Development of the ear begins during the first few weeks of pregnancy. At this time the developing fetus looks like a FISH with gills.

As the shape of the auricle forms, the developing ear moves (migrates) from under the chin to its proper position on the skull. These two patients have auricles that failed to completely move from under the chin to the skull.
This slide shows the proper position of the ear. The auricle should attain its adult size by age 8. The auricle should lie between the eyebrow and the bottom of the nose. It should not lie straight, but be parallel to the bride of the now. It should also lie approximately 6 cm (the average height of an adult ear) from the eye.


As  the ear is developing in the first few weeks  of gestation its shape not only changes to that  of a normal ear, but it moves from under the chin to it proper position on the skull.  These two patient’s developing ears (auricles) failed to adequately move to their proper adult position.


These diagrams picture the developing ear (auricle) from the first three weeks of pregnancy through the end of the third month of pregnancy.  Initially the ear looks like “gills” on a fish.  By the end of the third month of pregnancy, the ear has attained its adult shape.

Concomitant developing organ systems

Other organ systems are also developing at the same time as the ear. Therefore the doctor must evaluate a Microtia child’s kidneys, heart, neck, and middle ear that may also be abnormally affected.


Situations that may cause a child to have Microtia are

  1. Mother having fevers during the first few months of pregnancy.
  2. Any genetic predisposition (family history of others with ear anomalies).
  3. Mother having exposure to medications/environments that may affect development of the ear.
    • Accutane
    • Exposure to excessive radiation.
    • Thalidomide


Microtia occurs in 1:7,000 children.
30% of affected children have Microtia in BOTH ears.
30% of affected children have OTHER congenital anomalies that must be searched for.

Evaluation of susceptible organ systems

Several tests may be necessary to find other anomalies:

  1. Ultrasound of the kidneys.
  2. Heart beats.
  3. X rays of the neck
  4. Hearing testing

Treacher Collins Syndrome

This syndrome has several other issues including Microtia and hearing loss.info_on_the_ear_0046_Treacher Collins

Patients with Treacher Collins Syndrome have other abnormalities of their face.  Their ears are ”low set”, and their cheek bones have not properly developed.


Goldenhar’s Syndrome

These patients often also have problems with their kidneys.

info_on_the_ear_0045_Goldenhar’s Syndrome

This syndrome represents other developmental problems that can occur at the same time the outer ear (auricle) is developing.  The facial nerve  (nerve to the face) has not developed causing a paralysis of this patient’s right side of  his face.  The ears are also “low set” and mal-developed. Also there are often problems with the kidneys with these patients.

Mandible and TMJ

Often one side of the face and jaw are smaller than the normal opposite side. This phenomenon is called “hemi-facial microsomia”.



The auricle is not round, triangular, or square, but OVAL shaped. It is not flat, but is three dimensional consisting of THREE layers (concha, scapha, and helix).

info_on_the_ear_0042_Anatomy info_on_the_ear_0043_Anatomy


Using ones fingers many anomalies can be easily seen.


Most Common Anomalies

  • Protruding ear
  • Concha too deep
  • Flattened helix
  • Low lying crus helicis
  • Overhanging helix
  • Scapha too narrow
  • Loss of fossa triangularis
  • Ears low set
  • Skin pocket too small
  • Lack of cartilage

Gradation of Deformities

These patients illustrate the most common deformity from a protruding ear, to and ear that “falls over” upon itself because of poor structural support, to Microtia where parts of the ear are absent.





Common Abnormalities (Dysmorphic)

This patient with a “protruding” auricle has two major defects. There is inadequate “folding” of the antehelix fold, and the inner layer (concha) is excessively deep.


Common Abnormalities (Dysplastic ears)

Dysplastic ears do NOT have all of the “parts” present. Reconstruction requires making a new framework.

info_on_the_ear_0035_common dysplastic info_on_the_ear_0036_common dysplastic

Dysmorphic Ears

When one uses their fingers to push the auricle backwards, many anomalies quickly come into view.


Ear Molding

These ears have all parts present, but only deformed. We can correct these problems with simple non surgical MOLDING procedures. However, reconstruction must be initialed within the first three days of birth while the ear cartilage is still soft and pliable.

info_on_the_ear_0030_ear molding
info_on_the_ear_0031_ear molding info_on_the_ear_0032_ear molding info_on_the_ear_0033_ear molding

Conchal Excision and Suture Setback

These deformities can be corrected WITHOUT incisions at age four.

This patient excessively “protruding” ears were corrected using an “incisionless otoplasty” technique.  No cuts (incisions) were made.  Bandages were removed after ONE day.

info_on_the_ear_0029_conchal setback

Conchal excision suture setback

This patient was helped with INCISIONLESS Otoplasty

This patient excessively “protruding” ears were corrected using an “incisionless otoplasty” technique.  No cuts (incisions) were made.  Bandages were removed after ONE day.

info_on_the_ear_0028_conchal setback incisionless

Dysplastic Ears

These problems require “open” surgery techniques to add support and add elements that are missing.





Timing of Reconstruction

This is the most severe ear deformity where most of the parts of the auricle never developed. Another common anomaly with Microtia is no ear canal is present (atresia).



info_on_the_ear_0022_microtiaThis is the most severe ear deformity where most of the parts of the auricle never developed. Another common anomaly with Microtia is no ear canal is present (atresia).

Microtia Reconstruction

It is essential to properly place (position) the newly reconstruct ear. These photographs demonstrate that an improperly positioned ear will give less than acceptable results. A template is drawn over the normal opposite ear. This “map” is drawn on the Microtia side to ensure that the new ear framework is properly placed.

info_on_the_ear_0019_microtia reconstructioninfo_on_the_ear_0018_microtia reconstruction

Templates for Configuration of Framework

A second template is copied from the normal ear to help us make the reconstructed ear look similar in shape and size to the normal ear.


Harvesting Rib Grafts

Patients have a choice to either use their own tissue from their ribs, or to use a preformed biosynthetic Medpor framework. If ribs are used to construct a framework, the lower ribs are harvested.

info_on_the_ear_0016_harvesting ribs

Cartilage Framework

A three layered rib cartilage framework is sculptured to conform to the shape and size of the normal side.

Transposition of Lobule

The ear lobe is moved to its proper position.


Creation of Tragus

  • Skin graft from postauricular area
  • Chrondrocutaneous graft




Elevation of Framework

Place the ear is elevated from the skull and a graft of skin is placed to gain “protrusion” of the ear.







Identification of Vascularity

We are now using a more effective procue that uses MEDPOR (a porous poly-ethylene framework) instead of ribs.  This reconstruction is accomplished in only TWO to THREE outpatient procedures.  We need to identify the vascularity of the blood vessels in the scalp as illustrated in this slide.


Sculpturing of Implant

The Medpor (porous polyethylene) framework is sculptured to match the size and shape of the opposite normal ear.


Post Auricular Skin Graft

A graft of skin in taken behind the normal ear to help “cover” the Medpor framework.


Abdomenal Skin Graft

Another graft of skin is taken from the “belly’ also to cover the Medpor framework.


Skin Graft from Abdomen

This skin graft from the belly is sutured to the back of the normal ear.


Medpor Implant

The sculptured Medpor implant is sutured into proper place.


Temporoparietal Fascial Flap

Tissue from the scalp (temporoparietal fascia) is folded onto the Medpor framework.


  • Superior Temporal vessels
  • 11 to 12 cm
  • Facial nerve
  • Folded over

TPFF Coverage

The temporoparietal fascia from the scalp is folded down and covers the Medpor framework.


Placement of Skin Graft

The previously harvested skin graft is placed over the framework.



  • Infections
  • Perichondritis
  • Malposition
  • Suture reaction
  • Keloid/Hypertrophic scarring