Researching Your Options

What options are available for reconstructing Microtia-Anotia?

Type I microtia can often be reconstructed with an otoplasty. Type II requires a reconstruction of the upper half of the pinna. Type III and type IV require complete ear reconstruction. Ear reconstruction options include a prosthesis, a silicone or Medpor polyethylene plastic framework covered by living tissue, or living rib graft cartilage framework covered by living tissue.

Why Choose a Prosthetic Ear?

Prosthetic ears can look very natural and can nicely match the contralateral ear when fabricated by a skilled technician. They attach to the patient’s head with either an adhesive or osseointegrated implants. It is Dr. Griffiths’ opinion that prosthetic ears are best suited for those who are not candidates for ear reconstruction surgery, or for a child who wants to buy time before pursuing surgery. It is important to note that scars can form as a result of placing implants. Though these devices help to prevent the prosthesis from falling off, scars can impact the quality of future microtia surgery.

It is important for patients and parents to understand that if they want to wait for surgery and use a prosthetic ear for the time being, that the skin under the prosthesis must not be violated with any surgical scars.

Why use MEDPOR (porous polyethylene plastic) as an ear framework?

The MEDPOR™ auricular prosthesis is made of porous polyethele. Advantages include avoidance of chest incision, lower operating room time, and the ability to be used by less experienced surgeons who do not have the artistic ability to carve ear framework out of cartilage. MEDPOR is also quite stiff and withstands the contractile forces of the surrounding tissues during the healing phase quite well. Natural appearing ears can be produced by experienced surgeons using MEDPOR. 

Why use autologous chest cartilage as an ear framework?

Rib cartilage for microtia reconstruction is harvested from the anterior chest from the sixth, seventh, and eighth ribs. Because we use your tissue, it will grow with you. In addition, you are less likely to develop infection or complications. In the hands of artistic, experienced microtia surgeons, cartilage can be craftfully carved into an ear framework that closely matches the contralateral (normal) ear.  We invite you to learn more about how to choose between rib graft and Medpor.

How big is the scar on the chest from the cartilage harvest?

Surgeons who do not perform rib cartilage microtia reconstruction will often show photos of poor scars from less experienced surgeons as a way to discourage patients from the treatment. 

What tissue does Dr. Griffiths use to cover the ear framework?

The one-stage procedure performed by Dr. Griffiths involves the use of a thin vascularized membrane that is placed underneath the scalp to cover the carved framework Patients can choose wether they would like a rib graft or a Medpor framework. This thin membrane is called the temporoparietal fascia. This thin highly vascular membrane is then wrapped around the ear framework to provide a complete vascular covering. Skin grafts that have been carefully chosen to provide the best texture and color match are then used to cover the fascia flap.  

Is tissue expansion ever used in these operations?

Some surgeons incorporate the aid of a tissue expander to stretch the overlying skin prior to inserting the framework for a three stage-reconstruction. Tissue expansion does involve multiple visits to the physician’s office to inflate the tissue expander. The first stage is to place the tissue expander. The second stage is to remove the tissue expander, place the framework, and rotate the lobule. The third stage is used to create the ear canal if the patient is a candidate.

Is it possible to reconstruct the ear canal at the same time as reconstructing the external ear?

Yes, Dr. Griffiths works with an otolaryngologist at St. Luke’s Children’s Hospital who performs the ear canal reconstruction on patients who have been evaluated by temporal bone computed tomography (CT) scan and found to be good candidates for canalplasty. The canal can be reconstructed while Dr. Griffiths is carefully carving and constructing the ear framework. By working together, Dr. Griffiths and our otolaryngologist have condensed what can be up to five separate operations into one. The entire ear and ear canal are surgically created in ONE operation. The cost and time savings for the family is significant.  The aesthetic and functional results are better.  Patients travel from all over the nation and internationally for this special combined procedure. 

How is the ear canal reconstructed (canalplasty)?

Patients with microtia and aural atresia are evaluated preoperatively with an audiogram and a temporal bone CT scan. Our specially trained otologist then looks at the studies to determine if your child is a candidate for canalplasty. The goal of the operation is to create an opening through the temporal bone and to reconstruct the tympanic membrane (ear drum), which would allow sound waves to move the inner ear bones. The inner ear bones then transmit the sound vibrations to the cochlea. The surgery is performed by our otologist using a high powered surgical microscope. After the canal is created, the ear drum is reconstructed with a small fascia graft. The canal is then lined with a split thickness skin graft. A special stent is fabricated to hold all the tissues in place during the healing phase.

What other hearing options are available if my child is not a candidate for a canalplasty?

Dr. Griffiths strongly advocates hearing restoration in children with both bilateral and unilateral microtia atresia. If your child is not a candidate for canalplasty, there are other options to consider. Bone anchored hearing aids convert sound into vibrations and then transmit the vibrations directly to a titanium abutment that is attached to the cranial bone. Common devices include the Cochlear™ Baha® Connect system, and the Oticon Ponto Pro. An alternative device attaches to the scalp with a magnet rather than an abutment which eliminates the percutaneous abutment. Common devices include the Sophono™ Alpha 2 made by Medtronic, the Cochlear™ Baha® Attract system, and the MED-EL BONEBRIDGE. Our otologist would be happy to review your options with you.

What if my child has bilateral microtia?

The first thing to focus on is hearing. If your child also has aural atresia (missing ear canals) then he or she would benefit greatly from wearing vibrating hearing aids held on with a soft headband as soon as possible. These hearing devices not only enhance hearing but also help maintain the health of the brain auditory cortex, and accelerate speech development. If you have tried to obtain hearing aids and have been unsuccessful, please contact our office. We can help you fight your insurance company to get what your child needs (We have helped children from all around the country)! More formal hearing restoration options can be considered when your child is six years and older.

A patient with bilateral microtia will require a minimum of two separate operations:

• A single-stage reconstruction of one ear will be followed several months later by single-stage operation on the other.
• A full thickness skin graft from another area of the body will usually be necessary.
• If the patient with bilateral microtia also has bilateral aural atresia, then hearing restoration surgery (canalplasty or a bone anchored implant) is usually performed at the same time as the microtia surgery.

What can I do if my child has Hemifacial Microsomia or Goldenhar syndrome?

Hemifacial microsomia and Goldenhar syndrome manifests themselves in degrees ranging from nearly unnoticeable to extremely severe. Children with hemifacial microsomia have underdevelopment of the jaw on one side (micrognathia) with associated tilting of the occlusal plane higher on the affected side. Patients also often experience:

• Underdeveloped cheekbone on the affected side
• Underdeveloped or deformed outer ear (microtia)
• A missing or undersized ear canal (congenital aural atresia)
• Underdevelopment of the eye and eye socket
• The hairline grows lower near the microtia ear remnant
• The corner of the mouth is larger on the affected side (lateral oro-facial cleft)
• In more severe forms, of hemifacial microsomia the ear remnant is on the cheek rather than by the sideburn

Goldenhar syndrome is a variant of Hemifacial microsomia with the same symptoms listed above. Children with Goldenhar syndrome also have a soft white or pink nodule located in the eye (epibulbar dermoid), a narrowing of one eye, notched lower eyelids, and occasionally anomalies of the spine (most typically cervical vertebrae deformities).

Can Microtia surgery be performed on patients with Hemifacial microsomia or Goldenhar syndrome?

Microtia surgery can be carried out on patients with Hemifacial microsomia or Goldenhar syndrome, but Dr. Griffiths has to pay special attention to the individual physical examination findings of each patient. He has to work with a lower hairline, a lower ear remnant (often located on the cheek), and an underlying skeletal abnormality all at once. He often counsels patients and parents to expect slightly less refined results in comparison to the results that can be achieved for a patient without Hemifacial microsomia.

What can I do if my child has Treacher Collins syndrome?

Patients with Treacher Collins syndrome, in addition to having bilateral microtia, also have abnormalities to their eyelids, malar eminence (cheek bone), and both lower and upper jaws. As a craniofacial surgeon, Dr. Griffiths is well equipped to treat each of these deformities depending upon the individual needs of your child, including the latest techniques in mandibular osseous distraction, orthognathic surgery, and micro-fat grafting.

Patients with Treacher Collins syndrome often have bilateral microtia and aural atresia. Your child will benefit greatly from wearing vibrating hearing aids held on with a soft headband. These hearing devices help accelerate speech development and also help maintain the health of the brain's auditory cortex.

Regarding your child’s bilateral microtia, Dr. Griffiths can easily reconstruct both ears in two operations.

Can Dr. Griffiths help us if my child has bilateral microtia?

Yes he can! A patient with bilateral microtia will require a minimum of two separate operations. A single-stage reconstruction of one ear will be followed several months later by single-stage operation on the other. A full thickness skin graft from another area of the body will usually be necessary.  If the patient with bilateral microtia also has bilateral aural atresia, then hearing restoration surgery (canalplasty or a bone anchored implant) is usually performed at the same time as the microtia surgery.

Bilateral microtia is most commonly seen in patients with Treacher Collins syndrome, but can occur in non-syndromic patients. Patients with Treacher Collins syndrome, in addition to having bilateral microtia, also have abnormalities in the upper and lower jaws, zygomatic arch, malar eminence (cheek bone) and eyelids. As a craniofacial surgeon, Dr. Griffiths is well equipped to treat each of these deformities depending upon the individual needs of your child, including the latest techniques in orthognathic surgery and osseous distraction.

What postoperative/long-term follow-up care is required after microtia surgery?

After a patient returns home, Dr. Griffiths likes to have photographs emailed to him periodically so he can carefully monitor the healing. It is important that a local physician be available to communicate with Dr. Griffiths and provide localized care if needed. A plastic surgeon is best suited for this role but a qualified ENT would also work. These arrangements should preferably be made prior to having your child travel to Boise for the operation. Dr. Griffiths will assist you in arranging follow-up care through a backup physician if necessary for those who live out of the state or out of the country. 

After a patient returns home, Dr. Griffiths likes to have photographs emailed to him periodically so he can carefully monitor the healing. It is important that a local physician be available to communicate with Dr. Griffiths and provide localized care if needed. 

How old does my child need to be to have their ear reconstructed?

The optimal time for reconstructing an external ear using autogenous rib cartilage is six years of age.  If a Medpor framework is chose, the surgery can be done as early as age four.

What if my child already has already had a BAHA implant? Can an external ear still be reconstructed?

Yes, it certainly can. When the BAHA posts are placed, incisions are made in the skin traditionally used for a three- or two-stage ear reconstruction. A one-stage reconstruction utilizing temporoparietal fascia flap can easily be utilized to reconstruct an ear in a microtia patient who has already had BAHA implant reconstruction.

What if my child has already had canalplasty or reconstruction of the external auditory canal for aural atresia?

Canalplasty prior to microtia reconstruction places scars in the skin traditionally used for multi-stage ear reconstruction.  Most rib graft surgeons will not take on such a patient.  Dr. Griffiths with his novel one-stage ear reconstruction technique can utilize a temporoparietal fascia flap to cover either a rib graft or Medpor framework on a patient who has previously had a canalplasty or aural atresia repair.

Scheduling and Planning Your Evaluation and Surgery

How do I arrange to meet Dr. Griffiths?

Please call Dr. Griffiths’ office (208-433-1736) or contact us here if you would like to arrange an appointment to meet in the office. If you live out of state or out of the country we can arrange for a video conference to take place. It will be important for you to fill out medical history paperwork and send detailed photographs of your child’s ear prior to the video consultation. The video consultation time can be arranged with appropriate translation services for non-English-speaking families and patients.

How long will I need to arrange to stay in Boise?

You will need to come into Boise the day before your scheduled surgery. During this time, you can meet with Dr. Griffiths face-to-face and he will make detailed measurements and templates off your child’s normal ear. You can also meet with our otologist if your child is a candidate for hearing restoration surgery at the same time as the microtia reconstruction.  Most children spend one night in the hospital following surgery. Occasionally, we will have a child that will spend longer if they have specific needs that need to be addressed. You will need to arrange to stay in Boise until your child's new ear has healed appropriately, which can take between eight and 20 days. International patients often travel to see other parts of the USA after two weeks in Boise and fly back to see Dr. Griffiths before they return home.

What options do I have for lodging when I arrive in Boise?

Dr. Griffiths’ staff will assist you in making reservations at a lodging facility close to the hospital where you will be close enough to walk to Dr. Griffiths’ office. Most families prefer facilities with a small kitchen and access to local restaurants and entertainment.

Will additional surgeries be needed?

Occasionally in the first two weeks after surgery, a small procedure might be necessary if any part of the underlying rib cartilage or Medpor framework becomes exposed due to non-adherence of the skin grafts or fascia flap. This complication is rare, but Dr. Griffiths will monitor your child very closely during the time. Since 2014, Dr. Griffiths has only had this happen to one patient. Late postoperative artistic adjustments are rare.  

Where does Dr. Griffiths perform his surgeries?

St. Luke's Children’s Hospital in Boise, Idaho.

What is the cost for Microtia ear reconstruction surgery?

Microtia reconstruction is traditionally covered by most major medical insurance policies. Out-of-pocket costs can vary depending upon the patient’s individual plan. Primary costs involve the hospital fees, anesthesia fees, and the surgeon fees. Dr. Griffiths' office will work with your individual insurance plan to obtain pre-certification for the reconstruction of your child’s ear and try to provide a very close estimate of out-of-pocket costs. If you do not have traditional medical insurance or if you are traveling from outside the United States, Dr. Griffiths’ office can provide quotes for you.

How do I pay for surgery if my family does not have the financial resources?

Many families have held successful community fundraisers to raise money for their child’s surgery. This does involve some family and community outreach. Please contact Dr. Griffiths’ office for a list of community resources and ideas. Dr. Griffiths tries to work with each patient to help their dream of a new ear come true.

Future Research and Alternative Treatments

How soon will biotechnology be able to produce a 3-D printed ear?

Researchers recently reported using a biological 3-D printer to print an ear framework out of cartilage. This is very exciting news leaving many to question when this new technology will be available for their child. The printer must use a liquified cartilage that must be extruded through the print head. Although this works great with plastics that can be treated to harden as soon as the material is extruded, cartilage gels remain soft after being extruded and immediately lose the detail of the intended shape.  You may want to watch this video and compare the framework that 3-D printing can produce with what Dr. Griffiths can carve from autologous rib cartilage. 

Additionally, the cartilage would not only need to hold its shape immediately after being extruded, but it must also withstand the contractile forces of the overlying skin grafts and fascia flaps after it is implanted. Contrary to popular belief, the entire ear cannot be printed (skin, fat, cartilage, nerves, arteries and veins). The printed cartilage framework must still be surgically implanted under skin and subcutaneous tissue to provide the blood supply. It is Dr. Griffiths’ opinion that this is primarily a research interest and is not clinically applicable.

What about growing ears on the backs of nude mice?

Researchers have shown that cartilage cells known as chondrocytes can be grown on a resorbable polyglycolic acid framework in a petri dish in a laboratory. The framework and chondrocytes are then implanted under the skin of a mouse that has had its immune system compromised so that it will not reject the grafted ear. These mice are hairless and are commonly called “nude mice.” Many parents of children affected with microtia are expressing interest in whether this technology could be applied in the future to humans. It is Dr. Griffiths’ opinion that this is primarily a research interest and is not clinically applicable. The laboratory grown ear framework has been unable to withstand the contractile forces of the overlying skin grafts and fascia flaps and eventually loses its shape. Also, valuable skin grafts, skin flaps and fascia flaps needed to cover the laboratory ear construct would not be available for future reconstructive salvage operations.

Ear Anatomy for Reference

Definitions

• Aural atresia - missing ear canal
• Autologous - a graft harvested from your own body
• Canal stenosis - narrow ear canal or mild form of aural atresia
• Microtia - missing external ear
• Unilateral - one-sided
• Bilateral - two-sided
• Contralateral - the opposite side of the body from the involved ear
• Temporoparietal fascia flap (TPF) - a thin membrane underneath the scalp and sideburn that contains sensory nerves with blood vessels This thin membrane can be used as a vascular supply for microtia reconstruction.  
• STSG - split thickness skin graft
• FTSG - full thickness skin graft
• Tympanoplasty - reconstruction of the eardrum
• Medpor - prosthetic material used by some surgeons in reconstructing the external ear, manufactured by Stryker
• BAHA - bone anchored hearing appliance 
• BCHA - bone conducting hearing aid

Contact Dr. Griffiths

For answers to any questions that have not been addressed here, contact Dr. Griffiths to schedule a consultation, or call us directly at (208) 433-1736. Our team looks forward to working with you.