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Archive for the ‘ear reconstruction’ Category

OR Snapshots – ePTFE Implant Framework in Ear Reconstruction

Sunday, September 24th, 2017

 

Reconstruction of the lost ear requires a two-layer approach. The base la\yer is the firm and shaped framework which replaces the missing natural cartilage. The choices for the framework are either rib cartilage or synthetic framework.  The second layer is the need for vascularized tissue coverage which, in cases of large amounts of ear loss, would be a temporoparietal fascial flap and a skin graft.

While there are debates about the merits of a cartilage or an implant base layer, the one huge advantage that a synthetic framework has is the avoidance of a donor site. Historically the biomaterial porous polyethylene its what has been used for synthetic ear reconstruction frameworks. It has the advantage of surface porosity and good soft tissue adherence. But it is a difficult material to shape and assemble its preformed pieces. It is also a very stiff and inflexible material of which natural ear cartilage is not.

An innovation in ear reconstruction implants is the combination of 3D design/printing and the use of a softer implant material. In unilateral ear loss or deformities a 3D CT scan can be used to make an exact replica of the opposite normal ear cartilage. Usually this will include the soft tissue earlobe as well as that is difficult to surgically create. From this auto design an implant can be fabricated. This its then made from a newer material, a solid silicone base covered with an ePTFE coating. The silicone provides the shape and flexibility that more closely resembles ear cartilage and the ePTFE coating allows for soft tissue adherence.

An ear framework that is computer generated saves operative time and ensures the best potential ear shape result. It still needs to be covered by a vascularized soft tissue layer. But that need is necessary regardless of the material composition of the ear framework. 

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Osseointegrafted Implant Prosthetic Ear Reconstruction

Saturday, September 16th, 2017

 

Background: Loss of an ear can occur from a variety of reasons including cancer resection and traumatic avulsion. Such ear amputations pose major reconstructive challenges which can be done using an autogenous method (cartilage framework and vascularized soft tissue cover), completely prosthetic method (ear prosthesis) or a combination of both autogenous tissue and prosthesis. (synthetic ear framework with vascularized soft tissue cover)

While I typically prefer some form of autogenous reconstruction, there is a role for a completely prosthetic ear reconstruction approach. There is no denying that a prosthetic ear created by a Maxillofacial Prosthetist creates the best match to the opposite ear. But the long-term success of an ear prosthesis is directly related to the patient’s comfort in wearing it. If the patient has little confidence that it will stay in place then they are unlikely to use it.

While prosthetic ears were once held in place by adhesives, this is not a reliable method for stabilizing something to the side of the head..Borrowing from dental implant technology, the use of osseointegrated implants has long eclipsed the use of adhesives by providing a bone anchorage method for prosthetic stability.

Case Study: This 35 year-old male had his left ear removed due to melanoma skin cancer. He also had a superficial parotidectomy and sentinel lymph node biopsy. This left him with Frey’s syndrome as well as the absence of his ear. He opted for a completely prosthetic ear reconstruction method.

Under general anesthesia he had a first stage placement of two osseointegrated implants as well as a sheet of Alloderm over the parotidectomy site to treat his Frey’s syndrome. A second procedure was done three months later to uncover his implants and skin graft around them.

A prosthetic ear was created onto which magnetic attachments were placed on its posterior surface. These served as fixation posts onto which the ear prosthesis could attach. This created the bone anchored ear prosthesis.

While a prosthetic ear creates the best looking ear, it will require maintenance on a regular basis. The implant posts must be kept clean so a tight soft tissue collar is maintained. (much like the gums tissues around a tooth) The ear prothesis will need periodic replacements due to color fading and the wear and tear from daily use.

Highlights:

  1. The stability of prosthetic ear reconstruction depends on osseointegrated titanium implants.
  2. Osseointegrated implants need a tight soft tissue collar for long-term retention.
  3. The patient will require multiple prosthetic ears over time due to material aging and discoloration.

Dr. Barry Eppley

Indianapolis, Indiana

Computer-Designed Synthetic Framework in Ear Reconstruction

Saturday, August 26th, 2017

 

Reconstruction of lost or congenitally malformed ears requires the combination of a solid framework and soft tissue coverage of it. Two techniques for making a framework for the ear have been developed over the years. By history and still commonly used today is to make the framework by harvesting and assembling rib cartilage grafts. While technically challenging to successfully create the intricate topography of the ear, its autologous composition offers a hardy framework that is very durable over time and has a very low risk of any complications long-term. It also can be placed under the existing skin over the implantation site if it is of good quality.

The other ear reconstruction technique is to use a premade synthetic framework. This creates the best shape of the ear, shortens the operative time and avoids a rib graft harvest scar and its associated discomfort. But it can not just be placed under the natural thin skin of the ear. It requires a vascularized tissue cover, using a pedicled temporalis flap turned down from above to cover the synthetic framework, which is then covered by a skin graft. This requires two donor sites from the temporal scalp (fascial flap) as well as the thigh. (skin graft)  Adequate soft tissue cover is of paramount importance to avoid the risks of implant exposure and infection both short and long-term.

The traditional ear synthetic framework is that of porous polyethylene or Medpor. It comes in a variety of implant shapes and parts to be assembled during surgery based on the size and shape of the opposite normal ear. While creating acceptable results, this assembly approach never creates a prefect match to the opposite ear.

To improve the matching of a synthetic framework to the opposite ear, I have been using a computer-designed ear reconstruction frameworks. From a 3D CT scan of the patient, an exact replica of the cartilage framework of the opposite ear is mirrored onto the missing side. This computer design is then turned into a synthetic ear framework made of a composite silicone base with an ePTFE coating.

This ePTFE ear implant, in addition to having the best size and shape match possible to the opposite ear, also has one other very favorable characteristic. It is soft and flexible like natural ear cartilage (other synthetic frameworks are very rigid and unnatural feeling)  and as a result can well tolerate any trauma to the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Long-Term Outcome of ePTFE Ear Reconstruction

Sunday, August 6th, 2017

 

Ear reconstruction for partially or completely removed/lost ears in adults must take into consideration the needed soft tissue coverage. While the cartilage of the ear can be replaced by either a synthetic framework or rib cartilage, it requires vascularized tissue and a skin graft to have a reconstruction result that survives and hopefully looks good. Contrary to the understandable perception of some patients, you can’t just put a skin graft directly on cartilage or a synthetic material.

In most cases of major ear reconstruction, the key element is what is known as a TPF flap. This stands for a temporoparietal fascial flap. Fed its blood supply by the ascending superficial temporal artery passing in front of the ear, this is the fascial layers (excluding the deep fascia) overlying the temporal muscle on the side of the head. This thin tissue can be raised off the entire temporal muscle and turned down to cover a synthetic or cartilage ear framework. It is onto this tissue that a skin graft can then be placed to complete the third layer of the reconstruction.

What is important for patients to understand is that healing of these complex ear reconstruction is a process. Right after surgery and for the first month or so the ear reconstruction often looks little like an ear. The tissues are swollen and distorted and it can just look like a swollen indistinct mass one the side of the head. It takes time for the swelling to goo down and, just as importantly, the overlying soft tissue coverage to shrink down and stick into all the details of the framework. Here is an example of a partial ear amputation due to skin cancer with an immediate ePTFE framework covered by a TPF flap and skin graft. It sort of looks like an ear at the end of surgery but will get quote swollen and distorted for weeks afterward.

When seen at three months after surgery, the ear looks more defined and some of the details of the framework can finally be seen. While it will never look exactly like what was removed, it creates an acceptable looking result.

The long-term aesthetic outcome of ear reconstruction awaits the contraction of the thin overlying vascularized tissues to adapt to the framework. This ‘shrink wrap’ effect is a process that takes months after the surgery to reveal its full effects.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Constricted Ear Reconstruction

Wednesday, May 10th, 2017

 

Background: One of the most common congenital malformations of the external ear is that of the constricted ear deformity.  It goes by a number of other names such as lop ear and cup ear. But they all fall under that of an ear constriction issue. Think of the outer helical rim as a draw string and all types of constricted ears appear based on how tight the draw string is pulled. Underlying all of the presentations of the constricted ear is that some amount of tissue deficiency (skin and cartilage) exist.

The constricted ear appears in a variety of manifestations. In all types the top of the helical rim is folded over. (hence the term lop ear)  In more severe forms the cartilage of the helical rim and scapula is deficient creating a tighter roll and small ear. (thus the term cup ear) The one consistent difference between a constricted ear and microtia is that an external auditory canal is present the former but not in the latter.

Reconstruction methods of the constricted ear depend on the severity of the deformity. In more severe forms cartilage grafts are needed. This in most cases means that a rib graft framework needs to be used to  create the deficient upper east cartilage.

Case Study: This 7 year-old female was born with a severely constricted ear and multiple skin tags. As an infant her skin tags were removed.

At age 6 a first stage ear reconstruction was done using a rib graft framework under general anesthesia. The cartilage ear framework was placed underneath the unfolded ear skin as well as the surrounding post auricular skin. Several subsequent reconstructive stages were done including a postauricular release and full thickness skin graft placement.

The constricted ear is a challenging reconstruction which can be only slightly less difficult to do than a complete microtia. It does have the benefits of an existing earlobe, external auditory canal, concha and tragus which help make for a favorable result in many cases.

Highlights:

  1. Many congenital ear deformities fall into the category of a constricted ear deformity with contraction around the helical rim due to underdevelopment.
  2. Reconstruction of the underdeveloped ear framework requires an autologous rib graft method.
  1. The constricted ear deformity requires multiple stages of reconstruction to achieve its final effect.

Case Study – ePTFE Ear Implant Reconstruction

Saturday, April 15th, 2017

 

Background: Ear reconstruction is most commonly done using autologous graft materials. Whether it is microtia reconstruction using rib cartilage in children or adult ear reconstruction using cartilage grafts and pedicled skin flaps, the patient’ own tissues offer the least risk of postoperative complications and should be done when possible.

The use of synthetic frameworks or implants for ear reconstruction has its origin and current use with Medpor material. Most commonly done as an alternative to the use of rib cartilage in congenital microtia deformities in children, it offers a premade and well shaped ear implant. As a substitute for a hand-carved rib cartilage ear framework, it requires vasculrized tissue cover using the temporalis fascial flap (TPF flap) covered with a split-thickness skin graft. Its benefits is that it usually creates a much better shaped ear in the end and does so in less operative time with no need for a rib graft donor site.

While Medpor ear frameworks are effective, the material itself does not replicate very well the physical characteristics of natural ear cartilage. It is much more stiff (in fact rigid) and lacks any substantial flexibility. While creating a nice ear shape it does not create a good feeling ear. This stiffness can make the Medpor framework ear prone to occasional discomfort and skin breakdown due to pressure or trauma.

Case Study: This 78 year-old male has multiple basal cell skin cancers on his left ear on both front and back ear surfaces. It was decided that the best treatment for his ear cancer was near amputation. He was interested in a synthetic ear implant as opposed to a rib graft. Under general anesthesia he had a subtotal ear resection preserving the superior helical root, concha and earlobe.

Using an ePTFE coated composite ear implant, it was carved into a shape replicating the portion of the ear cartilage removed. This was then sutured to the remaining ear cartilage.

A TPF flap was raised through a vertical incision above the ear. It was folded down over the ear framework, preserving its temporal vascular pedicle, and sewn into the tissue edges around the remaining ear. A split-thickness skin graft was harvested from the thigh and laid over the TPF flap and sewn into place.

With healing time and tissue contraction, the details of the ear framework will eventually become more apparent through the applied vascular cover. In the long run the reconstructed ear will have a more natural feel due to the inherent softness of the ePTFE material.

Highlights:

  1. Synthetic ear reconstruction relies on the use of a Medpor ear framework covered by a fascial flap and skin graft.
  2. A new synthetic ear implant made of a composite silicone and ePTFE coating offers a softer and more flexible design.
  3. Composite ePTFE ear frameworks offer a carving feel that is identical to that of natural rib.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Microtia Rib Graft Ear Reconstruction

Friday, December 23rd, 2016

 

The ear is composed of two basic structures, cartilage and skin. The cartilage component of the ear is considerable as only the earlobe is not supported by it. The cartilage is solely responsible for the very complex shape of the ear with its many hills, valleys, ridges and curves that are seen externally. How it gets this shape is an embryological marvel as six hillocks fuse in utero to ultimately create what we see as the external ear.

While cartilage supports all the convexities and concavities of the ear, its most important contribution is to its elevations or convexities. (helical rim, superior and inferior crus, antihelix, tragus and antitragus) Cartilage can be removed from any of the concave areas and the shape of the ear would not change. This is well known from the common harvesting of ear cartilage in rhinoplasty from the concha, the largest ear concavity which looks the same both before and after graft harvest.

rib-graft-microtia-ear-reconstruction-dr-barry-eppley-indianapoliosThe greatest illustration of the role of cartilage in the shape of the ear is in microtia reconstruction. For children born with parts or all of the external ear missing, the traditional ear reconstruction method is done with rib cartilage. Portions of ribs 6, 7, and 8 are used to create a cartilage ear framework for insertion under the skin. In making his ear framework the complete concept of the ‘hills and valleys’ of the ear must be artistically created by carving and assembling the pieces of rib cartilage. The eventual shape of the ear is seen many months after surgery as the overlying skin shrinks into and around its cartilage shape.

Of all the shaping procedures that are done in plastic surgery throughout the body, making an ear out of rib cartilage in microtia reconstruction certainly qualifies as a sculpting surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Grafting for the Stiff Medpor Ear Recconstruction

Wednesday, September 28th, 2016

 

Microtia is a congenital condition where all or major parts of the ear are missing. Two methods of microtia reconstruction have evolved using either one’s own ribs or through the use of a synthetic framework. Autologous microtia reconstruction is done to using portions of the cartilaginous #7, 8 and 9 ribs to create the base framework of the ear. Alloplastic microtia reconstruction uses a synthetic performed ear framework made of a Medpor material that is simultaneously covered by a vascularized temporal fascial flap. Such ear reconstructions are usually done around ages 6 to 8 years old.

medpor-ear-framework-dr-barry-eppley-indianapolismedpor-ear-framework-back-side-dr-barry-eppley-indianapolisBoth microtia ear reconstruction methods have their own unique advantages and disadvantages. The Medpor ear reconstruction framework offers the advantages of a well-shaped preformed ear framework and the avoidance of a donor rib scar and harvest site. Because it is a stiff material, however, it can feel fairly rigid. The rigidity of the wedge on the back part of a Medpor ear framework, which allows it to have good projection from the side of the head, can be a source of ear stiffness and rigidity.

medpor-ear-framework-reduction-dr-barry-eppley-indianapolismedpor-ear-reconstruction-fat-grafrt-dr-barry-eppley-indianapolisTo reduce the rigidness of a Medpor ear reconstruction, the wedge on the back part of the ear framework can be shaved down from an incision on the back of the ear. This is then filled with a dermal-fat graft placed into the space where the wedge of Medpor material was removed. Some slight projection of the ear reconstruction may be lost but the ear will have some flexibility when pressed on.

While many rib graft microtia reconstructions need projection and a more rigid graft placed behind it, a synthetic framework often needs the opposite. The preformed framework provides good projection but at the expense of ear stiffness. The ear is made of flexible cartilage that springs in and out and that is a feature that a plastic material can not do.

Dr. Barry Eppley

Indianapolis, Indiana

Surgical Correction of the Constricted Ear Deformity

Monday, May 30th, 2016

 

One of the major types of congenital ear deformities is that of the constricted ear. It is estimated that it represents about 10% of all congenital ear deformities. It is a variable ear deformity that has been described by multiple classification systems (e.g. Tanzer, Cosman, Ngata) with associated surgical strategies based on its classification. The numerous classification systems can be confusing and it is not easy to always define what type of surgery is best for the variable presentations in which the constricted ear is seen.

Constricted Ear Reconstruction with Rib Graft Insertion Dr Barry Eppley Indianapolis Constricted Ear Reconstruction with Rib Grarft Dr Barry Eppley IndianapolisIn the May 2016 issue of Plastic and Reconstructive Surgery, a paper was published entitled ‘Classification and Algorithmic Management of Constricted Ear: A 22-Year Experience’. Over 160 ears that had a lidded helix, compressed scapha and triangular fossa and an overall cuplike appearance were used as the clinical material for the study. The authors classification system uses a antihelical tubing test and a scapha-helix push test. By these two methods four types of contricted ear are identified. Type 1 constricted ears can be treated by an antihelical tubing procedure using horizontal mattress sutures placed on the backside of the ear. A type 2 constricted ear was treated by  tumbling concha-cartilage flap combined with a mastoid hitch suture. In type 3 constricted ears an antihelical wrapping technique using a free floating rib cartilage graft was used. In type 4 constricted ears where a shortage of helix exists, a helical expansion technique using a rib graft and preauricular and scapha skin flaps was used.

Based on their experience the authors have evolved to the following concepts for the constricted ear. First, waiting to age 12 or older allows for better results. Second, the existing cartilage framework was not sectioned but rolled and grafted to prevent unnatural shapes. Third, rib grafts are better than ear cartilage grafts for helical expansion. Lastly, the protruding part of the constricted ear is often overlooked and needs to be corrected by mattress sutures and/or mastoid hitch sutures.

The constricted ear and microtia have some overlap in their features. What separates them surgically is that in the constricted ear the existing cartilage framework is maintained and cartilage and soft tissue flaps are added to it. In microtia, the existing framework is unusable and has to be replaced. This paper provides an effective surgical strategy for the constricted ear that allows for a single stage correction without removal of any of the existing ear framework

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Macrotia Ear Reduction

Sunday, December 6th, 2015

 

Background: The embryology and development of the human ear is a marvel in not only its complexity but how well it works most of the time. It is created by the merging of six separate tissue segments (hillocks) in utero that create the recognizable ear that is a collection of various ridges and valleys. But due to its complex shape the ear is prone to a wide variety of congenital anomalies of which microtia is the most severe.

macrotiaThe opposite of microtia is macrotia where the ear is abnormally large. Unlike microtia where various parts of the ear are either missing or deformed, in macrotia the ear components are normal but bigger than desired. The ear is usually felt to be large primarily because it is vertically long. Various parts of the ear may be bigger than normal but usually the upper and lower thirds of the ear are what is too long.

The average height of the ear, as measured from the bottom of the lobule to the top of the upper helix, is in the range of 60 to 65mms. (average of 63mms) While they are some slight differences in these measurements between men and women, they are not all that different. (around 5% or less) The average length of the earlobe is around 18mms or about 1/3 of the total ear height.The average height of the pinna or cartilaginous portion of the ear, calculated by subtracting the earlobe height from the total ear height, was around 45mms.

Case Study: This 27 year male had ears that he felt were too big (long) as well as stuck out. He had seen other plastic surgeons but they only wanted to fix the protruding aspect of them. His total ear height was 76mms with an earlobe length of 24mms.

Vertical Ear Reduction result intraop Dr Barry Eppley IndianapolisUnder local anesthesia with infiltration around the base of his ear, three specific ear reshaping procedures were done. The earlobe was vertically reduced by 6mms with a helical rim excision technique. The upper third of the ear was reduced by 7mms using  scaphal excision of cartilage and outer skin with a helical rim reduction. (scapha-helical rim flap) Lastly ear was set back with concha-mastoid sutures from a postauricular incision. At the end of the procedure the total ear height was 65mms.

Macrotia ear reduction is done by reducing the height of the ear from the top (scapha-helical reduction) and bottom (earlobe reduction) simultaneously. Correction of any ear protrusion can be safely done during macrotia reduction surgery.

Highlights:

  1. Macrotia is an aesthetically abnormal enlargement of the ear that is most manifest in the vertical dimension.
  2. Macrotia ears usually have a combined increased height of the upper ear and longer earlobe.

3) Macrotia ear reduction surgery is done by an upper ear scapha-helical reduction flap and a helical rim earlobe reduction.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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