International Consensus Recommendations on Microtia, Aural Atresia and Functional Ear Reconstruction

In the recently published article “International Consensus Recommendations on Microtia, Aural Atresia and Functional Ear Reconstruction”, by Zhang et al. ^[1], international recommendations have been provided, by giving plastic surgeons an insightful and extremely useful review on functional ear construction. The advantages of this article is that it provides a collective expert opinion from a team of experienced professionals worldwide that can provide guidance and advice on controversial or less common occurrences to the intended users. Additional topics could have been tackled in the paper. However, adult patients were overlooked in the treatment of microtia, and the reason stated by the author is surgery is not optimal in adulthood.

Based on our clinical experience of many years, a considerable number of patients with microtia delayed treatment until adulthood owing to various clinical and social reasons, such as unfamiliarity with the anomaly by their primary doctor. Adults differ from children in psychosocial and physiological states, and this should affect the treatment approach followed by the surgeon. Although challenging, ear reconstruction by the autologous costal cartilage method was performed successfully in our institution with good use of the following techniques, which we believe demand further discussion.

1. Pre-operation: Preoperative evaluation is critical in harvesting cartilage for adult patients with cartilage calcification. As recommended by the author, costal cartilage B-ultrasound can be used to determine whether the costal cartilage is hollow or calcified1. Preoperative three-dimensional scanning combined with additive manufacturing techniques to observe the extent of calcification may reduce the surgical time and enhance surgical results ^{[2, 3]}.

2. Inter-operation: Basic physiological differences in adult cartilage require modifications in the technique when fabricating. Minimization of the operative stages was reported to improve early social return of patients ^[4]. However, some adult patients may need more pieces of cartilage to cut out from to assemble the anatomical structures of the ear because calcified cartilage is harder to bend and manipulate. The size and shape of adult cartilage can also provide advantages to make up for the calcification ^[5].

3. Post-operation: Adults are at risk of cartilage graft deformation because the calcified cartilage is brittle and rigid. Patients need to be followed up for a longer period of time to detect issues regarding the absorption and deformation of the reconstructed auricle. More information is yet found regarding corresponding measures in cases of post-operational deformation owing to the brittleness of cartilage.

Although current surgical techniques, such as the ones mentioned above, have shown to be satisfactory, the search for the most appropriate management choice for adult patients is still ongoing, and a guideline with respect to this criterion is still lacking. Expert recommendations and opinion on this topic would enhance the value of this article and greatly benefit the target population.