The aim of this paper is to report my experience of 352 ear reconstructions to correct microtia with Brent's technique (n = 184) and Nagata's technique (n = 144). The remaining 24 were atypical presentations reconstructed in a one-stage procedure. Brent's technique is a safe, step-by-step, four-stage reconstruction and Nagata's technique involves only two stages. Nagata's innovations include transposing the lobule of the auricle during the first stage, carving a framework that includes the tragus, and constructing the posterior wall of the concha during the second stage. Cases of typical microtia have been selected to illustrate the advantages and pitfalls of both techniques.

Ear reconstruction is considered to be a challenging form of surgery. In cases of microtia, surgeons must reconstruct complex missing contours, which necessitates the use of a support and skin remnants to cover this support. Although the use of synthetic material has been proposed in order to avoid harvesting and carving cartilage, the best long-term choice for reconstructing an ear is autologous rib cartilage. This procedure requires good understanding of the 3-dimensional architecture of the ear and learning the step-by-step construction of a harmonious framework (which with practice will become the most straightforward part of the procedure). Surgery, usually performed at the age of 9 or 10 years, is planned in 2 stages. In the first stage, the framework is placed under a skin pocket. Six months later, the sulcus is created using an additional cartilage graft for projection and a skin-grafted galeal fascial flap. In order to shorten the learning curve, a detailed carving process is described here, as well as a tool to enable training before surgery. Remnants of the microtic ear can have many different shapes; therefore, a comprehensive approach to skin management is proposed, providing a simple surgical classification for all types of microtia. Furthermore, some refinements of the cartilage framework and the construction of the retroauricular sulcus have improved results. Whenever possible, successful reconstruction of a microtic ear with autologous rib cartilage, as opposed to synthetic materials, is by far the best option.

Sculpting a tridimensional autologous rib cartilage framework is essential to restore a natural ear shape and becomes routine with preoperative training, but management of the skin is the key to minimizing complications. Here the authors provide a classification scheme to manage auricular skin: Type 1 is a Z-plasty with transposition of the lobule; type 2 is a transfixion incision of the microtic ear; type 3 exposes the cartilage remnants through a cutaneous incision. They also explain how to choose between the three types, depending upon the auricular skin potential. With training and method, results in ear reconstruction using autologous rib cartilage are excellent and reproducible.

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