Groundbreaking ear reconstruction surgery to be performed on teen at Joburg hospital

FIRST FOR SOUTH AFRICA

On Friday, 29 August, a groundbreaking surgery is set to be carried out at the Nelson Mandela Children’s Hospital in Johannesburg, involving the reconstruction of an ear using the Su-por technique — the first time this procedure is performed in South Africa.

The patient, a 15-year-old from KwaZulu-Natal, is being treated for microtia, a rare congenital condition that results in the underdevelopment of the outer ear.

“This South African first represents not only a technological marvel but a true opportunity to change a child’s life. That is a big win for us. Our department is committed to improving the lives of children with ear, nose and throat conditions,” said Dr Mogau Lamola, head of the ENT department at the Nelson Mandela Children’s Hospital.

The procedure is being funded by the Ear and Eye Clinic in Alberton and the Give an Ear Foundation, in partnership with the Nelson Mandela Children’s Hospital. The patient, who would not otherwise have been able to access specialised care, will receive the surgery at no cost to their family.

Daily Maverick spoke to South African ear, nose and throat (ENT) surgeon, Dr Duane Mol, who co-founded the Ear and Eye Clinic and will be leading the surgery on Friday.

The Su-por technique uses a biocompatible, porous polyethylene implant to form the ear. Mol described the material as strong, flexible and very resistant to cracks.

Since 2004, Mol has reconstructed outer ears for many children using a rib cartilage graft technique, which he learned in Germany from Dr Henning Frenzel, an ENT specialist from Lübeck.

This method involves harvesting cartilage from the patient’s chest, sculpting it into an ear shape and implanting it beneath the skin, according to the Nelson Mandela Children’s Hospital.

“[Frenzel] was pretty much the only guy in Germany that was doing this procedure, and I told him we needed this in South Africa and that I would go for some training there. Eventually, I invited him to come to South Africa so we could start doing this here for kids. In 2014, we operated on our first child here, and since then, we’ve done three or four a year,” said Mol.

The rib cartilage graft technique requires two or three surgeries, said Mol. However, the newer Su-por method requires only one procedure. Over the past few years, Mol has spent time in Germany mastering this surgery alongside Frenzel.

There are two methods for creating the polyethylene implant. One, which is more expensive, involves sending a 3D impression of the patient’s ear to the company that makes the device. This is then used to form a matching ear for the other side. The other involves ordering one of 24 pre-set ear shapes from the company.

Children affected by microtia often have only a small nub of cartilage in place of the ear, rather than features like the lobe, tragus and helical rim, according to the Nelson Mandela Children’s Hospital. Sometimes, there is no visible ear at all. Atresia, which frequently accompanies microtia, is the absence or closure of the ear canal.

In South Africa, microtia occurs in about one in 8,000 live births, according to Mol. At the Ear and Eye Clinic, which Mol established in 2017 along with two colleagues, there are currently 41 children waiting for ear reconstruction surgery.

The patient who is due to receive the Su-por implant on Friday has a syndrome called hemifacial microsomia, where one side of the face is underdeveloped. During the surgery, the team will raise and reconstruct his ear, while sealing an external ear canal that does not allow him to hear.

Down the line, the patient will require a second operation to receive a hearing implant.

The surgery will be long and complex, lasting around 12 hours. A team of about 10 health professionals will be assisting with the procedure, including Mol’s wife, Dr Therina Mol, and Dr Tercia Tsakani Nkuna-Shilenge of the Nelson Mandela Children’s Hospital.

“We’ve got to allow for everything … so we’ve been liaising very closely with the teams,” said Mol, adding that staff from the hospital and the Ear and Eye Clinic had participated in a simulation of the procedure on Saturday, 23 August, to prepare.

The complicated aspect of the surgery involves raising the temporoparietal fascia flap on the patient’s head in preparation for the implant, said Mol. This involves raising a thin layer of connective tissue around 14cm long and 11cm wide.

“It takes you roughly half an hour per centimetre to raise that flap … so that’s where most of the time goes. Once it’s raised, you use that flap to give blood supply to this … polyethylene implant,” explained Mol.

“You can’t just put that implant under the skin — it doesn’t live, it’s going to die … but if you can give it a blood supply, then it will stay inside the body. And that’s what we’re doing with that flap, engaging blood supply to actually cover the device.”

Mol is a consultant at the Nelson Mandela Children’s Hospital. The health facility has stated that Friday’s surgery presents a “valuable teaching opportunity” that will help to expand local expertise.

“It will be observed by medical professionals, including nurses and aspiring specialists, who are training to treat microtia,” said the hospital.

There have been several barriers to implementing the Su-por technique in South Africa up to this point.

As microtia is relatively rare worldwide, specialised surgical expertise has been slow to gain traction, according to Nelson Mandela Children’s Hospital. Few local surgeons see enough cases to specialise exclusively, and those who do have had to seek advanced training abroad.

At the moment, there is only one company that’s licensed to 3D-print the Su-por implants, and the cost of these devices is high. For Friday’s surgery, the implant alone costs about R80,000.

Mol said he hoped to attract funding to provide more of the procedures in South Africa in future.

“There’s one company that services the whole world … so unfortunately, you can’t really negotiate too much on the price of the device. We’re just trying to make sure this works, so I think that’s down the line,” he said.

The Nelson Mandela Children’s Hospital noted that for the patient, the procedure marks more than just a surgical milestone, but also a chance to “hear more fully, to have more confidence in their appearance, and to grow up feeling just like other children.”