— Balancing Hearing Reconstruction and Otoplasty For many years whenever I have been in the Ear Specialist Clinic, I have encountered anxious parents who have come in with their babies shortly after full term because of their children’s ear deformities. Usually, parents are most concerned about the hearing loss and cosmetic defects caused by the ear deformity, and in the case of binaural deformities, they are more concerned about the impact on hearing. Malformations of the auricle and middle ear not only have an impact on the localization of hearing, but more importantly, on the psychological development of the child. If bilateral, it can affect the child’s speech development, resulting in slurred speech. Currently, it is difficult to address both hearing and otoplasty in these congenital middle and outer ear malformations, whether in plastic surgery or otolaryngology, which often leads to patient confusion and remains an extremely challenging problem for physicians. Therefore, it is crucial to spread general knowledge about the treatment of these congenital disorders. Epidemiological surveys have shown that the incidence of aural anomalies and microtia is about 1.40 per million in China and 0.1 – 6.4 per million in countries around the world. If we include those with simple ear canal stenosis or atresia and middle ear malformation, there are more than 3 million patients with various types of congenital ear malformations in China. Hearing loss and severe cosmetic deformities have a serious impact on auditory localization, child speech development, and child psychological development. This is a disease group that requires the joint attention of otologists and plastic surgeons. Because malformations of the external ear are often accompanied by malformations of the tympanic wall, malformations of the auditory chain, facial nerve malformations, or vascular malformations. The presence of these malformations poses additional and more serious risks to surgical treatment and makes rehabilitation of hearing more difficult. Therefore, a thorough audiological and imaging examination should be performed before deciding on treatment to fully understand the anatomical malformations and development of the ear in order to decide on the surgical approach and predict the surgical outcome. In cases of unilateral ear deformity, the hearing level of the contralateral ear determines the treatment of the deformed ear. If the hearing of the contralateral ear is normal and language learning is not affected, although the affected ear does not need to be treated urgently, the psychological impact on the child should be considered and it is usually more reasonable to choose surgery at the age of 6. After the age of greater than 14, the effect of ossicular reconstruction will decrease. Of course, patients can also wear hearing aids to improve source localization, broaden the frequency response range and reduce sound distortion. For patients with binaural malformations, almost all otologists advocate early hearing evaluation and early use of hearing aids or appropriate surgical treatment to improve hearing as much as possible. For people with monaural malformation hearing loss, the question of whether to treat them surgically has been a controversial one. Many physicians believe that the decision to operate should be made carefully in cases of unilateral ear deformity. This is because even in carefully screened cases, only about 50% of postoperative cases are likely to achieve a hearing threshold of less than 25 dB or better, and only in these patients is surgery worthwhile. For surgical treatment of unilateral ear deformities, the chances of hearing improvement have increased due to improvements in surgical techniques and diagnostic techniques, and the use of advanced technology to reduce the risk of surgery. However, we still believe that surgery for ear malformations with the goal of obtaining binaural hearing should be subject to strict selection criteria. In cases of bilateral atresia, the timing of surgery is also a concern for parents, with surgery usually being performed at school age 6 years. At this age, the child is more likely to undergo various ear function tests, accurate audiological testing can be performed, and the development of the middle ear mastoid airspace system is gradually completed, allowing the child to cooperate with postoperative care and treatment. For a long time, due to the lack of effective cooperation between otolaryngology and plastic surgery, in addition to the technical difficulties of auricular reconstruction and hearing reconstruction, there is a lack of overall concept and design between the various procedures of auricular reconstruction, external auditory canal reconstruction and hearing reconstruction, which seriously affects the effectiveness of surgical treatment and the depth of clinical research on this type of disease. From the ear surgery point of view, the main point in the diagnosis and treatment of ear malformation is to determine whether there is a possibility of improving hearing, because about 60% of patients can improve their hearing through surgery; at the same time, because some patients with ear malformation, especially those with external canal stenosis, are prone to the formation of cholesteatoma. Therefore, otologic surgery must first evaluate the patient for otologic deformities, and only then consider the cosmetic aspects of the ear deformity. From the plastic surgery point of view, ear deformity or absence is an important aspect that affects the psychological and social adaptation of children. However, since hearing reconstruction surgery uses a postauricular incision and the classical ear reconstruction method uses the skin behind the ear and rib cartilage, this means that the classical ear reconstruction method will be more difficult to perform and basically difficult to implement, as hearing and appearance cannot be reconciled. This means that it is even more difficult to perform the classical auricular reconstruction procedure. We have made some progress in the access to the external auditory canal, the repair of the ear canal wall, and the simultaneous surgery of total auricular reconstruction and hearing reconstruction. The adoption of the anterior approach to the external auditory canal has solved the problem of postoperative infection in the large mastoid cavity; the adoption of the free split thick skin slice to repair the external auditory canal has avoided postoperative scar contracture and restenosis of the external auditory canal, and the postoperative “dry ear” time has been greatly reduced. These advanced methods of external auditory canal repair not only guarantee improved hearing, but also lay the foundation for the reconstruction of a more three-dimensional auricle. In carefully selected cases, auricular reconstruction, external auditory canal reconstruction and hearing reconstruction can be performed at the same time for more satisfactory results.