.png){kind=small}
.png){kind=small}
BackTable / ENT / Article
Microtia Surgery: From Diagnosis to Reconstruction
Dana Schmitz • Feb 15, 2024 • 38 hits
Microtia surgery embodies a remarkable blend of technical innovation and empathetic patient care. Central to this approach is the early, comprehensive engagement with families, ensuring they are fully informed and supported from diagnosis through to surgical planning and follow-up. The advent of 3D printing and modeling utilizing high-resolution CT scans represents a pivotal advancement in the field, enabling surgeons to craft highly detailed, sterilizable models of the ear. This not only aids in accurate surgical planning and execution but also serves as an invaluable educational tool for both families and novice surgeons. Microtia surgical technique, from the preparation of the skin pocket to the nuanced art of cartilage carving with precision blades, requires care and precision at each step.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• Conversations in the clinic between parents and the surgical team are divided into hearing and ear reconstructive topics. Yearly follow-ups monitor hearing aid usage, school accommodations, audiograms, and the health of the non-affected ear, while the normal ear and chest are measured annually to determine surgical timing.
• Chest measurements around the xiphoid area indicate cartilage availability for surgery, with 60 centimeters as a general benchmark.
• Standard teaching suggests that the ear reaches about 80% of its growth around 5-6 years of age.
• Obtaining a CT scan for all patients allows understanding of the temporal bone anatomy and ensures the candidate's suitability for ear canal reconstruction.
• 3D printing produces a sterilizable, high-fidelity model of the ear, which is slightly smaller than the actual ear to account for the skin envelope.
• Precise placement of the new ear is determined using skull landmarks such as orbits and mastoid suture lines. Measurements are taken from the canthus to the desired ear position, and relative to the nasal dorsum for precise placement.
• The sequence of ear assembly begins with the base plate, followed by the antihelix, P1 (support), helical rim, tragus, and ends with anti-tragus.
Table of Contents
(1) Initial Consultation & Surgical Decision-Making in Microtia Care
(2) Microtia Ear Reconstruction Surgery with 3D Printing & Modeling
(3) Auricular Reconstruction in Microtia Ear Surgery: Proportions & Techniques
(4) Carving & Suturing Techniques in Microtia Ear Reconstruction Surgery
Initial Consultation & Surgical Decision-Making in Microtia Care
In the complex journey of treating patients with microtia, early interactions and decision-making play pivotal roles. The importance of the initial consultation phase is emphasized, noting that most families are often unaware of the condition prenatally, making the diagnosis a surprise post-delivery. With a compassionate approach, parental emotional wellbeing is first addressed, followed by a conversation explaining hearing and ear reconstruction aspects. Regular follow-ups provide an opportunity to measure the normal ear's growth and the chest frame, which offers valuable insight when considering surgical intervention timing.
[Dr. Gopi Shah]
Before we get into the surgical techniques, when do you usually meet these families? Do you ever have any prenatal visits, or do you meet them in their first six months of life? When is your first meeting with some of these kids?
[Dr. Mai Thy Truong]
That's a great question. I would say the majority of families don't get the prenatal diagnosis. That's because if you look at an ultrasound, the way the ear is shaped, it's very hard to catch the ear in a single plane. A microtia ear, unless there's an anotia, even then it's just too hard to see. I think if you get a 3D ultrasound, maybe you'll catch it, but most families don't know. Usually, it's like a surprise at delivery. My heart goes out to these parents, especially the moms. It's like the surprise that you weren't expecting, so we like to consult when they're born. That initial consultation is in the hospital, or if they're born in another hospital, after their newborn hearing screening, I'll see them in their infancy.
[Dr. Gopi Shah]
Okay. Then when you meet the family, I find that that first conversation can be really difficult in terms of explaining everything that's going on and the trajectory of it. What is your conversation like?
[Dr. Mai Thy Truong]
First, I really want to design it well, so the first thing is, these patients get extra long visits. It's not my standard new patient visit. We double-team it, Dr. Kay Chang and I. We're a two-surgeon team. We're like mom and dad in the OR and in consultation. We're a really good balance. We sit down with the parents. I really like to get a feel on emotionally where they are, because if they're just not there, then our first visit is just to hold their hands and really remind them that their kid is going to grow up and be awesome, no matter what they choose.
We purposefully divide the conversation into hearing topics, and then ear reconstructive topics. We ask the parents, "Where would you like to go with this conversation?"
[Dr. Gopi Shah]
How do you usually follow them? What's your follow-up plan until you start considering surgery?
[Dr. Mai Thy Truong]
We see them initially as a newborn until a hearing status is decided. If it's very straightforward, we fit them with a hearing device, which is called the Baha on a soft band. As soon as that's ready, then we see them once a year.
[Dr. Gopi Shah]
When you see them once a year, are you getting audios as well on your good ear? I find that initially when I first started practicing, sometimes I would be so focused on the microtic ear, but I would feel like, "Wait a second, that good ear needs to be extra specially taken care of." Meaning this is your ear where if we're starting to get ear infections or fluid, or if there's any concerns in school and where the child should sit, do y'all talk preferential seating and talk to the families about some of that?
[Dr. Mai Thy Truong]
Yes. I think every year our goal is like, "Are they wearing their hearing aid, their Baha Softband?" If not, are we doing an FM system at school? Are they getting their preferential seating? How are they coping with it? We always like to talk to them about advances in hearing devices and hearing implants, the ear health of the other ear, any obvious genetic syndromes that may be more apparent and other consults that may be needed, and then a check-in with the parents, like, "Hey, how are you guys doing? Any speech delay? What are you guys thinking about surgery?" All the surgical options.
For me, it's really important, whatever surgical option they choose, I want to help them coordinate the care. That it's very planned.
[Dr. Gopi Shah]
Absolutely. Then on those check-ins, the yearly check-ins, are you getting just an audiogram usually, a behavioral audio?
[Dr. Mai Thy Truong]
I get an audiogram, then two things that we like to do is we like to measure their normal ear and measure their chest frame. Measuring their normal ear gets us a sense of when the ear stops growing. After doing this for many years, it becomes very apparent there are growth spurts in the ear where we'll see them, we're like, "Your ear grew 5 millimeters."
Then when we're trying to decide, "Is this a good age to do surgery?" "Your other ear has stopped growing." It's just nice to know.
[Dr. Gopi Shah]
I feel like the textbook teaching is about six to seven years old of when it's about 80%. Is that a good number or do you find with the measurements, there's a wider range or it could be younger or much older even? What have you found?
[Dr. Mai Thy Truong]
I think that five to six is 80% is about right, but seven to nine, that growth is pretty stable. 7 to 10, that's a preferable age.
[Dr. Gopi Shah]
When you take the chest measurements, where exactly are you placing the measuring tape? I would imagine the chest would probably continue to still grow. Is there a certain cutoff? What are you looking for in that measurement?
[Dr. Mai Thy Truong]
This is not perfect. The idea is we're trying to see if the chest frame is robust enough for surgery. Something that's very standard is at the xiphoid. We take it at the xiphoid, we go all the way around. It's not a perfect measurement. If the child is obese, it's not a good reflection of their chest frame, but it's something. We have a standard goal of 60 centimeters. We've learned that if there's 60 centimeters circumference, then in general, we'll have enough cartilage to make an entire ear.
[Dr. Gopi Shah]
Okay. Sorry to jump back to the ear measurements. Are we doing length, width, projection? Is it with one of those measuring tapes? Are you getting a protractor out? What's happening?
[Dr. Mai Thy Truong]
This is awesome because it's weird. If you look at an ear, no matter what, there's at one point, the longest point. We just pick the longest point. I have this special caliper. I got it from Dr. Fee. My old head and neck attending. He called it the golden rule. It has a little clasper, so it can pretty accurately measure the ear.
[Dr. Gopi Shah]
That's from bottom of the earlobe to the--
[Dr. Mai Thy Truong]
To the very tippy top.
[Dr. Gopi Shah]
Okay. Got it.
[Dr. Mai Thy Truong]
Wherever along the ear it's longest.
[Dr. Gopi Shah]
Okay.
[Dr. Mai Thy Truong]
Which I call the ear access. Ears have an access. Some people have really turned ears, and some people have ears that are really straight up and down.
Listen to the Full Podcast
Earn CME
Reflect on how this Podcast applies to your day-to-day and earn free AMA PRA Category 1 CMEs. Follow the button below to claim your credits on CMEfy.
Stay Up To Date
Follow:
Subscribe:
Sign Up:
Microtia Ear Reconstruction Surgery with 3D Printing & Modeling
Microtia surgery, particularly for grade 3 conditions, has witnessed significant advancements with the integration of 3D printing and modeling. High-resolution CT scans generate highly detailed and sterilizable 3D printed models of the ear, which mimic the intricate relationships between various anatomical landmarks. This innovation ensures accurate ear placement during surgery by making comparisons to these detailed models, rather than solely relying on traditional techniques like flat drawings or photographs. The process not only elevates the precision of surgical outcomes but also provides a tangible tool for surgeons during the actual procedure.
[Dr. Gopi Shah]
Okay. That's also very good to know. All right. Let's get into the surgical details because unless, like you said, you really have had a lot of training in microtia or that's what you plan to do, I would say most of us aren't going to be doing microtia surgery, but we do have to understand how it works. Also, again, what is our screening process for the other ear? Which we were able to touch on. I wanted to talk to you, Thy, about the surgery, given your expertise and experience.
Let's say the child is seven years old. You feel that the growth in the chest is, it's the robust 60 plus centimeters. The ear, the last year or two, has hit its maybe peak or that 80% to 90% of what we normally think. We're talking about grade 3 microtia. We can focus on that, I think, first. For your preparation, are you using 3D printing? Is that part of your preparation? Tell us how you start kind of planning your surgery.
[Dr. Mai Thy Truong]
Okay. The first thing is we get a CT scan for all kids. That allows us to understand the temporal bone anatomy. Make sure we know if they're a good candidate for ear canal reconstruction. Make sure there's no cholesteatoma or anything happening behind the little ear, the underdeveloped ear that we can't see. That gives us information about the other ear.
I meet with a company that takes that really fine detail of the other ear. We make it into a mirror image. We have what we call a planning session. We take it and we design each individual segment that I would actually carve during surgery, which is the helix, the antihelix, the tragus-antitragus complex, and then make an actual 3D printed model. The thing that's different about this than other people who say they use models is that it's high fidelity. Our CT scans are 0.25 millimeter thickness. It's printed in a sterilizable material. You know how some 3D prints are just globby? This is really a perfect ear.
We've learned how to design it in a way that really matches the surgery, which means it actually has to be a little bit smaller than the regular ear to account for the skin envelope. You have to design it in a way that's similar to how you carve it. For every surgery, I have this ear that I'm holding in my hands to help me carve. When you first start carving an ear, it's so complex, the three-dimensionality of it. The traditional surgeon uses photos that are posted on the wall of the patient, and then a flat drawing on an X-ray film.
It's very hard to know the peaks and the troughs and how things relate to each other, so as an early carver, having this ear in my hands, I've really learned a lot about the relationship of each thing. I just think anyone who's starting out doing microtia surgery, I think they should have this 3D model. By the end, it's so funny because I showed Dr. Firmin my 3D model and I was just so proud of myself. I was like, "Look, Dr. Firmin, what we're doing now." She looked at it and she was like, "I don't need this." She didn't.
[Dr. Gopi Shah]
Then in terms of the Firmin technique, you have your CT scan, your 3D model, and now the patient is in the OR, are there measurements that you take or anything that you do before, the prep and all that stuff? Are these measurements in the office, the OR? Let's get into that.
[Dr. Mai Thy Truong]
The weirdest thing about prep for this surgery, as opposed to other reconstructive surgeries that we do, is that we're trying to match something to the other side, which happens to be on the other side of the head, which is not always in your field of view. Then there's all these things about the ear, how tall it is, how front or back it is, and then how turned it is. Surgeons have tried many different ways to do this and it's quite challenging. Some surgeons will leave the whole head prepped, in view for the surgery, so that they can constantly refer back to the other ear.
I worry constantly about sterility because the nose and the mouth and the eyes and the hair, we're putting a cartilage framework into a pocket. I just don't want any risks of infection. This 3D modeling that I do, the amazing thing is I can work with a computer programmer and we can place it perfectly in place on a picture. The way we do it is we use the actually skull landmarks. We line up the orbits and line up all the mastoid suture lines and actually the bony landmarks instead of the soft tissue. Then we place the ear.
Before surgery, I have a picture of where the new ear should go relative to the microtia ear. At the end, when I draw my drawings, I have this comparison. It's not perfect, but it's really nice to know, "Hey, this looks very similar to my 3D printing." That's really upped our game in terms of size and placement.
[Dr. Gopi Shah]
Do you use that to help you decide where your incisions are made or in relation to what level of the eye you're putting it, the angle? Tell me exactly how the drawing and the details of that help you. How do you apply it, I guess, when you're operating?
[Dr. Mai Thy Truong]
You do some measurements from the canthus to where the new ear should go, both the oral and the ocular canthus. Then you take measurements relative to the nasal dorsum. Then you draw where your ear should go. Then to decide on your incision, you say, if this is where the new ear should go, how do I make the skin of the microtia ear go there? Then decisions are made on incision.
[Dr. Gopi Shah]
Wow. Okay. At this point, the patient is not prepped and draped. Your markings are giving you an idea and a measuring. Patient is asleep, your bed is 180, all that, but this is the pre-marking everything out.
[Dr. Mai Thy Truong]
Yes. I really do think the time spent for that stage is really, really important. That 3D picture that I get from the company ahead of time, I actually do that in my mind. I have decided on the incision from that 3D modeling session.
[Dr. Gopi Shah]
Then you have the model with you in the OR and you do your measurements, figure out your landmarks, and then you can also place the model and then see how that then is, how you want to do your incisions based on that. That's very cool. Okay. Then are you tegaderming the eyes and then prepping everything out? Are you covering the mouth with your towels? I think these details are important.
[Dr. Mai Thy Truong]
The classic Firmin approach is that once you do your drawings, the most important drawing on the face near the ear is the angle of the ear, the axis of the ear. On the cheek, there's going to be an arrow that will guide you to which axis the ear should be placed once it's in its pocket. That drawing is left on the cheek near the ear and will be in the field. I cover it with a Tegaderm so that it doesn't get washed away with the surgery. Then I have my drawing of where the ear should go, and I cover everything else up.
[Dr. Gopi Shah]
Okay. You're not using the contralateral ear at this point. You don't need to because you have your models and your measurements.
[Dr. Mai Thy Truong]
Yes, and my drawings.
Auricular Reconstruction in Microtia Ear Surgery: Proportions & Techniques
The art of microtia surgery is delineated into multiple phases, with each requiring meticulous precision and planning. The skin pocket, which plays a pivotal role in the post-operative appearance of the ear, needs to be carefully prepared. When constructing the auricular framework, a 3D model serves as a guide for determining the rib portions to be used. While the base plate stands out as a critical component, surgeons often engage in detailed planning to decide which rib piece corresponds to each subunit of the ear. The inking process, vital for maintaining proportions, is done using a specific technique to ensure precision, highlighting the intricacies and minute details surgeons must consider, down to the millimeters.
[Dr. Gopi Shah]
Got it. Okay. Now we've done the rib harvest, let's talk about what you're doing at the back table and creating the framework. You have this rib, I assume that's what you also use the 3D model that you have.
[Dr. Mai Thy Truong]
Yes. It's interesting. I prepare all the surgeons in the room for the three phases of microtia surgery. That's to mentally prepare them. Phase one is two teams harvesting the rib and preparing the skin pocket. The preparation of the skin pocket is probably the most important for the outcome of the surgery. There's two main battles. You must make a nice framework because nothing is hidden under the auricular skin. That's a commandment from Dr. Firmin. She has 10 commandments.
It's so true. You can have a beautiful skin pocket, but if your framework at the end of the day is not harmonious or not nice, it will be evident. It may not be evident in the first post-op week, but in four months when the skin edema is all gone, then you'll see it. Skin pocket is important and it's all about planning your skin approach. That's done and then we go to the back table. Then we have our 3D model. We use that model to then draw X-ray film to cut it out to decide which piece of rib goes to what.
[Dr. Gopi Shah]
Is it the same floating for the helix every time or do you re-look at everything that you have in terms of the rib you have and then decide?
[Dr. Mai Thy Truong]
You look at the rib that you have and then decide. There are some classic patterns. One branch point is, is that floater big enough for a helical rim? Yes or no? On a smaller kid like age seven, a lot of times the answer is no. When it's not, at the harvest, we go for the next rib. We actually harvest bigger rib. That's decided intra-op while the rib is being harvested often.
[Dr. Gopi Shah]
You talked about the five microtia subunits, I think. You talked about creating the helix. Can you go through those? Are you creating those subunits separately first? Does it all carve out as one piece? How does that work?
[Dr. Mai Thy Truong]
No. I definitely draw each piece on all the ribs that's harvested and I plan it before any cut is made. That used to stress me out because once you cut that's all the rib you get. The most important for me is having a good base plate because that's the ear itself. Then I think the antihelix is the next important thing. There's two worlds of thought. The antihelix or the Y piece is either a single piece that you cut right in half and you split or a wide piece of rib that you cut out in between. I can look at a surgeon and their work or their ears and I'll know which they did. Of course, what I'm looking at is probably not what anyone else is looking at, but deciding where those pieces come from is the next step, and inking it out.
[Dr. Gopi Shah]
Then after you've inked it out and you feel good with the subunits you have, I assume you look at the model-- I just see myself walking in circles, second-guessing myself. Anyway. Then what's your next step? Then what do you do?
[Dr. Mai Thy Truong]
The inking it out is actually quite a big deal.
[Dr. Gopi Shah]
Are you just using one of those purple skin marking pens, they have it on the back table for you, or is there a special cartilage inking pen?
[Dr. Mai Thy Truong]
Dr. Firmin and Dr. Nagata use this amazing damping paper. They would dip it in ink. They would cut it out and then they would literally stamp on the cartilage. It was the most amazing thing. It was this beautiful stamp of the ear. That ink that they used is not FDA-approved, so we can't use it. I just use a purple marker. You end up going through quite a few markers because it doesn't last, but they're only $2. It's okay. Then drawing it out. There's like a little art to it because you have to dot around but draw on the inside. It's all about proportions. If you aren't aware of where you cut relative to the inside or the outside of your drawing, your proportions will be all wrong.
[Dr. Gopi Shah]
You're talking about the width of the actual ink or the mark?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
Because we're talking about millimeters at this point. Do you always do it the same way where, okay, I know that my outside is going to be bigger than my inside and the inside of the dot is more consistent with the framework and the model, or?
[Dr. Mai Thy Truong]
I know that because I'm using a cut-out piece of X-ray to draw onto the rib and then I'm dotting around it, so then I remove it and I draw on the inside of that line and then I'll cut on the line.
Carving & Suturing Techniques in Microtia Ear Reconstruction Surgery
Various blades are used for specific outcomes in microtia surgery. For example, an 11-blade can carve beautiful curves, but it may not achieve full thickness. This potential shortfall is compensated by finishing the curve with a 15-blade. This intricate process helps avoid unwanted re-cuts. Additionally, while cartilage can be held with forceps, the tactile feedback from fingers offers enhanced haptic perception, aiding precision. The choice between monofilament sutures and steel sutures is crucial, with the latter offering a sturdier hold and reduced cartilage resorption, as shown in research. The construction of the ear has a sequential order, starting with the base plate, then the antihelix, followed by P1, helical rim, tragus, and finally, anti-tragus.
[Dr. Gopi Shah]
What do you use to carve? What kind of blade do you like?
[Dr. Mai Thy Truong]
I'm really particular. We always need to have an 11-blade, a 10-blade, a 15-blade, and a 2, 3, and 4-hole punch, as well as some carving tools. The punches, I learned, are always sharp because they're disposable. They're amazing to carve out the scapha. Dr. Firmin has these lovely carvers to scoop out those pieces. What I learned over time is that there are these really curved places that you're carving and the best way to get those curves are with an 11-blade because it's very sharp.
You're going to get through these really amazing curves with the 11-blade, but what you're going to realize is that it's very hard to get full thickness with an 11-blade. You'll start to curve but you won't be full thickness. If you try to go back with the 11-blade, then you'll cut into your original curve and so people are scared to use the 11-blade. I always say in my carving sessions that you start with the 11-blade to get those beautiful curves but you finish with the 15 because the 15 is small and then can follow the curves without re-cutting into it. Does that make sense?
[Dr. Gopi Shah]
Yes, it does. You're not scraping or cutting into the piece that you actually need. You want to have a clean through and through cut.
[Dr. Mai Thy Truong]
Exactly, yes.
[Dr. Gopi Shah]
Okay. I need to take one of these carving courses. What are you holding the cartilage with? What kind of forcep? I would imagine you have in the other hand, or are you holding the cartilage–
[Dr. Mai Thy Truong]
Fingers.
[Dr. Gopi Shah]
Your own hands?
[Dr. Mai Thy Truong]
Yes. I have all these memories of watching Dr. Firmin carve because it's an amazing thing to watch. She would often cut herself, every surgery, because we were using needles and knives. Changing gloves is just have 30 sets of gloves. I wouldn't say that I cut myself that often, but I'm really big into haptics. I love how my fingers feel, how the instruments feel. I really feel like feeling it is important.
[Dr. Gopi Shah]
Are you using loops?
[Dr. Mai Thy Truong]
Loops.
[Dr. Gopi Shah]
Loops. Okay. Then what if you break it or it bends, what do you do?
[Dr. Mai Thy Truong]
I cry? No, I'm just kidding.
[laughter]
[Dr. Gopi Shah]
What if something happens, what do you do in those situations? Let's say just I can imagine the cartilage in some places it's just getting too thin to manipulate, right?
[Dr. Mai Thy Truong]
This is why carving is so stressful and it's not one of those things we're like, "Hey, try it." You know what I mean? You've got to practice. I practiced on foam. Foam because that's what Dr. Firmin chose. I love it. It's very similar. You just can't make that mistake. I think that's why the helical rim is so stressful too. We spend a lot of time on the helical rim. Actually, while one person is carving the base plate and the antihelix, one person is doing the helical rim. Because it's really thin, one wrong move and it will break.
[Dr. Gopi Shah]
That's probably the one part that everybody looks at, right? The most visual part of the repair. Tell me about putting the parts together now. What kind of sutures do you use for that?
[Dr. Mai Thy Truong]
Okay. There's two worlds to do this. One is with monofilament sutures, clear sutures. The other is steel sutures. Nagata and Firmin are classically steel sutures.
[Dr. Gopi Shah]
What O is that?
[Dr. Mai Thy Truong]
5/0. 5/0 steel. I personally believe in it. Originally we started with sutures, Dr. Chang and I, because we didn't have the steel. It's really hard to get unless you know how to get it. I have two reasons. One is we use steel sutures on straight needles. That allows you to pin the framework in place onto a block. That really sets the shape. The other thing is when you're spinning a wire–
[Dr. Gopi Shah]
I was so bad at it, but I remember spinning the wire.
[Dr. Mai Thy Truong]
Remember spinning the wires?
[Dr. Gopi Shah]
It wasn't always tight enough or it would spin on itself. I was really bad at it.
[Dr. Mai Thy Truong]
Do you remember how there's a lot of tension in the wire? Did you have them pre-tighten the wire? Do you remember your scrub tech doing that?
[Dr. Gopi Shah]
I don't remember that as well.
[Dr. Mai Thy Truong]
There's something about wire that has tension in it that there's more or less that you have a sense of. There's something about how you can spin a wire and not actually place that much tension on these two pieces of cartilage. Whereas tying a knot down and keeping that tension so that the knot doesn't move, in my mind, always places tension on that cartilage. With cartilage ears, you always worry about resorption. When there's resorption, you're trying to figure out why.
There was this brilliant study by a Chinese group that did consecutive microtia repairs with monofilament sutures and then with wires. They happened to use titanium wires, but titanium and steel I think are probably similar. They showed that the wire had less resorption. When I say consecutive, I mean hundreds. Their practice is so robust. Their study of their outcomes was so robust also. We use wires. We spin them.
[Dr. Gopi Shah]
Okay. You spin them. This might be a dumb question, but you use your needle driver to help you spin them, you're spinning them with your hands? I don't remember. Maybe having something with my needle driver and using that initially just to see how far down I wanted it to go.
[Dr. Mai Thy Truong]
It's a wire spinner actually, made for wires. This natural grip that you spin. Then you see the loops and then you feel the tension in the wire as you spin.
[Dr. Gopi Shah]
Okay. Can use regular suture scissors or do you have to use a wire cutter?
[Dr. Mai Thy Truong]
Wire cutters.
[Dr. Gopi Shah]
Okay.
[Dr. Mai Thy Truong]
Literally, there's this little pile of wires in the back table when you're done.
[Dr. Gopi Shah]
Then after you've cut, do you have to curl them down the edge?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
How long is your tail?
[Dr. Mai Thy Truong]
2 to 3 millimeters.
[Dr. Gopi Shah]
Okay. Then you [unintelligible] just a single bend or something so it doesn't stick out?
[Dr. Mai Thy Truong]
Yes. We used to obsess about cutting a little edge with the wires. Honestly, the framework gets enveloped in a capsule. As long as it's flush, it's been good, but it does have to be flush against the framework. I always laugh when we're doing this wiring because it's intimate because we're both holding the ear, me and my co-surgeon, which is usually Dr. Chang unless I'm on a medical mission. I'm not even thinking about it, but I'm actually holding their hand.
[Dr. Gopi Shah]
To make sure that it's stable, you need all hands on deck, if you will.
[Dr. Mai Thy Truong]
Yes. I'm holding the framework and I'm holding their hands while I'm spinning because I'm just trying to get a sense. I had someone tell me recently, oh, I was holding their hand. I was like, "I was?"
[Dr. Gopi Shah]
[laughs] What's the order of putting the subunits together?
[Dr. Mai Thy Truong]
There is an order.
[Dr. Gopi Shah]
What is it?
[Dr. Mai Thy Truong]
Absolutely.
[Dr. Gopi Shah]
Because I can imagine it's got to turn and twist a little bit, right?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
There's going to be a little rotation as--
[Dr. Mai Thy Truong]
That's right. If something is off, the ear is not harmonious. You have a base plate and then it's always the antihelix because that little Y, if it's pointing in the wrong direction, everything is off. It's the base plate and then the antihelix. Then after the antihelix, it is the support, which Dr. Firmin calls the P1. That is a support under the base plate, which then supports the root of the helix and the tragus. It helps make the ear a complete circle. It's base plate, antihelix, P1, helical rim, tragus, anti-tragus.
Podcast Contributors
Dr. Mai Thy Truong
Dr. Mai Thy Truong is the fellowship director of pediatric otolaryngology at Stanford University in California.
Dr. Gopi Shah
Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.
Cite This Podcast
BackTable, LLC (Producer). (2023, April 11). Ep. 104 – Microtia Surgery in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
Podcasts
Articles
Microtia Ear Surgery Closure Technique & Postoperative Management
The Finer Points of Microtia Ear Surgery