Refinements in autologous ear reconstruction: descriptive surgical technique and experience of 400 consecutive cases at a tertiary referral center in the UK

  • Ahmed S. MazeedEmail author
  • Neil W. Bulstrode
Original Paper



Ear reconstruction for microtia is a great challenge in plastic surgery. Autogenous costal cartilage has remained the material of choice for framework fabrication. We describe our preferred technique and provide several refinements which have been developed over years to improve the outcome and minimize complications, based on experience with 406 cases.


Esthetic outcome scoring was performed by evaluating all subunits of the reconstructed ears as well as the overall integration of the ear with the face (15 esthetic parameters). These were graded, using a 5-point ordinal scale from 1 (very poor) to 5 (very good). The course of improvement of the overall esthetic score was assessed using one-way ANOVA test with Bonferroni post hoc analysis.


The overall complication rate was 15%. Wire extrusion was the most common (12.8%). The rate of revision procedures was 11.8%. The helix and concha had the highest esthetic score (3.4 each). The overall esthetic score was 3.2 on average. The overall score showed statistically significant improvement after the first 50 cases (p = 0.02) and another increase after performing 250 cases. The difference between the esthetic score of the first and the last subgroup of cases is highly significant (p < 0.001).


Autologous ear reconstruction is a complex surgery with inevitable learning curve. Undertaking an adequate training is advised to achieve pleasing results. Having a regular high volume case load is essential to achieve significant improvement in outcomes. The goal of having nationally designated ear reconstruction units is highly recommended.

Level of evidence: Level IV, therapeutic study.


Microtia Ear reconstruction Costal cartilage Microtia outcome Microtia esthetic score 



The authors would like to thank Maria-Elena A. Salfelder (medical student, Ludwig-Maximilians-University of Munich, Germany) and Kate Howson (medical student, Barts and the London School of Medicine, UK) for their valuable contribution in retrieving and organizing the patients’ data and photographs. The authors are grateful to Dr. Ahmed Elshamy (Assistant Lecturer, Mansoura University, Egypt) for his help in the statistical analysis and interpretation of data for the study.

Compliance with ethical standards

Funding information


Conflict of interest

Ahmed S. Mazeed and Neil W. Bulstrode declare that they have no conflict of interest.

Ethical approval

For this type of study formal consent from a local ethics committee is not required.

Informed consent

Informed consent was obtained from parents/legal guardians of all individual participants included in the study. Additional informed consent was obtained from parents/legal guardians of all individual participants for whom identifying information is included in this article.


  1. 1.
    Brent B (2002) Microtia repair with rib cartilage grafts: a review of personal experience with 1000 cases. Clin Plast Surg 29(2):257–271PubMedCrossRefGoogle Scholar
  2. 2.
    Mazeed AS, Saied S, Abulezz T, Youssef G, Bulstrode NW (2019) Recommendations for the development and reform of microtia and atresia services. J Craniofac Surg 30(4):1135–1139PubMedCrossRefGoogle Scholar
  3. 3.
    Rueckert F, Brown FE, Tanzer RC (1990) Overview of experience of Tanzer’s group with microtia. Clin Plast Surg 17:223–240PubMedGoogle Scholar
  4. 4.
    Brent B (1980) The correction of microtia with autogenous cartilage grafts: I. The classic deformity. Plast Reconstr Surg 66:1–12PubMedCrossRefGoogle Scholar
  5. 5.
    Brent B (2000) The team approach to treating the microtia atresia patient. Otolaryngol Clin N Am 33:1353–1365CrossRefGoogle Scholar
  6. 6.
    Gilles H (1920) Plastic surgery of the face. Frowde, Hodder & Stoughton, LondonCrossRefGoogle Scholar
  7. 7.
    Tanzer RC (1959) Total reconstruction of the external ear. Plast Reconstr Surg Transplant Bull 23:1–15PubMedCrossRefGoogle Scholar
  8. 8.
    Tanzer RC (1971) Total reconstruction of the auricle. The evolution of a plan of treatment. Plast Reconstr Surg 47:523–533PubMedCrossRefGoogle Scholar
  9. 9.
    Im DD, Paskhover B, Staffenberg DA, Jarrahy R (2013) Current management of microtia: a national survey. Aesthet Plast Surg 37:402–408CrossRefGoogle Scholar
  10. 10.
    Brent B (1980) The correction of microtia with autogenous cartilage grafts: II. Atypical and complex deformities. Plast Reconstr Surg 66:13–21PubMedCrossRefGoogle Scholar
  11. 11.
    Nagata S (1993) A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg 92:187–201PubMedCrossRefGoogle Scholar
  12. 12.
    Firmin F (2010) State-of-the-art autogenous ear reconstruction in cases of microtia. Adv Otorhinolaryngol 68:25–52PubMedGoogle Scholar
  13. 13.
    Firmin F, Marchac A (2011) A novel algorithm for autologous ear reconstruction. Semin Plast Surg 25:257–264PubMedPubMedCentralCrossRefGoogle Scholar
  14. 14.
    Karanth SK, Mokal NJ (2008) Silicone Foley’s catheter: a useful splint in ear surgeries. Indian J Plast Surg 41(1):51–54PubMedPubMedCentralCrossRefGoogle Scholar
  15. 15.
    Vercruysse H Jr, Green JIJ, Osman G, Harrison B, Miyagi K, Bulstrode NW (2018) Splinting after ear reconstruction: a stepwise and inexpensive workflow protocol. Ann Plast Surg 80(4):356–358PubMedCrossRefGoogle Scholar
  16. 16.
    Henderson R, Moffat C, Stewart K, Clapperton K (2015) UK Care Standards for the management of patients with microtia and atresia 2015. Accessed 5 October 2019
  17. 17.
    Fattah A, Sebire NJ, Bulstrode NW (2010) Donor site reconstitution for ear reconstruction. J Plast Reconstr Aesthet Surg 63:1459–1465PubMedCrossRefGoogle Scholar
  18. 18.
    Mendis KC, Pafitanis G, Bulstrode N (2019) A technique to aid minimal access harvesting in the second stage of autologous ear reconstruction. Ann R Coll Surg Engl 101(4):304PubMedCrossRefGoogle Scholar
  19. 19.
    Long X, Yu N, Huang J, Wang X (2013) Complication rate of autologous cartilage microtia reconstruction: a systematic review. Plast Reconstr Surg Glob open 1:e57PubMedPubMedCentralCrossRefGoogle Scholar
  20. 20.
    Cugno S, Bulstrode NW (2019) Cartilage exposure following autologous microtia reconstruction: an algorithmic treatment approach. J Plast Reconstr Aesthet Surg 72(3):498–504PubMedCrossRefGoogle Scholar
  21. 21.
    Breugem CC, Stewart KJ, Kon M (2011) International trends in the treatment of microtia. J Craniofac Surg 22(4):1367–1369PubMedCrossRefGoogle Scholar
  22. 22.
    Bulstrode N, Stewart K, Moffat C (2015) What age to offer ear reconstruction? J Plast Reconstr Aesthet Surg 68(9):1322–1323PubMedCrossRefGoogle Scholar
  23. 23.
    Steffen A, Wollenberg B, Konig IR, Frenzel H (2010) A prospective evaluation of psychosocial outcomes following ear reconstruction with rib cartilage in microtia. J Plast Reconstr Aesthet Surg 63:1466–1473PubMedCrossRefGoogle Scholar
  24. 24.
    Byun S, Hong P, Bezuhly M (2016) Public perception of the burden of microtia. J Craniofac Surg 27(7):1665–1669PubMedCrossRefGoogle Scholar
  25. 25.
    Ohara K, Nakamura K, Ohta E (1997) Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr Surg 99(4):1030–1036PubMedCrossRefGoogle Scholar
  26. 26.
    Brent B (1999) Technical advances in ear reconstruction with autogenous rib cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg 104:319–334CrossRefGoogle Scholar
  27. 27.
    Osorno G (2001) Microtia reconstruction. Eur J Plast Surg 24:107–113CrossRefGoogle Scholar
  28. 28.
    Zhao Y, Wang Y, Zhuang H, Jiang H, Jiang W, Hu X, Hu S, Wang S, Pan B (2009) Clinical evaluation of three total ear reconstruction methods. J Plast Reconstr Aesthet Surg 62(12):1550–1554PubMedCrossRefGoogle Scholar
  29. 29.
    Cronin TD, Ascough BM (1978) Silastic ear construction. Clin Plast Surg 5(3):367–378PubMedGoogle Scholar
  30. 30.
    Cronin TD, Greenberg RL, Brauer RO (1968) Follow-up study of silastic frame for reconstruction of external ear. Plast Reconstr Surg 42:522–529PubMedCrossRefGoogle Scholar
  31. 31.
    Beahm EK, Walton RL (2002) Auricular reconstruction for microtia: part I. anatomy, embryology, and clinical evaluation. Plast Reconstr Surg 109(7):2473–2482PubMedCrossRefGoogle Scholar
  32. 32.
    Reinisch J (1999) Microtia reconstruction using a polyethylene implant: an 8-year surgical experience. Paper presented at the Abstract and presentation at the 78th annual Meeting of the American Association of Plastic Surgeons, Colorado Springs, CO, USA, May 5Google Scholar
  33. 33.
    Romo T 3rd., Fozo MS, Sclafani AP (2000) Microtia reconstruction using a porous polyethylene framework. Fac Plast Surg 16(1):15–22CrossRefGoogle Scholar
  34. 34.
    Walton RL, Beahm EK (2002) Auricular reconstruction for microtia: part II. Surgical techniques. Plast Reconstr Surg 110(1):234–249PubMedCrossRefGoogle Scholar
  35. 35.
    Younis I, Gault D, Sabbagh W, Kang NV (2010) Patient satisfaction and aesthetic outcomes after ear reconstruction with a Branemark-type, bone-anchored, ear prosthesis: a 16 year review. J Plast Reconstr Aesthet Surg 63(10):1650–1655PubMedCrossRefGoogle Scholar
  36. 36.
    Thorne CH (2014) Ear reconstruction. In: Thorne C (ed) Grabb and Smith's plastic surgery, 7th edn. Williams & Wilkins, Philadelphia, pp 285–293Google Scholar
  37. 37.
    Zim SA (2003) Microtia reconstruction: an update. Curr Opin Otolaryngol Head Neck Surg 11(4):275–281PubMedCrossRefGoogle Scholar
  38. 38.
    Firmin F, Dusseldorp J, Marchac A (2016) Principles of two-stage autologous ear reconstruction. In: Firmin F (ed) Auricular Reconstruction. pp 3-21Google Scholar
  39. 39.
    Chin WS, Zhang R, Zhang Q, Xu Z, Xu F, Wu J, Li D (2011) Techniques for improving tragus definition in auricular reconstruction with autogenous costal cartilage. J Plast Reconstr Aesthet Surg 64(4):541–544PubMedCrossRefGoogle Scholar
  40. 40.
    Xu Z, Zhang R, Zhang Q, Xu F, Li D, Li Y (2019) New strategies for tragus and antitragus complex fabrication in lobule-type Microtia reconstruction. Plast Reconstr Surg 144(4):913–921PubMedCrossRefPubMedCentralGoogle Scholar
  41. 41.
    Kawanabe Y, Nagata S (2006) A new method of costal cartilage harvest for total auricular reconstruction: part I. Avoidance and prevention of intraoperative and postoperative complications and problems. Plast Reconstr Surg 117:2011–2018PubMedCrossRefGoogle Scholar
  42. 42.
    Sabbagh W (2011) Early experience in microtia reconstruction: the first 100 cases. J Plast Reconstr Aesthet Surg 64(4):452–458PubMedCrossRefGoogle Scholar
  43. 43.
    Cugno S, Farhadieh RD, Bulstrode NW (2013) Autologous microtia reconstruction combined with ancillary procedures: a comprehensive reconstructive approach. J Plast Reconstr Aesthet Surg 66(11):1487–1493PubMedCrossRefGoogle Scholar
  44. 44.
    Nagata S (1994) Modification of the stages in total reconstruction of the auricle: part IV. Ear elevation for the constructed auricle. Plast Reconstr Surg 93(2):254–266PubMedCrossRefGoogle Scholar
  45. 45.
    Li D, Zhang R, Zhang Q, Xu F, Xu Z, Tang X (2012) Titanium mesh strut: a novel instrument for firm elevation of the reconstructed auricle. Aesthet Plast Surg 36(3):746–749CrossRefGoogle Scholar
  46. 46.
    Lim SY, Mun GH, Hyon WS, Bang SI, Oh KS (2006) The elevation of the constructed auricle with a temporoparietal fascial flap wrapping a resorbable plate. J Plast Reconstr Aesthet Surg 59(5):505–509PubMedCrossRefGoogle Scholar
  47. 47.
    Tegtmeier RE (1977) A silicone foam ear dressing. Plast Reconstr Surg 60(1):131–132PubMedCrossRefGoogle Scholar
  48. 48.
    Bhandari PS, Singh S (2013) Dental impression compound as an effective splint for maintenance of ear elevation in microtia reconstruction. Indian J Plast Surg 46(3):518–520PubMedPubMedCentralCrossRefGoogle Scholar
  49. 49.
    Ohjimi H, Ogata K (1996) An elastic plastic splint to compress the ear after reconstruction using a temporoparietal fascial flap. Ann Plast Surg 36(6):652–654PubMedCrossRefGoogle Scholar
  50. 50.
    Yotsuyanagi T, Yamauchi M, Yamashita K, Yamada T, Kato S, Suzuki A, Saito T (2014) Correction of lobule-type microtia: part 2: the stage of ear elevation. Plast Reconstr Surg Glob open 2(9):e208PubMedPubMedCentralCrossRefGoogle Scholar
  51. 51.
    Cho BC, Kim JY, Byun JS (2007) Two-stage reconstruction of the auricle in congenital microtia using autogenous costal cartilage. J Plast Reconstr Aesthet Surg 60(9):998–1006PubMedCrossRefGoogle Scholar
  52. 52.
    Akter F, Mennie JC, Stewart K, Bulstrode N (2017) Patient reported outcome measures in microtia surgery. J Plast Reconstr Aesthet Surg 70(3):416–424PubMedCrossRefGoogle Scholar
  53. 53.
    Hamzavi S (2015) Porous polyethylene implant and rib cartilage in ear reconstruction: a comparison. Fac Plast Surg 31(6):611–616CrossRefGoogle Scholar

Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Plastic and Reconstructive SurgeryGreat Ormond Street HospitalLondonUK
  2. 2.Department of Plastic and Reconstructive Surgery, Sohag Cleft and Craniofacial UnitSohag University HospitalSohagEgypt
  3. 3.Institute of Child HealthUniversity College LondonLondonUK

Personalised recommendations