Ears for the earless

7th February 2013

 

How should we regard our pinnae? Are they the pointless vestigages of human evolutionary development? Are they a God given appendage essential for the maintenance of human aesthetics? Is their subtle curvature essential for accurate reflection of our auditory world? Or are they simply our “peacock feathers” intrinsically vital in human communication. 

We know from the experience of our patients that the absence or deformation of an ear has very significant emotional impact. Our emotional bond is perhaps best quantified by the predisposition of the cruelest tyrants and terrorists to inflict emotional turmoil upon individuals and families and to induce fear within society at large by the deliberate amputation of the ear. Why choose the ears as the organ of sacrifice; the immediate visibility of their absence, their ease amputation, ease of postage or more likely the deep seated angst imparted by their removal? And yet, as documented in this edition by Jumei et al, patients and families born with congenital microtia equally feel the emotional impact of absent ears. Depression, interpersonal and social difficulties were all demonstrable effects in children and families growing up with ‘nothing more’ than a small ear. Children very easily notice if someone differs from “the normal” and they can be very cruel and straightforward when expressing their thoughts about it. Even though the microtic children usually notice their “difference” around the age of 3 to 3.5 years old, in our experience the real psychological toll rarely starts until 2-3 years later.

Sadly, in the UK at least, our ear reconstruction clinics are not the sole reserve of patients with a congenital aetiology. It would seem that ear is an easy target of alcohol-induced aggression and arguably as much a victim of the “binge drinking” as the liver. As can be seen from the following eloquent paper by Firmin et al. ear reconstruction surgeons are also called upon to rectify and reconstruct the effects of previous otoplasty procedures. Our French colleagues may be too polite to say so but it is the experience of many that this most frequently results from an anterior scoring approach, which involves stripping the skin from both sides of the auricular cartilage.

In any straw poll of ear reconstruction surgeons one finds an avocation of a conservative approach to otoplasty based predominantly on posterior suturing. The results in most cases may be similar but significant deforming complications are more likely with an aggressive approach involving degloving of the anterior skin. Finally there is a modern fad in western societies for piercing not just the soft lobule of the ear but also the auricular cartilage. This has immediate adverse effects on structure . Secondary infection of such piercing results in a steady stream of individuals presenting with post infective ear deformity. Finally the increased prevalence of skin cancer, particularly in younger patients, places demands upon services.

Irrespective of the aetiology of ear deformity patients all have a common desire. They wish a restoration in the form of their ear or ears. They wish their reconstruction to be achieved with minimal inconvenience, minimal risk from surgery and minimal risk of long-term difficulties. For decades the widely held views of medical and indeed plastic surgical communities was that the aesthetic results of attempts to reconstruct the external ear did not justify the effort. Otolaryngologists and plastic surgeons alike were more often found to be counseling against ear reconstruction. The bone-anchored prosthesis was widely regarded as the safe and predictable option and autologous reconstruction as the poor cousin. Unfortunately in many parts of the world through the 1980s and 1990s the “don’t do it” camp may well have had ample justification for their pessimism.

2009 marks the fifty-year anniversary of Tanzer’s first description of total ear reconstruction using autologous costal cartilage. Perhaps at the anniversary of that landmark paper it is time to take stock and re-evaluate.  The course was set by that paper, the momentum increased by the massive contributions of Brent, Firmin, Nagata and others.  The authors would now contend that reliability of ear reconstruction “in the right hands” beyond doubt. It is entirely possible to create consistently beautiful ears such as the ears of uncle and nephew created decades apart by Tanzer and Brent. We strongly believe that every patient or parent seeking ear reconstruction has the reasonable right to expect a successful outcome. That is not to say that complications may not occur but they should in reality be the exception and they should as with any other reconstructive procedure be rectifiable.

We talk about the "right hands' to do the job but it is difficult to define who these might be and even more difficult to legislate that such hands should have exclusive rights to ear reconstruction And yet the challenge remains for all patients is to find the right man or woman for the job. One might argue that within the context of socially provided healthcare the designation of centres of excellence is one manner in which this might be achieved. Sweden for example has designated ear reconstruction as highly complex and since 2000 has recommended that children with Microtia be treated in one recognised centre in Malmo. This year the authorities have started a process labeling that single centre as the only legitimate clinic, which is allowed to perform such operations. Scotland has also recently moved to fund a national service with complex surgical ear reconstruction procedures undertaken in a single centre by a single surgical team. Others might argue that the free market is a better arbiter of excellence. Let patients choose their surgeon by reputation and thus let excellence be defined by market forces. Designation or indeed reputation alone however cannot guarantee satisfactory outcomes. Careful audit and evaluation are critical to develop and maintain standards. Targeted training to equip future ear reconstruction surgeons is pivotal. Yet a balance must be maintained between insuring the passage of skill between generation and the overenthusiastic generation of legions of young surgeons with little chance of generating the necessary caseload volume.

There are three main options we can offer the patient with microtia or ear deficiency through other aetiologies. First, there is always the possibility of doing nothing. Some, but very few patients, prefer not do undergo advanced surgery of any kind. It is important for their doctor to understand and accept their point of view and not try to persuade them to choose reconstruction. Inform them about all the options and welcome them back in the future if they would change their mind.

Secondly, using non-autogenous material e.g. the titanium screw attached silicone epithesis or auricular reconstruction with artificial materials such as Medpor®. These techniques must also be presented and the pros and cons explained thoroughly to the patients and their parents. Beautiful results using Medpor®. results are demonstrated in the accompanying paper from Beijing. The authors of this editorial and many other ear reconstruction surgeons have concerns with regard the long-term propensity of a hard plastic material to extrude with significant adverse consequences. Indeed  et al document this to have occurred in 13.5% of their patients.

Finally, we have the reconstruction with autogenous material. There are some minor differences between different techniques, e.g. Brent, Nagata, Firmin, but they all are based on a reconstruction totally depending on the patient’s own tissue; rib cartilage, skin flaps, skin grafts, fascia flaps etc. The number of stages varies from two to four depending on the technique chosen. Although fewer surgical stages often means more time consuming operations and longer hospitalisation at each stage.

In severe cases, previously repeatedly operated patients with extensive scars and severely injured local tissue, there is no possibility of having an adequate and safe skin coverage over the cartilaginous framework. In these cases the technique with a pre-laminated flap is a new option. Building up the cartilaginous ear on the forearm, and then with microsurgical technique, moving the ear as a free-flap to its proper location can now be offered as an autogenous reconstruction to patients otherwise in whom the only other option would be a silicone epithesis.

Timing of surgery for patients with congenital microtia remains a source of debate even amongst the authors of this editorial! The parents usually would like to have the malformation “fixed” during the very early childhood but the child him/herself rarely has any wishes to be hospitalised and undergo repeated surgery before the age of 5-6 years. An argument can be made for starting early e.g. when the child is aware of the “problem” and also him/herself would define it as a “problem”. Psychological studies suggest that there is a risk for the child of having a permanent self-image of being abnormal if the deformity/malformation still is present when they reach the age of 10 years. It is however clear that if psychological concerns are to be ameliorated then the quality of the reconstruction is paramount.

Depending on how much rib cartilage is needed in the different reconstruction techniques, the age of the first operation differs. Brent opts to start reconstruction at around the age of six. There is a requirement when choosing autologous reconstruction for a sufficient volume of costal cartilage and therefore sufficient growth of the child. Furthermore many teams prefer the child to understand the process and to eagerly want the ear to be reconstructed. For these reasons Nagata for example prefers to defer to between 8 and 10 to insure that sufficient volume of cartilage is available to create an aesthetically beautiful ear.

In October 2007, the legion of surgeons with an interest in ear reconstruction met in Edinburgh. It was, by our estimates, only the fourth such gathering in history. The enthusiasm was palpable and by popular acclaim the results being displayed were definitive evidence that this area of sub- specialisation has come of age. One can now, with a degree of confidence, assert that a reasonable ear reconstruction should be the reasonable expectation for every patient, at least for those areas of the world represented. 

 

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