RECONSTRUCTIVE SURGERY
Auricular Reconstruction With Prolonged Tissue Expansion and Porous Polyethylene Implants Nathan Andrew Kludt, MD, and Hugh Vu, MD Objective: This study aimed to present our clinical experience using a prolonged tissue expansion technique and a Medpor framework for congenital microtia reconstruction. Methods: Auricular reconstruction was performed in 3 surgical stages. In the first surgical stage, a 60-mL custom kidney-shaped tissue expander is placed subcutaneously in the retroauricular mastoid region. The tissue expander is then serially expanded to maximum volume plus 30%. The tissue expander is then left fully expanded for 3 to 6 months. In the second surgical stage, the tissue expander is removed and a single-piece Medpor implant is placed and covered entirely by the expanded skin flap, without application of a fascial f lap or skin graft. In the third stage, we perform an excision of the remnant microtic ear. Results: A total of 15 patients were included with postoperative follow-up ranging from 6 months to 5 years. The draped soft tissue envelope was thin enough to show the reconstructed ear with excellent definition of the framework. Complications in this series included 1 case of partial implant exposure. Conclusions: The use of a Medpor framework after prolonged tissue expansion provides a well-defined, well-projected ear with robust soft tissue coverage. The expanded skin envelope with this method provides sufficient retroauricular nonYhair-bearing skin tissues for draping the framework without the need for temporoparietal fascial f lap or skin grafting. This alternative surgical method reduces surgical time and morbidity, and facilitates an aesthetic, natural-appearing reconstruction of the auricle. Key Words: ear reconstruction, tissue expansion, Medpor framework (Ann Plast Surg 2014;72: S14YS17)
T
he human ear is one of the most complex 3-dimensional structures of the external human body. Satisfactory treatment of the microtic ear represents a technical and artistic challenge for plastic surgeons. Numerous surgical techniques have been introduced for ear reconstruction with remarkable success.1Y4 Autologous costal cartilage has been considered the most dependable material for the auricular framework. However, it has 2 important drawbacks, namely, donor-site morbidity in the chest wall after cartilage harvest and surgeon difficulty with the intricate fabrication of the cartilage framework. With the development of porous, high-density polyethylene, Medpor (Porex; Porex Surgical, Newman, Ga), these difficulties can be easily overcome. It has been more than 21 years since Wellisz et al5 first reported its application in auricular reconstruction; yet, the Medpor framework has not been widely used in microtia reconstruction because of concerns of implant exposure. Many previous techniques have focused on the use of temporoparietal fascial f laps and skin grafts to decrease implant exposure complications.6,7 Tissue expansion for auricular reconstruction was
Received July 15, 2013, and accepted for publication, after revision, January 23, 2014. From the University of California Davis Medical Center, Sacramento, CA. Conflicts of interest and sources of funding: none declared. Reprints: Nathan Andrew Kludt, MD, University of California Davis Medical Center, 2221 Stockton Blvd, Room 2125, Sacramento, CA 95817. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-S014 DOI: 10.1097/SAP.0000000000000178
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www.annalsplasticsurgery.com
first described by Neumann8 in 1957, followed by Brent,9 Tanino and Miyasaka,10 and Hata et al11 with marginal success. Improved success was not attained until 2006 when a large series of ear reconstructions with tissue expansion were reported.2 Unfortunately, skin grafts and temporoparietal fascial f laps were still required to provide coverage and prevent implant exposure. With our technique of prolonged expansion, we have been able to provide supple, thin, and well-vascularized skin f laps to drape the Medpor framework without the need for temporoparietal fascial f laps or skin grafts. We perform our ear reconstruction using a prolonged tissue expansion process with a Medpor ear framework in a 3-stage technique.
METHODS Operative Procedure Auricular reconstruction was performed in 3 surgical stages as follows: (1) implantation of an appropriately sized tissue expander in the mastoid region, (2) removal of the tissue expander and placement of a single-piece Medpor framework, (3) excision of the remnant microtic ear.
Stage I: Tissue Expander Implantation Surgery at this stage was performed under general anesthesia and using tumescent local anesthesia. A template was made of the contralateral normal ear, with the root of the helix and lobule identified (Fig. 1A). A 3-cm incision within the postauricular scalp was made parallel to the temporal hairline (Fig. 1B). A subcutaneous pocket was then dissected immediately above the postauricular fascia. The pocket was dissected large enough to accommodate the tissue expander. After meticulous hemostasis was obtained, we inserted a custom kidney-shaped tissue expander with an integrated magnetic port (7 4.5 1.5 cm, 62-mL volume) (Fig. 1C). It was then placed as far anterior as necessary often under the remnant cartilage. A negative pressure drain was inserted into the pocket and 2-layered wound closure was performed before application of a pressure dressing. Inflation was begun 7 days postoperatively and generally performed twice weekly. Expansion was commonly completed in 6 to 8 weeks when the tissue expander was fully expanded plus an additional 30%, to provide adequate skin for draping the implant, approximately 80 mL (Fig. 2). The tissue expander then remained in place, fully expanded for an additional 3 to 6 months.
Stage II: Auricular Reconstruction The expander was def lated and removed through the incision made in the previous surgery (Fig. 3). The capsule was left entirely intact. We used the medium-sized, single-piece Medpor implant for simplicity and projection. After inserting the Medpor framework into its appropriate position, the expanded skin f lap was used to cover the entire framework (Fig. 4). The single-piece Medpor has a lobule component and requires no additional skin grafting as the postauricular sulcus is already created with the expanded skin. A negative pressure drain was placed to preserve a healthy contact between the ear framework and expanded skin f lap.12 Two-layered wound closure was performed and a pressure dressing applied. Annals of Plastic Surgery
&
Volume 72, Supplement 1, May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 1, May 2014
Ear Reconstruction with Prolonged Tissue Expansion
FIGURE 1. A, Template of normal ear. B, Planned pocket dissection and incision. C, Placement of tissue expander.
Stage III: Excision of Remnant Microtic Ear The final stage was performed 3 to 6 months after the auricular reconstruction and involved excision of the remnant microtic ear and closure. The remnant microtic ear is removed at this stage to avoid any potential complications that may occur with expanding a previously incised area. The Medpor implant has a lobule; therefore, lobule transposition at this stage was not necessary.
RESULTS
FIGURE 2. Fully expanded tissue expander.
FIGURE 3. Def lation of expander. * 2014 Lippincott Williams & Wilkins
We performed auricular reconstruction using the prolonged tissue expander technique and Medpor framework in 15 patients with follow-up ranging from 6 months to 5 years. The mean age at time of reconstruction was 7 years, with a range from 6 to 12 years. Eight patients were men and 7 women, all with either grade 3 or 4 microtia. The draped skin was thin enough to show the framework with excellent contour (Fig. 5). The reconstructed ear had a stable shape and the skin color and texture was nearly the same as the normal surrounding skin. Our complications included exposure of the Medpor framework in 1 patient. This occurred early in our experience after an additional
FIGURE 4. Medpor implant. www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Annals of Plastic Surgery
Kludt and Vu
& Volume 72, Supplement 1, May 2014
FIGURE 5. Three-week postoperative results.
procedure was performed to further deepen the postauricular sulcus using a skin graft. The skin graft healed, but the patient scratched her ear repeatedly, causing a small skin breakdown exposing the implant. A portion of the implant was subsequently resected and covered with a random flap. No other implant exposures or complications, including deflation or infection were noted.
DISCUSSION The auricle is one of the most sophisticated 3-dimensional structures of the external body. Microtia reconstruction is recognized as one of the most difficult and challenging surgical procedures in the field of plastic surgery. The classic techniques of Brent,1 Tanzer,3 and Nagata4 involve a multistaged procedure that often requires multiple autologous rib grafts. In practice, only a few surgeons are able to consistently produce ideal results after completion of the multistage surgeries.1 There are also complications associated with the harvest of autologous rib cartilage to create the auricular framework, including pneumothorax, thoracic scoliosis, and chest-wall deformity.13,14 The use of Medpor implants has produced high-quality results in auricular reconstruction.6,15 However, it has been plagued by considerable exposure and failure rates, necessitating the use of temporoparietal fascial flaps and skin grafts to decrease complications.2 Our described technique of the use of Medpor framework after prolonged tissue expansion provides a well-defined, well-projected ear with robust soft tissue coverage. The prolonged expansion time allows the skin to stabilize and thicken. The use of expanded skin with this method provides sufficient retroauricular nonYhair-bearing skin S16
www.annalsplasticsurgery.com
tissues for draping the framework without the need for temporoparietal fascial flap or skin grafting. It also preserves the temporoparietal fascial flap for complication repair if necessary. The only major drawback we see to this technique is the prolonged expansion time. This alternative surgical method reduces surgical time and morbidity, and facilitates an aesthetic, natural-appearing reconstruction of the auricle. In our opinion, this technique has reduced a complex and challenging surgical procedure to essentially an outpatient procedure that most plastic surgeons can perform successfully.
REFERENCES 1. Brent B. Technical advances in ear reconstruction with autologous costal cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg. 1999;104:319. 2. Romo T, Presti PM, Yalamanchili HR. Medpor alternative for microtia repair. Facial Plast Surg Clin North Am. 2006;14:129Y136. 3. Tanzer RC. Total reconstruction of the external ear. Plast Reconstr Surg. 1959;23:1Y15. 4. Nagata S. Modification of the stages in total reconstruction of the auricles: part I. Grafting the three-dimensional costal cartilage framework for lobuletype microtia. Plast Reconstr Surg. 1994;93:221Y230. 5. Wellisz T, Dougherty W, Gross J. Craniofacial applications for the Medpor porous polyethylene flexblock implant. J Craniofac Surg. 1992;3:101Y107. 6. Yang SL, Zheng JH, Ding Z, et al. Combined fascial flap and expanded skin flap for enveloping Medpor framework in microtia reconstruction. Aesthetic Plast Surg. 2009;33:518Y522. 7. Romo T 3rd, Reitzen SD. Aesthetic microtia reconstruction with Medpor. Facial Plast Surg. 2008;24:120Y128.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 1, May 2014
8. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg. 1957;19:124Y130. 9. Brent B. The correction of microtia with autogenous cartilage grafts: II. Atypical and complex deformities. Plast Reconstr Surg. 1980;66:13Y21. 10. Tanino R, Miyasaka M. Reconstruction of microtia using tissue expander. Clin Plast Surg. 1990;17:339Y353. 11. Hata Y, Hosokawa K, Yano K, et al. Correction of congenital microtia using the tissue expander. Plast Reconstr Surg. 1989;84:741Y751. 752Y753.
* 2014 Lippincott Williams & Wilkins
Ear Reconstruction with Prolonged Tissue Expansion
12. Bangun K, Chen PK, Goh RC, et al. Negative pressure manoeuvre in microtia reconstruction with autologous rib cartilage. J Plast Reconstr Aesthet Surg. 2010;63:1279Y1282. 13. Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr Surg. 1997;99:1030Y1036. 14. Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction: along-term study. Plast Reconstr Surg. 1995;95: 961Y968. 15. Romo T 3rd, Fozo MS, Sclafani AP. Microtia reconstruction using a porous polyethylene framework. Facial Plast Surg. 2000;16:15Y22.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S17
Auricular Reconstruction With Prolonged Tissue Expansion and Porous Polyethylene Implants Nathan Andrew Kludt, MD, and Hugh Vu, MD Objective: This study aimed to present our clinical experience using a prolonged tissue expansion technique and a Medpor framework for congenital microtia reconstruction. Methods: Auricular reconstruction was performed in 3 surgical stages. In the first surgical stage, a 60-mL custom kidney-shaped tissue expander is placed subcutaneously in the retroauricular mastoid region. The tissue expander is then serially expanded to maximum volume plus 30%. The tissue expander is then left fully expanded for 3 to 6 months. In the second surgical stage, the tissue expander is removed and a single-piece Medpor implant is placed and covered entirely by the expanded skin flap, without application of a fascial f lap or skin graft. In the third stage, we perform an excision of the remnant microtic ear. Results: A total of 15 patients were included with postoperative follow-up ranging from 6 months to 5 years. The draped soft tissue envelope was thin enough to show the reconstructed ear with excellent definition of the framework. Complications in this series included 1 case of partial implant exposure. Conclusions: The use of a Medpor framework after prolonged tissue expansion provides a well-defined, well-projected ear with robust soft tissue coverage. The expanded skin envelope with this method provides sufficient retroauricular nonYhair-bearing skin tissues for draping the framework without the need for temporoparietal fascial f lap or skin grafting. This alternative surgical method reduces surgical time and morbidity, and facilitates an aesthetic, natural-appearing reconstruction of the auricle. Key Words: ear reconstruction, tissue expansion, Medpor framework (Ann Plast Surg 2014;72: S14YS17)
T
he human ear is one of the most complex 3-dimensional structures of the external human body. Satisfactory treatment of the microtic ear represents a technical and artistic challenge for plastic surgeons. Numerous surgical techniques have been introduced for ear reconstruction with remarkable success.1Y4 Autologous costal cartilage has been considered the most dependable material for the auricular framework. However, it has 2 important drawbacks, namely, donor-site morbidity in the chest wall after cartilage harvest and surgeon difficulty with the intricate fabrication of the cartilage framework. With the development of porous, high-density polyethylene, Medpor (Porex; Porex Surgical, Newman, Ga), these difficulties can be easily overcome. It has been more than 21 years since Wellisz et al5 first reported its application in auricular reconstruction; yet, the Medpor framework has not been widely used in microtia reconstruction because of concerns of implant exposure. Many previous techniques have focused on the use of temporoparietal fascial f laps and skin grafts to decrease implant exposure complications.6,7 Tissue expansion for auricular reconstruction was
Received July 15, 2013, and accepted for publication, after revision, January 23, 2014. From the University of California Davis Medical Center, Sacramento, CA. Conflicts of interest and sources of funding: none declared. Reprints: Nathan Andrew Kludt, MD, University of California Davis Medical Center, 2221 Stockton Blvd, Room 2125, Sacramento, CA 95817. E-mail: [email protected]. Copyright * 2014 by Lippincott Williams & Wilkins ISSN: 0148-7043/14/7201-S014 DOI: 10.1097/SAP.0000000000000178
S14
www.annalsplasticsurgery.com
first described by Neumann8 in 1957, followed by Brent,9 Tanino and Miyasaka,10 and Hata et al11 with marginal success. Improved success was not attained until 2006 when a large series of ear reconstructions with tissue expansion were reported.2 Unfortunately, skin grafts and temporoparietal fascial f laps were still required to provide coverage and prevent implant exposure. With our technique of prolonged expansion, we have been able to provide supple, thin, and well-vascularized skin f laps to drape the Medpor framework without the need for temporoparietal fascial f laps or skin grafts. We perform our ear reconstruction using a prolonged tissue expansion process with a Medpor ear framework in a 3-stage technique.
METHODS Operative Procedure Auricular reconstruction was performed in 3 surgical stages as follows: (1) implantation of an appropriately sized tissue expander in the mastoid region, (2) removal of the tissue expander and placement of a single-piece Medpor framework, (3) excision of the remnant microtic ear.
Stage I: Tissue Expander Implantation Surgery at this stage was performed under general anesthesia and using tumescent local anesthesia. A template was made of the contralateral normal ear, with the root of the helix and lobule identified (Fig. 1A). A 3-cm incision within the postauricular scalp was made parallel to the temporal hairline (Fig. 1B). A subcutaneous pocket was then dissected immediately above the postauricular fascia. The pocket was dissected large enough to accommodate the tissue expander. After meticulous hemostasis was obtained, we inserted a custom kidney-shaped tissue expander with an integrated magnetic port (7 4.5 1.5 cm, 62-mL volume) (Fig. 1C). It was then placed as far anterior as necessary often under the remnant cartilage. A negative pressure drain was inserted into the pocket and 2-layered wound closure was performed before application of a pressure dressing. Inflation was begun 7 days postoperatively and generally performed twice weekly. Expansion was commonly completed in 6 to 8 weeks when the tissue expander was fully expanded plus an additional 30%, to provide adequate skin for draping the implant, approximately 80 mL (Fig. 2). The tissue expander then remained in place, fully expanded for an additional 3 to 6 months.
Stage II: Auricular Reconstruction The expander was def lated and removed through the incision made in the previous surgery (Fig. 3). The capsule was left entirely intact. We used the medium-sized, single-piece Medpor implant for simplicity and projection. After inserting the Medpor framework into its appropriate position, the expanded skin f lap was used to cover the entire framework (Fig. 4). The single-piece Medpor has a lobule component and requires no additional skin grafting as the postauricular sulcus is already created with the expanded skin. A negative pressure drain was placed to preserve a healthy contact between the ear framework and expanded skin f lap.12 Two-layered wound closure was performed and a pressure dressing applied. Annals of Plastic Surgery
&
Volume 72, Supplement 1, May 2014
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 1, May 2014
Ear Reconstruction with Prolonged Tissue Expansion
FIGURE 1. A, Template of normal ear. B, Planned pocket dissection and incision. C, Placement of tissue expander.
Stage III: Excision of Remnant Microtic Ear The final stage was performed 3 to 6 months after the auricular reconstruction and involved excision of the remnant microtic ear and closure. The remnant microtic ear is removed at this stage to avoid any potential complications that may occur with expanding a previously incised area. The Medpor implant has a lobule; therefore, lobule transposition at this stage was not necessary.
RESULTS
FIGURE 2. Fully expanded tissue expander.
FIGURE 3. Def lation of expander. * 2014 Lippincott Williams & Wilkins
We performed auricular reconstruction using the prolonged tissue expander technique and Medpor framework in 15 patients with follow-up ranging from 6 months to 5 years. The mean age at time of reconstruction was 7 years, with a range from 6 to 12 years. Eight patients were men and 7 women, all with either grade 3 or 4 microtia. The draped skin was thin enough to show the framework with excellent contour (Fig. 5). The reconstructed ear had a stable shape and the skin color and texture was nearly the same as the normal surrounding skin. Our complications included exposure of the Medpor framework in 1 patient. This occurred early in our experience after an additional
FIGURE 4. Medpor implant. www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S15
Annals of Plastic Surgery
Kludt and Vu
& Volume 72, Supplement 1, May 2014
FIGURE 5. Three-week postoperative results.
procedure was performed to further deepen the postauricular sulcus using a skin graft. The skin graft healed, but the patient scratched her ear repeatedly, causing a small skin breakdown exposing the implant. A portion of the implant was subsequently resected and covered with a random flap. No other implant exposures or complications, including deflation or infection were noted.
DISCUSSION The auricle is one of the most sophisticated 3-dimensional structures of the external body. Microtia reconstruction is recognized as one of the most difficult and challenging surgical procedures in the field of plastic surgery. The classic techniques of Brent,1 Tanzer,3 and Nagata4 involve a multistaged procedure that often requires multiple autologous rib grafts. In practice, only a few surgeons are able to consistently produce ideal results after completion of the multistage surgeries.1 There are also complications associated with the harvest of autologous rib cartilage to create the auricular framework, including pneumothorax, thoracic scoliosis, and chest-wall deformity.13,14 The use of Medpor implants has produced high-quality results in auricular reconstruction.6,15 However, it has been plagued by considerable exposure and failure rates, necessitating the use of temporoparietal fascial flaps and skin grafts to decrease complications.2 Our described technique of the use of Medpor framework after prolonged tissue expansion provides a well-defined, well-projected ear with robust soft tissue coverage. The prolonged expansion time allows the skin to stabilize and thicken. The use of expanded skin with this method provides sufficient retroauricular nonYhair-bearing skin S16
www.annalsplasticsurgery.com
tissues for draping the framework without the need for temporoparietal fascial flap or skin grafting. It also preserves the temporoparietal fascial flap for complication repair if necessary. The only major drawback we see to this technique is the prolonged expansion time. This alternative surgical method reduces surgical time and morbidity, and facilitates an aesthetic, natural-appearing reconstruction of the auricle. In our opinion, this technique has reduced a complex and challenging surgical procedure to essentially an outpatient procedure that most plastic surgeons can perform successfully.
REFERENCES 1. Brent B. Technical advances in ear reconstruction with autologous costal cartilage grafts: personal experience with 1200 cases. Plast Reconstr Surg. 1999;104:319. 2. Romo T, Presti PM, Yalamanchili HR. Medpor alternative for microtia repair. Facial Plast Surg Clin North Am. 2006;14:129Y136. 3. Tanzer RC. Total reconstruction of the external ear. Plast Reconstr Surg. 1959;23:1Y15. 4. Nagata S. Modification of the stages in total reconstruction of the auricles: part I. Grafting the three-dimensional costal cartilage framework for lobuletype microtia. Plast Reconstr Surg. 1994;93:221Y230. 5. Wellisz T, Dougherty W, Gross J. Craniofacial applications for the Medpor porous polyethylene flexblock implant. J Craniofac Surg. 1992;3:101Y107. 6. Yang SL, Zheng JH, Ding Z, et al. Combined fascial flap and expanded skin flap for enveloping Medpor framework in microtia reconstruction. Aesthetic Plast Surg. 2009;33:518Y522. 7. Romo T 3rd, Reitzen SD. Aesthetic microtia reconstruction with Medpor. Facial Plast Surg. 2008;24:120Y128.
* 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Annals of Plastic Surgery
& Volume 72, Supplement 1, May 2014
8. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg. 1957;19:124Y130. 9. Brent B. The correction of microtia with autogenous cartilage grafts: II. Atypical and complex deformities. Plast Reconstr Surg. 1980;66:13Y21. 10. Tanino R, Miyasaka M. Reconstruction of microtia using tissue expander. Clin Plast Surg. 1990;17:339Y353. 11. Hata Y, Hosokawa K, Yano K, et al. Correction of congenital microtia using the tissue expander. Plast Reconstr Surg. 1989;84:741Y751. 752Y753.
* 2014 Lippincott Williams & Wilkins
Ear Reconstruction with Prolonged Tissue Expansion
12. Bangun K, Chen PK, Goh RC, et al. Negative pressure manoeuvre in microtia reconstruction with autologous rib cartilage. J Plast Reconstr Aesthet Surg. 2010;63:1279Y1282. 13. Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracic scoliosis after costal cartilage graft harvesting. Plast Reconstr Surg. 1997;99:1030Y1036. 14. Thomson HG, Kim TY, Ein SH. Residual problems in chest donor sites after microtia reconstruction: along-term study. Plast Reconstr Surg. 1995;95: 961Y968. 15. Romo T 3rd, Fozo MS, Sclafani AP. Microtia reconstruction using a porous polyethylene framework. Facial Plast Surg. 2000;16:15Y22.
www.annalsplasticsurgery.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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