Vibrant Soundbridge and Porous Polyethylene Auricular Reconstruction in a Single‑Stage Procedure

Abstract

Microtia with aural atresia presents a dual challenge—restoration of external ear anatomy and rehabilitation of conductive hearing loss. Multiple staged procedures are often required, increasing patient burden. This study presents a single-stage surgical approach combining auricular reconstruction using Porous High-Density Polyethylene (pHDPE, Medpor^®) with simultaneous implantation of a Vibrant Soundbridge (VSB) and intraoperative audiological evaluation. To assess the surgical feasibility, safety, and postoperative cosmetic and audiological outcomes of a combined one-stage Medpor reconstruction and VSB implantation in a patient with grade 3 microtia and congenital aural atresia. A male in his early teens with right-sided grade 3 microtia and complete external auditory canal atresia underwent simultaneous Medpor auricular reconstruction and active middle ear implantation using the VSB system. The Floating Mass Transducer was attached to the short process of the incus. Intraoperative audiological measurements confirmed appropriate device coupling. The surgery included detailed preoperative planning, use of a temporoparietal fascial flap, and full-thickness skin grafting. Postoperatively, the patient demonstrated a significant improvement in hearing thresholds with a pure-tone average of 30 dB HL. Cosmetic results were excellent, and no surgical complications were reported. The patient reported enhanced auditory perception and satisfaction with both function and appearance. This case highlights the safety and effectiveness of combining Medpor auricular reconstruction with VSB implantation in a single procedure. The approach offers functional and esthetic benefits while reducing the need for multiple surgeries. Further studies with larger cohorts and longer follow up are needed to validate patient selection criteria and optimize treatment protocols for this complex congenital condition.

Introduction

Microtia, which can occur in any severity from slightly deformed to complete absence, is a congenital anomaly in the structure of the auricle. ¹ Microtia is as common as 1 in 6,000 to 12,000 live births, with an estimated prevalence of approximately 0.015%. ² Etiology is multifactorial, including prenatal exposure to air pollution, teratogens, genetic and anatomic factors, and ethnicity. Microtia is more commonly seen in males and is usually unilateral, with approximately 60% of unilateral cases involving the right ear. ³ This deformity is also often associated with stenosis of the external auditory canal and conductive hearing loss.^4–6 Patients with microtia and atresia face a dual challenge: esthetic auricular reconstruction and rehabilitation of conductive hearing loss.

There are several surgical methods reported in the literature for reconstructing the external ear, including staged auricular reconstruction, soft tissue expansion, and the use of Porous High-Density Polyethylene (pHDPE, Medpor^®) material for ear reconstruction.^7,8 Medpor has the benefit of decreased operative time and negates the need for donor site morbidity, and therefore, may be a suitable option for patients and families seeking rapid, effective cosmetic reconstruction. ⁹ While there are several options for surgical auricular reconstruction and hearing rehabilitation, such as canaloplasty, bone conduction devices, and the active middle ear implant, the treatment for microtia with atresia remains problematic. At the same time, however, traditional hearing aids are not feasible due to the lack of an external auditory canal, and canaloplasty challenging ¹⁰ and frequently associated with restenosis, tympanic membrane lateralization, and recurrent infections.^11,12 Many cases describe a two-stage surgery in which hearing is restored either before or after auricular reconstruction. The combination of Medpor auricular reconstruction, Vibrant Soundbridge (VSB), and postoperative audiological measurement has not yet been adequately described, and no standardized protocol exists for a combined single-stage procedure. Recent systematic evidence has confirmed that VSB implantation is an effective and safe option for hearing rehabilitation in congenital aural atresia, with consistent improvements in audiological outcomes and acceptable complication rates. Despite growing evidence supporting VSB for aural atresia, standardized protocols for integrating VSB with single-stage Medpor reconstruction remain limited. ¹³ This knowledge gap emphasizes the importance of gathering more evidence to guide clinical practice and patient outcomes.

This study is significant because it addresses the limited data on the feasibility and outcomes of single-stage surgery combining Medpor auricular reconstruction with VSB implantation for patients with microtia and aural atresia, aiming to optimize both cosmetic and functional results while minimizing surgical interventions. The objectives are to describe the combined technique; evaluate cosmetic and audiological outcomes; identify factors influencing success and complications; and highlight the role of multidisciplinary collaboration.

Case presentation

A male patient in his early teens with no significant medical history presented to the otology clinic at King Fahad Central Hospital, Jazan, Saudi Arabia with right auricular malformation and hearing loss since birth. The patient's family reported significant emotional distress related to the cosmetic appearance of the ear, expressing a strong desire to address both functional hearing loss and esthetic concerns in a single-stage intervention.

The reporting of this case follows CARE guidelines. Written informed consent for treatment and separate written consent for publication (including use of images) were obtained from the patient and guardian. All personal identifiers have been removed. ¹⁴

Clinical examination revealed a nonsyndromic facial appearance with right-sided grade 3 microtia (Figure 1(a)). Pure tone audiometry (PTA) demonstrated severe conductive hearing loss in the right ear, with an air -bone gap of ∼50–60 dB across test frequencies. The left ear showed normal hearing thresholds (Figure 1(b)).

Figure 1.

(a) Clinical photograph showing a nonsyndromic facial appearance with right-sided grade 3 microtia. (b) Preoperative pure-tone audiometry (PTA) demonstrating severe conductive hearing loss (CHL) in the right ear, with an air–bone gap of approximately 50 to 60 dB across all frequencies. The left ear shows normal hearing thresholds. (c) Preoperative surgical markings for auricular reconstruction. The red lines indicate the mapped course of the superficial temporal artery (anterior and posterior branches). The green line outlines the planned skin incision for temporoparietal fascia flap elevation and Medpor framework placement.

Preoperative planning for auricular reconstruction involved the use of a transparent silicone film to replicate the contours of the healthy contralateral ear—including the external nose, lateral canthus, auricle, and eyebrow—onto the affected side. Specific measurements were taken for auricular width and length, the distance between the ascending helix and lateral canthus, the distance from the lobule's lowest point to the oral commissure, and the angle between the nasal bridge and the long axis of the ear. Mapping of the superficial temporal artery was also conducted to guide vascular flap design (Figure 1(c)).

High-resolution computed tomography of the temporal bone showed acceptable mastoid aeration, complete external auditory canal atresia, malformed malleus and incus, partial anterior displacement of the facial nerve, and a hanging stapes located anteriorly within a narrow parietal middle ear cavity (Figure 2(a)). Based on these findings, the hearing implant committee decided on a surgical plan including Medpor auricular reconstruction with skin grafting (harvested from the right thigh and left postauricular region) and VSB implantation. Bonebridge was considered as a backup option in case intraoperative anatomical limitations precluded VSB placement.

Figure 2.

(a) High-resolution computed tomography (HRCT) of the temporal bone showing acceptable mastoid aeration, complete external auditory canal atresia, and malformations of the malleus and incus. Partial anterior displacement of the facial nerve and a hanging stapes located anteriorly within a narrow parietal middle ear cavity are also observed. (b) Intraoperative microscopic view showing the Floating Mass Transducer (FMT) coupled to the short process of the incus using an SP-coupler (Vibrant Soundbridge, MED-EL). The FMT is securely positioned within the middle ear cavity, confirming successful coupling during the single-stage procedure.

Under general anesthesia (without muscle relaxants), surgery was performed with continuous facial nerve monitoring. The operative field and graft donor sites were sterilized with povidone-iodine and draped. Two full-thickness skin grafting were harvested from the right thigh and the left postauricular region, and the donor sites were closed primarily.

The Medpor reconstruction began with the elevation of the temporoparietal fascial flap and excision of the auricular remnant, which was fashioned into a lobule. The residual auricular cartilage was preserved and reshaped to form a tragus. A postauricular incision (∼2 cm) was extended down to the periosteum to allow for small cavity mastoidectomy, followed by posterior tympanotomy and facial recess opening.

Intraoperatively, the ossicular chain was inspected: both the malleus and incus were malformed, though the short and long processes of the incus were present. The displaced facial nerve partially obscured the anterior crus of the stapes, but the ossicles were found to be mobile. The Floating Mass Transducer (FMT) of the VSB system was coupled to the short process of the incus using a Short-Process Coupler (Figure 2(b)).

Intraoperative Auditory Brainstem Response (ABR) testing was performed using the Eclipse EP25 system and AcoustiAP interface, CE-Chirp^® stimulus at 49.1 Hz rate delivered directly to the VSB implant's FMT via a modified processor. Surface electrodes were positioned on the forehead, mastoid, and temporal region, keeping impedance below 5 Ω. Bandpass filtering and artifact rejection minimized electrical noise. Stimulation began at 100 dB nHL, decreasing gradually until wave V was no longer detectable; the threshold was defined at 45 dB nHL (Figure 3(a)). The procedure was completed in under 10 minutes and confirmed satisfactory coupling of the implant intraoperatively. To objectively quantify VSB coupling efficiency, coupling quality index derived from intraoperative ABR thresholds was used in recent studies to predict postoperative performance. At an empirically determined cut-off value of 22.6 dB, the coupling quality index achieved a sensitivity of 70% and a specificity of 90% for distinguishing good from loose coupling, indicating acceptable diagnostic accuracy for intraoperative use. This suggests that values below or equal to the threshold can indicate good coupling, contrary to higher values. ¹⁵

Figure 3.

(a) Intraoperative auditory brainstem response (ABR) showing identifiable waves III and V down to 45 dB nHL, confirming adequate Vibrant Soundbridge (VSB) coupling; intraoperative ABR reflects coupling efficiency and is not directly comparable to postoperative behavioral audiometry. (b) Intraoperative view of the reshaped Medpor framework secured to achieve optimal contour and stability. (c) Coverage of the Medpor implant with a temporoparietal fascial flap and skin graft, providing well-vascularized support for long-term stability.

Medpor framework was reshaped based on the preoperative esthetic measurements and fixed in place with sutures (Figure 3(b)). The temporoparietal fascial flap was draped over the Medpor implant, followed by placement of the skin graft (Figure 3(c)). A negative-pressure drain was placed and removed 3 days postoperatively.

Perioperative medications included intraoperative cefazolin, intravenous cefuroxime for 7 days, followed by oral amoxicillin/clavulanate for 1 week, plus topical fusidic acid ointment.

After 3 months the patient achieved an excellent cosmetic result following auricular reconstruction (Figure 4(a)), and audiological follow up demonstrated a significant improvement in right ear hearing, with a postoperative aided PTA of 30 dB HL (Figure 4(b)). The patient subjectively reported the ability to hear environmental sounds he had never perceived before and expressed high satisfaction with the outcome, especially reporting improved binaural perception.

Figure 4.

(a) Three-month postoperative photograph demonstrating an excellent cosmetic outcome following auricular reconstruction. The reconstructed auricle shows natural contour, symmetry, and skin integration, reflecting successful healing and esthetic restoration. (b) Postoperative pure-tone audiometry (PTA) demonstrating significant hearing improvement in the right ear. The aided thresholds show a postoperative pure-tone average of 30 dB HL, indicating functional gain following Vibrant Soundbridge (VSB) implantation. The left ear maintains normal hearing levels.

Discussion

Surgical treatment of aural atresia in association with microtia remains one of the most challenging otological procedures despite significant technical progress and the increasing use of implantable hearing devices. Due to the patient's anatomy, Middle Ear Implants (MEIs) such as the VSB was chosen as the optimal implant. The VSB has also been successfully used in cases such as a single-stage procedure or combined with auricular reconstruction, and recent systematic data support its long-term safety and stable hearing gain in patients with aural atresia.^{10,13,16–19}

Although several reports suggest that VSB implantation is ideally performed prior to auricular reconstruction to support earlier binaural auditory development, this was not possible in the present case because the patient first presented for clinical care at a later age.^20,21 The timing of intervention therefore reflected delayed initial presentation rather than a deviation from the recommended treatment sequence.

In prior reports, VSB implantation has been performed concurrently with auricular reconstruction using autologous rib cartilage as the framework, allowing simultaneous auditory rehabilitation and auricular reconstruction while reducing the total number of surgical procedures, overall operative time, and recovery-related absence from school.^{10,17,18,20,22} These studies similarly reported no intraoperative or postoperative adverse events.

In this study, postoperative air-conduction thresholds remained stable, and no worsening of residual hearing was observed following VSB implantation combined with auricular reconstruction. These findings demonstrate that the combined procedure is safe and effective for patients with microtia and aural atresia. This aligns with previous reports,^10,17,18 which also documented stable hearing outcomes and emphasized the importance of careful patient positioning and padding to prevent pressure necrosis and alopecia during lengthy surgeries. These stable postoperative thresholds and the absence of device-related complications are consistent with larger series and recent reviews that report durable hearing gains and low complication rates in atresia patients implanted with VSB. ¹⁹

Satisfactory cosmetic outcomes were achieved in the present case. From an audiological perspective, VSB implantation resulted in a postoperative aided pure-tone average (PTA) of 30 dB HL at 3 months, representing a clinically meaningful improvement. The patient also reported substantial subjective hearing benefit and high satisfaction associated with the experience of balanced binaural hearing. These outcomes are consistent with previously published reports. For example, one study achieved favorable floating mass transducer (FMT) coupling to the round window in a patient with bilateral microtia and fibrous atresia, with aided thresholds ranging from 15 to 30 dB HL across frequencies from 750 to 6000 Hz. ²³ Another study reported positive audiological outcomes in patients with unilateral atresia -microtia, with successful FMT placement on the stapes, ossicular chain, or round window during auricular reconstruction, achieving a mean aided threshold of approximately 24 dB HL at 6 months postoperatively. ¹⁰

A major limitation of this study is its single-case design and short follow up, which limit the generalizability and long-term assessment of outcomes. Although the combined Medpor reconstruction and VSB implantation offer cosmetic and functional benefits, their use may not be suitable for all patients due to anatomical variability and surgical complexity.

Although the overall safety profile of porous polyethylene reconstruction is well established, the risk of implant exposure or infection remains a concern. Modern surgical techniques have significantly reduced complication rates. In this approach, several preventive and management strategies are employed. First, to protect the VSB implant from potential spread of infection from the auricular reconstruction site, the mastoid approach is routinely covered with A 0.5-mm polydioxanone (PDS) film was placed prior to soft tissue closure, creating a physical barrier between the two surgical sites. Second, the porous nature of Medpor^® facilitates collagen deposition and vascular ingrowth, which inherently protects against extrusion and infection while allowing systemic antibiotic delivery to the implant when needed.

Another limitation is the lack of a formal intraoperative coupling quality index. Although intraoperative ABR was used to confirm satisfactory coupling in this case, applying a validated coupling quality index could have allowed objective grading of coupling efficiency and facilitated comparison with other cases. ¹⁵ Future cases could benefit from incorporating such an index into the intraoperative protocol to guide real-time adjustments and potentially optimize postoperative hearing outcomes.

Furthermore, the current evidence lacks standardized protocols and long-term data, particularly regarding speech outcomes, quality of life, and device durability. Risks specific to alloplastic reconstruction, such as infection, implant exposure, and limited revision options, must also be considered. The findings should therefore be interpreted cautiously, as larger series are needed to determine which patients are most likely to benefit from a single-stage approach.

Conclusion

The present case illustrates the feasibility of performing Medpor auricular reconstruction and VSB implantation in a single operation session for a patient with microtia and aural atresia. The combined technique resulted in favorable cosmetic healing and measurable hearing improvement, with good early patient satisfaction. While findings cannot be generalized from a single case, the results support feasibility and inform future prospective series. Further studies with larger samples and longer follow up are needed to clarify patient selection criteria and refine best practices for this combined technique.