Bilateral Microtia Recorrection with Costal Cartilage Graft
Patient born with external ear deformity The patient is a 13-year-old boy from Chittoor in Andhra Pradesh, India. He had been born without external ears. There were only rudimentary structures present at the site of bilateral ears. He had been diagnosed with hemifacial microsomia with bilateral microtia. There was also gross asymmetry of his face. The patient had faced constant bullying over the years in school. He had very few friends and had slowly grown depressed about the appearance of his face. Approximately a year ago, he had refused to go to school until his ear deformity had been corrected. He stated that he wanted big prominent ears. His parents had approached a cosmetic surgeon in a nearby city who had examined the patient. He had weighed all treatment options. Realizing that the patient needed microtia correction surgery, he had presented the treatment plan to the parents. They had consented to the surgery. He had been admitted to the hospital and had subsequently undergone surgery. However, the patient and his parents were not satisfied with the results of the surgery. There had been slight asymmetry of the cartilaginous form of the external ears. There were also hypertrophic scars, which were unsightly. They felt that the scar tissue needed to be addressed. It however did not involve a large area of skin. Realizing that this needed to be corrected, parents had made wide enquiries regarding the best hospital to get the problem addressed. They had subsequently been referred to our hospital for his correction surgery. Our hospital is a renowned center for facial cosmetic surgery in India. Cosmetic correction of deformities involving both bone and soft tissues are addressed at our hospital. Facial asymmetry correction surgery is a specialty at our hospital. Jaw deformity correction, ear deformity correction, scar revision surgery, cosmetic rhinoplasty and cleft deformity correction surgery are routinely performed here. Initial presentation at our hospital for treatment Dr SM Balaji, microtia correction surgeon, examined the patient and obtained a detailed history. The patient’s parents explained their anxieties and fears regarding the failed surgery. A complete clinical examination was performed and comprehensive radiographic studies including a 3D CT were ordered. It was determined that there was deficiency of cartilage that had been placed in the first surgery. The patient and his parents were reassured and counseled extensively. His 3D CT scan revealed the presence of an anatomically patent, middle ear, inner ear and ear canal. Clinical examination also revealed facial asymmetry on the left side. Auditory testing was also performed for the patient. This revealed that he had about 70-80% hearing in both the ears despite the absence of external ear structures A brief introduction to microtia and its etiological factors Microtia is a congenital deformity where the pinna is underdeveloped. Complete absence of the external ear is referred to as anotia. Because microtia and anotia have the same origin, the complex can be referred to as microtia-anotia. Microtia can be either unilateral or bilateral. It occurs approximately in 1 out of every 8000–10000 live births. The right ear is more commonly affected in cases of unilateral microtia. Microtia may occur as a complication of taking Accutane (isotretinoin) during pregnancy. The etiology of microtia in children however remains uncertain. It is suspected to be genetic in origin along with being a complication of gestational diabetes. Risk factors also include very low birth weight. Treatment planning explained to the patient and his parents in detail It was planned to correct the asymmetrical form of bilateral ears from the previous surgery. This would be followed by a subsequent stage at a later date where the ear structures would be elevated followed by creation of the ear lobule in the final stage of the surgery. They were in agreement with the treatment plan and the patient was scheduled for surgery. Harvesting of rib graft and placement at the site of bilateral ear deformity Under general anesthesia, a left inframammary incision was made and dissection was performed down to the ribs. Costochondral grafts were harvested and Valsalva maneuver was performed to ensure that there was no perforation into the thoracic cavity. The wound was then closed in layers with sutures. This was followed by incisions performed over the asymmetrically constructed ear structures. The costochondral grafts were shaped and tunneled to ensure that the resultant ear form was symmetrical and esthetically pleasing. Incisions were then sutured using nonresorbable sutures. Parents express their satisfaction with the cartilaginous ear framework The patient and his parents were very happy with the esthetic outcome of the corrective surgery. There was a well defined and symmetrical cartilaginous framework to the ears bilaterally. They could clearly visualize the ear taking shape. Parents expressed that the patient had definitely cheered up following the surgery. They stated that he was looking forward to the subsequent stage of the surgery. The ear elevation surgery using skin graft will be performed after about 6 months. Surgery Video
Microtia Second Stage Ear Reconstruction Surgery
Girl born with deformed right external ear The patient is a now 24-year-old girl from Ranchi in Jharkhand, India who was born with near total absence of her external right ear. She had just a peanut like wedge instead. There was also absence of an external ear canal and eardrum. Her marriage had been fixed three years ago and they had approached a local plastic surgeon. Upon examining the patient, he had realized that she needed to get it addressed at a specialty center. He had then referred them to our hospital for treatment. Our hospital is a premier surgical center for microtia surgery in India. Many patients have been rehabilitated here and are leading completely normal lives today. Our hospital is a premier center for facial plastic surgery in India. Initial presentation and consultation at our hospital Dr SM Balaji, ear reconstruction surgeon, examined the patient and conducted a detailed evaluation. He explained to the patient the processes involved in ear reconstruction surgery. Microtia surgery is performed in three stages. The first stage involves reconstruction of the ear using rib cartilage. A skin pocket is first created at the site of the missing external ear. The cartilage is then banked in the skin pocket created at this location. The patient has already undergone this stage of the surgery two years ago at our hospital. Lobule shifting had also been completed. She now presents for the second stage microtia surgery. Presentation and classification of microtia ear deformity Microtia is a congenital deformity where the external ear is underdeveloped. Complete absence of the external ear is referred to as anotia. Microtia can be unilateral or bilateral and occurs in around 1 out of about 8,000–10,000 births. The right ear is more commonly affected than the left ear. Unilateral microtia is more common than bilateral microtia. Microtia is graded according to its severity. In grade I microtia, there is a less than complete development of the external ear with identifiable structures and a small but present external ear canal. Grade II microtia manifests a partially developed ear with an underdeveloped upper half. The external ear canal is closed leading to conductive hearing loss. Grade III microtia is more severe with near complete absence of the external ear with just a small peanut-like structure along with the absence of the external ear canal and ear drum. This is also the most common form of microtia. Grade IV microtia denotes the complete absence of the external ear. Second stage microtia surgery for ear reconstruction After a clinical evaluation, the second stage surgery for ear elevation was scheduled for the patient. Under general anesthesia, the banked cartilage was first removed. This was followed by excision of the scar in the inframammary region where the graft for the first stage had been harvested. A full thickness skin graft was then obtained from the hip region and right ear elevation was done using the banked graft and the full thickness skin graft. Successful completion of the second stage microtia repair The ear was successfully elevated, but constant monitoring was needed to ensure that the site of the graft did not develop an infection. Routine check-up was performed for a period of about one month. The patient and his parents were very happy with the results of the surgery. Surgery Video
Bilateral Ear Reconstruction – Microtia – 1st Stage
Microtia deformity of the external ears Microtia is a congenital condition in which there in poor development of the ears. Correction involves staged reconstruction of the ear using autogenous costal cartilages. A template is utilized to create the form of the proposed external ear. Three surgeries complete reconstruction of the microtia affected ear. Patient presents to our hospital for specialized microtia surgery This is a young 13-year-old boy from Tirupati, Telangana with microtia. His parents brought him to our hospital for bilateral microtia repair. Dr SM Balaji, microtia repair specialist, explained the surgery to them. They agreed to proceed with surgery. Microtia surgery of bilateral ears performed for young boy from Tirupati After general anesthesia, rib grafts were first harvested. Grafts obtained were from the fourth, fifth and sixth ribs. A Valsalva maneuver was then performed. This was to rule out accidental perforation into the thoracic cavity. Using a metal template, the sixth rib graft was first carved and sculpted to form the external ear framework. This was done for both the right and the left sides. The other graft pieces were then fixed and secured with nonresorbable sutures. Care was taken to maintain symmetry between the frameworks of both ears. The skin of the right ear was first incised and underlying tissues dissected to create a pocket. The framework of ribs was then tunneled into the pocket. Skin was then sutured and surgical drain placed at the site. This step will help adapt the skin to the cartilage framework. The left ear was then addressed. Second stage repair will be after about 3 months. This will be for elevation of the framework inserted in the first stage.
Microtia – Ear Lobe Correction – Balaji Dental and Craniofacial Hospital, India
Expert correction of microtia done at our hospital Microtia is a congenital malformation of variable severity of the external ear. Correction of this deformity is through reconstruction surgery. Dr SM Balaji is an expert at microtia correction. This staged procedure gives the best results for microtia correction. Stage 2 microtia correction after successful stage 1 microtia surgery The patient is now 14 years old. He has already undergone stage 1 costal cartilage placement under the skin. This had recreated the form of the left pinna. Stage 2 surgery involves lifting up the reconstructed left pinna. This lies flat against the side of the head after the stage 1 surgery. His left ear lobe was also deformed with skin tags. This too needed corrective surgery. He presents now for stage 2 surgery. Lifting up of reconstructed external ear from side of head Under general anesthesia, an incision was first made around the reconstructed pinna. This was then lifted up and stabilized in position with sutures. Attention was then turned to the deformed ear lobe. A skin incision was first made in the ear lobe and adapted to give normal form to the deformed lobe. Sutures were then used to close the incision. The patient expressed his happiness at the results before discharge from the hospital.
Hemifacial Microsomia and Microtia with absence of condyle corrected with reconstruction of ramus and condyle
Patient with hemifacial microsomia presents for treatment Hemifacial microsomia is a congenital disorder. It affects the development of usually one side and rarely both sides of the face. One child in every 5600 children born worldwide is afflicted by hemifacial microsomia. This condition results from the abnormal development of the first and second pharyngeal arches. Ears, mouth, and lower jaw bone are most often affected. The patient here is a young girl with hemifacial microsomia. She has left microtia and absence of the left mandibular condyle. Her parents researched the Internet for the best facial reconstruction surgeon. They zeroed in on our hospital based upon the Internet search results. Growth centre transplant planned for replacing missing condyle Dr SM Balaji examined the patient and ordered 3D axial CT scans. This revealed the presence of a rudimentary left condyle. He planned reconstruction of the condyle and ramus with costochondral rib grafting. This procedure is also known as growth centre transplantation. Parents of the patient were in full agreement with the treatment plan. Costochondral rib graft with perichondrium obtained Under general anesthesia, a costochondral rib graft with perichondrium was first obtained. The incision was then closed after ensuring absence of thoracic perforation. Subcuticular sutures closed the incision for minimal post healing scar. Surgical reconstruction of missing left condyle Following this, markings were then made over the mastoid region. This was to map out the distorted anatomy of the underlying structures. An incision was first made followed by dissection down to the condylar region. Facial nerve and parotid duct were duly protected throughout the surgery. The rudimentary condyle was present below the ear tag. The pterygomandibular raphae was then stripped off. The costochondral graft was then positioned in the posterior ramus. Upper part of the growth centre transplant was then positioned in the glenoid fossa. This was then fixed with screws. The incision was then closed in layers using subcuticular sutures. The patient recovered well from general anesthesia. The patient presented later at our hospital and expressed complete satisfaction. Surgery Video
9 Year old boy from Seychelles gets a new external ear – Ear Reconstruction Surgery
Ear Reconstruction Surgery(Microtia) for a Seychelles boy 9-year-old Nathan Parkash from Seychelles was born with completely absent external portion of his right ear, he only had a very small, rudimentary ear lobule. His left ear was normal. Doctors in his hometown diagnosed that the child’s hearing was normal. As the boy started going to school, his social interactions increased, children at school began teasing him because of his ear. He suffered ridicule and unwelcome stares. He saw that he was not able to wear sunglasses and walkmans like his fellow mates. He started becoming psychologically depressed about his appearance. Slowly he became withdrawn and self-conscious. His parents were becoming increasingly worried for their child’s poor self-esteem. They looked for hospitals that do ear reconstructions all around the world and they found that such centers are very few and the results were not up-to the mark. Usually people from Seychelles go to South Africa or Dubai for medical treatment. They found that very few hospitals were available for doing such procedures but the outcomes were not satisfactory. The Govt. of Seychelles referred them to our hospital for the ear reconstruction surgery (Microtia) as they found the surgical results of the surgeon to be exceptionally best in India. Dr. S.M. Balaji decided to perform complete ear reconstruction in 2 stages using the boy’s own rib graft (costochondral graft) as artificial materials can lead to inherent problems like infection, allergy and loss of stability over time. Using the patient’s own graft is the best technique giving permanent and stable results. The first stage was called cartilage-banking surgery. Based on the measurements of the normal left ear, a template was made. It was important to do this correctly as the ear characteristics have to be accurately replicated to achieve symmetry. A costochondral graft was taken from the rib. Using the template as reference, the graft was contoured to create the structural framework. This is most crucial and has to be done with great precision and accuracy. The skin of the right ear was raised creating a pocket and the cartilage framework was placed below the skin. Additional piece of cartilage was also placed adjacent for future use. A surgical drain was placed that created a suction making the overlying skin to adapt to the framework and the ear shape was achieved After 3 months the second stage surgery called ear-lifting surgery was done. Using the excess preserved cartilage and skin graft, the entire ear framework was lifted from the side of the head giving a normal, raised appearance to the ear. Following reconstruction the ear was given a more aesthetic, natural-looking appearance. As the boy grows the normal left ear will grow, but the reconstructed right ear will not increase in size. So to avoid re-surgery, the right ear was reconstructed with a higher dimension matching the adult size. Following second stage surgery the boy is delighted about his “new ear”. Also he is happy that he won’t be teased any longer. He and his parents are happy with the surgery outcome and returned to their hometown. He may require revision surgery at later stage. Ear reconstruction surgeries are challenging and must be performed with skill, care & artistic sense. Timely correction of ear defects is important for the person’s physical and emotional well-being. Surgery Video: