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ORIGINAL ARTICLE |
https://doi.org/10.5005/jp-journals-10003-1480
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Single-stage Pinna Reconstruction in Thailand Experience
1,2Department of Otorhinolaryngology, Ramathibodi Hospital, Rajdhevee, Bangkok, Thailand
Corresponding Author: Navarat Apirakkittikul, Department of Otorhinolaryngology, Ramathibodi Hospital, Rajdhevee, Bangkok, Thailand, Phone: +66 022011515, e-mail: navarat.gib@gmail.com
How to cite this article: Tungkeeratichai J, Apirakkittikul N. Single-stage Pinna Reconstruction in Thailand Experience. Int J Otorhinolaryngol Clin 2023;15(3):132–135.
Source of support: Nil
Conflict of interest: Dr Jumroon Tungkeeratichai is associated as the Editorial board members of this journal and this manuscript was subjected to this journal’s standard review procedures, with this peer review handled independently of these Editorial board members and their research group.
Received on: 26 August 2022; Accepted on: 28 May 2023; Published on: 09 January 2024
ABSTRACT
Background: Microtia reconstruction is one of the most challenging for the surgeon. In 1970, Brent modified Tanzer’s technique and became the foremost expert in microtia reconstruction with a 4-stage procedure. The most popular in Asia is Nagata from Japan, who developed Tanzer’s technique with 2-stage procedure. Reinisch has proposed to use porous polyethylene (PPE) (Medpor) in microtia reconstruction, and Romo also reported that using temporoparietal fascial flaps to surround the Medpor implant appears to have significantly reduced its failure. In Thailand, single-stage pinna reconstruction was experienced for more than 10 years, but no systematically demonstrated clinical outcome of this procedure.
Objective: To study the clinical success rate and complication of single-stage pinna reconstruction in Thailand experience.
Materials and methods: The data were recorded from 1 January 2009 to 31 December 2019 from every patient who underwent single-stage microtia reconstruction at Ramathibodi Hospital by a single surgeon (the author). A total of 81 patients were included in this study.
Results: Male patients were 50 (62.5%) cases, and female patients were 30 (37.5%) cases. The mean age of the patient was 16 years old (range 1–59 years old). The majority of 78 cases (97.5%) were unilateral microtia reconstruction. About 67 cases (83.75%) underwent single-stage microtia reconstruction successfully without any complications. Only 13 (16.25%) cases had problems and some need solutions. There were 6 cases of early complications and 7 cases of late complications. In the early complication group, there was 1 case of hematoma and 5 cases of implant exposure. In the late complication group, all 7 patients encountered implant exposure problems. Among these patients, 5 patients needed only a single repair, and 2 patients had to undergo multiple surgeries. In our experience since 2009, only 1 patient was necessary to perform removal of prosthesis. Hence, our success rate of a single-stage microtia reconstruction using Medpor prosthesis has been 98.75%.
Conclusion: Single-stage microtia reconstruction with porous high-density polyethylene implant is one of the safe and successful techniques to reconstruct microtia problems. The most advantages are that the procedure can be performed in a single procedure at younger age and lower morbidity, compared with costal cartilage uses. However, further study must be performed to decrease complications. In our experience, the successful rate is excellent.
Keywords: Medpor implant, Single-stage pinna reconstruction, Temporoparietal fascia flap.
INTRODUCTION
Microtia reconstruction is one of the most challenging for the surgeon. It requires the maintenance of three-dimensional details of a ear pinna under the coverage of a two-dimensional skin surface with additional shape compared with the other normal side.1,2
The earliest reports of auricular reconstruction date back to 600 BC by the Indian surgeon Sushruta Samhita, who used local skin flaps for ear lobe reconstruction. In 1970, Brent modified Tanzer’s technique.3–5 He became the foremost expert in microtia reconstruction with 4-stage procedure, and the most popular in Asia is Nagata from Japan. He developed Tanzer’s technique with 2-stage procedure.6–9 New material high-density porous polyethylene (Medpor) is a stable, alloplastic implant that can integrate with host tissues and resistant to infection.10–12 Reinisch has proposed to use porous polyethylene (Medpor) in microtia reconstruction,13 and Romo also reported that using temporoparietal fascial flaps to completely surround the Medpor implant appears to have significantly reduced its failure.14,15
MATERIALS AND METHODS
The data were recorded from 1 January 2009 to 31 December 2019 from every patient who underwent single-stage microtia reconstruction at Ramathibodi Hospital by a single surgeon (the author). A total of 81 patients were included in this study.
Surgical Technique
Preoperative Preparation
The site of the implant is planned following anatomical position of the ear (Fig. 1). The superior aspect is at the level of the supraorbital rim or tail of the eyebrow, and the inferior aspect is at the base of nasal columella. The long axis of the ear lies 15–20° posteriorly to the vertical axis (nasal bridge). The width of the ear is around 55% of its length when measured perpendicular to the long axis. The auriculocephalic angle is 25–35°.
Fig. 1: Anatomical reference for microtia reconstruction
The scalp was shaved in the area 18 cm away from the remnant or 12 cm above the line of the upper part of the helix. Anterior and posterior branches of the superficial temporal artery were palpated and marked.
Local Anesthesia
The skin incision was made in Z-shape on the scalp, and Z-plasty incision on the lobule remnant. The incision line was infiltrated with 0.5% lidocaine with 1:200,000 adrenaline.
Implant Preparation
Two parts of Medpor implants (base and helical rim) were sutured together for three points with nylon 3-0 and soaked in povidone solution (Fig. 2).
Fig. 2: Medpor preparation
Full-thickness Skin Graft (FTSG)
Full-thickness skin graft can be harvested from the abdominal, chest, or inguinal area. The graft is designed in an elliptical shape, around 3.5–4 cm in width and 8–9 cm in length, not too thin and not too thick to preserve Medpor definition (Fig. 3).
Fig. 3: Harvest full-thickness skin graft (FTSG) at inguinal area
Temporoparietal Fascia (TPF) Flap
The scalp was elevated in two planes to take the TPF flap. The first is to elevate in the subfollicular plane using Colorado needle fine-tip cautery and Steven’s scissors. The second is to bluntly elevate the TPF flap from the deep temporal fascia using Colorado tip monopolar cautery and Rhytidectomy scissors. The flap is elevated, including both the anterior and posterior branches of STA, which often have a loop connection, in a size of 12 cm width and 11 cm height. Care must be taken to avoid injury to the temporal branch of the facial nerve by identifying Pitanguy’s line.
Implant Placement
After deciding the location of Medpor, the TPF flap is flipped over to cover all the framework and sutured together with Vicryl 3-0. This process is orderly performed in T-junction fashion, from the inferior, posterior, and anterior sites of the framework, respectively. The Radivac drains are inserted into the scalp flap and under the helical part of Medpor before suturing TPF separately. This step produced a negative pressure on the Medpor framework, thus alleviating the flap to drape onto the framework perfectly. Two pieces of FTSG are used to cover the anterior and posterior parts of the framework, suturing with Nylon 5-0. Subcutaneous tissue and skin of the scalp are reapproximated using Vicryl 3-0 and 5-0 in children or Nylon 5-0 in adults (Fig. 4).
Fig. 4: Medpor surgical reconstruction procedure
Postoperative Care
The surgical wound was applied with terramycin ointment and Sofra tulle. Two pieces of cotton soaked with terramycin ointment were placed on the antihelix and concha area. The radivac drain and the sutures were removed at 7–10 days and 10–14 days, respectively.
RESULTS
From the demographic data in Table 1, male patients were 50 (62.5%) cases and female patients were 30 (37.5%) cases. The mean age of the patient was 16 years old (range 1–59 years old). The majority of 78 cases (97.5%) were unilateral microtia reconstruction though bilateral cases were only 2 (2.5%) (Table 1).
| Demographics | n (%) |
|---|---|
| Male | 50 (62.5%) |
| Female | 30 (37.5%) |
| Age; median (range) | 16 (5–59) |
| Unilateral | 78 (97.5%) |
| Bilateral | 2 (2.5%) |
From the study, 67 cases (83.75%) underwent single-stage microtia reconstruction successfully without any complications. Only 13 (16.25%) cases had problems and some need solutions. There were 6 cases of early complications, which happened within 1 month after surgery, and 7 cases of late complications.
In the early complication group, there was 1 case of hematoma and 5 cases of implant exposure. The hematoma was a minor complication and could be simply solved by blood clot removal. Implant exposure, that occurred in 1 month, had been explored and repaired in different techniques, including resuture in 2 cases, rotational flap in 1 case, FTSG in 1 case, and deep temporal fascia flap in 1 case. Unfortunately, one patient in this group, who underwent deep temporal fascia flap because of TPF flap failure, later showed recurrent exposure at 14 months after the first repair, and Medpor prosthesis removal was inevitable.
In the late complication group, all 7 patients encountered implant exposure problems. Among these patients, 5 patients needed only a single repair and 2 patients had to undergo multiple surgeries. Aside from exposure problems that took place earlier, these late-onset complications were assumed to be from patient factors. From the surgeon’s experiences, almost all microtia patients who had undergone the surgery were children. Pressure trauma, which happened from a sleeping position, was an annoying hassle to deal with. Generally, both children and their parents were prescribed to avoid lying in a lateral decumbent position on the side of the operation strictly. However, dealing with the kids was always naturally indeterminate. Five patients who needed only a single-stage solution consisted of partial excision of prosthesis in 2 cases, rotational flap in 1 case, advancement flap in 1 case, and deep temporal flap in 1 case. Moreover, there were 2 patients who needed more than a single surgery. One was an 8-year-old male patient who performed an advancement flap after the first reconstruction at 6 months and another rotational flap at 16 months. A more complicated case was a 7-year-old male patient. He had an advancement flap and three times of rotational flap. However, none of the patients in this group needed a prosthesis removal.
In our experience since 2009, only one patient was necessary to perform a removal of prosthesis. Hence, our success rate of a single-stage microtia reconstruction using Medpor prosthesis has been 98.75% as in Table 2.
| n | % | |
|---|---|---|
| Total number | 80 | 100 |
| Complication | 13 | 16.25 |
| • Early | 6 | 46.15 |
| • Late | 7 | 53.85 |
| Success rate (no prosthesis removal) | 79 | 98.75 |
DISCUSSION/OUTCOME
Single-stage total pinna reconstruction with porous polyethylene (PPE) (Medpor) implant is an excellent alternative to traditional autologous rib cartilage reconstruction. Medpor is a highly durable, biocompatible, and nonresorbable material that was used as an implant in various facial plastic procedures such as malar, nose, chin, and ear surgery. The advantages of PPE are beautiful esthetic results and less resorption compared with cartilage.11–13 Since Medpor is a prefabricated prosthesis, it provides for both the surgeon and patient with shorter operative time, earlier age of intervention, and single procedure. Furthermore, donor site morbidity from harvesting rib cartilage is no longer a concern in alloplastic reconstruction, even in daily activity or during hard workouts.16–18 It is now even considered a standard method of treatment for microtia by some surgeons because of the highly successful outcomes reported.19,20 Implant exposure caused by flap failure has been described consistently since alloplastic material usage. Since Reinisch and Lewin modified technique that incorporates TPF flap for soft tissue coverage, the exposure rates in Medpor reconstruction have decreased from 44 to 7.3%.13 Small defects less than 0.5 cm can be closed by wide undermined and primary suture. If the defect is expanded to more than 1 cm, local flap is recommended. Surgical debridement and a local flap typically solve the problem. Preauricular or postauricular rotation flap is done to cover the defect. Skin graft is often inadequate due to no blood supply at the wound bed in the patient with exposed Medpor. In cases of immediate exposure, the cause is most likely an injury to the posterior branch of superficial temporal artery. We can prevent this complication by elevating the temporoparietal fascia flap more posteriorly to allow the arterial supply of the occipital artery for flap survival. For early complications of flap necrosis occurring in 1–2 weeks postoperatively can be treated by harvesting the deep temporal fascia flap with a local skin flap to completely cover the reconstructed ear. Appropriate wound care is crucial to safely preserve the framework and prevent further exposure. Moreover, in a prospective study using validated questionnaires to evaluate quality of life and patient satisfaction after Medpor total ear reconstruction, Braun et al. found that the quality of life improved in 75.6% of adults and 100% of children; 72.7% of adults and 85% of children were happy with their esthetic results.21
CONCLUSION
Single-stage microtia reconstruction with porous high-density polyethylene implant is one of the safe and successful techniques to reconstruct microtia problems. The most advantages are that the procedure can be performed in a single procedure at younger age and lower morbidity, compared with costal cartilage uses. However, further study must be performed to decrease complications. In our experience, the successful rate is excellent.
ORCID
Navarat Apirakkittikul https://orcid.org/0000-0003-0016-9618
REFERENCES
1. Sclafani AP, Mashkevich G. Aesthetic reconstruction of the auricle. Facial Plast Surg Clin North Am 2006;14(2):103–116. DOI: 10.1016/j.fsc.2006.01.004.
2. Quatela VC, Thompson SK, Goldman ND. Microtia reconstruction. Facial Plast Surg Clin North Am 2006;14(2):117–127. DOI: 10.1016/j.fsc.2006.01.002.
3. Brent B. Technical advances in ear reconstruction with autogenous rib cartilage grafts: Personal experience with 1200 cases. Plast Reconstr Surg 1999;104(2):319–334. DOI: 10.1097/00006534-199908000-00001.
4. Brent B. Microtia repair with rib cartilage grafts: A review of personal experience with 1000 cases. Clin Plast Surg 2002;29(2):257–271. DOI: 10.1016/s0094-1298(01)00013-x.
5. Tanzer RC. Microtia – A long-term follow-up of 44 reconstructed auricles. Plast Reconstr Surg 1978;61(2):161–166. DOI: 10.1097/00006534-197802000-00001.
6. Nagata S. A new method of total reconstruction of the auricle for microtia. Plast Reconstr Surg 1993;92(2):187–201. DOI: 10.1097/00006534-199308000-00001.
7. Nagata S. The modification stages involved in the total reconstruction of the auricle: Part I. The modification in the grafting of the 3D costal cartilage framework (3D frame) for the lobule type microtia. Plast Reconstr Surg 1994;93(2):221–230. PMID: 8310014.
8. Nagata S. The modification stages involved in the total reconstruction of the auricle: Part II. The modification in the grafting of the 3D costal cartilage framework (3D frame) for the concha type microtia. Plast Reconstr Surg 1994;93(2):231–242. PMID: 8310015.
9. Nagata S. The modification stages involved in the total reconstruction of the auricle: Part III. The modification in the grafting of the 3D costal cartilage framework (3D frame) for the small concha type microtia. Plast Reconstr Surg 1994;93(2):243–253. PMID: 8310016.
10. Shanbhag A, Friedman HI, Augustine J, et al. Evaluation of porous polyethylene for external ear reconstruction. Ann Plast Surg 1990;24(1):32–39. DOI: 10.1097/00000637-199001000-00006.
11. Williams JD, Romo T III, Sclafani AP, et al. Porous high-density polyethylene implants in auricular reconstruction. Arch Otolaryngol Head Neck Surg 1997;123(6):578–583. DOI: 10.1001/archotol.1997.01900060020003.
12. Sclafani AP, Romo T III, Silver L. Clinical and histologic behavior of exposed porous high-density polyethylene implants. Plast Reconstr Surg 1997;99(1):41–50. DOI: 10.1097/00006534-199701000-00007.
13. Reinisch JF, Lewin S. Ear reconstruction using a porous polyethylene framework and temporoparietal fascia flap. Facial Plast Surg 2009;25(3):181–189. DOI: 10.1055/s-0029-1239448.
14. Romo T III, Fozo MS, Sclafani AP. Microtia reconstruction using a porous polyethylene framework. Facial Plast Surg 2000;16(1):15–22. DOI: 10.1055/s-2000-7322.
15. Romo T III, Reitzen SD. Aesthetic microtia reconstruction with Medpor. Facial Plast Surg 2008;24(1):120–128. DOI: 10.1055/s-2008-1037453.
16. Adams WP Jr, Rohrich RJ, Gunter JP, et al. The rate of warping in irradiated and nonirradiated homograft rib cartilage: A controlled comparison and clinical implications. Plast Reconstr Surg 1999;103(1):265–270. DOI: 10.1097/00006534-199901000-00042.
17. Thomson HG, Kim TY, Ein SH. Residual problems in chestdonor sites after microtia reconstruction: A long-term study. Plast Reconstr Surg 1995;95(6):961–968. DOI: 10.1097/00006534-199505000-00002.
18. Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr Surg 1997;99(4):1030–1036. DOI: 10.1097/00006534-199704000-00017.
19. Stephan S, Reinisch J. Auricular reconstruction using porous polyethylene implant technique. Facial Plast Surg Clin N Am 2018; 26(1):69–85. DOI: 10.1016/j.fsc.2017.09.009.
20. Storck K, Staudenmaier R, Buchberger M, et al. Total reconstruction of the auricle: Our experiences on indications and recent techniques. Biomed Res Int 2014;2014:373286.
21. Braun T, Gratza S, Becker S, et al. Auricular reconstruction with porous polyethylene frameworks: outcome and patient benefit in 65 children and adults Plast Reconstr Surg 2010;126:1201–1212. DOI: 10.1097/PRS.0b013e3181ebe391.
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