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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.

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