MICROTIA RECONSTRUCTION:
RESTORING A MISSING EAR

When 8-year-old Karina Guevara told her father she wanted a new ear for Christmas, we were determined to give her one," says Paul J. Carniol, MD. On December 22, the otolaryngologist began reconstruction of Karina's ear at UMDNJ-University Hospital. Carniol had been following the child, who suffers from a condition known as microtia, since she was five.

Microtia, or "little ear," is the most severe of the congenital ear deformities. Typically, one ear is missing; in its place are two small nubs of tissue.

Microtia reconstruction, a complex procedure, is performed in three or four stages, usually beginning at age six or seven. In Karina's case, surgery was delayed for a few years because she was so small for her age. Prior to the surgery, a template is made of the child's normal ear (or a parent's, if both of the child's ears are affected). The contours of the ear are traced onto a piece of x-ray film, providing a model for the new ear.

During the first stage of surgery, cartilage is removed from the patient's ribs and made into a frame to provide structure for the new ear. Using the x-ray film template, the surgeon carves the cartilage into the basic shape of the ear. A second cartilage graft is carved into the helix, or upper curved portion of the ear, and the two pieces of cartilage are joined with sutures. The cartilage frame is then implanted under a flap of skin. The new ear is now in place, but it lies perfectly flat against the head.

"Karina did not have usable cartilage for a baseplate, so this had to be created from portions of her ribs instead," says Carniol. The cartilage in the upper nub of the microtia was inadequate for reconstruction and was therefore removed.

The second stage of surgery occurs three or four months later. In this stage the lower nub of soft tissue is relocated and used to create an earlobe. Great care is taken to match the normal ear as closely as possible. In the third stage, which occurs several months later, the reconstructed ear is lifted away from the head at an angle, and a skin graft placed behind it. If a fourth stage is necessary, it is usually just to further refine the shape and position of the reconstructed ear.

Karina will have the second stage of reconstruction this summer, and the third procedure about a year later. "When her ear is finally reconstructed, it will be a good, but not perfect replica of her other ear," Carniol says. "But it is a tremendous improvement over what was there before."

Children with microtia have no hearing in the affected ear. Hearing can be restored through further surgery on the ear canal and middle ear. Often, together with the ear deformity, there are deformities of the bones in the middle ear. The percentage of hearing that can be restored depends on the extent of the middle ear malformation.

"If a patient's hearing is normal in the other ear, the family often forgoes the additional surgery," says Carniol. "They are so relieved that their child now has two ears that they're not as concerned with restoring hearing."

Microtia reconstruction is uncommon, with fewer than 100 performed in the US each year. "The disorder seems to be most common among South and Central American children," says Carniol, who is a clinical assistant professor of surgery at UMDNJ-New Jersey Medical School, and also maintains a private practice in Summit. He sees a few patients with microtia each year and performs the reconstruction about once every year or two.

Carniol, who also specializes in laser surgery, recently published a comprehensive book on the subject. Laser Skin Rejuvenation (Lippincott Raven) discusses the biophysics and techniques of laser skin resurfacing, laser scar contouring, and other facial rejuvenation procedures.

Says Carniol: "When we finished the first stage of Karina's surgery, she said to me, 'Thank you so much for my Christmas present.' It is so gratifying to be able to help a child in this way."