What are the step‑by‑step surgical procedures for reconstructing microtia in a 6‑10‑year‑old child, and where can I find video demonstrations of each stage?

Microtia Reconstruction: Surgical Steps and Video Resources

I cannot provide video demonstrations as the evidence provided does not contain links to surgical videos, but I can outline the established surgical technique based on the available literature.

Surgical reconstruction of microtia in children aged 6-10 years follows a staged approach using autologous rib cartilage, typically performed in 2-4 stages beginning around age 8 years or when the eighth rib cartilage length matches the healthy ear's helix length. 1, 2

Optimal Timing for Surgery

The ideal timing for microtia reconstruction is when the eighth rib cartilage length approximately equals the helix length of the healthy contralateral ear, which typically occurs between ages 8-10 years. 2

• Preoperative assessment should include low-dose multi-slice CT scanning to measure the eighth rib cartilage and compare it to the healthy ear's helix length (from helical crus to the joint of helix and earlobe). 2
• Surgery can proceed when these measurements are approximately equal, as this ensures adequate cartilage for framework construction. 2
• In children where the eighth rib is slightly shorter, helix fabrication can be accomplished by adjusting the helical crus length, though outcomes may be less optimal. 2
• Patients younger than 8 years typically lack sufficient rib cartilage volume for optimal reconstruction. 1

Specialist Selection

Children with microtia should be referred to a pediatric plastic surgeon, as the American Academy of Pediatrics explicitly recommends this specialty for congenital malformations of head and neck structures, including the ear. 3, 4

• A pediatric otolaryngologist with appropriate training is also an acceptable specialist for congenital ear malformations. 3
• All patients 5 years or younger requiring surgical care must be managed by pediatric surgical specialists. 5

Stage 1: Framework Construction and Placement

The first stage involves harvesting autologous rib cartilage from ribs 6-9 and constructing a three-dimensional auricular framework that is placed in a subcutaneous pocket on the mastoid plane. 1, 6, 7

Cartilage Harvest:

• The sixth and seventh ribs are harvested while preserving the synchondrosis to form the base framework. 1
• The eighth rib provides cartilage for the helical rim. 1
• Additional cartilage from the ninth rib may be used for structural support. 1

Framework Fabrication:

• The triangular fossa and scapha are carved into the groundplate to create three-dimensional structure. 1
• The eighth rib cartilage is fixed as the helical rim to the base framework. 1
• The framework is optimized to match the contralateral healthy ear in size and contour. 6

Framework Placement:

• A thin subcutaneous pocket is created on the mastoid plane using non-scarred elastic skin. 8
• The cartilage framework is positioned with careful attention to proper location and orientation. 6
• Using very thin skin flaps over the framework allows better definition of cartilage detail and skin-cartilage coaptation. 8

Stage 2: Lobule Rotation and Auriculocephalic Angle Creation

The second stage, performed 5-6 months after the first, involves rotating the lobule into proper position and elevating the reconstructed ear to create the auriculocephalic angle. 1, 6, 7

Lobule Positioning:

• The lobule from the microtia remnant is rotated inferiorly into position on the helical rim. 6
• This stage benefits from the splicing capability developed after initial framework placement. 8

Ear Elevation:

• The reconstructed ear is raised from the mastoid to create proper projection. 7
• A cartilage wedge (often from additional rib cartilage) is placed to maintain the auriculocephalic angle. 1
• A temporalis fascia flap is used to cover the cartilage graft. 1
• Split-thickness skin graft from the hairbearing scalp covers the fascial flap. 1

Conchal Depression:

• Formation of the conchal depression and limited elevation of the helical rim are performed during this stage. 6, 8

Stage 3: Tragus Formation (Optional)

The third stage involves formation of the tragus using a composite graft from the contralateral ear. 6

• This stage is performed several months after stage 2. 6
• A composite graft (cartilage and skin) is harvested from the opposite healthy ear. 6

Stage 4: Final Refinements

A final stage addresses minor adjustments and refinements to optimize aesthetic outcome. 1, 6, 8

• This may include scar revisions, contour adjustments, or symmetry corrections. 1
• Not all patients require this fourth stage. 6

Critical Pitfalls to Avoid

• Do not attempt reconstruction before adequate rib cartilage is available - insufficient cartilage length leads to unsatisfactory outcomes and may require cartilage splicing with suboptimal results. 2
• Avoid thick skin flaps over the framework - thin flaps provide better cartilage definition and prevent late framework deformation. 8
• Do not reconstruct the external canal or middle ear in unilateral microtia with normal contralateral hearing - these procedures may compromise external ear reconstruction results. 8
• Ensure referral to appropriate pediatric surgical specialists - outcomes are significantly better when children are operated on by surgeons who preferentially treat pediatric patients. 5, 9

Donor Site Considerations

• Rib cartilage harvesting causes specific donor-site morbidity that should be discussed with families preoperatively. 1
• The chest wall deformity is generally well-tolerated and considered acceptable given the excellent cosmetic outcomes achieved. 1

Expected Outcomes

• Satisfactory aesthetic results are achieved in the majority of patients (approximately 90-95%) when adequate cartilage is available and proper technique is followed. 2, 7
• All reconstructions can be performed without major complications when executed by experienced surgeons. 7
• Patient satisfaction rates are high, with most patients satisfied starting from the first surgical stage. 7