Rib Graft Technique

Reminder: Any child or adult who is born with Microtia does not have to have surgery if he/she does not wish to. If you like your little Microtia ear and would like to keep it just the way it is, you absolutely have the right and the choice to do so. However, if you believe that by having surgery, you will personally live a happier life, be able to wear glasses, be able to hear better through Atresia repair (canalplasty) if you are a candidate, and no longer be bullied, then of course surgery is an option that can help. A little Microtia ear should never be thought of as being “broken” and is not something that needs to be “fixed.” Microtia does not affect one’s intelligence, how you think, or what you would like to become in life. Surgery is always an option that can often times help improve self esteem and rescue an individual from depression depending on what they have experienced in life because of their little ear(s). Whether you are interested in having surgery or not, it is very important that you do your research and know what all of your choices and options are so that you can make the decision that is best for you.

  • I have decided not to label advantages and disadvantages for both the Rib Graft and Medpor techniques as they are both excellent options for ear reconstructive surgery. Surgical technique and medical advancements made in reconstructive surgery are always improving. What matters most, is that you have done your research, asked to see before and after pictures from at least a few different surgeons, speak with families who have already had surgery, and believe in the decision you make. When you feel comfortable with your research and the conversations you have had, then you will feel comfortable making a decision that is best for you or your child. Always stand by your decision and never criticize anyone for the decisions they have made. There is no right or wrong decision here, it is what you personally believe is the best decision for you.

Rib Graft Surgical Technique:

The Rib Graft technique is known as the “Gold Standard” for ear reconstructive surgery and has been around since the 1920’s. Rib Graft surgery utilizes the body’s own biological tissues (rib cartilage and skin). When the body’s own tissues are utilized for building a Rib Graft ear, the ear will grow with the body because all tissues used are living. There are two different Rib Graft techniques used today:

1. The “Brent Technique”– named after Dr. Burt Brent (USA). Dr. Brent has been performing Rib Graft surgery for 35 years. Dr. Brent has also reconstructed over 2,000 new ears during his professional medical career, catering to Microtia. Dr. Brent’s technique allows for Rib Graft surgery to be achieved in three stages. Sometimes, a fourth stage is needed to fine tune the reconstructed ear and smooth out the earlobe.

The stages used in the “Brent” technique are as follows:

Stage I: Develop the auricular framework by harvesting a section of the rib cartilage (requires a 1” to a 1.5” length incision) over the 6th, 7th and 8th ribs and then carefully sculpting the rib cartilage by stitching it into a newly shaped framework that is shaped like an ear. The newly shaped framework is then sewn into a skin flap or skin pocket beneath the scalp on the skull (where the ear will be located) very carefully, being sure not to damage the newly created blood vessel network that has been created for the new ear. The ear is then suctioned to the skull (with two drains, one behind the ear and one beneath the ear) helping the skin adhere to the new cartilage framework (also preventing blood clots) and so the ear can begin healing.

Duration of surgery: 2. 5 hours to 3.5 hours and requires one overnight stay in the hospital. The drains may be removed at 1 to 1.5 weeks following surgery along with the sutures being removed following 7 to 10 days. It is suggested to wait 2 to 3 months before beginning Stage II for proper healing.

Stage II: Lobule transposition. The creation of the earlobe is then achieved by making one incision in front of the ear and one incision behind, carefully relocating the earlobe into place on the reconstructed ear.

Duration of surgery: approximately 1 hour and is considered out patient surgery so you can go home following the procedure. It is suggested to wait another 3 months before beginning Stage III for proper healing. Sutures may be removed following 7 to 10 days.

Stage III: This is known as the elevation stage which involves making a slit behind the ear to carefully release the ear from beneath the scalp skin, lifting it away from the skull giving it projection or a high profile (3D) look. A skin graft is then used to cover up the back side of the ear. The skin graft can be taken either from the back side of the buttocks or from the groin area (where no hair grows). This depends on the surgeon’s technique who is performing the surgery. The Tragus (little cartilage like flap located in front of the ear canal) may also be constructed during this stage. This stage of the surgery also helps create a pseudo ear canal with a shadowing affect that provides a depth perception look as if an ear canal exists (if a patient is not a candidate for canalpasty (atresia repair)). Any symmetrical issues with the ear may also be corrected at best during Stage III. Depending on the outcome of the surgery or any other challenges that may be involved, such as a low hair line, or if the patient has Goldenhar Syndrome or Treacher Collins, or waiting on jaw distraction surgery during Hemifacial Microsomia cases, additional surgeries may be needed for additional fine tuning. Some times the Tragus is formed during the fourth stage of surgery, again depending on your surgeon of choice’s technique.

Duration of surgery: is approximately 2 to 3 hours and is considered out patient surgery so you can go home the same day. Sutures may be removed 10 to 15 days following surgery. Again, if an additional surgery is required it is suggested to wait another 2 to 3 months for proper healing. The reconstructed Rib Graft ear will be stiffer than the non-Microtic ear because it is made from Rib material.

  • The Brent Technique for Rib Graft can start as early on children as five years of age, although age six is preferred. However, it is more desirable to wait until they are closer to age six, seven or eight because the older a child is, the better they listen during the healing process. For example, an older child understands not to pick, scratch or sleep on their ear that has been operated on. They’re easier to work with during the healing process. They can also be a part of the decision to have surgery.

2. The “Nagata Technique”named after Dr. Satoru Nagata (Japan). Dr. Nagata’s technique allows for Rib Graft surgery to be achieved in two stages.

Stage I:Develop the auricular framework by harvesting a section of the rib cartilage and then carefully sculpting the rib cartilage by stitching it into a newly shaped framework that is shaped like an ear. An incision between ribs 6 though 9 is often made for harvesting the needed rib cartilage. The newly shaped framework is then sewn into a skin flap or skin pocket beneath the scalp on the skull (where the ear will be located) very carefully, being sure not to damage the newly created blood vessel network that has been created for the new ear. The ear is then suctioned to the skull (with two drains, one behind the ear and one beneath the ear) helping the skin adhere to the new cartilage framework (also preventing blood clots) so the ear can begin healing. During this same stage, the ear lobe is also created. Duration of surgery: 4 hours to 6 hours and requires one overnight stay in the hospital. It is suggested to wait 4 to 6 months before beginning Stage II for proper healing.

Stage II: This stage involves both the elevation stage and the Tragus stage. During the elevation stage, Dr. Nagata will take a second section of rib cartilage from the chest area near the sternum and carve a wedge piece out of the cartilage and insert this wedge piece of rib cartilage behind the ear (wrapped with a skin graft for vascularation), giving the ear projection. Dr. Nagata’s technique also involves the creation of a better made Tragus. The Tragus is a bit thicker and si more supported with a higher profile look to it. Duration of surgery: 3 to 5 hours and the patient can go home…

  • Dr. Francoise Firmin practices the “Nagata” technique. However, Dr. Firmin does not make two separate incisions for harvesting rib cartilage. During the first incision, Dr. Firmin will carve an extra section of rib and sew this piece into the skull (the sulcus of the tempero-parietal fascia flap)…called “banking” in the ear pocket. Then, during the elevation stage, Dr. Firmin will remove the “banked” piece of cartilage and use this piece (again wrapped in a skin graft) for behind the ear to help with projection.
  • Dr. Arturo Bonilla will utilize a piece of Medpor material for inserting behind the ear to help with projection during the elevation stage.
  • The “Nagata” technique for Rib Graft can start as early on children at 10 years of age. The “Nagata” technique may use a slightly different style of making the framework of the ear and does require the use of more rib cartilage than the “Brent” technique uses to make the Rib Graft framework. it is best to wait until a child is age ten for surgery because the non-Microtic ear is fully grown by then, so that the child is old enough to be a part of the decision making process for surgery and so the child can be more cooperative during the healing process.
  • Note: Some surgeons can achieve Rib Graft ear reconstructive surgery in just one stage. Surgery time for Rib Graft ear reconstructive surgery in one stage can take anywhere from 10 hours to just under 20 hours depending on the challenges of the patient. For example, for children having been born with Goldenhar Syndrome or Treacher Collins, the surgery times may be closer to 15 or 16 hours due to a lower hair line, etc… Also, if a patient is diabetic, the surgeon may require extra time to perform the surgery assuring that no additional vessels are cut or additional bleeding does not occur during the procedure. Dr. Russel Griffiths is one of the surgeons who has been successful at completing a Rib Graft ear in just one stage of surgery.

  • Note: Some, but not all Rib Graft surgeons insert a Medpor wedge or block behind the newly reconstructed Rib Graft ear during the “elevation stage” to help the ear maintain its projection. Many Rib Graft ears have been known to lose their 3 Dimensional look as they will flatten to the head over time. The use of a Medpor wedge can help prevent this from happening. Many Rib Graft surgeons will utilize a section of rib cartilage traditionally instead of Medpor.

  • Note: Some surgeons practice Rib Graft reconstruction using some techniques from the “Brent” technique and also from the “Nagata” technique. As each surgeon’s skill and technique of his/her own is mastered, and a surgeon will find what works best for the patient and what offers an easier and more successful outcome for themselves. Ask your surgeon of choice to walk you through the steps of their technique and don’t be afraid to ask questions. It will only help you understand more about the surgery itself. Dr. Charles Throne is one of the surgeons who utilizes a little of each technique during the reconstruction of a Rib Graft ear.

What age is should a child have Rib Graft surgery?

Typically “the age of discovery”, is about 3 – 3 1/2 years of age, when the child begins to notice the body, his/hers and others. The “age of concern” usually impacts around 7 or 8 years of age when socialization begins. Typically surgery is not done before 1st or 2nd grade; age 6 is considered the best for the “Brent Technique.” Prior to this age, children may not yet be ready for surgery or just don’t seem to react much to their little ear. Below are some statistics on what age Rib Graft is typically performed:

Statistics on what age the Rib Graft is performed:

47.2% at 6-7 years of age
21.1% between 8-10 years of age
14% between 11-12 years of age

  • These statistics were presented at the 2010 Rib Graft conference in NY with Dr. Burt Brent and Dr. Brad Kesser.

Note: The Rib Graft technique can be achieved as early as five years of age, most commonly between ages 6 and 8 years of age. Age 10 for the “Nagata” technique.

Note: Rib Graft ears are favored among families and individuals that believe in using the individual’s own biological tissues so that the ear continues to grow.

Note: Rib Graft is favored among parents who may want their children to be able to be old enough to be a part of making the decision on surgery. If Rib Graft is performed early enough (between the ages of 5 and 6 years of age), it is possible that your child will not remember any surgical trauma and it may be before they are old enough to be bullied in school.

For more details on Rib Graft surgery, you are welcome to visit the following websites:

www.microtia.us.com and click on “Auricular Reconstruction”

www.microtia.net and click on “Surgical Details”

www.earreconstructionspecialist.com and click on “Treatment Options”

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