Microtia and the Changing Possibilities of Ear Reconstruction

For children born with microtia, ear reconstruction has long meant decisions that reach beyond appearance alone. At Columbia, advances in synthetic cartilage, patient-specific modeling, and multidisciplinary care are changing what is possible—offering families a more precise, less invasive path toward reconstruction and hearing support. In this interview, Thomas Imahiyerobo, MD, Director of Cleft and Craniofacial Surgery discusses the latest in treatment.

Can you explain what microtia is?

Microtia, or ear abnormalities in general, are the most common congenital facial abnormality.

The majority are what we call minor ear malformations. The ear has formed and all the major parts are there, but they may not be in the right position: too folded, underfolded, too forward, or too far back. Those are very common, and in this day and age we try to treat them non-surgically with things like infant ear molding.

But we still see a lot of children at Columbia who have a major ear malformation, where some portion or all of the external ear has not formed. When the majority of the external ear has not formed, we call that microtia. It can range from an ear that is simply smaller than the other side all the way to anotia, when there is no external ear, just skin, and not even an ear canal.

How is microtia treated?

There are various techniques, but they all fall under the umbrella of microtia reconstruction. The classic way to treat microtia involves rib reconstruction. The ear is mostly made out of cartilage, and the most common source of donor cartilage in someone’s body is the ribs.

Most microtia reconstruction worldwide is done with rib cartilage. It can take several ribs, most commonly parts of the sixth, seventh, and eighth ribs. We use the cartilaginous part of the ribs, not the bony part. The donor rib cartilage can be fashioned into an ear and then transferred up to the side of the head, under the skin envelope, to form an ear.

Is that usually done in one operation?

Typically, no. There are two major schools of reconstruction. There is the Nagata form, which involves two steps, and then there is another form that involves three steps.

But what Dr. Naikhoba Munabi does now takes that a step further. She does not use the child’s ribs at all. With advances in medical modeling and prosthetic materials, she performs a reconstruction based on MEDPOR, a synthetic replacement for cartilage. The MEDPOR can be carved into the shape of an ear, placed under the patient’s own tissue, and combined with skin grafts. With that approach, the whole ear surgery can be done in one step.

At the minimum, the benefits include a one-step surgery and no donor site, which is huge. Not having to take the child’s ribs is a major advantage. Many people would also argue that the aesthetics of the MEDPOR reconstruction look better. It is really a win-win for patients.

Are children with microtia usually affected on one side or both?

You can see all versions, but typically it is just one ear. You can have microtia where the internal ear is totally normal, so the child does not have an external ear but still has the potential to hear. You can also have microtia where the internal ear is congenitally affected too. That is why we have formed a multidisciplinary team.

Our multidisciplinary microtia team at NYP includes plastic surgeons, led by Dr. Munabi; ENT colleagues in otology, who help with the internal ear aspects; and audiologists, who help patients optimize hearing.

How common is that kind of comprehensive microtia program?

Some other major children’s hospitals have similar teams. Children’s Hospital Los Angeles, where we recruited Dr. Munabi from, probably has a similar team. But there are very few places that do MEDPOR reconstruction.

We have one of the only MEDPOR centers in the tri-state area. A lot of patients from this part of the country still travel to Los Angeles, where this technique really began, to get surgery. With Dr. Munabi here, we are able to give patients an option locally.

What is next in microtia reconstruction?

Dr. Munabi has either done or is about to do her first case with a new MEDPOR substrate that allows for patient customization. It is called Su-Por, and to me, that is really the culmination of a lot of cool techniques.

You are taking the MEDPOR technique, which already has benefits in terms of aesthetics, no donor site, and one-step surgery, and adding customization. With this, she can do a virtual planning session for the Su-Por ear. Based on the patient’s CT and size characteristics, they can match it more specifically to the child’s other native ear and create a customized MEDPOR construct. Then she can implant that into the patient.

To me, that is really the final evolution of reconstructive processes for the ear. That is a program she has been able to get off the ground for us here, and we are really excited about it.