Ear reconstruction was first referred to in the Susruta Samhita, where a cheek flap was suggested for repairing the earlobe. As early as 1597, the Italian surgeon Tagliacozzi described and illustrated repair of both upper and lower ear deformities with skin flaps from behind the auricular region. In Germany in 1845, Dieffenbach described repair of the ear’s middle third with an advancement skin flap. This may occasionally still have application today.
This early work focused mainly on traumatic deformities. However, by the end of the 19th century, surgeons began to address congenital defects, particularly prominent ears.
The origin of microtia repair had its significant beginnings in 1920, when Gillies buried carved homograft rib cartilage under mastoid skin, then separated it from the head with a flap of neck skin. Pierce (1930) modified this method by lining the new ear’s posterior surface with a skin graft and building the helix with a flap of rolled up skin. Gillies (1937) repaired more than 30 microtic ears using ear cartilage from the patient’s mother; these were found to progressively resorb and disappear.
Young and Peer(1948) turned to autogenous rib cartilage, which they ingeniously diced and placed in a vitallium ear-shaped mold beneath the abdominal skin. After five months they retrieved the banked mold, opened it, and harvested the framework of cartilage chips, which had united by scar tissue that had grown through the mold’s fenestrations. Although this framework contracted and the shape withered, this technique led to a wave of ear enthusiasm which again turned to homograft cartilage. Experiencing the same frustration of others, Steffensen (1952) used preserved rib cartilage to produce excellent results, but three years later reported progressive resorption of the same cartilage frameworks.
A major breakthrough came in 1959, when Tanzer rekindled using autogenous rib cartilage, which he carved in a solid block. His excellent results have persisted during the years.
In an effort to circumvent the significant operation to harvest rib cartilage, Cronin (1966) introduced silicone ear frameworks, but found that, like other inorganic implants (e.g., polyethylene, nylon mesh, Marlex, polyester net, and Teflon), they suffered a high incidence of extrusion. Initially, Cronin minimized this problem by covering the framework’s rim with extra tissue grafts and flaps, but later when he found that the alloplastic frames still extruded, he discontinued this practice and stopped using them altogether.
To this date, autogenous cartilage remains the most reliable material that produces results with the least complications. Although various donor sites have been used for harvesting the cartilage, only rib cartilage provides a substantial source for fabricating a total ear framework. Even contralateral ear cartilage (from the conchal “bowl”) has been used for this purpose, but it is best to reserve auricular cartilage for repairing small partial ear defects, for which considerably less tissue bulk is needed.
Although Tanzer began his pioneering work in ear reconstruction somewhat late in his career and therefore only operated on 43 microtia patients, his results were excellent. Building upon Tanzer’s sound principles, Brent, Firmin, Nagata and Park among others refined his technique and a two-stage autogenous ear reconstruction is the state of the art today. In some cases, even a one-stage reconstruction can be done.
In recent years, Reinisch became a strong proponent of a one stage ear reconstruction technique using Medpor® in combination with parietotemporal fascia and skin grafts. In experienced hands this technique gives excellent results although one has to keep in mind that the ear is reconstructed with porous polyethylene, an inorganic material.