RECONSTRUCTIVE SURGERY
Ear reconstruction
There is a wide range of procedures to treat either absence at birth of an ear (Microtia) or loss of or damage to an ear.
Ear loss - major causes are bites, road traffic accidents and shootings, followed by burns, failed surgery to set back prominent ears, and infected piercings. If the tissues have not been damaged by previous trauma or surgery, it is possible to fashion a completely new ear in two operations six months apart. In some circumstances, the two stages can be rolled into one, with a minor procedure later.
Microtia - this affects about 1 in 6000 children, of whom 10% have both ears affected. In most cases, a small fold of skin or rather less may be present where the ear should be.
It is possible to reconstruct either with the patient's own tissues (Autogenous ear reconstruction) or if tissue damage is too severe, anchor a prosthetic ear to the bone at the side of the head. As results from autogenous ear reconstruction improve, prosthesis has become a much less favoured option. A number of patients with a prosthetic ear, even those with very good results, seek advice about the possibility of converting to the autogenous option. However, if there is severe damage to the tissues or blood supply at the site of the missing ear, prosthetic reconstruction is preferred.
The first stage of a simple autogenous ear reconstruction takes between four and five hours under general anaesthetic. The first step is to map the shape of the normal opposite ear. When both ears are lost, such as in burned patients, an ear shape can be copied from a willing relative. The shape is drawn on a see-through plastic sheet, and then cut out to leave a template which can be sterilised for use throughout surgery.
Where there has been tissue damage, complex autogenous reconstruction may be feasible by first increasing 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. If neither option is available then a free flap or bone anchored prosthesis is required.
For major defects, a detailed framework (ideally of costal cartilage from the patient's rib or artificial material) is essential, with loose and pliable skin of good quality which will mimic the folds of a normal ear. Costal cartilage repairs itself in the event of minor trauma and is less prone to infection and extrusion. It is harvested through a small incision made in the chest wall at the edge of the ribcage of the opposite side. A small drain is left in this wound so that pain-relieving medicine can be given directly into the area. A small piece of cartilage is usually stored here to be used to jack out the ear at the second stage.
About six months later, the new ear can then be lifted from the side of the head, so that it projects normally, with a groove behind it. The block of costal cartilage stored beneath the scar in the chest wall is used to maintain projection, and the two raw surfaces, one behind the ear and one on the side of the head, are covered by a mixture of grafts (usually from the thigh) and skin flaps harvested locally. This second stage surgery takes almost two hours under general anaesthetic, leaving minimal scarring.
Bone anchored prostheses
Under general anaesthetic, any ear remnant is removed and two or three small titanium implants are placed into the bone on the side of the head. Once firmly embedded, these become the anchors, at a second stage, for metal “abutments”. Once all has healed, extensions can be attached to the abutments and a false ear attached either with 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.