Constructing Confidence : Dr. Robert Ruder used cows’ ribs to find a way to create human ears from rib cartilage. His ingenuity and dedication have given those with microtia new hope.
Plastic surgeon Robert Ruder can now look back at those days at the Vons 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 surgeon, who has heard many sad playground tales. “Most of these kids have terrible (emotional) problems, and the families suffer. Families are often not aware that something positive can be done.”
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.
When Mark Garcia, 10, was born without a left ear, his parents, Mario and Rosario, began a frustrating quest to see if anyone could fix the defect. After many dead-ends, the Lynwood family was finally referred to Ruder. Mark is about halfway through the multistage reconstruction. But his life has already changed, his mother says.
“He is so happy,” Rosario Garcia says. “He used to be at a school where the other kids would laugh at him. He would cry at school, and he had so many problems that I had to move him to a private school. He wanted so much to be normal.”
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 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. The patient had undergone reconstructive surgery in Sweden but was unhappy with the result. Ruder wasn’t sure he could help.
“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.
“That was what stimulated my interest--knowing that there was an area of medicine that needed attention,” he says. “I tried to pick up the best tips from each person who was doing the surgery, and it just evolved. Each procedure we did was better than the last.”
He selected his first patient--a child--because the youngster thought any ear would be better than no ear.
“We had a child who was psychologically devastated by his ear,” the surgeon recalls.
The child underwent a series of four operations and many other office visits, Ruder says. “Then I waited 1 1/2 years to see if it lasted.”
At first, Ruder wasn’t sure how well the procedure would work because grafted tissue is often reabsorbed. He was thrilled when that didn’t happen.
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.
Ruder was opposed to performing the surgery in adults--until he met Leah Hulce, who was 39 at the time.
“I never thought 39 was old--but it is for ears,” he says. “I told Leah I had not done anyone of that age and that the literature suggested many, many problems and the results were not that good.”
But Hulce, who was born without a right ear, persuaded Ruder to take on her case.
“I’ve never been shy about my ear,” says Hulce, who lives in Redondo Beach. “My father gave me a real sense of ‘You are OK.’ It was nothing to be ashamed of. When I was little and kids would tease me, I would say ‘That’s the way God made me.’ ”
Hulce’s positive attitude served her well. She learned to read lips and turn her head to pick up sounds with her left ear. She wore her hair up and hung a single earring on her left ear.
“I used to sometimes think, what if I had a chance to have my ear repaired? But then I thought, ‘Why should I?’ ”
About four years ago, however, things changed. Hulce, the mother of two, suddenly had trouble hearing out of her good ear. “It scared me to death because there was no backup.”
At the House Ear Institute, Hulce was told that there was no obvious cause for the hearing loss. The doctor then recommended that Hulce have her right ear reconstructed--to her amazement.
“I had no idea that this surgery was available,” Hulce says. “I had been so busy with my life. I went back to work after this appointment and I sat there at my desk stunned. I knew right away that I wanted to do it. Then I cried--for two hours. Obviously being able to hear is a lot more important to me than I had ever thought.”
Ruder began reconstructing Hulce’s ear in February, 1992.
“He was going out on a limb with me, but he realized how determined I am. He would tell me, ‘Leah, you are going to get discouraged. You’re going to want to quit.’ But I am an extremely determined person.”
Ruder was right in some ways. The surgery was more difficult and the ear’s appearance was not as good as seen in younger patients. But Hulce says the surgery has helped her in many ways.
“It’s nice to have something to put my glasses on,” she says of her new ear, which is slightly misshapen and more fleshy looking than the left ear. “And the reassurance is tremendous. There is not that feeling that my other ear is going bad and I’ll be dead in the water.”
It took about a year to develop hearing in the new ear, Hulce says. First, she heard a flushing toilet. Then, one day, she realized she could identify where the speakers were located in her car. So Hulce decided to put her new ear to the ultimate test. She gathered her family and some friends in her living room, shut her eyes and told them to move around the room and speak.
“I could point to where they were,” she says. “I sat there and cried. That was a good day.”
Building an Ear
Making an ear takes four operations and several months.
* First surgery: An E-shaped piece of rib is removed from the patient.
Piece is sculpted to resemble an ear and is inserted in a pocket of skin.
* Second: The fatty remnant of the ear, which patients often call the nub, is transposed to a lobe.
* Third: Otolatryngologists form an ear canal as a link to inner ear.
* Fourth: A groove is made behind the ear using grafts.
After completion of the surgery, it can take 12 to 18 months for hearing to develop.
* Source: Dr. Robert Ruder.