Sculpting Ears: Reconstructions that Span Art and Medicine
Ilinger outside a large auditorium at Dartmouth-Hitchcock Medical Center as I wait for the midday session to begin. I have decided to attend part of the biennial Radford C. Tanzer Plastic Surgery Symposium, held in October 2009. Physicians have come to DHMC from all over the country, even from abroad, to give presentations about surgical outcomes, breast reconstruction, and new techniques and tools for repairing mangled wounds as well as congenital malformations of faces, tongues, and ears.
Only one other person is hanging out in the lobby with me—a handsome young man with an ID badge pinned to his navy blue blazer. I ask him whether he is in charge, and he laughs. "No, no," he says. "I'm here to listen to Dr. Brent and to thank him. My mother will be here, too, for the same reason." We talk for a few minutes, and I discover that he was a patient a long time ago of Dr. Burton Brent, the keynote speaker at the 2009 Tanzer Symposium. We end up sitting together, his mother on his other side.
For this midday session, medical professionals have packed the banked theater to hear about advanced techniques for reconstructing an outer human ear (not the hearing mechanism, but the part that is visible). This kind of plastic surgery is so vital to the idea of identity that I'm reminded of the photographs one sees in magazines—of children with severe harelips and cleft palates—in ad campaigns asking for donations to support the repair of such defects.
Why am I here? A friend has invited me because she knows I'm curious about how an ear is reconstructed. I am an outsider with a nonprofessional, personal interest in damaged ears as a consequence of an automobile accident 50 years ago, when I was a college student. My ear came close to being cut off when my head went through the windshield and back again. Examining one of the long scars that ran from my nose to my ear, several months after my initial surgery, the reconstructive surgeon said, "You were lucky your head went back through that jagged glass in the position it did, or you wouldn't have a right ear." Two years later, Volvo would introduce the modern three-point seat belt.
Before retiring four years ago, Nancy Pompian directed student disabilities services at Dartmouth, where she worked with students with learning, physical, and psychiatric disabilities. Previously, she was a naturalist at the Audubon Society and a book editor in New York and Boston.
It was only recently that I discovered it is possible to reconstruct an external ear. The friend who invited me to this symposium was Sheila Tanzer; her late husband, Dr. Radford Tanzer (whose name the symposium bears), was a pioneer in the field of ear reconstruction. Every other year, plastic surgeons and others in the field come together at DHMC for a symposium sponsored by the Radford C. and Sheila H. Tanzer Endowment Fund, which supports education in plastic surgery "while emphasizing qualities of integrity, humility, and passion in the pursuit of excellence in the specialty," as I read in the program. I watch people greet each other, and I sense that the camaraderie around me hints at these qualities.The mood in the room confirms my impulse to be here, even though I have no expertise in medicine.
From the lectern, before the moderator ushers in the keynote speaker, he introduces to the audience Dr. Tanzer's first and oldest patient. Almost 60 years ago, a young boy's parents brought him from northern New Hampshire to Mary Hitchcock Memorial Hospital in Hanover. At that time, Dr. Tanzer was the only plastic surgeon in New Hampshire, Vermont, and Maine, and no satisfactory method existed in the medical annals for building an external ear. The boy, who had been born with one normal ear and one undeveloped ear, would be Tanzer's first patient. It was having the challenge of this young patient that motivated Dr. Tanzer to work to solve the problem—using a drawing board and practicing with cadaver cartilage. He practiced until he felt prepared to try his new method, and he performed the surgery as soon as the boy was six years old.
Smiling shyly from the third row, where he's sitting with his wife and his mother, the man in his late fifties acknowledges the introduction. He's come to the symposium today to hear one of Dr. Tanzer's successors, Dr. Burton Brent, speak on the topic of "Carrying Forth the Tanzer Tradition: A 30-Year Personal Experience with 1,875 Total Ear Reconstructions with Autogenous Rib Cartilage Grafts."
It doesn't take much imagination to know what a difference a normal outer ear would make to a child. No more embarrassed self-consciousness, no taunting from other children. For a child—or an adult, for that matter—it could mean the difference between acceptance and isolation from a society that glances at and then looks away from a defect so obvious, whether it's congenital or whether it results from an electrical accident, a burn injury, or a mutilating car wreck.
Everything about Dr. Brent's presentation is fast: his speech and his quick tour through countless before-and-after slides portraying the building of external ears, a challenge he has described as "the most difficult thing we see in plastic surgery." He tells us that the best materials with which to practice cartilage sculpting are potatoes and carrots. He clicks on a slide of a vegetable platter at a cocktail party—celery sticks, carrot sticks, and in the center a dozen white ears carved out of potatoes—and then on a slide of a "seafood platter," with deep-fried potato ears on the side. And next come a few slides of Dr. Brent's sculptures in his studio in California, where his practice is located. The surgeon needs to practice ahead of time to shape each individual ear—to match one new ear to an existing ear or to build two ears that match—since the actual cartilage-shaping must be done quickly while the patient is under sedation.
In addition to being a busy plastic surgeon, Dr. Brent is a gifted sculptor who works in steel, bronze, and other media. At the zoos of San Francisco, San Diego, and Seattle, children climb all over his bronze hippos. Some of his sculptures—like a seven-foot steel polar bear at the San Diego zoo—are taller than he is.
Burt Brent was already a young plastic surgeon when he heard Radford Tanzer lecture at a conference in 1970. Dr. Brent's wife had said to him, "Rad Tanzer is retiring. You should think about taking up his ear work." It wasn't long before Dr. Brent drove to Hanover, where he and Dr. Tanzer talked, starting with Tanzer's work on World War II soldiers with torn-off or blown-off ears. He had experimented with cartilage from cadavers in his first attempts but found that the cartilage didn't hold up. They then discussed Dr. Tanzer's technique for building the framework of an ear using the patient's own rib cartilage. Today, we are watching pictures of Dr. Brent carving a new outer ear. He creates a cartilage helix, the outer curved ear framework, then makes an incision precisely where the helix-shaped cartilage will be inserted. We see a slide of a tiny vacuum tool that sucks out air from the incision after the ear is in place in its skin pocket.
Dr. Brent says he does not operate on children under age six. "Or we'd have to get them in one of these," he says, as he flashes up a slide of a dog wearing an upturned funnel-shaped collar to prevent scratching. "Age three is the age of awareness, but six to eight is the age of concern," he goes on to explain. Also, by that age there is enough cartilage to work with. He always uses, as Dr. Tanzer did, cartilage from the opposite side of the site for the new ear. "It just works better, for some reason." More importantly, children over age six will be less likely to fight the healing process. They're motivated to be sure their new ear is a success.
Some ear-reconstruction patients are born with a normal hearing mechanism—the ear canal, the cochlea, and all the other intricate parts—but in others both the external ear and the mechanism to hear are missing. Either way, as Dr. Tanzer wrote about the external ear 50 years ago, "the ears should be reconstructed [by the age of six]. . . . The psychic trauma of a conspicuous deformity precludes further delay." And if possible, he added, the surgery "should include improvement of hearing on at least one side."
The young man I met in the lobby is sitting directly to my right, so I can easily admire the helix of his left ear. Within it are complex curves and recesses, which were added in a subsequent operation. I suddenly I realize that this ear I'm looking at was made from his own rib cartilage. As Dr. Brent says, "Rib cartilage can go through anything. It's alive, it grows."
Afew weeks later, I find myself at a luncheon gathering, sitting across the table from Sam Drazin of Norwich, Vt., the young man I sat next to at the symposium. Sam—who has worked at an elementary school for the past two years and is currently in his last year of college, earning a degree in education—is enthusiastically describing a lesson plan from the week before. It had been Halloween week, and so he led his sixth-graders through a series of exercises and activities involving Edgar Allan Poe's "The Raven."
As lunch continues, we become friends, and I learn more about Sam's history. He was born with Treacher Collins Syndrome, a condition in which children are normal except for certain underdeveloped craniofacial bone structures. For Sam, it meant a receding jawbone and chin, downward-slanting eyes, and microtia—small, undeveloped ears. In 1993, when Sam was six, he had ear reconstruction by Dr. Brent on both ears—a series of operations over the course of a year—plus some subsequent surgeries by another surgeon on his jaw and nose.
Because he was born without ear canals, Sam wears bone-conductive hearing aids. They work by sending the vibrations of sound waves through his skull to his inner ear, and they enable him to follow a conversation with ease. Since he could understand speech during the crucial time when his language skills were developing, he acquired normal speech, and his expressive language is exceptionally clear and concise. He is one of those people whose intelligence and zest shine from his eyes and are conveyed through the tone and fluency of his speech. Sam's life experiences have been challenging, and he says that just as Dr. Brent shaped his ears, "My life experiences have shaped who I am today and influence my teaching style and passion for helping individuals younger than myself to find their way through life's mazes."
Sam had his picture taken with Dr. Brent after the symposium. It was difficult to tell who took the most pleasure from their encounter. Dr. Brent had reconstructed Sam's ears 17 years earlier, and until the symposium in October 2009 hadn't seen his patient since. Who was happiest with Sam's adult face? Sam, or the surgeon who had helped provide him with the gift of normal appearance? Or was it a third person, standing off to the side, watching them together and smiling—Sam's mother, Hope?
To see videos of ear reconstruction by Dr. Burton Brent, click here.
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