Last updated before 2017

Dr. Douglas Henstrom - former (until 2017) University of Iowa Facial Plastic and Reconstructive Surgeon 

For appointment please call: 319-356-3600

1. Microtia
   • Microtia literally means "little ear.” It indicates a small, abnormally shaped or absent external ear. It can occur on one side only  ("unilateral") or on both sides ("bilateral"). Unilateral occurs in 90% of the cases. Such an ear is formed this way before birth. Usually there is a corresponding absence of the ear canal and opening (meatus). Often the microtic ear, looks like a small narrow structure with some ear cartilage on the top connected to earlobe-like tissue on the bottom. It is usually about the size of half a small finger. Variations in size and shape can occur.
2. What Causes Microtia?
   • In the majority of patients, the condition appears to occur for unknown reasons. In few cases, microtia may be genetically inherited, since more than one member of the family can have this condition. Certain drugs can cause microtia such as thalidomide or Accutane™ but these are rarely used anymore.
3. How is the Hearing with Microtia?
   • Microtia usually affects only one side. The other ear usually hears normally. Therefore, the child's speech and language develops normally. A hearing test is essential, however, because sometimes the normal appearing ear might actually not hear. The ear with microtia usually has an approximately 60 dB hearing loss. (This amount of hearing loss is like having your ear canal completely plugged.)
4. Can Microtia Be Corrected?
   • Microtia can be operated on for correction.
5. What is the Surgical Procedure?
   • There are several options for patients with microtia. Each procedure has advantages and disadvantages. The standard procedure is to harvest rib tissue and to carve it into the shape of an ear and then implant it under the skin where the ear should be. Subsequent procedures are performed to move tissue to create an earlobe and to separate the ear from the side of the head and to give the reconstructed ear finer detail.
   • Another technique is to use a prosthetic ear in which titanium screws are implanted into the side of the head, and an artificial ear is attached at a later time.
   • A third technique, is the use of artificially prefabricated implants made out of biocompatible material. This is implanted under the skin. Subsequent procedures may be needed, much like refining the implanted rib cartilage that can be used.
6. Should the Child be Evaluated Early in Life?
   • Hearing needs to be evaluated. The parents can find out more information about microtia and aural atresia. The jaw can be checked.
7. Can Anything be Done for the Hearing?
   • The Food and Drug Administration in the United States has approved a type of hearing aid called the "bone anchored hearing aid" (BAHA) which is a small box attached to a small screw imbedded in the skull. This can be placed within the hair so it is not conspicuous and tends to provide better amplification of hearing than other hearing aids.
   • More recent developments of Bone Anchored Hearing Devices are now generally favored as the method of choice for improving hearing on the affected side.
   • There are times when the anatomy is sufficiently favorable that drilling a hole to create a new ear canal and eardrum to connect to the hearing bones in the middle ear is possible. This procedure is called an aural atresia repair and is usually performed after a reconstruction for the external ear has been started or completed.
   • An appointment with our neurotologist will be made to help educate you about hearing rehabilitation options.
8. Do Other Conditions Commonly Co-exist with Microtia?
   • At the same time our ear team takes care of the external ear and the hearing issues, we join forces with the Oral and Maxillofacial Surgery team for jaw evaluation in microtia patients. Findings demonstrate that nearly half of patients with microtia have jaw malformations. Other conditions such as facial paralysis can also co-exist. Fortunately, most of the time, patients with microtia have an isolated condition and no other major congenital anomalies.
9. Is this a complicated type of surgical procedure?
   • Very few surgeons perform surgical correction of microtia on a regular basis. This has to do with the rarity of the condition as well as with the interest of various surgeons. Depending on the type of surgical procedure utilized, surgery could be a single stage, but usually it is a multi-staged procedure.
10. How Long Do We Have to Wait to Get the Ear Fixed?
    • There are substantial reasons for waiting until the child is 8 years of age or older to fix the external ear. Occasionally, with a mild or moderate microtia configuration, the ear can be operated on earlier in life. Your physician can help educate you on the reasons for waiting and the appropriate timing in your individual case.
11. What Should Parents of a New Baby With Microtia Be Told?
    • Please remember that you have a wonderful baby that has a smaller issue involving an ear. The emphasis should be to try in providing all the love the child normally would need and dealing with the ear in a relatively matter-of-fact fashion without letting the ear shape overshadow the child.
12. Will My Insurance Company Pay for a "Cosmetic" Procedure?
    • A malformed ear that undergoes surgery is not "cosmetic" but is a reconstructive procedure. Such surgery differs from cosmetic surgery in which one starts with a relatively normal anatomic structure and is just trying to change its appearance. Therefore, the procedure should be covered by insurance
13. Is There Research Being Done to Try and Create Simpler Ways to Fix an Ear?
    • Tissue engineering has produced an image that many people have seen in the broadcast media that was referred to as "the mouse with an ear on its back." This technique was developed by Dr. Charles Vacanti in his tissue engineering lab, located in Massachusetts. Dr. Henstrom spent 2 years collaborating with Dr. Vacanti and assisting in his tissue engineering lab experiments in the rodent model to improve the eventual applicability of this research into humans.

1^st STAGE MICROTIA SURGICAL PROCEDURE

1. PREOP
   1. Mark xray film for placement of new ear, using good ear as a template. Mark from oral commissure, lateral alar base and lateral canthus.
      Also draw in the markings of the good ear as a template and larger outer portion of ear for use; then can cut that out.
   2. All film can be placed between two sterile Tegaderms to keep sterile and use later in the case.
2. HEAD
   1. Use plain 1/100,000 epi without lidocaine in the temporal area, around native ear remnant, but sparingly around lobular tissue that will be transposed.
   2. Oral intubation, tube down midline
   3. If necessary, may conservatively shave hairline along area of new ear pocket
   4. Outline area of new ear placement, then plan pocket of skin elevation 2 cm greater than ear.
   5. Mark incisions and inject
   6. Tape behind ears and head drape stapled to tape. Leave both ears out and visible and enough room for pocket elevation and drains on the affected side.
   7. Prep and drape out entire face and both ears
3. CHEST
   1. Use contralateral ribs for harvest
   2. Prep out with betadine widely
   3. Plan out access and where the tube will run.
   4. Mark out xyphoid and inf edge of ribs. (Incision placement depends on size of rib cage and need for which ribs. Generally a 5-6 cm incision is used.
   5. Incise through skin, sub q, superficial fascia
   6. Identify vertically oriented edge of rectus abdominus muscle-use Kelly clamp to spread between and open pocket, then hands/fingers to spread tissue apart
   7. Identify (usually with fingers)-underlying ribs to use, including floater. Bluntly push tissue off cartilage superficial surface.
   8. Start dissecting off inferior aspect of floater using short, sharp scissors (cautery to help) to cut and push tissue away from cartilage. Remember pulmonary parietal pleura very close to rib. Avoid pneumothorax.
   9. Keep working under and around rib-moving laterally till you identify bony/cartilaginous junction (change in color and texture/feel)-remove floater at this point with blade and malleable behind cartilage b/t lung.
   10. Use Inner ear template (already made) on remaining ribs to locate area on cartilage for excision-mark, then free up.
   11. Keep wide field exposure-especially under cartilage
   12. After cartilage all harvested. Check for pleural damage and pneumo with irrigation and Valsalva.
   13. If repair needed-close with a 3-0 vicryl on a non-cutting (tapered) needle in purse string fashion over a red-rubber catheter while lungs fully expanded, and then recheck for leak
   14. Close fascial layers and skin. Drain generally not necessary. Steri strips and gauze and tegaderm.
4. HEAD
   1. For first stage Nagata technique, will flip lobule portion posteriorly according to planned incisions.
   2. Incise and elevate appropriately. Create pocket and thin skin to adhere well and obtain perfect hemostasis.
   3. Protect the Superficial temporal vessels at all times
   4. Place 2 TTS drains and have them exit posteriorly through scalp. Secure with 4-0 silk suture-not to tight and not to loose. These drains have to always work for this surgery to be successful.
   5. Place 1 larger French drain and have exit through posterior scalp, secure with  3-0 silk suture
   6. Pack pocket with gauze until ear construct ready for placement
   7. Once construct is ready, bring into field and feed it into pocket gently. Place drains in appropriate positions internally to work the best.
   8. Ensure location of ear as well as angulation
   9. Lobular remnant must be bivalve to receive end of cartilage construct. Do so conservatively so as to not compromise blood supply.
   10. 5 Stitch technique for lobule reconstruction/placement (traditional 2^nd stage combined in this procedure)
       1. Deliver construct into opened lobule
       2. stitch #1 posterior/anterior deep soft tissue under cartilage then bilaminar. This sets the lobule up and back.
       3. #2 then #3-bilaminar from medial to lateral setting the lobule back on the post skin
       4. #4-setting the lobule to the helix on the lateral most part of the skin/helix-outside and easy but have to get it just right, or it will notch
       5. anterior face-deep soft tissue on face of ear after raising small face lift skin ant to ear, must bring skin together with deep soft tissue suture
       6. close skin with nylons
   11. Ensure all drains are working at all times
   12. Mastoid dressings
5. BACK TABLE (cartilage cutting and ear construct creation)
   1. Draw on table cover the ear you are reconstructing, ensuring correct side of head. Use this for reference throughout procedure. 
   2. Floater rib #8 or 9 used as helix. Need to make it a rectangle with convex side to go on inside. Leave about 1-1.5 cm wide if possible. Distal end of helix goes to level of antitragus, superior end becomes helical root
   3. Create concha, fossa triangularis, scaphoid fossa with ribs 6,7,8 block.
   4. Fixate block construct and floater/helix with 4-0 stainless steel suture and 4-0 clear nylon. Always tying and securing on posterior side. Steel suture is always tightened by going clockwise.