Engineering an Ear

Kidstuff Story_Fernando Merino-Lopez_CHKD

Fernando Merino-Lopez is an 11-year-old from Virginia Beach whose charismatic smile reveals a deep dimple. He’s anxious to show off his new haircut – a cropped, closely shaved style that he just recently had the courage to get, thanks to surgeons at CHKD.

For the first 10 years of his life, Fernando kept his hair long to hide the fact that he did not have an ear on the right side.

Fernando was born with microtia and atresia, a condition in which the outer ear, ear canal and eardrum are underdeveloped or absent. It occurs to some degree in approximately one in 6,000 children. Of the three levels of the condition, Fernando had grade 3 microtia – the most severe form. His outer ear consisted of a small bud of cartilage and the beginnings of an earlobe. He was completely missing his right ear canal and could not hear on his right side.

In addition to the challenges of limited hearing, Fernando was teased about his missing ear. “Fernando grew his hair longer when he started to realize his ear was deformed,” Maria Merino-Lopez says. “I would tell him, ‘Fernando, don’t be bashful. Just tell them that’s how you were born.’ It was difficult.”

Five years ago, Fernando’s family lived in Washington State, and doctors there suggested a standard surgical correction to the boy’s condition. They could remove a piece of Fernando’s rib cartilage and use it as a framework to build an outer ear, but his family was reluctant to put their son through the invasive procedure. Soon after, the family moved to Virginia Beach, and Fernando’s pediatrician, Dr. Kate Crandley of Tidewater Children’s Associates, a CHKD Medical Group practice, recommended Fernando visit CHKD’s Cleft and Craniofacial Center for a consultation.

Dr. George Hoerr , a CHKD pediatric plastic surgeon, evaluated Fernando in the spring of 2014. “When I first met Fernando, I knew we could give him a good-looking ear,” says Dr. Hoerr, who proposed an advanced reconstructive ear surgery that would be much less invasive than the standard procedure. Instead of rib cartilage, Dr. Hoerr would use a synthetic implant to provide a shape for the ear – a specialized technique he has used for ear reconstruction on the East Coast for more than two decades.

“This approach has several advantages for young patients,” says Dr. Hoerr. “Children can undergo surgery as early as 3 or 4 years of age. Without the need for rib cartilage, recovery is much easier and can be completed with fewer visits to the surgeon. The synthetic implant helps makes it easier to shape an ear that is more natural in appearance.

Fernando and Dr. Hoerr_CHKD

But Dr. Hoerr was eager to give Fernando even more than a cosmetic solution. “I had great hope we could not only build Fernando a natural-looking outer ear but also give him the ability to hear in his right ear,” Dr. Hoerr says. He called on Dr. Stephanie Moody Antonio, a pediatric otologist, to evaluate Fernando for surgery to create the ear canal and eardrum necessary for hearing. 

Hearing tests and a CT scan were promising. There were a few important anatomical parts needed in order for Fernando to be a good candidate for ear canal reconstruction – including a cochlea and hearing nerve. “On a 10-point scale used to judge the potential for successful reconstruction, Fernando had a score of 8,” says Dr. Moody.

Rebuilding Fernando’s ear would be a two-step process. First, Dr. Moody would construct an ear canal opening and an eardrum and adjust the middle ear bones to allow Fernando to hear. Next, Dr. Hoerr would follow with reconstruction of the outer ear. “Traditionally, the outer ear would be reconstructed first and the ear canal second. In Fernando’s case, however, I had the advantage of putting the ear canal exactly where it belonged based on the underlying anatomy instead of having to adjust placement of the ear canal to the outer ear reconstruction,” says Dr. Moody. “This approach also gave Dr. Hoerr a blueprint of exactly where to construct the outer ear in relationship to the ear canal, maximizing both appearance and function.”

Kidstuff_Engineering an EarThat summer, Fernando had his first surgery to open the ear canal and build his eardrum. Dr. Moody drilled through the bone just behind the inner ear to create an ear canal and designed an eardrum from a small piece of tissue from Fernando’s scalp. Then, she used a skin graft to line the ear canal. The procedure was a success. “He was able to hear out of his right ear for the first time,” says Dr. Moody. Because he still has some hearing loss, future procedures are planned to reconstruct the hearing bones and continue to improve Fernando’s hearing ability.

After the inner ear had healed for a year, Fernando underwent surgery to reconstruct his outer ear this past fall. Dr. Hoerr carved the synthetic implant to closely match Fernando’s left ear, crafting it approximately 10 percent larger than Fernando’s left ear to account for growth. An incision was made above the ear to take tissue lying just beneath Fernando’s scalp, which Dr. Hoerr stretched over the synthetic ear framework, covering it with living tissue. Once in place, Dr. Hoerr took a skin graft from Fernando’s inner arm – skin that closely matches the ear in color and texture – to cover the entire new ear.

“The procedure went very smoothly,” says Dr. Hoerr. Fernando returned to surgery a month later for some minor touch ups to his skin graft, and just weeks after surgery, swelling was gone and the color of the ear began to look natural. Six months after the procedures, it was hard to tell the ear wasn’t there all along.

When Dr. Hoerr, Dr. Moody and Fernando met this spring for a follow-up visit, it was a time for celebration. Not only was Fernando sporting his newly healed ear, his new haircut spoke volumes of the young man’s newfound confidence.

His school friends noticed this new look too, he told his doctors. “I could hear my classmates whispering in homeroom. And I could hear them out of my new ear, which was even better,” Fernando says, a huge grin forming between his dimpled cheeks. “I looked so different that day that my teacher almost marked me absent until I said, ‘I’m here! I’m here!’”

Dr. Kate Crandley practices with Tidewater Children's Associates, a practice of CHKD Medical Group. 

Dr. George Hoerr practices with CHKD Surgical Group's Plastic and Maxillofacial Surgery practice. 

Dr. Stephanie Moody Antonio practices with EVMS ENT.