Objective <p>To evaluate the efficacy and safety of modified three-stage tissue expansion ear reconstruction in patients with bilateral congenital microtia and Bonebridge implantation.</p> Methods <p>A retrospective analysis was conducted on 18 patients with bilateral congenital microtia treated between January 2021 and December 2024. All patients underwent bilateral ear reconstruction, with one side having prior Bonebridge implantation. Modified three-stage tissue expansion ear reconstruction was performed. Surgical outcomes were assessed through objective measurements and patient satisfaction scores, while monitoring Bonebridge device function.</p> Results <p>Mean follow-up was 12.94 ± 3.87 months. No significant differences were found between the reconstructed ear and contralateral reconstructed ear in circumference, width, length, or auriculocephalic angle (<i>p</i> &gt; 0.05). Overall patient satisfaction reached 88.9%, with VAS scores improving from 0.67 ± 0.59 preoperatively to 8.22 ± 1.18 (<i>p</i> &lt; 0.001). Four patients (22.2%) experienced mild complications, all successfully managed. Audiological evaluation showed no significant difference in unaided bone conduction thresholds pre- and postoperatively (28.3 ± 5.6 dB HL vs. 27.9 ± 5.8 dB HL, <i>p</i> = 0.82), indicating preservation of inner ear function. Aided speech recognition scores remained stable (92.4 ± 4.3% vs. 91.8 ± 4.7%, <i>p</i> = 0.68), and all patients demonstrated normal Bonebridge electronic function and coupling test results.</p> Conclusions <p>Modified three-stage tissue expansion ear reconstruction is a safe and effective treatment for bilateral microtia patients with Bonebridge implantation. Through precise preoperative localization, compartmentalized dissection strategy, individualized expansion protocol, and meticulous framework implantation technique, satisfactory aesthetic outcomes can be achieved while protecting Bonebridge device function and preserving residual hearing.</p> Level of evidence <p>4.</p>