular cartilage are packed densely into
silastic mold to prefabricate the tympanic mem-
brane. The external ear canal is also prefabricated
with rib hyaline cartilage positioned in a silastic
cylinder. These are stored in the subcutaneous tho-
racic wound. At the second stage, the ear frame-
work is mobilized and the prefabricated tympanic
membrane and external ear canal are placed. At
the third stage, the canal is exteriorized and skin
grafted. In a later publication, he states there was
no restenosis of the canal but “reaching a near-
normal hearing is not the rule.” There continues
to be further investigation of surgical options.
Bilateral microtia patients have unique chal-
lenges for hearing restoration. The bone-anchored
hearing aid (BAHA; Cochlear, Mölnlycke, Sweden;
and Ponto; Oticon, Kongeballen, Denmark) Cen-
tennial, Col.) has been used since 1977, relying on
bone conduction directly to the cochlea.57 It does
472e
not depend on a functioning middle ear or a pat-
ent canal. The most common practice is placement
of a unilateral bone-anchored hearing aid in bilat-
eral microtia and bilateral conductive hearing loss
patients because a single hearing aid will stimulate
both cochleae simultaneously. Recent evidence
suggests that restoration of binaural hearing in
fact results in greater stimulation of the cochlea
and better directional hearing, space perception,
and speech recognition in noise.58–63 Janssen et al.
summarized these findings in a recent systematic
review of 11 articles, concluding that bilateral bone-
anchored hearing aid use results in improved hear-
ing sensitivity and speech perception in the quiet,
speech perception in noise, localization and later-
alization, and patient perception of quality of life
and overall sound quality.64 With this evidence, the
verdict is still controversial but warrants expand-
ing our therapeutic options to those with bilateral
microtia and bilateral conductive hearing.
Thoughts are evolving in unilateral microtia
patients with unilateral conductive hearing loss. Tra-
ditional thinking was that hearing on a single side
was sufficient for speech development and hearing
in education. A recent review of auricular recon-
struction states that most children with unilateral
microtia are born “adjusted to their monaural con-
dition.”12 Studies suggest that the educational and
cognitive developmental consequences of unilat-
eral hearing loss warrant reevaluation of traditional
practice and application of early treatment (Ref-
erence 66 Level of Evidence: Therapeutic, IV).65–67
Evidence indicates that there is both audiologic
and subjective benefit when treating unilateral
conductive hearing with a bone-anchored hear-
ing aid.68–70 Further study is needed and treatment
must be individualized. Giving patients the option
of trying a cutaneous bone conduction hearing
aid (i.e., Softband; Cochlear) in consideration of
a permanent bone-anchored hearing aid is reason-
able.71 Newer implantable hearing devices such as
the Vibrant Soundbridge and Bonebridge (Med-El
Corp., Innsbruck, Austria) and the Sophono Sys-
tem (Sophono Inc., Boulder, Colorado) are now
being studied. Their long-term success in hearing
restoration and effects on external ear reconstruc-
tion still require further evaluation.72–75
Autogenous Ear Reconstruction and the
Bone-Anchored Hearing Aid
There are obvious conflicting needs between
the otologist and the reconstructive surgeon
regarding placement of the bone-anchored hear-
ing aid and the timing of surgery. Appropriate
placement of the bone-anchored hearing aid is
Volume 134, Number 3 • Microtia Reconstruction
Fig. 7. Planning bone-anchored hearing aid implant site place-
ment using a “dummy” hearing aid and ear template at the
future site of autogenous ear reconstruction.
crucial both for hearing and to avoid scarring the
site of future autogenous reconstruction (Fig. 7).
The reconstructive surgeon would like the bone-
anchored hearing aid placed posterior to its nor-
mal position. The otologist has concerns that the
bone-anchored hearing aid will pick up sound from
behind the patient not contributing to binaural
hearing. A true team approach will alleviate both
surgeons’ concerns. Studies addressing this are
few.76 One promotes an optimal positioning of 6.5
to 7 cm posterior to the auditory meatus. We have
Fig. 8. The patient who had a bone-anchored hearing aid placed at
age 5 years using the technique as illustrated in Figure 7 and later
Nagata-type reconstruction of conchal type microtia at age 8 years.
Fig. 9. Planning bone-anchored hearing aid implant site place-
ment at second-stage Nagata type reconstruction using a
dummy hearing aid.
performed implantation on patients both before
and after autogenous reconstruction on average
5.6 cm from the pseudomeatus, with no difference
in complications; however, both procedures were
performed by the same surgeon (G.H.W.). The
pediatric otologist would prefer that the bone-
anchored hearing aid be sited and implanted as
Fig. 10. The same patient following successful autogenous ear
reconstruction and fitting with the bone-anchored hearing aid.
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 Plastic and Reconstructive Surgery • September 2014

Fig. 11. Ear carving training models that come apart into the various pieces that need to be carved
from costal cartilage. These can be used for training or sterilized and used as a guide intraoperatively.

early as possible (presently, at approximately age 5 LEARNING TO PERFORM EAR

years) to optimize hearing development (Fig. 8).
The plastic surgeon would prefer that the bone-
anchored hearing aid implantation be performed
after autogenous reconstruction (age 8 to 10
years) to not compromise the autogenous recon-
struction (Figs. 9 and 10). The successful use of a
bone-anchored hearing aid after a porous polyeth-
ylene reconstruction has also been reported.50
RECONSTRUCTION
Learning to perform ear reconstruction is a
challenge.77–81 The major emphasis has been on
learning to carve an ear framework from costal
cartilage. More recently, the appropriate treat-
ment of the soft tissues has been emphasized as
a major contributing factor to the ultimate aes-
thetic result.

Fig. 12. Model of right sixth, seventh, and eighth rib cartilage
made from a dental impression material used to practice carv- Fig. 13. Carved ear framework using the costal cartilage model
ing an ear framework. shown in Figure 12.

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Volume 134, Number 3 • Microtia Reconstruction
Some type of “observership” and then “giv-
ing it a go” has been a very common approach.
The “I tried a few but gave up because my results
weren’t very good” approach is no longer accept-
able. Historical training methods have been poor
or lacked realism. Although carving a vegetable, a
piece of soap, or a piece of foam tests the artistic
ability of the participant, cartilage from the sixth,
seventh, and eighth ribs presents unique chal-
lenges of shape, form, and consistency, requiring
careful intraoperative decisions that are often not
reversible. Using cadaver cartilage is not practi-
cal because it is usually calcified, stiff, and brittle,
not simulating the real surgical circumstance.
Possible disease transmission is also an issue. The
development of more realistic ear carving mod-
els (Figs. 11 through 13) are allowing surgeons
to test their aptitude and gain experience before
performing an actual reconstruction. (See Video,
Supplemental Digital Content 4, which displays
the tutorial and demonstration of a Nagata frame-
work. This video is available in the “Related Vid-
eos” section of the full-text article on PRSJournal.
com or, for Ovid users, at http://links.lww.com/
PRS/B58.) Wilkes and Guilfoyle82 have produced
a training app available at iTunesU, and Chen has
a training model demonstration on YouTube.83
Firmin has also developed a “trainer” for learning
ear reconstruction.14
TISSUE ENGINEERING
Excellent reviews of the current state of tissue
engineering in auricular cartilage reconstruction
were published in 2012.84,85 Tissue engineering
offers great promise for the future, but major
Video 4. Supplemental Digital Content 4, which displays the tuto-
rial and demonstration of a Nagata framework, is available in the
“Related Videos” section of the full-text article on PRSJournal.com or,
for Ovid users, at http://links.lww.com/PRS/B58.
hurdles remain.86–92 No material presently avail-
able, either autogenous or alloplastic, completely
mimics the characteristics of auricular cartilage
and can produce a normal appearing and func-
tioning reconstructed ear.
The first problem is to create a three-dimen-
sional scaffold onto which cartilage cells can
anchor and subsequently grow. Biological scaf-
folds mimic cartilage extracellular matrix. Natu-
ral materials that have been explored include
hydrogel, hyaluronic acid, chitosan, and collagen
derivatives. Their limitations are poor mechani-
cal strength, fast degradation, and antigenicity.
Synthetic polymers have the advantage of being
custom-made, whereby the biological and mate-
rial properties can be controlled. However, they
do elicit an immunologic response and lack the
surface characteristics favoring cellular attach-
ment and growth. Attempts are being made with
surface modifications to optimize chondrocyte-
scaffold interaction. Multiple polymers have been
trialed and produced cartilage formation with
variable loss of shape. Strides have been made in
the precision design and construction of auricular
molds based on the normal contralateral ear. The
use of three-dimensional computer-aided design/
manufacturing has helped make very accurate
scaffolds. The designer can control porosity,
shape, and permeability.
Chondrocytes, both autogenous and xeno-
genic, have been used as the main cell source for
auricular cartilage engineering. One hundred mil-
lion cells are needed to create an adult ear. Auricu-
lar and nasal chondrocytes yield more cartilage at
a faster rate than articular cartilage. They also have
superior histologic and biochemical properties.
475e
 Plastic and Reconstructive Surgery • September 2014
Fig. 14. Carved ear framework from tissue-engineered cartilage.
(Used with permission from Yanaga H, Imai K, Fujimoto T, Yanaga
K. Generating ears from cultured autologous auricular chondro-
cytes by using two-stage implantation in treatment of microtia.
Plast Reconstr Surg. 2009;124:817–825.)
Fig. 15. Result of microtia surgery using tissue-engineered
cartilage 4 years 6 months after implantation into the
temporal area. (Used with permission from Yanaga H, Imai
K, Fujimoto T, Yanaga K. Generating ears from cultured
autologous auricular chondrocytes by using two-stage
implantation in treatment of microtia. Plast Reconstr Surg.
2009;124:817–825.)
476e
The continued problems remain of dedifferentia-
tion of cells, limited donor supply, and short time
frame for proliferation. The use of chondrogenic
stem cells from bone marrow, periosteum, and adi-
pose is being explored. Managing the cell cultures
through pathways not fully understood has proven
challenging. Inducing factors to stimulate carti-
lage formation include growth factors and bioreac-
tors. Uncontrolled cell proliferation and potential
tumor growth are still concerns.
The use of new “smart” scaffolds of nanocom-
posite polymers with surface modifications to stim-
ulate and control cell attachment, growth, and
differentiation and populated with stem cells may
be the way of the future. The problems of skin cov-
erage of the framework and its effect on the ulti-
mate aesthetics will still prove to be challenging.
Clinical application is in its infancy. Four
patients underwent reconstruction using a two-
stage approach, with cultured chondrocytes
injected into the abdominal wall, forming a
mature block of cartilage.93 In a second stage,
an ear framework was created. No absorption
of chondrocytes was observed (Figs. 14 and 15).
Composite tissue allotransplantation of an ear has
not been reported, but the anatomical and techni-
cal aspects of harvesting the auricle as a neurovas-
cular facial subunit have been described.94
CONCLUSIONS
The future of ear reconstruction rests with
tissue engineering and possibly composite tissue
allotransplantation. Hearing restoration will be
achieved with completely implantable hearing
devices or new surgical techniques. When these
goals are attained, current approaches described
will be rendered obsolete.
Gordon H. Wilkes, M.D.
University of Alberta
No. 174 Meadowlark Health Center
156 Street and 87 Avenue
Edmonton, Alberta T5R 5W9, Canada
gordon.wilkes@albertahealthservices.ca
PATIENT CONSENT
Patients provided written consent for the use of their
images.
ACKNOWLEDGMENTS
The authors thank Kathy Bush for administrative
assistance and Farzine MacRae for film editing.
Volume 134, Number 3 • Microtia Reconstruction
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