Surgeon Devises Method For Making Ears From Ribs

Plastic surgeon Robert Ruder can now look back at those days at the grocery store with a smile. At the time, however, it was a little embarrassing.

On weekends, he would saunter up to the meat counter and ask the butcher for a bundle of leftover cows’ ribs.

“He thought I was crazy,” Ruder recalls. “I didn’t want any meat on the bones. He didn’t know how to charge me.”

But the butcher obliged and Ruder took the ribs home to his kitchen. He worked on a dozen ribs. Then 50, then 100.

Two hundred cows’ ribs later, Ruder was ready. He had enough practice to try what other pioneering surgeons had been struggling with for several decades without great success: build a human ear from scratch.

In fact, Ruder’s innovation - sculpting a graft of human rib cartilage to form an ear - has led to a very effective procedure to correct microtia, a relatively common birth defect in which a small nub is formed instead of an ear.

And because only a few surgeons worldwide specialize in the laborious series of operations, Ruder attracts patients from around the world, many of them children devastated not so much by the deformity, but by how other kids view them.

“At around age 5 or 6 is when the other kids start destroying them” with cruel teasing, says Ruder, a Beverly Hills, Calif., surgeon, who has heard many sad playground tales. “Most of these kids have terrible (emotional) problems, and the families suffer.”

His patients, who now number 162, say the procedure is worthwhile, even though it takes many months and costs about $15,000. Insurance sometimes covers part of the costs, Ruder says. For families who cannot afford the surgery, Ruder often absorbs the costs in exchange for whatever the family offers - everything from baked goods to time spent counseling and supporting other families who are just beginning the process.

Microtia affects one out of 7,000 newborns and involves just one deformed ear in about seven out of 10 cases. Usually, the other ear looks and functions normally. The defect is sometimes inherited. The acne drug Accutane , which should not be taken during pregnancy because of its link to many serious birth defects, can cause microtia in fetuses. Sometimes the cause is simply unknown.

The ear begins to form in the third week of fetal development, but something goes wrong. The result is just a tiny nub that looks like a fleshy earlobe.

Often, however, the patient has an intact inner ear and can hear muffled sounds despite the fact that the outer ear is missing - a situation not unlike having a baby grand piano with its lid shut. People with one good ear develop full speech and have only modest difficulty hearing. Many also learn to read lips.

“With microtia, the kids often hear themselves louder but they can’t hear other people. Or they can hear, but you have to talk loudly. These people are often perfectly normal in every way but the ear,” says Ruder, 49, who saw his first patient in the 1980s.

“I didn’t think there was a real state-of-the-art treatment. So I started to do research on it,” he says.

Intrigued that he might be able to reconstruct an ear and improve a patient’s hearing, Ruder visited one doctor in Japan and another in San Francisco who had adopted various ways to rebuild the ear. Surgeons had tried using Silastic, a rubbery plastic, and had even made ears out of cartilage from the ribs of cadavers. But sometimes the shape did not hold up or look normal.

Ruder thought that perhaps a patient’s own ribs could be used and began his experiments with cows’ ribs.

In the first stage of the surgery, a piece of rib is removed from the patient, is sculpted and is set in place within a pocket of skin. (That’s where all that practice on cows’ ribs came in handy, Ruder says.) Tubes are inserted to allow fluid to drain. That part is often the hardest on the patient because of the rib graft.

In the second operation, done in an outpatient surgical suite, the existing piece of ear - the nub - is reversed to form the earlobe.

In the third procedure, an otolaryngologist creates an ear canal and eardrum to link the outer ear to the fine bones of the inner ear. The ear canal is made from a skin graft from the stomach or leg and the eardrum is made from a graft of muscle behind the ear, says Dr. Antonio Dela Cruz, an otolaryngologist and director of education at the House Ear Institute in Los Angeles.

“We mechanically connect the newly grafted eardrum to the bone so that outside vibrations can move the eardrum and receive sound,” Dela Cruz says. “The bones are usually there but are often frozen - they don’t move - and they need to be freed up using a laser.”

Like Ruder, Dela Cruz says he finds the reconstruction one of the most rewarding surgeries he performs. “Especially,” he says, “when it’s a child who has the deformity in both ears.”

Months after the surgery on the inner ear, the final operation is performed: A groove is made behind the otherwise flat ear.

There are some risks to the surgery. Some people develop large scars called keloids. And infections and blood clots are a risk of almost any surgery.

Moreover, the age of the patient is a concern. It’s best to wait until age 8, when the existing ear has reached adult size and can be used for an accurate comparison. But, after about age 30 or so, the surgery becomes problematic because the rib cartilage used for the graft turns to bone, which is much harder to shape and riskier to graft.