This document discusses microtia reconstruction using Medpor implants. It describes the grades of microtia from mild (Grade 1) to complete absence of the ear (Grade 4). The procedure involves marking positions, identifying arteries, elevating skin flaps, harvesting grafts, implant construction, placement and fixation, and closure. Key steps include harvesting contralateral and abdominal skin grafts, shaping the implant, securing the implant and transposing the earlobe. The results show initial swelling resolving over a month. Complications can include skin graft loss or exposure requiring further procedures.

1. Microtia: Medpor
Reconstruction
Philip AYoung, MD
Aesthetic Facial Plastic Surgery, PLLC
Face to Face
Ho Chi Minh City,Vietnam
2014

2. Microtia:
Spectrum of congenital malformations:
1. Grade 1 slightly smaller ear with the majority of structures present
2. Grade 2 greater deficiency of ear structures (absent lobule, helix)
3. Grade 3 classic peanut deformity
4. Grade 4 Anotia complete abscense
Etiology:
1. Not well understood
2. 3rd week of gestation: hillocks of His develop around otic placode
3. Thalidomide and Accutane have caused microtia
4. Ethane Dimethanesulfonate dose dependent changes
Epidemiology:
1. 2-3 births in 10000 increased rates in Asians, Hispanics
2. Navajo 1 in 1200
3. More commonly male, unilateral 90%, right sided
4. Risk Factors: higher altitudes, high birth order, increased paternal age,
prenatal drug exposre

3. Grade 1:

4. Grade 1 majority structures are present, ear is
slightly smaller

5. Grade 2:

6. Grade 2 greater deficiency with possible absent
helix, lobule

7. Grade 3:

8. • Grade 3 Classic Peanut ear
• To Grade 4Anotia complete absence of the
ear

9. Microtia:
Options:
1. Prosthesis: Using 3 titanium screws or use of
adhesives, prosthesis usually needs to be replaced
every 3 years. Costs (3000-7000) and more
2. Medpor: Use ofTpf flap contralateral skin graft,
abdominal skin graft, excellent biocompatibility,
stability, tissue integration (150 micrometer pore
size), resistance to infection, supports secondary
intention healing
3. Costal Cartilage: Ribs 6-8, and floating 9th rib,
Contralateral,

10. Medpor:
Age:
1. Classically age 5-6 is the earliest
2. Ear can grow up until 15,
3. Cartilage remnant has been shown to grow, Medpor
is an alloplast
Points:
1. Medpor 2 component is around 2000
2. The operation can take 6-7 hours
3. Includes: marking the position, identifying the ST artery with
doppler, Elevating the sptf skin flap not the actual flap with
remnant removal (save), harvesting contralateral ear skin graft,
harvesting abdominal skin graft, Covering ear with abdominal
skin graft, implant construction, implant placement, Complete
sptf elevation and coverage of implant, coverage of implant
with ear skin graft, drain placement, watertight closure,

11. Medpor:
Marking the Ear Position:
1. Lateral Canthus, Alae, Oral Lateral
Commisures
2. Visual Inspection from multiple
angles from frontal aspect

12. Medpor:
Marking the Ear Position:
1. Close up of the radiograph

14. • Here is the ear drawn out.
• I like to orient the ear anteriorly to see how it
will rest at the right angle
• That is why there are 2 pictures ears drawn
out

15. Medpor:
Track the Course of the Superficial
Temporal Artery - Doppler:
1. Becomes more superficial around the helix
anterior superior attachment about 1 cm
anteriorly
2. Branch point approximately 4-6 cm superiorly

16. Medpor:
Track the Course of the Superficial
Temporal Artery - Doppler:

17. • Here is the artery marked out
• I couldn’t reliably find the other branch
• The incisions are zigzagged to avoid incisions
over the spta

19. • This diagram shows where the incisions would
be and the path of the artery
• Notice how the incisions cross over the artery
minimally

20. Medpor:
Elevate the SuperficialTemporal Artery
Flap:

21. • The elevation is in the subcutaneous plane just
superficial to the superficial temporal fascia
• Usually the plane is clear, make sure to do it
bluntly
• Extra bleeding means your likely in the wrong
plane

22. Medpor:
Taking out the Remnant:

23. • Here is the dissection of the remnant cartilage
• At this point you can also get the earlobe
ready for transposition based on inferiorly

24. Medpor:
Harvesting the Contralateral ear skin
graft:

25. • You can wait to see how much skin you need
but the larger the better
• The more you have the same skin on one side
the better
• You can pretty much use the whole post
auricular area and up to the hairline as shown

26. Medpor:
Harvesting the Contralateral ear skin
graft:

27. • The ear is pinned forward with 2-0 nylon
• And as you can see the whole post auricular
surface is taken

28. Medpor:
Harvesting the abdominal skin graft:

29. • The length is based on (the way I choose to do
this is) how the long the ear is times two and
the width
• Is based on the distance from the helix to the
hairline approximately

30. Medpor:
Harvesting the abdominal skin graft:

31. • I use permanent sutures to close the deep
layers staggered with non absorbables
• 3-0 nylon, 3-0 biosyn
• Then 4-0 nylon and 5-0 prolene

32. Medpor:
Defat the grafts:

33. • Defat the graft to help with survival as well as
contour refinement of the implant

34. Medpor:
The abdominal skin graft goes over the
post auricular defect:

35. • Here is the abdominal skin graft being placed

36. Medpor:
Apply the Bolster:
1. Xeroform and 2-0 nylons

37. • I use xeroform and 2-0 nylon

38. Medpor:
Post Operatively:

39. • Post operatively
• Not the prettiest result
• But I have not done any resurfacing to
improve this and this is at the one month post
procedure time point

40. Medpor:
Implant Reconstruction:
1. I use 4-0 nylon, cautery option,
mersilines option

41. • Bacitractin in a 60 cc syringe
• Vacuum suctioned negative pressure to pull air out and pull
in the bacitracin
• 4-0 nylon to reconstruct versus mersiline or cautery
(reinisch)
• Dr. Reinisch cuts out the segment where the incisura
connects to the base to create a bigger concha?
• This is harder than it looks

42. Medpor:
Implant Reconstruction:
1. The bottom helix and base is cut off

43. • The bottom helix and base are cut off
• Allows the earlobe to be softer
• Kept if there is no earlobe remnant
• You can control how big the ear is with this part of the
procedure
• I think I left too much for this particular patient but can
go back and take off more

44. Medpor:
EarlobeTransposition and preparing the
earlobe to accept bottom of the
implant:

45. • You may need to dissect the earlobe in half to
accept the lower portion of the implant

46. Medpor:
Finding the right position for the
implant:

47. • I then use both drawings that I made earlier to
find the right position and verify it visually
from mutliple angles even sitting patient up
and getting opinions from others in the room

48. Medpor:
I fix the implant with 4-0 nylon as well

49. • I fix the implant with 4-0 nylon as well

50. Medpor:
Now we elevate the flap, usually the dimensions are
10 x 5 cm but you need to verify that it will completely
cover the implant

51. • I fix the implant with 4-0 nylon as well
• Video 87
• May need to reinject this will bleed a lot

52. Medpor:
-superficial plane is subcutaneous deep to hair follicles
-deep plane is just above deep temporalis fascia

53. Medpor:
Here is another picture of the superficial and deep
layers

54. Medpor:
-Here the drains have been placed one under implant,
one under donor site
-The suction is tested for contour
-The flap has been sewn around the implant

55. Medpor:
-The Earlobe is being sewn into place

56. Medpor:
-The skin graft is being sewn into place

57. Medpor:
-More of the finished product

58. Medpor:
Results from this patient:

59. • At first the contours are not as distinct due to the
swelling
• This was gradual over the first month
• We had some skin graft loss and were worried about
sptf death
• Some exposures can be fixed with local flaps, occipital
artery flap, or loss of the implant

60. Medpor:
Results from this patient:

61. • The ear looks lower partly because of the
superior pole being more medialized
• You can elevate the whole ear and there are
approaches that you can do based on a
superior flap of the superficial temporal artery
system

62. Rib:
-Most people wait until the child is at least 5-6 years old
-Harvest from the 6-9 rib contralateral side
-synchondrosis of 6,7,8 and floating portion of 9th rib

63. • The ear looks lower partly because of the
superior pole being more medialized
• You can elevate the whole ear and there are
approaches that you can do based on a
superior flap of the superficial temporal artery
system