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Reconstruction of damaged ears
Ear reconstruction is requested by two main groups; those who have been born without an ear, a condition known as microtia, and those who have lost a normal ear through trauma, failed surgery or disease. Some sufferers do not wish to have the defect reconstructed. For the remainder, there are 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 (using Branemark fixtures).
Microtia
Microtia is the term used to describe a small or absent ear. It is rare, affecting one in 7,000 babies. In one in ten of these babies, both 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 apparent at birth, sometimes 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.
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 (about 9% of cases), then 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.
Standard Autogenous Reconstruction
Autogenous reconstruction can usually be completed in two stages, both requiring a general anaesthetic if the tissues have not been damaged by previous trauma or surgery. At the first stage, which takes between four and five hours, a replacement ear framework is carved from cartilage taken from the ribcage and inserted into a pocket made beneath the skin on the side of the head. Where possible, the existing ear is used as a model for the new one. The skin is then sucked down onto the framework using drains to allow the detail of the framework to show through. This leaves an ear shape which lies flat against the side of the head, under the skin.
Six or so months later, at the second stage, the ear is raised from the side of the head and the back of the ear resurfaced using grafts and flaps harvested locally. Second stage surgery takes almost two hours.
Using this technique it is usually possible to mimic the opposite normal ear in shape and size. The cartilage used to carry out this reconstruction is, however, a little stiffer than the opposite normal ear and as such does not bend in the same way. Nevertheless, most people prefer this technique, particularly since the cosmetic results are now very good.
The ideal age for surgery is over the age of 9 or when the chest circumference is greater than 60cm, 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.
Autogenous Reconstruction for low hair line or for damaged tissues
If a microtia remains unoperated until the definitive reconstruction is performed, then the standard two stage reconstruction is usually all that is required. For cases in which there is a low hair line, or for ears which have been damaged by trauma, failed surgery or previous insertion of Branemark implants, it is sometimes necessary to first increase the amount of available skin cover by inserting a tissue expander as an initial procedure, or by raising a temporoparietal fascial flap at the time of the first stage surgery.
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.
Prosthetic (Branemark) 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.
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.
Comparison of Autogenous and Prosthetic Reconstruction
Autogenous reconstruction means reconstruction using the patient’s own tissues, and it is the gold-standard of ear reconstruction. Such reconstructed ears need no on-going care, and because they are formed of living tissue, they do not require replacement, nor do they become infected, unlike ears reconstructed by covering a silicone framework (Medpor implant) with skin. The metal pins inserted into the skull in a Branemark reconstruction require daily cleaning, as does the prosthetic ear, so that debris does not build up around them.
Although the costs of placement of Branemark implants appear marginally cheaper than an autogenous reconstruction, there is then an on-going cost for replacement of the prostheses, so that, for a child currently aged 10 with average current life expectancy, the additional lifetime cost based on a new prosthesis every 18 months, would be a minimum of approximately £90,000. Thus, Branemark reconstruction is generally best reserved for those who are elderly and have perhaps lost an ear through cancer, those whose burns have severely scarred the tissues on the side of the head, or those who are too infirm for invasive surgery.
NOTES FOR PATIENTS WITH HEALTH INSURANCE
Your insurer may ask you for a procedure code to indicate to them the type of procedure you are considering. The applicable codes include: D0310, T0320 Exploratory Thoracotomy, T0810 Resection of Rib, S3620 Full Thickness Skin Grafts and S2400 Large Local Flap). However, there is no code for multiple complex Z-plasties, carving of the cartilage framework from rib segments, nor for framework assembly, which doubles the procedure time.
Many insurance companies, such as BUPA and WPA have designated the procedure of special complexity, to enable reimbursement of fees in full. We would emphasise, however, that such authorities are awarded on a case-by-case basis, and are often strongly resisted by certain Insurers.
There may also be an excess on your policy, or specific exclusions. We respectfully request that you settle the fees in full pre-operatively and request reimbursement from your Insurer, if applicable. For detailed information on the surgical procedures involved, we recommend that your insurance company advisors consult the following texts:
Rib graft reconstruction vs Osseointegrated prosthesis for microtia: A significant change in patient preference. Gault DT Clinical Otolaryngology. 2001, 26, 274-277
Reconstruction of the ear. Gault DT. A chapter for Principles and Practice of Head and Neck Oncology Editors Peter Rhys Evans, Patrick Gullane & Paul Montgomery. Martin Dunitz 2003
Management Of Congenital Deformities Of The External And Middle Ear. Gault DT A chapter for Scott Brown’s Otorhinolaryngology, 2008
It is vital that you discontinue smoking for at least six weeks before and six weeks after surgery. We ask that you discontinue aspirin medication SEVEN days pre-operatively, Warfarin four days pre-operatively and garlic and ginko tablets two weeks pre-operatively (these medicines can cause unwanted bleeding after surgery). Please discontinue oral contraception or HRT medication one cycle pre-operatively (to reduce the risk of thrombosis). You may resume two weeks after the surgery. You should contact your Family Doctor to discuss another method of contraception to cover the interval. Finally we ask you to discontinue Valerian and Kava containing herbal medicines two weeks before surgery as these medicines can increase the sedative effects of general anaesthesia.
Parents of children having ear reconstruction often target the summer holidays of the year in which their child changes school as the best time for first stage surgery. Others prefer to bring the surgery forward just a little so that both first and second stages are complete by the time the child goes to Senior School.