Fernando was born with microtia, a condition where the outer ear is underdeveloped or absent. He was missing his entire right ear. Doctors at CHKD reconstructed Fernando's ear using a novel two-step process. First, Dr. Moody created an ear canal and eardrum, allowing Fernando to hear from his right ear for the first time. Then Dr. Hoerr built an outer ear using a synthetic implant, giving Fernando a natural appearance. Six months after surgery, Fernando's ear had healed beautifully. He gained confidence from his new ear and haircut, and was thrilled to hear his classmates at school.

1. WRITTEN BY Rich Radford
PHOTOGRAPHY BY Susan Lowe
Feature
6 Children’s Hospital of The King’s Daughters SPRING 2016 7
Engineering
anEar ernando Merino-Lopez is an 11-year-old from Virginia
Beach whose charismatic smile reveals a deep dimple.
He’s anxious to show off his new haircut – a cropped,
closely shaved style that he just recently had the
courage to get, thanks to surgeons at CHKD.
For the first 10 years of his life, Fernando kept his hair long to
hide the fact that he did not have an ear on the right side.
Fernando was born with microtia and atresia, a condition in
which the outer ear, ear canal and eardrum are underdeveloped
or absent. It occurs to some degree in approximately one in 6,000
children. Of the three levels of the condition, Fernando had grade
3 microtia – the most severe form. His outer ear consisted of a
small bud of cartilage and the beginnings of an earlobe. He was
completely missing his right ear canal and could not hear on his
right side.
In addition to the challenges of limited hearing, Fernando was
teased about his missing ear.“Fernando grew his hair longer when
he started to realize his ear was deformed,” Maria Merino-Lopez
says. “I would tell him, ‘Fernando, don’t be bashful. Just tell them
that’s how you were born.’It was difficult.”
Five years ago, Fernando’s family lived in Washington state,
and doctors there suggested a standard surgical correction to
the boy’s condition. They could remove a piece of Fernando’s
rib cartilage and use it as a framework to build an outer ear,
but his family was reluctant to put their son through the
invasive procedure. Soon after, the family moved to Virginia
Beach, and Fernando’s pediatrician, Dr. Kate Crandley of
Tidewater Children’s Associates, a CHKD Medical Group practice,
recommended Fernando visit CHKD’s craniofacial center for
a consultation.
Dr. George Hoerr, a CHKD pediatric plastic surgeon, evaluated
Fernando in the spring of 2014. “When I first met Fernando, I
knew we could give him a good-looking ear,” says Dr. Hoerr,
who proposed an advanced reconstructive ear surgery that
would be much less invasive than the standard procedure.
Instead of rib cartilage, Dr. Hoerr would use a synthetic implant
to provide a shape for the ear – a specialized technique he has
used for ear reconstruction on the East Coast for more than
two decades.
CHKD surgeons reconstruct an ear

2. 8 Children’s Hospital of The King’s Daughters
“Thisapproachhasseveraladvantagesforyoungpatients,”
says Dr. Hoerr.“Children can undergo surgery as early as 3 or
4 years of age. Without the need for rib cartilage, recovery
is much easier and can be completed with fewer visits to
the surgeon. The synthetic implant helps makes it easier to
shape an ear that is more natural in appearance.
But Dr. Hoerr was eager to give Fernando even more than
a cosmetic solution. “I had great hope we could not only
build Fernando a natural-looking outer ear but also give him
the ability to hear in his right ear,” Dr. Hoerr says. He called
on Dr. Stephanie Moody Antonio, a pediatric otologist, to
evaluate Fernando for surgery to create the ear canal and
eardrum necessary for hearing.
Hearing tests and a CT scan were promising. There
were a few important anatomical parts needed in
order for Fernando to be a good candidate for ear canal
reconstruction – including a cochlea and hearing nerve.“On
a 10-point scale used to judge the potential for successful
reconstruction, Fernando had a score of 8,”says Dr. Moody.
Rebuilding Fernando’s ear would be a two-step process.
First, Dr. Moody would construct an ear canal opening
and an eardrum and adjust the middle ear bones to
allow Fernando to hear. Next, Dr. Hoerr would follow with
reconstruction of the outer ear. “Traditionally, the outer ear
would be reconstructed first and the ear canal second. In
Fernando’s case, however, I had the advantage of putting
the ear canal exactly where it belonged based on the
underlying anatomy instead of having to adjust placement
of the ear canal to the outer ear reconstruction,” says Dr.
Moody. “This approach also gave Dr. Hoerr a blueprint of
exactly where to construct the outer ear in relationship to
the ear canal, maximizing both appearance and function.”
That summer, Fernando had his first surgery to open the
ear canal and build his eardrum. Dr. Moody drilled through
the bone just behind the inner ear to create an ear canal
and designed an eardrum from a small piece of tissue
from Fernando’s scalp. Then, she used a skin graft to line
the ear canal. The procedure was a success.“He was able to
hear out of his right ear for the first time,” says Dr. Moody.
Because he still has some hearing loss, future procedures
are planned to reconstruct the hearing bones and continue
to improve Fernando’s hearing ability.
“When I first met
Fernando, I knew
we could give him a
good-looking ear.”
- Dr. George Hoerr
A synthetic implant pictured
here was used to shape
Fernando’s new ear.
Fernando had the beginnings
of an outer ear, but was born
without an ear canal and was
deaf in his right ear.
Drs. Moody Antonio (left) and Hoerr
(right) examine Fernando’s healed ear.
SPRING 2016 9

3. 10 Children’s Hospital of The King’s Daughters
Dr. Stephanie Moody Antonio
Dr. George Hoerr
Dr. Kate Crandley
Dr. Stephanie Moody Antonio
practices with EVMS ENT.
For more information on
CHKD ENT surgery, visit CHKD.org/ENT.
Dr. George Hoerr practices with CHKD
Surgical Group’s Plastic Surgery practice.
For more information on
CHKD plastic and reconstructive surgery,
visit CHKD.org/PlasticSurgery.
Kate Crandley practices with
Tidewater Children’s Associates,
a practice of CHKD Medical Group.
For more information on CHKD primary care
physicians, visit CHKD.org/FindADoctor.
After the inner ear had healed for a year, Fernando
underwent surgery to reconstruct his outer ear
this past fall. Dr. Hoerr carved the synthetic implant
to closely match Fernando’s left ear, crafting it
approximately 10 percent larger than Fernando’s left
ear to account for growth. An incision was made above
the ear to take tissue lying just beneath Fernando’s
scalp, which Dr. Hoerr stretched over the synthetic
ear framework, covering it with living tissue. Once in
place, Dr. Hoerr took a skin graft from Fernando’s inner
arm – skin that closely matches the ear in color and
texture – to cover the entire new ear.
“The procedure went very smoothly,” says Dr. Hoerr.
Fernando returned to surgery a month later for some
minor touch ups to his skin graft, and just weeks after
surgery, swelling was gone and the color of the ear
began to look natural. Six months after the procedures,
it was hard to tell the ear wasn’t there all along.
When Dr. Hoerr, Dr. Moody and Fernando met this
spring for a follow-up visit, it was a time for celebration.
Not only was Fernando sporting his newly healed ear,
his new haircut spoke volumes of the young man’s
newfound confidence.
His school friends noticed this new look too, he told
his doctors. “I could hear my classmates whispering
in homeroom. And I could hear them out of my new
ear, which was even better,” Fernando says, a huge
grin forming between his dimpled cheeks. “I looked so
different that day that my teacher almost marked me
absent until I said, ‘I’m here! I’m here!’”
Six months after surgery, Dr. George Hoerr was
delighted to see Fernando – who was sporting
a new outfit and haircut for the occasion.
SPRING 2016 11