J Oral Maxillofac Surg 64:1639-1654, 2006 Surgical Versus ... · of Microtia: The Case for...

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CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART ONE

J Oral Maxillofac Surg64:1639-1654, 2006

Surgical Versus Prosthetic Reconstructionof Microtia: The Case for Prosthetic

Reconstruction
Gregory G. Gion, BA, BS, MMS, CCA*
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he auricular prosthesis and the autogenous recon-truction must ultimately be judged on their ability toree the patient from the stigmatization of their con-ition. Excellent esthetic results are key in providingatients with the confidence that their correction willo undetected. There are other technical and psycho-ogical issues that impact prostheses success in par-icular, but the wide variability in esthetic qualityvailable historically and around the world todayight still be unnecessarily complicating if not bias-

ng the treatment selection process. The thrust of thisrticle is to provide current advantages and futureotential of prostheses, along with demonstration ofsthetic results that are possible with ear prostheses.he hope is that readers will come away more en-

ightened, more optimistic, and more confident inharing information on prostheses with colleagues,arents, or patients. This might be helpful to thoseatients with an ambiguous prognosis who, for lackf knowledge, might otherwise undergo fruitless at-empts at autogenous reconstruction.

Surgeons and others involved in the decision-mak-ng process with parents of children with microtia arencouraged to become familiar with the importanteferences. The criteria for treatment selection be-ween surgical and prosthetic approaches are well-eveloped and supported in Wilkes and Thorne.1,2

owever, the question for the patient or parent willlways remain prior to treatment; what will the finalesult really look like? This article is written from theoint of view of a medical artist/anaplastologist thatas practiced full time for 25 years creating and pro-iding silicone auricular, nasal, and orbital prostheses.he initial 4 years were in hospital-based positionsnd the last 21 years have been in private practice in

*Private Practice, Dallas, TX, and Madison, WI.

Address correspondence and reprint requests to Mr Gion: 10501

Central Expressway, Ste 314, Dallas, TX 75231; e-mail:

[email protected]

2006 American Association of Oral and Maxillofacial Surgeons

278-2391/06/6411-0012$32.00/0

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1639

ollaboration with university implant teams in Dallas,exas. This article suggests that the prosthetic optionas historically been poorly represented, even misrep-esented for various reasons, and that more should beublished in the future to give a more completeicture of the prosthetic option to help with thisecision of treatment selection. It is hoped that theuthor’s experience, not as plastic surgeon, implanturgeon, or prosthodontist, but as the silicone earpecialist of 25 years, will add a different perspectiveo help guide future decisions.

Treatment options for children with absence orther malformation of the pinna remain; no treat-ent, autogenous reconstruction, or prosthetic re-

onstruction. The literature provides guidance in therea of selection criteria for choosing between autog-nous and prosthetic reconstruction1-3 and severaleam studies help to add quantity and experientialnsight to the information pool on this topic.4-6 Somef the articles have been coauthored by the autoge-ous surgical and prosthetic representatives at largeenters that can evaluate patients, make a recommen-ation on the preferred treatment, and offer treat-ent of either kind at the center. The situation wherepatient would receive the very best results for either

reatment type from the same institution is rathernusual in the author’s experience. The idea of offer-

ng such comprehensive excellence under one roof isttractive, but parents should feel free to consultndependent anaplastologists as well. As a privatenaplastologist based 21 years in Dallas, the authoras enjoyed the professional enrichment of close col-

aboration and cross-referring of patients with maxil-ofacial surgeons and prosthodontists at Baylor Col-ege of Dentistry, Medical City Dallas, and theniversity of Texas Southwestern Medical Center.ome anaplastologists would agree that this experi-nce of professional autonomy has invested themore deeply in their patient and thereby elevated

nal prosthetic results and long-term care.The general opinion gleaned from the main refer-

nces seems to be that autogenous reconstruction is
he preferred method, if there exists a reasonable

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1640 TREATMENT OF MICROTIA: THE CASE FOR PROSTHETIC RECONSTRUCTION

hance for an esthetically acceptable result. What isudged to be esthetically acceptable is a question

orthy of much more study, both for surgical androsthetic results. There seems to be general agree-ent that surgical results are improving because of

he refinement of the techniques pioneered by Tanzernd further refined by truly gifted and experiencedpecialists like Brent, Firmin, Nagata, and very fewthers around the world. Many surgical outcomes areharacterized as “suboptimal” or “not entirely suc-essful” indicating results continue to be unpredict-ble.

On the other hand, prosthetic results are also im-roving in terms of stability, anatomical accuracy, andsthetics. With over 2 decades of experience inraniofacial implantology in the United States, and theontinual refinement of implant techniques to retainar prostheses, patients now enjoy predictable andepeatable attachment of the prosthesis with theromise of even more stable, secure, and sophisti-ated designs to come. The application of advancedigital technologies plays an increasingly importantole in planning and guiding endosseous implantlacement for bone-anchored prostheses as well as ineveral phases of ear prosthesis fabrication wherenatomical fit and bilateral symmetric accuracy ap-roach perfection. Perhaps as important has been therofound maturing of the field of anaplastology; spe-ifically, facial prosthetics, in which truly dedicatedrtist/clinicians have provided as their specialty es-hetic silicone auricular prostheses that often eclipsehose from nonspecialized dental labs where they arereated as incidental or ancillary services. The “pro-essionalization” of anaplastology and the dedicatedpecialization in silicone ear and facial prosthetics inarticular has raised the bar considerably over the lastwo decades. In view of these developments and theollaboration between anaplastologist, implant sur-eon and other team members, the prosthetic optionhould be considered equally with autogenous recon-truction in borderline cases.

he Anaplastologist’s Opinion

In the author’s opinion, children with microtiahould be provided the best chance to have their earsuccessfully surgically reconstructed, which meanshey should be evaluated and treated only by the bestn the specialty. The author recognizes the majorrticles on the criteria used in treatment selection. Ineneral, the articles discourage attempts at surgicaleconstruction for the child with a more profoundeformity or with certain complicating factors such as

ow hairline, unavailability of suitable soft tissue, etc.s an anaplastologist, the author would generally
gree with the major articles. As a nonsurgeon and g
onstudent of long-term autogenous sequelae, theuthor must defer to the selection criteria posed inhe major articles. However, in the author’s 25 yearsf creating ear prostheses, many have been for pa-ients with hemifacial microsomia, Goldenhar syn-rome, etc, who presented with histories of repeatednsuccessful attempts at reconstruction. Given thathere is some component of cases of unremittingamily pressure to reconstruct even in light of theurgeon’s caution, so there must be a component ofverzealousness or other motivation that promptsome surgeons to operate. There also is very likely aomponent of experienced pediatricians and othersho have steadfastly eschewed the idea of a prosthe-

is based, probably in part, on long-term patient dis-atisfaction with adhesives and/or very poor estheticesults or unfamiliarity with the recent advances inhe ear prosthesis option. The author believes that,enerally, patients with microtia should be evaluatedy only the very best dedicated ear reconstructiveurgeons. The present level of prosthetic outcomeuccess must become more visible so that selectionriteria are based on accurate offerings for each treat-ent type. In particular, it is incumbent on anaplas-

ologists specializing in ear (and facial) prostheses toresent and publish the results of their university orrivate practice experience.Patients must be referred only to surgeons such as

rent, Nagata, or the handful of similarly successfular reconstructive surgeons worldwide, who, withheir great experience, would be more likely to pre-ict the outcome as well as most likely to provide auccessful result. It is crucial that the initial attempte in the hands of one of the few experts. Perhapshese individuals would be less likely to undertakeases with poor prognoses for the sake of gainingore experience. Also of concern in the author’s

xperience is the notion that patients should be di-ected to major “centers” where they can make theirreatment selection and obtain successful results uti-izing either the surgical option or the prostheticption within the center. As with referral to an expertar reconstructive surgeon where location and hospi-al affiliation are secondary, so too should be theode of referral to the expert anaplastologist or team

hat includes a highly regarded anaplastologist.The anaplastologist, like the reconstructive sur-

eon, is charged with the formidable task of restoringhe delicate beauty of the human ear. Differentlyrained and equipped, perhaps, both specialists areesponsible for constructing the ear to the best ofheir ability and turning the patient toward the mirror,nd in doing this, altering the way the patients feelbout themselves and their presentation to the world.owever, anaplastologists as a group, unlike sur-
eons, have definitely not contributed significantly to

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GREGORY G. GION 1641

he literature to offer up a true representation of whats possible prosthetically. Whether this is due to ana-lastologists’ less scholarly educational preparation orimply the fact that the design and fabrication processeaves little time to write, it is unfortunate that signif-cant practice experiences have gone unpublished.he point here is that much of what has been pub-

ished in periodicals or texts on facial prosthetics isutdated, depicts technical or clinical solutions ofarrow application, or it presents a random pros-hetic result often selected and published by someonether than the anaplastologist who performed theesult. In short, serious facial prosthetists in privateractice or in universities who possess the right blendf training, talent, and time to put the treatment in itsest light still have not taken, or been given, as thease may be, the opportunities to show results theay world-class reconstructive surgeons have, for in-

tance.Noteworthy exceptions to this can be seen in a

ompilation by Branemark, the pioneer of osseointe-ration, in which solid prosthetic results from ana-lastologists around the world are seen.7 In a textritten by Thomas, he shows a comprehensive com-and of silicone facial prosthetics.8 However, even

hese sources are 8 or 10 years old. The author’spinion is that, aside from a few exceptions, the

iterature projects an incomplete if not inaccurateicture of what patients should expect in a prosthe-is.

Admittedly, even now, a continuum of ear pros-hetic results exists worldwide, from crudely formedasses of inferior materials slathered with color all

he way to inspired renditions so accurate and lifelikehat duplication is dishearteningly unlikely (with in-reased focus and resources for prostheses, hopefullye will see the adoption of sophisticated manufactur-

ng processes so patients can anticipate a lifetime ofonsistent duplication of the perfect match). Much ofhat is seen in publication falls somewhere in theiddle of this continuum. Ear prostheses seen inublication sometimes appear off balance slightly inpacity-translucence, off in hue (wrong color), off inalue (too dark or light), or off in chroma (too dull orntense), and anatomical form appears carved ratherhan organic and fleshy, as though the process wasurried. Margins may be easily detected. Historically,uch shortcomings might have been acceptable iniew of the unavailability of specialized staff and in-requency of facial patients. Conversely, some majorenters overwhelm even the facial specialist so thatompromises are made to accommodate the volumef patients.The prosthetics option will eventually provide aore accurate picture and better alternative in bor-

erline cases. This will happen when the facial pros- c

hetics professionals who have created their idealractice environment begin to publish and presenthe results of their work more seriously. Like eareconstructive specialists, there are very few anaplas-ologists worldwide who practice silicone facial anduricular prosthetics as their core competency. How-ver, unlike autogenous successes, prosthetic suc-esses occupy a relatively low profile. Some of theost impressive prosthetics results worldwide come

rom anaplastologists working in private settings,hich might mean that they are off the radar of

mportant referral networks and implant teams thathey should be a part of.

urgical Problems

In all of the important references it is agreed thathe surgical reconstruction of the human ear is anxtremely complex procedure. It is “in the upperchelons of reconstructive surgical procedures,”tates Walton.9 He continues, “Optimal results cannly be achieved through dedicated study and expe-ience.” This message that autogenous ear reconstruc-ion should be left to the talented and dedicated feweverberates throughout the literature. And this isarticularly true because the incidence of microtia/notia patients is relatively small; 1:5,000 according torent.10 It is clear that authors, most of whom areurgeons, make this point loud and clear repeatedly,nd with good reason. Complications at the ear re-onstruction site include exposure of the cartilageramework due to skin flap necrosis.9 This can beevastating to the reconstruction if not managed care-ully. If the framework cannot be salvaged it must beemoved and the operation considered a failure. Long-erm complications include the significant resorptionf the cartilage framework, which may or may notespond well to additional cartilage grafting to restorehe lost contour. There is always the chance that if theause for the resorption is not understood and cor-ected appropriately, this destructive process will re-ccur. Finally, resorption of the framework at the sitef synchondrosis can result in notching of the frame-ork, requiring reintervention.11

These complications may lead to a severely com-romised result. But even in the absence of compli-ations, the entire restoration might not achieve thelevation from the head to gain the approval of sur-eon and patient (Figs 1, 2). Walton states, “All au-hors agree that maximum relief of the construct isssential for the highest quality of reconstruction.”9 Ifhe reconstructed ear does not display normal eleva-ion and reasonable definition, observers will likelyetect it, especially during a face-to-face encounterhere both ears will be seen. Additionally, Thorne

oncedes that a suboptimal result might be uncorrect-

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ble.2 The poor autogenous or prosthetic subpar re-ult will attract attention or require some degree ofoverage or shadowing with hair or hat to minimizeetection. These patients (Figs 1, 2) preferred towipe the slate clean” and wear a prosthetic ear tochieve the balance and beauty of a normal-lookingar.Autogenous reconstruction also requires a sizeable

iece of rib cartilage for the ear sculpture, leaving a

FIGURE 1. A, B, Results of repeated autogenous reconstruction.

regory G. Gion. Treatment of microtia: The case for prostheticeconstruction. J Oral Maxillofac Surg 2006.

ompromised rib structure and a soft tissue deficit in c

he donor site. Although the ideal age for children toave ear reconstruction is generally agreed to bebout 6 years, Ohara reported that 64% of childrennder age 10 years had chest wall deformity com-ared with only 20% of older children.12 The emo-ional toll of parents and patients in failed attemptsnd the trauma and disfigurement to the donor site,lthough not precluding the autogenous option, cer-ainly must be considered a disadvantage of this op-ion. The presence of a long-lasting scar is yet anothereminder of the child’s imperfection, and will likelynvite more questioning from peers during athletic orummertime activities. To the child, it may become andditional reminder of the parent and other’s focus onhe microtic ear.

Also of concern is the degree to which the recon-tructed ear will grow to keep pace with the con-ralateral ear. Aguilar points out, in his reconstructiveechnique article, that studies in this area are seriouslyacking.13 He also cites that Brent addressed this issue,eporting on 76 patients operated on between ages 5nd 10 years.14 The report describes the majority ofases growing on pace with, or a few millimetersarger than, the contralateral ear, with only 10% lag-ing several millimeters behind. Aguilar states thatore such studies are indicated and the area is ripe

or further research.Then there is the question of long-term integrity of

he reconstructed ear. Will the reconstructed ear con-inue a trend in maturation into middle and old agehat reflects that of the contralateral ear? The largetudies of Brent14 and others report on the mainte-ance of the ear shape over 10 to 15 years, whichould measure the result when many in the group are

till relatively young, perhaps 16 to 30 years old. Inanzer’s comments after Brent’s article,14 he ob-erved some indications of loss of form after a longereriod. Fukuda made a similar observation in his very

ong-term study.15 Perhaps more time will be neededo measure long-term integrity of the reconstructionsy Brent, Nagata, and others. We cannot diminish thefforts and spectacular results of the best ear recon-tructions. However, the achievement of bilateralymmetry is an area where we will see an advantagef the prosthetic option, particularly for those whohoose to wear very short hairstyles.The obvious advantage of using one’s own tissue

or permanent reconstruction along with greater re-nement of techniques by experts seen in recentecades is still offset somewhat by the uncertainty ofhe actual results obtained by individual surgeons.ost surgeons do not have the experience to dupli-

ate the results of large specialized studies like thosef Brent, Firmin, Nagata, etc, and the failed attemptsre likely to compromise if not eliminate any future
hances for truly successful reconstruction.

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Gregory G. Gion. Treatment of microtia: The case for prostheticreconstruction. J Oral Maxillofac Surg 2006.


rosthesis as “Backup” ifutogenous Fails

There is some logic to the notion that because arosthesis can always be provided, why not try toeconstruct the ear surgically first. This is a reasonablehought if a child presents with microtia, anotia, orther correctable condition in the view of an expertar reconstructive surgeon. Of concern would be theendency to use the prosthesis option as a backup orecondary choice when in fact it should be the pri-ary choice to save a child unnecessary prolongedhysical and emotional pain. The failed autogenouseconstruction experience or, for that matter, anyesult that still draws immediate attention to the pa-ients head, cannot be easily dismissed. In the wake ofpoor result, the parents and patient will anticipate aaiting period to either accept and live with the

esult and the child’s continued social torment, theecision to undergo another attempt with less chanceor success, the decision to start the process againith another surgeon, or the difficult decision to

xcise the construct to prepare the area for a pros-hesis. In any event, surgical ear reconstruction isccompanied by trauma in multiple sites, possiblyver several years, considerable pain especially fromartilage harvest sites, possible need for adjunctiverocedures such as tissue expanders with other pos-ible complications further delaying the outcome,nd, of course, the extended focus on the ear duringcrucial period of a child’s psychosocial develop-ent.

naplastology: An Additional Asset forhe Prosthetic Option

The American Anaplastology Association is a groupf individuals with international representation that ispecifically dedicated to improving facial prosthetics.heir focus on the challenge of lifelike soft tissuerosthetics promises to further advance the resultsnd value of prosthetic reconstruction. Individualsho have specialized in silicone facial prostheticsave practiced in different settings using many differ-nt titles, including facial prosthetist, maxillofacialrosthetist, head and neck prosthetist, and even med-

cal sculptor. More recently, many individuals havesed the title of anaplastologist. Anaplastology is aelatively new term, defined in medical dictionariess: Application of prosthetic materials for construc-ion and/or reconstruction of a missing body partfrom the Greek ana, again, and plastos, formed).16

he field of anaplastology and the anaplastologistave come into existence largely because of increasedocus and dedication to the unique challenge of cre-
ting silicone facial prostheses. The American Ana-
IGURE 2. A, Right autogenous reconstruction. B, Implant-retainedrosthesis replaces autogenous construct.


FIGURE 3. A, Acceptable level of surface characterization andrefinement. B, Unacceptable voids and surface irregularity; artifacts ofcareless fabrication. C, Acceptable level of surface characterizationand refinement for the older patient.


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lastology Association, begun by Dr Walter Spohn attanford, had its first annual meeting in 1986. In 1987,he Association of Biomedical Sculptors begun byennis Lee at the University of Michigan in the late970s/early 1980s was essentially absorbed by themerican Anaplastology Association (AAA) to con-

inue their dedication to the specialty. The AAA hasnjoyed solid international participation every yearince 1986.

The current members have diverse educationalackgrounds including medicine, dentistry, dentalechnology, materials research, medical art/illustra-ion, and fine art, to name a few. There are alsoembers who originate from the fields of ocular pros-

hetics or limb prosthetics/orthotics. Although theiversity of education and training experiences pro-ides fertile ground for new ideas and informationxchange, membership in the AAA or using the titlef anaplastologist does not in any way indicate an

ndividual’s actual training or competence in provid-ng auricular or other facial prostheses. The Board forertification in Clinical Anaplastology (BCCA) has be-un the process of developing criteria to identify anndividual’s knowledge of basic materials and princi-les in the provision of anaplastology services. Arandfathering phase has identified subject matterxperts who are assisting with test development. TheCCA is a member of the National Organization forompetency Assurance (NOCA) and is pursuing ac-reditation through the National Commission forertifying Agencies (NCCA). These developments un-erscore an international effort to define this special-

zation and to promote a significantly higher level ofrosthetic result.

acial Prosthetist Selection

The success of implant-retained facial prosthesesas prompted the formation of teams with the goal ofroviding comprehensive centers for maxillofacialrosthetic rehabilitation. Within large medical institu-ions or dental schools, these teams often formround the reputations of attending surgeons androsthodontists. Some teams have recruited a dedi-ated anaplastologist or retained a proven indepen-ent facial prosthetist to assure that their patienteceives the maximum prosthetic outcome. Others

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™IGURE 4. A, Replacement prosthesis with patient preference foreavier margins to withstand adhesive regimen. B, Opacification/urface wear indicate daily use of and reliance on prosthesis welleyond recommended replacement interval.

regory G. Gion. Treatment of microtia: The case for prosthetic
econstruction. J Oral Maxillofac Surg 2006.

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nlist existing lab staff for the task, assigning them aitle such a medical artist. The latter approach mayrovide savings for departments and it may help in-ate the profile of the program. However, it does noterve the patient, institution, or the legitimate medi-al art-trained anaplastologist, and is not encouraged.hen patients are weighing the merits of autogenous

ersus prosthetic reconstruction, they should haveccess to full-time facial prosthetic specialists just ashey should have access to dedicated ear reconstruc-ive specialists. Patients should be referred to facialrosthetists who can show, through close-up photo-raphs, many excellent and varied types of prostheticar results. Providers should be experienced not justo provide conventional adhesive- or implant-retainedrostheses, but also more complex designs to exploitpportunities for anatomical or mechanical attach-ent. The author agrees with the plastic surgeonalton who states, “The weak link in this technology

the prosthetic option) lies in the quality of the pros-hesis itself, the life-like appearance of which isholly dependent on the artistry and skill of the

naplastologist”9 (Fig 3). The importance of this rela-ionship with an expert anaplastologist is restated byhe plastic surgeon Somers of Belgium.5

The provider of ear prostheses must possess alend of training and talent as well as a willingness toevote the time needed to render a result thatchieves true visual integration (VI). VI occurs whenhe prosthesis convinces the eye that it is vital, nor-

FIGURE 5. Right auricular prosthesis


al, and contiguous with surrounding anatomy. VI is t

ifficult to achieve consistently, but no less importanthan the requirement of functional integration (FI). FIccurs when a patient accepts a safe, secure, andanageable prosthesis, integrating it into the self im-

ge and daily life. The author advocates the use of VInd FI or similar language to frame the equal impor-ance and measurement of these criteria.

dvantages of Prostheses

Attempts have been made to measure facial pros-heses,17,18 and some studies have reported on overallatient satisfaction with maxillofacial prostheses.19

owever, in general, studies are vague and inconclu-ive for the purpose of developing treatment selec-ion protocol. What is reliable is the fact that manyen, women, and children have successfully and hap-ily worn ear prostheses for many years, many ofhem returning every few years over the course ofecades for replacement prostheses as they wear out.

48-year-old patient (Fig 4) has used an adhesive-etained prosthesis for many years after several sur-eries during childhood to reconstruct. The authoras provided this patient with prostheses since 1993.he patient opted to leave the surgical remnant of the

obule to reside beneath the prosthesis. This photo-raph showing the wear characteristics of a 5-yeareriod of daily use illustrates patients’ reliance on arosthesis and its integration into their daily life. More

requent repair, retinting, or replacement of the pros-

s balanced unremarkable silhouette.

ruction. J Oral Maxillofac Surg 2006.

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hesis is recommended, but this mail carrier now with

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hildren of his own will have the prerogative to ac-uire improved prostheses as he wishes. Althoughhese photos typify adhesive-related degradation ofilicone prostheses, they also hint at the even greaterongevity and ease of use of implant-retained versions.hey also give testament to patient usage and long-

erm satisfaction with prostheses. Check-up and re-urbishing every 1 or 2 years preserves margin esthet-cs and visual integration of the prosthesis.

ymmetry

Symmetry in particular is an important element,specially for those anticipating wearing a short hair-tyle not only as a child but also throughout theirdult life. In a normal social encounter, an auriculariscrepancy will likely be detected, drawing focusway from the human interaction and toward theissimilarity of the ears. This point is very pro-ounced in those with short hair styles and protrud-

ng ears (Fig 5). The success of osseointegrationakes the use and acceptance of the prosthesis evenore dramatic. With prosthetic accuracy and ease of

se increasing, the long-term studies will becomeore important in measuring how closely the autog-

nous reconstruction matches the contralateral earfter 20, 30, or more years when the patient reacheshe age of 40, 60, or 80 years.

Patients apparently are very concerned about sym-etry, based on the author’s experience with re-

uests to improve upon the results of unsuccessfulutogenous reconstructions. In these cases, patientsave autogenous structure that approximated theeneral size of the contralateral ear, but they seek arosthetic ear to cover and mask their reconstructiveesult (Fig 6). This would suggest that even havingheir own ear formed of their own body is less thanatisfactory, and that having a removable prostheticar that projects the natural esthetic beauty of normalnatomy is worth the daily regimen of prosthesissage. It may be that this combination of basic autog-nous structure and overlying prosthetic surface isorth the added cost and trouble of care and main-

enance because it makes the patients feel that theyave their own ear, and the prosthetic “sleeve” oroverlay” may be more easily accepted as an enhance-ent—an option to improve esthetics, not the cor-

ection of a gross defect. In some of these situations

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™IGURE 6. A, Patient with left autogenous reconstruction. B, Patientsing sleeve-type prosthesis to achieve a more normal appearance ofuperior auricular anatomy.

econstruction. J Oral Maxillofac Surg 2006.

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he patient does benefit by the retentive effect of thexisting ear, as it allows the prosthetic ear to slip overt like a glove, reducing or eliminating reliance ondhesive (Fig 7).

The importance of symmetry cannot be minimized.n the author’s experience, patients almost withoutail judge the prosthesis first on symmetry. Even whenatients verbally acknowledge the need for compro-ise of desired prosthesis shape due to existing anat-

my, implant abutments, etc, they continue to focusn and point out minute discrepancies in bilateralymmetry to the anaplastologist. This is common andconstant indication of the importance of symmetry.he author has accomplished symmetry by sculpting

n wax a mirrored rendition, usually by studying alaster cast made from an impression of the contralat-ral ear. However, the use of digital technologies suchs 3-dimensional scanners/printers now adds to thepeed, accuracy, and patient confidence in prostheticeplacement therapy. After 25 years of sculpting earsrom a lump of softened wax, we now use a RolandDX-15 3-dimensional scanner/printer in office to

ccomplish near-perfect initial bilateral symmetry. Ad-ptation to the defect contours and final surface de-ailing still require some effort, but less so. The ex-losion of digital applications not only promises to

mprove morphological accuracy, it promises to trans-er the saved time in sculpting hours and potentiallyn color quantification to the next challenge of achiev-ng a highly accurate and systematized reproduciblekin appearance in the prosthesis.

Prosthetic restoration, unlike autogenous recon-truction, is almost immediate. In cases where a pa-ient wants to know what a prosthetic result can offerithout osseointegration, the prosthesis can be cre-

ted and attached in 3 days. Waiting and worries ofhether the correct surgeon has been selected, tim-

ng of the surgeries, school absences, pain, complica-ions, and follow-ups are not present with the pros-hetic option. Children utilizing a bone-anchoreduricular prosthesis may require only a single surgeryollowed by integration time and prosthesis fabrica-ion time—a total period lasting as little as 12 weekst which time they have their “ear” and may beginntegrating it into their life. Despite having knowl-dge of and access to the best ear reconstructiveurgeons, some parents select osseointegration overhe uncertainty and prolongation of autogenous re-onstruction. A 6-year-old child (Fig 8) was evaluatednd the parents were encouraged to consult excellentar reconstructive surgeons. After this, the parentselected prosthetic reconstruction and the child re-eived implants and a completed prosthesis prior torst grade. Upon returning home after his first day hexpressed some regret that he received no extra at-

IGURE 7. A, Patient with right autogenous reconstruction. B, Patientsing an adhesive-free sleeve type prosthesis and subsequenteplacements.

ention—no classmates detected his prosthetic ear.

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early 1 year later, the child returned to the office foretinting of his prosthesis in preparation for the startf second grade. In a long-term study of quality andafety of osseointegration-supported ears, it is re-orted that many of the patients accepted the pros-hesis as their own.20 Studies of children’s and par-nts’ questionnaires report improved quality of life.6

There is also a high success rate for implants placedn the mastoid. During the years 1994 to 2004, ourmplant success rate has been 100%. Of a total of 92mplants placed in the mastoid by Dr. Douglas Sinn,he maxillofacial surgeon at the University of Texasouthwestern Medical Center, during these years forar prostheses created by the author we are not awaref any failures. Other advantages include, of course,o trauma of repeated surgeries associated with theeconstructed site and rib cartilage harvest site.

There has been justified concern that the place-ent of implants will preclude future attempts at

urgical reconstruction in “ideal” microtic ears. The m

uthor is much more comfortable and prefers thatell-situated microtic tissue be left alone to resideeneath the prosthesis (Fig 9). The presence of theemnant lobule, if well positioned under the prosthe-is, actually produces a snugger fit and more estheticargin with less chance for exposed scarring, con-

racture, etc. In cases where 2 or 3 implants arelaced into the mastoid, future reconstruction mayot be precluded. In some cases the prosthesis isesigned to blend into the remnant lobule, not cover

t. This can have the advantage of maintaining themportant visual continuity in color and texture be-ween the cheek and the ear lobe. In grade 1 andrade 2 microtia, excision for a prosthesis should notccur, generally. In some scenarios involving grade 2r 3 microtias, some patients and parents having dif-culty with their decision might benefit from havingprosthesis even with a compromised shape. It al-

ows them to understand how existing tissue compro-

IGURE 8. A, Untreated right microtia. B, Tentative acceptance ofmplant-retained prosthesis just prior to first grade. C, Annual retint ofrosthesis complete and ready for the second grade.

regory G. Gion. Treatment of microtia: The case for prostheticeconstruction. J Oral Maxillofac Surg 2006.

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ises the prosthesis, it allows accurate assessment of

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chievable esthetics in terms of color match, etc, andt introduces the reality of daily application and re-

oval of a prosthesis. This can be helpful beforeeciding to excise the remnant for osseointegrationnd eliminating an opportunity for later reconstruc-ion (Figs 9A-C).

The general advantage of the prosthesis is the po-ential to present normal appearance and be undetect-ble. In real-life situations where people have an op-ortunity to study one another’s ears such as crowdedlevators, grocery lines, etc, small deviations may beetected, so prostheses must be nuanced and formu-

FIGURE 9. A, Untreated left microtia. B, Sleeve or slip


ated to appear natural in different lighting conditions s

Figs 10A-C). Subtle coloration, convincing simulationf anatomy, and tightly fitting margins should beresent in the prosthesis. Unlike the trend in autoge-ous reconstruction where the chance for happinessnd success diminish with repeated attempts, pros-hetic results will likely improve, as will subsequentersions of the ear as technique is refined or a morealented/experienced anaplastologist is used. Therehould be no evidence that the ear form began as alay sculpting or wax carving. Contours should bemooth, rounded, and undulating, connoting soft-ess, especially in the child’s ear (Fig 11). There

e prosthesis in situ. C, Sleeve prosthesis and duplicate.


-on typ

hould be a slight vibrancy to mimic flushing. The

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eauty of the prosthesis option is that it can alwaysffer a future of continual improvement toward visualerfection. There is a certainty of lifetime symmetry

n the patient’s presentation to the world at the dis-retion of the patient. There are an infinite number ofpportunities to renew the ear, improve upon it withmerging technologies, and change it to more closelyimic the natural aging of the contralateral ear. There

s always hope for the patient to improve their situa-ion rather than resignation with the result of a singleurgical effort.

isadvantages of Prostheses

The most significant disadvantage of an auricularrosthesis is the fact that it is not part of the person.t is an appliance that must be removed regularly,leaned and maintained, and replaced every fewears. Some prosthetic designs feature an unestheticap in the posterior of the prosthesis used as a meanso ventilate the peri-implant tissues. However, weave provided auricular prostheses with no ventingr no visible vent designs since 1994 without inci-ent. On the question of security of the attachment,his is an area of significant personal frustration iniew of the overall elegance, beauty, and effective-ess of a carefully created prosthesis. Efforts to incor-orate other mechanisms to create stronger attach-ent are to be commended,21 although a definitive

oolproof mechanism has yet to be invented. Thetandard arrangement featuring the bar splint is diffi-ult to clean under, can become loose or get bent,nd still provides no absolute measure of security.ith the right force applied, the prosthesis can still

IGURE 10. A, Prosthesis under MacBeth daylight spectrum fixturesitu under daylight spectrum fixtures and north light (Sony image).


ecome dislodged without warning. The clips need to d

e adjusted, and they must be housed in an acrylicubstructure that sometimes results in significantompromise to the prosthesis’ contour. The free-tanding abutment and magnet approach offers easierleaning, no substructure, and less required force tottach and remove the prosthesis.22 The use of theargest magnets in conjunction with multidurometerilicone prostheses and techniques described inhomas22 significantly improves retention to matchr exceed that of bar-clip designs. In a recent versione combine these techniques with strategic place-ent of very soft compliant silicones to dampen typ-

cal dislodging forces. Even with a linear arrangementf abutments the method resists breakaway from an-erior and posterior applied forces (Fig 12).

n the Horizon

It is the author’s belief that the natural evolution ofontinued experimentation will feature a locking ele-ent of some type that will provide absolute retention

or the prosthesis, once engaged. This would mean thathe silicone prosthesis would deform completely undertress to the point of rupture of the material before therosthesis would be released. This alone would have aramatic effect on patient confidence and acceptance ofprosthesis. Other designs might feature softer materi-

ls or pivoting sections in the prosthesis as means tobsorb otherwise dislodging forces. A viscoelastic sili-one gel or like material might provide a more intimatenterface, acting as a tissue conditioner, secondary re-ention, and obviating the need for air vents. In anyvent, the solutions are exciting to anticipate becausehey will offer our patients a whole new level of confi-

rth light (Fuji image). B, Prosthesis in situ (flash photo). C, Prosthesis in


and no

ence and satisfaction with their prostheses. The solu-

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ions to these mechanical problems are unfortunately aunction of institutional research initiative and individualractitioner’s inventiveness and their respective re-ources. Auricular prostheses, like other extraoral pros-

IGURE 11. A, Left autogenous reconstruction. B, Construct excisednd duplicate.


heses, provide little economic or professional incentive a

or study compared with intraoral prosthetics, for in-tance. However, the increased interest and collabora-ion to solve such problems promise that long-estab-ished lines between disciplines will blur. The role of the

nial implants placed. C, Left auricular prosthesis in situ. D, Prosthesis


and cra

naplastologist will assume heightened interest and

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reater scrutiny due to the need for competency inigital technologies, artistic skill, and patient manage-ent. The added attention will likely inspire anaplastolo-

ists to achieve even greater esthetic results for theiratients.The prosthetics option has gained far greater merit

n the last decade because of the pioneering work of.I. Branemark. Branemark’s hope was that a prosthe-is should not be detectable at a distance of 1 meter orreater (personal communication). Branemark alsoxpressed that anaplastology, or the quality of therosthesis, was the limiting factor in the area ofraniofacial osseointegration rehabilitation (personalommunication). The prosthesis option seems to beegarded more highly and selected more often in

IGURE 12. A, Linear implant arrangement. B, Progress check oisplacement forces. E,F, Patient before and after attachment of impla


urope. Some European studies support overall satis- o

action with the prosthetic option.5,20 The authorelieves strongly that the prosthetics option in thenited States may still be given less serious consider-tion because of the widely varying quality in pros-heses. There is no apparent method to predict whichype of provider credential or practice setting willield even acceptable results. Unlike the professionalchool preparation and specialty certification neces-ary for anyone to reconstruct an ear or place implantxtures, there is not a universally accepted level ofreparation to create and provide a prosthetic ear.owever, in the author’s 25-year experience, there isow a palpable interest in the professionalization oflinical anaplastology (Board for Certification in Clin-cal Anaplastology). The solidification of anaplastol-

ic color application. C,D, On-mold check of resistance to typicalned prosthesis.


f extrinsnt-retai

gy has fostered professional identity and practice

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ynamics. Anaplastologists now are key to prostheticsseointegration success, which has inspired evenreater creativity and contribution to the field. Thisranslates to increased patient satisfaction with theirrosthesis and improved likelihood that they willaintain the needed long-term relationship with their

pecialists.There is the natural tendency for the anaplastolo-

ist to put the prosthesis option in the best possibleight. However, the intent has been to give propernd needed exposure to the high points and potentialf the option and not misguide the patient, family, orpecialist toward the wrong choice of treatment. Thenherent shortcomings of any prosthetic device areainfully obvious especially to the creator, and theuthor wholeheartedly agrees with Thorne,2 that aood autogenous reconstruction is more desirablehan any prosthetic result. It is only hoped that futureesults will become more predictable and treatmentelection easier as specialists hone their skills andearn from each other. Robert Kelton, PhD, offersuggestions for health care professionals workingith patients with craniofacial conditions.23

onvey to parents of affected newborns as muchoptimism about their child’s future as you can mus-ter: As Strauss (1999)23 makes clear, the attitudeyou communicate to parents is likely to have aprofound impact on the life of the affected family.

upport a team approach to treatment: It offers thebest hope for efficient, effective patient care. Fur-thermore, patients are likely to find the team ap-proach reassuring and as a result may participatemore actively and constructively in their own care.

ncourage parents to treat their affected child as nor-mally as possible: A child with facial anomalies willusually respond as well as any other child to a highstandard of conduct and achievement.

emain sensitive to the pain stigma causes, and en-courage parents to do all that is medically andfinancially feasible to repair stigmatizing facial dif-ferences. At the same time, remind parents not tobelieve every medical claim they hear, even whenthose claims originate with your well-meaning col-leagues.

ncourage patients to seek out others with similaranomalies, because people facing similar adversi-ties have much to teach one another.aintain a sense of humor. It will encourage parentsand patients to do likewise.

Collectively, these strategies will contribute signif-
cantly to healthy adaptation to craniofacial condi-
2

ions, and at the same time, may increase the satisfac-ion you derive from your efforts.

eferences1. Wilkes GH, Wolfaardt JF: Osseointegrated alloplastic versus

autogenous ear reconstruction: Criteria for treatment selection.Plast Reconstr Surg 93:967, 1994

2. Thorne CH, Brecht LE, Bradley JP, et al: Auricular reconstruc-tion: Indications for autogenous and prosthetic techniques.Plast Reconstr Surg 107:1241, 2001

3. Botma M, Aymat A, Gault D, et al: Rib graft reconstuctionversus osseointegrated prosthesis for microtia: A significantchange in patient preference. Clin Otolaryngol Allied Sci 26:274, 2001

4. Wazen JJ, Wright R, Hatfield RB, et al: Auricular rehabilitationwith bone-anchored titanium implants. Laryngoscope 109:523,1999

5. Somers T, DeCubber J, Govaerts P, et al: Total auricular repair:Bone anchored prosthesis or plastic reconstruction? Acta Oto-laryngol Belg 52:317, 1998

6. Rotenberg BW, James AL, Fisher D, et al: Establishment of abone-anchored auricular prosthesis (BAAP) program. Int J Pe-diatr Otolaryngol 66:273, 2002

7. Branemark P-I, DeOliveira MF: Craniofacial Prostheses: Ana-plastology and Osseointegration. Hanover Park, IL, Quintes-sence Publishing, 1997

8. Thomas KF: Prosthetic Rehabilitation. Hanover Park, IL, Quin-tessence Publishing, 1994

9. Walton RL, Beahm EK: Auricular reconstruction for microtia:Part II. Surgical technique. Plast Reconstr Surg 110:234, 2002

0. Brent B: The pediatrician’s role in caring for patients withcongenital microtia and atresia. Pediatr Ann 28:374, 1999

1. Firmin F: Ear reconstruction in cases of typical microtia. Per-sonal experience based on 352 microtic ear corrections. ScandJ Plast Reconstr Hand Surg 32:35, 1998

2. O’Hara K, Nakamura K, Ohta E: Chest wall deformities andthoracic scoliosis after cartilage graft harvesting. Plast ReconstrSurg 99:1030, 1997

3. Aguilar FE: Auricular reconstruction in congenital anomalies ofthe ear. Facial Plast Surg Clin North Am 9:159, 2001

4. Brent B: Auricular repair with autoenous rib cartilage grafts:Two decades experience with 600 cases. Plast Reconstr Surg90:335, 1992

5. Fukuda O: Long-term evaluation of modified Tanzer ear recon-struction. Clin Plast Surg 17:241, 1990

6. Stedman’s Medical Dictionary (ed 27). Hagerstown, MD: Lip-pincott Williams & Wilkins, 2000

7. Roefs AJ, vanOort RP, Schaub RMH: Factors related to theacceptance of facial prostheses. J Prosthet Dent 52:849,1984

8. Lowenthal U, Sela M: Evaluating cosmetic results in maxillofa-cial prosthetics. J Prosthet Dent 48:567, 1982

9. Markt JC, Lemon JC: Extraoral maxillofacial prosthetic reha-bilitation at the M. D. Anderson Cancer Center: A survey ofpatient attitudes and opinions. J Prosthet Dent 85:608, 2001

0. Westin T, Tjellstrom A, Hammerlid E, et al: Long term studyof quality and safety of osseointegration for the retention ofauricular prostheses. Otolaryngol Head Neck Surg 121:133,1999

1. Lemon JC, Chambers MS: Locking retentive attachment for animplant-retained auricular prosthesis. J Prosthet Dent 87:336,2002

2. Thomas KF: Freestanding magnetic retention for extraoralprosthesis with osseointegrated implants. J Prosthet Dent 73:162, 1995

3. Kelton RW: Facing up to stigma: Workplace and personalstrategies. Cleft Palate Craniofac J 38:245, 2001

J Oral Maxillofac Surg 64:1639-1654, 2006 Surgical Versus ... · of Microtia: The Case for...

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Transcript of J Oral Maxillofac Surg 64:1639-1654, 2006 Surgical Versus ... · of Microtia: The Case for...