CME Auricular Reconstruction: Indications for Autogenous ... · for prosthetic ear reconstruction is the acquired total or subtotal auricular defect, most often traumatic or ablative

CME

Auricular Reconstruction: Indications forAutogenous and Prosthetic TechniquesCharles H. Thorne, M.D., Lawrence E. Brecht, D.D.S., James P. Bradley, M.D., Jamie P. Levine, M.D.,Paul Hammerschlag, M.D., and Michael T. Longaker, M.D.New York, N.Y.

Learning Objectives: After studying this article, the participant should be able to: 1. Describe the alternatives for auricularreconstruction. 2. Discuss the pros and cons of autogenous reconstruction of total or subtotal auricular defects. 3.Enumerate the indications for prosthetic reconstruction of total or subtotal auricular defects. 4. Understand the com-plexity of and the expertise required for prosthetic reconstruction of auricular defects.

The indications for autogenous auricular reconstruc-tion versus prosthetic reconstruction with osseointegratedimplant-retained prostheses were outlined in Plastic andReconstructive Surgery in 1994 by Wilkes et al. of Canada, butbecause of the relatively recent Food and Drug Adminis-tration approval (1995) of extraoral osseointegrated im-plants, these indications had not been examined by asurgical unit in the United States. The purpose of thisarticle is to present an evolving algorithm based on anexperience with 98 patients who underwent auricular re-construction over a 10-year period. From this experience,the authors conclude that autogenous reconstruction isthe procedure of choice in the majority of pediatric pa-tients with microtia. Prosthetic reconstruction of the au-ricle is considered in such pediatric patients with congen-ital deformities for the following three relative indications:(1) failed autogenous reconstruction, (2) severe soft-tis-sue/skeletal hypoplasia, and/or (3) a low or unfavorablehairline. A fourth, and in our opinion the ideal, indicationfor prosthetic ear reconstruction is the acquired total orsubtotal auricular defect, most often traumatic or ablativein origin, which is usually encountered in adults. Althoughprosthetic reconstruction requires surgical techniquesthat are less demanding than autogenous reconstruction,construction of the prosthesis is a time-consuming taskrequiring experience and expertise. Although autoge-nous reconstruction presents a technical challenge to thesurgeon, it is the prosthetic reconstruction that requireslifelong attention and may be associated with late com-plications. This article reports the first American series ofauricular reconstruction containing both autogenous andprosthetic methods by a single surgical team. (Plast. Re-constr. Surg. 107: 1241, 2001.)

Alternatives for auricular reconstruction in-clude autogenous reconstruction using a rib

cartilage framework, prosthetic reconstructionwith osseointegrated implants for retention ofthe prosthesis, or use of an alloplastic frame-work (e.g., porous polyethylene) rather than acartilage framework. The latter alternative isnot addressed in this article. The complicationrate and eventual extrusion rate associatedwith Silastic frameworks make its use undesir-able.1–3 Recent reports of polyethylene frame-works are encouraging but await long-termevaluation.4

The choice between the two remaining tech-niques, autogenous reconstruction and pros-thetic reconstruction, depends more on thesurgeon’s training and tradition than on ananalysis of which procedure is preferable in agiven clinical situation. For example, most chil-dren with microtia in the United States aretreated with autogenous techniques. In con-trast, the same deformities in Sweden are morecommonly treated with prosthetics.5,6 The indi-cations for prosthetic reconstruction havebeen outlined by Wilkes et al.7 of Canada, butno American series combining autogenous andprosthetic techniques has been published.

In the hands of an experienced plastic sur-geon who performs the procedure on a regularbasis, autogenous techniques yield consistentresults in the majority of pediatric patients withmicrotia. Several large series have been re-ported that demonstrate excellent results.8–10

From the Institute of Reconstructive Plastic Surgery, New York University Medical Center. Received for publication July 15, 1999; revised March24, 2000.

1241

Most surgeons, however, do not have the expe-rience with this rare condition (approximately1:4000 births) to duplicate the results reportedin the large series. In addition, autogenous earreconstruction has the disadvantage that a sub-optimal result might be uncorrectable.

Although prosthetic reconstruction of theauricle has an established track record outsidethe United States, it did not become a viablealternative in the United States until January of1995, when the Food and Drug Administrationapproved the extraoral use of Brånemark os-seointegrated implants (Nobel Biocare USAInc., Yorba Linda, Calif.). Before that date, earprostheses were not well tolerated because ofthe inconvenience and ineffectiveness ofchemical adhesives. Osseointegration, the di-rect structural connection between living boneand a load-carrying implant, has reduced theproblems of prosthesis retention andinconvenience.5,6,11

We postulate that each of these two methodshas a role in auricular reconstruction and thatneither technique is appropriate for every clin-ical situation. Therefore, the purpose of thisarticle is to present an evolving algorithm forauricular reconstruction based on the seniorauthors’ (C.H.T. and L.E.B.) experience withpatients who have undergone auricularreconstruction.

MATERIALS AND METHODS

Between 1989 and 1998, a total of 145 pa-tients were evaluated in a multidisciplinaryfashion with regard to plastic surgery, pros-thodontics, and otolaryngology. The senior au-thors, C.H.T. (plastic surgery) and L.E.B.(prosthodontics) performed reconstructiveprocedures on 98 patients during that timeperiod. A total of 84 patients underwent auto-genous reconstruction using the technique de-scribed by Brent.8 All patients in this groupwere children with microtia (Fig. 1).

Prosthetic reconstruction was performed in14 patients (18 ears) after the Food and DrugAdministration approval of Brånemark im-plants (Nobel Biocare) in 1995. The prostheticgroup contained patients in both the pediatric(six patients, 10 ears) and adult (eight patients,eight ears) age groups; it included patientswith congenital, posttraumatic, and postabla-tive deformities (eight, three, and three pa-tients, respectively). The age and diagnosis ofeach patient in the prosthetic group are shownin Table I.

In the prosthetic group, both the plastic sur-geon and prosthodontist were present in theoperating room at the time of fixture place-ment. In the initial patients in the series, thetranscutaneous abutments were placed at a sec-ond stage approximately 3 months after im-

FIG. 1. Autogenous reconstruction. The patient underwent a staged reconstruction, as described by Brent.8 (Left) Preoperativeappearance; (center and right) postoperative result. On frontal view, the position of the auricle is symmetrical, as judged by theposition of the earrings. This patient’s microtic vestige contained a tragus-like structure, making that stage of the reconstructionmore favorable than average.

1242 PLASTIC AND RECONSTRUCTIVE SURGERY, April 15, 2001

plant placement. In the more recent cases, thefixtures and abutments were placed concomi-tantly in a single stage.

As experience with the prosthetic techniquewas obtained and literature from other coun-tries using the technique was acquired, theauthors developed an algorithm for distin-guishing between candidates for autogenousreconstruction and prosthetic reconstruction.

RESULTS

Despite increased experience with the pros-thetic technique, after using it in the pediatricage group the authors have not altered theiropinion that the majority of children with con-genital anomalies are best treated with auto-genous techniques. Nevertheless, there is asubset of pediatric patients with congenitalanomalies in whom it may be reasonable toconsider prosthetic ear replacement. On thebasis of our experience, we arrived empiricallyat the following relative indications for pros-thetic reconstruction (the first three relativeindications involve congenital cases; the fourthinvolves acquired deformities):

1. Failed Autogenous Reconstruction

Patients with a failed autogenous reconstruc-tion may represent the ideal indication in thepediatric age group for an implant-retainedprosthesis (Fig. 2). The scarring associatedwith previous surgical attempts may precludefurther autogenous reconstruction or requiretransfer of a temporoparietal flap for frame-work coverage. In some patients, the tem-poroparietal fascia may have been used, neces-sitating either microvascular transfer of thecontralateral temporoparietal fascia or a pros-thetic reconstruction. In dark-skinned patients

prone to hypertrophic scarring, scalp incisionsassociated with temporoparietal flap harvestmay present a significant deterrent to thattechnique, and prosthetic reconstruction maybe a better alternative than a second attempt atautogenous reconstruction. Moreover, patientsand their families may be hesitant to proceedwith a second attempt at autogenous recon-struction after an initial failure.

2. Severe Soft-Tissue and/or Skeletal Hypoplasia

Patients with hemifacial microsomia whodemonstrate the extreme manifestations ofsoft-tissue deficiency and/or skeletal hypopla-sia represent the most challenging clinical sce-nario, and no perfect solution currently exists.

Some patients with hemifacial microsomiapresent with tight skin, absence of a superiorskin remnant, and a small or almost absentlobule (Fig. 3). The cutaneous deficit limits theresult that can be obtained with autogenousreconstruction. For example, there may be in-adequate skin to drape into the interstices of aframework. In some patients, the cutaneous

FIG. 2. A failed autogenous reconstruction. The patienthad undergone attempts at auricular reconstruction else-where. In addition to the scarring associated with the failedauricular reconstruction, the patient also has hypertrophicscarring in the scalp, most likely related to temporoparietalflap harvest. Further attempts at autogenous reconstructionwould be difficult, making prosthetic reconstruction a rea-sonable option.

TABLE IImplant-Retained Prosthetic Reconstruction

Patient Age Unilateral or Bilateral Diagnosis

1 4 Unilateral Congenital2 8 Bilateral Congenital3 9 Bilateral Congenital4 14 Unilateral Congenital5 14 Bilateral Congenital6 15 Bilateral Congenital7 25 Unilateral Congenital8 28 Unilateral Congenital9 34 Unilateral Posttraumatic

10 49 Unilateral Postablative11 53 Unilateral Posttraumatic12 53 Unilateral Posttraumatic13 61 Unilateral Postablative14 63 Unilateral Postablative

Vol. 107, No. 5 / AURICULAR RECONSTRUCTION 1243


deficit is such that the placement of a standardframework will result in ischemia of the over-lying tight skin. In those patients it is necessaryto reduce the projection of the framework toensure viability of the overlying skin, whichfurther limits the ultimate result.

Skeletal hypoplasia also limits the result thatcan be obtained by autogenous reconstruction.Some patients present with a temporal concav-ity resulting from hypoplasia of the mandibularramus and the temporal bone, such that anyreconstructed auricle will not project ade-

quately (Fig. 4). Despite mandibular recon-struction, the contour of the temporal regionremains uncorrected.

Patients with the more severe manifestationsof hemifacial microsomia often present withthe limitations of soft-tissue hypoplasia andskeletal hypoplasia concomitantly. Not only isautogenous reconstruction limited, but the de-gree of facial asymmetry makes auricular re-construction less of a priority. The more severethe asymmetry, the greater the relative impor-tance of the orthognathic surgery and the mi-crovascular soft-tissue augmentation, the re-sults of which (being closer to the facialmidline) are more noticeable on frontal view.In these patients it may not be possible toproduce an aesthetically adequate auricle us-ing autogenous techniques. These patientsface numerous reconstructive procedures forthe skeletal and soft-tissue hypoplasia and maybe better treated with an implant-retainedprosthesis and alterations in hairstyle.

The authors’ treatment algorithm continuesto evolve in these difficult cases. Currently un-der investigation is a change in the order ofreconstructive procedures; the soft-tissue aug-mentation is currently performed before auric-ular reconstruction, completely correcting thetemporal concavity, and then auricular recon-struction is considered on this reconstructedplatform.

3. Low or Unfavorable Hairline

Management of the hairline is always an is-sue in the patient with a congenital ear defor-mity. If the hairline is slightly low, a compro-mise can be struck by constructing an auriclethat is smaller than the normal side. In thismanner, the superior aspect of the frameworkis not covered with hair. From an aestheticpoint of view, it is more important to have thecaudal aspect of the auricle (lobule) in a sym-metric position relative to the contralateralside than to have symmetry of the superioraspects of the auricle, which are more easily

FIG. 4. Combination of soft-tissue and skeletal hypoplasia.This patient demonstrates the extreme manifestation ofhemifacial microsomia with severe soft-tissue and hard-tissuehypoplasia. Although autogenous techniques can be used toconstruct an auricle, the temporal concavity limits the result.In addition, the patient will require numerous surgical pro-cedures, including orthognathic surgery and microvascularsurgery. Prosthetic reconstruction of the auricle is simplerand less invasive, and it may appeal to the patient and his orher family for those reasons. Nevertheless, the ideal proce-dure may be to disguise the temporal deficiency with themicrovascular soft-tissue augmentation and then to performautogenous ear reconstruction.

FIG. 3. Severe soft-tissue hypoplasia. (Above) Preoperative appearance demonstrating almost complete absence of any auricularvestige. In addition, the hairline is slightly low. (Center, left) Preoperative plan indicating the desired position of the eventualprosthesis and the anticipated location of the fixtures within the auricular outline. The location of the fixtures may be modifiedintraoperatively, depending on the thickness and quality of the bone. (Center, right) Appearance after the excision of hair-bearingscalp, placement of fixtures, split-thickness skin graft, and placement of the transcutaneous abutments. Note the soft-tissueirritation. The patient had been wearing the prosthesis for several months. Inflammation is quite common in children who donot care for the area as meticulously as an adult patient. This degree of erythema responds well to using aggressive hygiene aroundthe abutments and decreasing the number of hours per day that the patient wears the prosthesis. (Below) Postoperative result.Note the difficulty in disguising the anterior margin of the prosthesis in the absence of a tragus.


camouflaged by hairstyle. A small amount ofhair over the superior aspect of the auricularreconstruction can be treated in a number ofways: electrolysis, laser ablation, and excision/skin graft. In addition, various techniques havebeen described to alter the hairline before ini-tiating autogenous reconstruction.12,13 In pa-tients who present with an extremely low hair-line, however, in whom the majority of theframework would be covered with hair-bearingskin, prosthetic reconstruction represents an

alternative (Figs. 5 and 6). Although these pa-tients can undergo autogenous reconstructionwith temporoparietal flap coverage of theframework, that technique may not be desir-able in all patients.

As laser technology improves, it may becomepossible to permanently ablate the hair in theprecise location for auricular reconstruction,but at the present time, the hair removal is notpermanent and repeated treatments are re-quired. In addition, the hair-bearing scalp con-

FIG. 5. A bilateral low or unfavorable hairline. (Above) Preoperative appearance. The hairline is extremely low, extendingalmost to the angle of the mandible. (Below, center) Intraoperative photograph indicating the area where the hair-bearing scalpwill be removed and the temporal skull will be covered with a split-thickness skin graft. The ideal location of the fixtures hasbeen marked within the outline of the eventual auricle. The patient is shown with facial nerve monitors in place, an importantsafety measure when complex external auditory canal remnants are excised. Hidden behind the auricular vestige in the centerof the photograph, outlined by the marking pen, is a malpositioned external auditory meatus. The patient had a long, serpiginousexternal auditory canal remnant, which opened to the skin in that location. The tract was completely excised. (Below, left)Intraoperative photograph demonstrating skin-graft and transcutaneous abutments on one side. (Below, right) Mild inflammationaround the abutments is evident.


sists of thicker skin than that which would nor-mally cover an ear framework, which furtherblunts the ultimate aesthetic result, even if thehair has been removed.

4. Posttraumatic or Postablative Auricular Defects

Patients with posttraumatic or postablativeauricular defects are more often adults, andtheir defects differ from those of children withcongenital deformities in several ways. First,the skin loss and scarring resulting fromtrauma or previous surgery may make standardautogenous reconstruction difficult. Second,the tragus is frequently preserved in the trau-ma/ablative patient, making the aesthetics ofprosthetic reconstruction much more favor-able (Fig. 7). The presence of a tragus allowsthe anterior border of the prosthesis to behidden, a major aesthetic benefit. In general,patients with congenital deformities do nothave a tragus, and the anterior margin of theprosthesis, no matter how elegantly con-structed, is always visible. The presence of atragus is important enough for the aesthetics ofthe result that it may be reasonable in somepatients to reconstruct the tragus before pros-thetic reconstruction of the remaining auricle.The authors, however, have no experience withthis modification. Third, adults tend to havemore heterogeneous skin pigmentation andheterogeneous skin texture, which makes theprosthesis much less visible than in a young

child with smooth, homogeneous skin color andtexture. Finally, adults are less inclined to un-dergo staged reconstruction, and prosthetic re-construction may be, or may be perceived as, asimpler alternative. In addition, some patientswho have undergone resection of the auricle foroncologic indications may have been treatedwith radiotherapy, which further complicates, orprecludes, an autogenous reconstruction.

DISCUSSION

Autogenous ear reconstruction using a ribcartilage framework was first described by Gil-lies,14 later developed by Tanzer,15–17 and fur-ther refined by Brent.8 As a result of thesereports, particularly the large series by Brent,autogenous reconstruction using cartilageframeworks has become the standard tech-nique for ear reconstruction in the UnitedStates. Nagata, of Japan,10 and Firmin, ofFrance9 also presented large series of patientswho demonstrated superb results with autoge-nous reconstruction. The standard results ob-tained by these experts are difficult to matchbecause the deformity is rare. As in other areasin plastic surgery, but perhaps even more so,the first attempt at reconstruction is of para-mount importance because a suboptimal resultmay be uncorrectable.

Because consistently good results with autog-enous reconstruction have proved elusive inthe hands of many surgeons around the world,

FIG. 6. Postoperative result. On frontal view the bilateral prostheses are symmetrical, resultingin the eyeglasses appearing to be level. On oblique view, the hairstyle that attempts to disguisethe anterior margin of the prosthesis is demonstrated.


other techniques for auricular reconstructionhave been evaluated. To date, replacing thecartilage framework with an alloplastic frame-work has not proved to be effective. Croninintroduced the Silastic framework, and thetechnique was complicated by a high rate offramework extrusion.1–3 Many of these compli-cations occurred late, often years after the orig-inal procedure. Reinisch used a frameworkconsisting of polyethylene (Medpor, PorexSurgical Inc., Atlanta, Ga.) in more than 100patients, with promising early results. His ini-

tial cases demonstrated a 44 percent complica-tion rate.4 Changes in the operative technique,consisting of complete coverage of the alloplas-tic framework with a temporoparietal flap,have almost eliminated the complication ratein the short run. Although the technique isencouraging, it may be a decade or more be-fore the long-term outcome of the alloplasticframework is determined.

Prosthetic reconstruction of the auricle hasbeen available for centuries, but ineffective,messy, and inconvenient adhesives have de-

FIG. 7. Postablative indication for prosthetic reconstruction. (Above, left) Intraoperative photograph demonstrating the defectafter resection of the auricle for malignant melanoma with multiple satellite lesions. (Above, center) Intraoperative photographfollowing posterior cheek advancement to cover the lateral surface of the tragal cartilage, and skin-graft coverage of the exposedmastoid bone and the medial surface of the tragus. (Above, right) Appearance of the soft tissue demonstrating the absence ofinflammation around the abutments because of the patient’s compliance with treatment and use of adequate hygiene. (Below)Postoperative appearance of the prosthesis. The prosthetic auricle is on the patient’s left side.


tracted from its practicality. In addition, thereis tremendous variability in the aesthetic qual-ity of prostheses and, given the problems withretention, any prosthesis must be aestheticallyexcellent for the patient to tolerate its use.

As documented by reports of Brånemark os-seointegrated titanium implants (Nobel Bio-care) for the retention of dental prostheses,these fixtures have been used in other parts ofthe craniofacial skeleton for the retention ofprosthetic devices. Tjellstrom reported on thetechnique for the retention of auricular pros-theses.5,6 Although the intraoral uses of tita-nium implants have been available for sometime, it has only been since 1995 that the tech-nique has been approved for extraoral use inthe United States.

Although Wilkes et al. elegantly describedthe indications for prosthetic ear reconstruc-tion, no American series combining autoge-nous reconstruction and prosthetic reconstruc-tion has yet been published.7

The advantages and disadvantages of the twotechniques (autogenous reconstruction andimplant-retained prosthetic reconstruction)are enumerated below:

1. Finite Nature of Autogenous Reconstruction

Once an autogenous reconstruction is com-pleted, the patient requires no further treat-ment. In contrast, prosthetic reconstruction re-quires replacement of the prosthesis every 2 to5 years for the life of the patient. In addition,the skin/implant interface is prone to irrita-tion, and there may be periods of time whenthe patient cannot wear the prosthesis. In ourexperience, irritation at the skin/implant in-terface is common in children (Fig. 3, center,right and Fig. 5, below, right), who may not ad-minister the meticulous hygiene necessaryaround the transcutaneous abutments.

2. Psychological

Once completed, autogenous ear recon-struction in the pediatric patient is incorpo-rated immediately into the patient’s self-image,allowing most patients to put the deformitybehind them and move forward with life’sother priorities. By contrast, the prosthetic au-ricle must be put in place every morning andremoved every night for the life of the patient,serving as a daily reminder to the patient ofhis or her deformity. When the prosthesis isnot in place, the metal retention suprastruc-

ture is exposed, giving the patient a “bionic”appearance.

3. Resistance to Trauma and Infection

Once incorporated, the cartilage frameworkof an autogenous reconstruction is largely re-sistant to trauma and infection. Lacerationsthat expose the incorporated cartilage heal un-eventfully, and any infection in the regiontends to respond to antibiotics. In contrast,although quite sturdy, the abutment/fixturecomplex can be dislodged and even lost if sub-jected to sufficient trauma. For this reason,some contact sports may not be advisable, oreven possible, for children with implant-retained prostheses.

4. Aesthetics

An experienced and talented anaplastologistcan produce a prosthetic auricle of superb aes-thetic quality and with a degree of detail andprojection that cannot be matched by an au-togenous reconstruction. Nevertheless, noprosthesis has the texture, temperature, andquality of normal skin. In addition, the pros-thesis can approximate but not duplicate pre-cisely the color match of an autogenous recon-struction. Finally, as mentioned above in thediscussion of posttraumatic and postablativedeficits, the absence of a tragus in most pedi-atric patients with a congenital deformity is alimiting factor in the aesthetics of a prostheticreconstruction. (As Firmin points out, it is alsoa limiting factor in the final aesthetics of aBrent-type reconstruction.9) The anterior mar-gin of the prosthesis, which cannot be dis-guised behind the tragus, will always be visible,no matter how expert the anaplastologist.

5. Cost

Despite the large up-front costs associatedwith autogenous reconstruction the lifetime re-quirements for care and prosthetic replace-ment (every 5 years, minimum) especially in apediatric patient with a long life-expectancy,make the costs associated with prosthetic re-construction greater than the cost of autoge-nous reconstruction. In addition to financialcost, the need for lifelong medical surveillancefurther adds to the burden of the prostheticalternative.

6. Lifeboat

Finally, an autogenous reconstruction doesnot “burn bridges” for future prosthetic recon-


struction, but prosthetic reconstruction doespreclude future autogenous reconstruction.Prosthetic reconstruction requires excision ofall ear remnants and of the skin and soft tissuein the region, making a subsequent autoge-nous reconstruction almost impossible. In fact,we have found that the ideal soft-tissue envi-ronment for the implant-retained prosthesis isa skin graft directly on bone. On the otherhand, if a misadventure occurs with autoge-nous reconstruction, prosthetic reconstructionis still an option.

Because of the overwhelming advantages ofautogenous reconstruction, it remains thetechnique of choice for children requiring au-ricular reconstruction. The fact that the tech-nique requires experience does not change itsdesirability.

Nevertheless, prosthetic reconstruction is avaluable technique. The primary indication isthe acquired deformity, generally a result oftrauma or ablative surgery. Relative indicationsexist in the congenital cases, when the aesthet-ics of a prosthesis are sufficient to overcomethe disadvantages described above. The fourindications described represent situations inwhich the results from autogenous reconstruc-tion are limited, making prosthetic reconstruc-tion a reasonable alternative.

The neophyte is cautioned against the beliefthat prosthetic reconstruction is easier or lesstime-consuming than autogenous reconstruc-tion. Relatively “easy surgery” does not meanan “easy reconstruction.” Although the plasticsurgeon’s role in a prosthetic reconstructionmay be confined to fixture placement andpreparation of the local soft tissue, construc-tion of the retention mechanism and the pros-thesis is extremely time-consuming, requiringnumerous visits over the course of weeks. Forthis reason, it is easy for the plastic surgeon tounderestimate the requirements for prostheticreconstruction.

In addition, as with autogenous reconstruc-tion, the ultimate aesthetics of the result de-pend on the skill of the person creating theactual prosthesis. Even if the fixtures are wellincorporated in bone and the soft tissue hashealed around the abutments, the reconstruc-tion is not a success unless the prosthesis is ofexcellent quality.

The authors have not had difficulty with fu-ture integration despite the thin bone in pedi-atric patients. Although it is ideal to insert thefixtures in bone measuring at least 3 mm in

thickness, the bone is frequently 1 to 2 mmthick in young patients. The holes are carefullydrilled to avoid injury to underlying dura. Evenif the bone is thin, 3-mm fixtures are placed,indenting the dura as they are inserted. If thedrilling encounters a mastoid air cell, the fix-tures are placed in the same manner, regard-less of the bone thickness. To date, no fixtureshave been lost. In patients in whom there isconcern about bone thickness, it may be rea-sonable to delay the placement of transcutane-ous abutments until a second surgical stage.

Skin expansion has been suggested as anancillary technique for patients with tight skinor an inadequate amount of skin. In this series,the authors did not find it useful.

One final factor that may discourage pros-thetic reconstruction in the United States islow reimbursement from insurance compa-nies. It is difficult to find a talented, experi-enced prosthodontist or anaplastologist to per-form time-consuming prosthesis constructionwithout a financial incentive. Other health-care systems around the world (e.g., Canadaand Sweden) may lessen the above bias towardautogenous reconstruction, but the vagaries ofhealth-care economics do not change the un-derlying reality that a good result from auto-genous reconstruction is more desirable thanany prosthetic result.

In the seminal article on this subject byWilkes et al., the indications used by their teamfor prosthetic reconstruction are listed: cancerresection, radiotherapy, absent lower half ofthe ear, severely compromised tissue, patientpreference, failed autogenous reconstruction,potential craniofacial anomaly, and poor oper-ative risk.7 Although we chose to list fewer in-dications for the prosthetic alternative, ourconclusions are essentially identical.

SUMMARY

As the technology of tissue engineering im-proves and experience is gained with Medpor(Porex Surgical) and other materials, it is pos-sible that there may be alternatives to autoge-nous reconstruction and prosthetic reconstruc-tion of the auricle. Nevertheless, in the opinionof the authors, for now the latter two tech-niques represent the optimal choices for mostpatients requiring total or subtotal auricularreconstruction. In our opinion, it is unlikelythat the role of prosthetic reconstruction willincrease. More probably, continued advancesin techniques supporting autogenous recon-


struction (e.g., laser ablation of hair, improvedtechniques for skeletal reconstruction, and tis-sue-engineered cartilage frameworks) will ex-tend the indications for autogenous recon-struction to those patients in the fourcategories above who are not ideal candidatesat present. The primary indication for pros-thetic reconstruction will remain the acquiredtotal or subtotal auricular defect, generally inthe adult patient.

Charles H. Thorne, M.D.812 Park AvenueNew York, N.Y. [email protected]

REFERENCES

1. Cronin, T. D. Use of a Silastic frame for total and sub-total reconstruction of the external ear: Preliminaryreport. Plast. Reconstr. Surg. 37: 399, 1966.

2. Cronin, T. D. Reconstruction of the ear in one stagewith Silastic framework and fascial flap. Presented atthe Annual Meeting of the California Plastic SurgicalSociety, Monterey, Calif., March 9, 1979.

3. Cronin, T. D., and Ascough, B. M. Silastic ear construc-tion. Clin. Plast. Surg. 5: 367, 1978.

4. Reinisch, J. Microtia reconstruction using a polyethyl-ene implant: An eight year surgical experience. Pre-sented at the 78th Annual Meeting of the AmericanAssociation of Plastic Surgeons, Colorado Springs,Colo., May 5, 1999.

5. Tjellstrom, A. Osseointegrated implants for replace-ment of absent or defective ears. Clin. Plast. Surg. 17:355, 1990.

6. Tjellstrom, A., Lindstrom, J., Nylen, O., et al. The bone-anchored auricular epithesis. Laryngoscope 91: 811,1981.

7. Wilkes, G. H., Wolfaardt, J. F., and Dent, M. Osseointe-grated alloplastic versus autogenous ear reconstruc-tion: Criteria for treatment selection. Plast. Reconstr.Surg. 93: 967, 1994.

8. Brent, B. Auricular repair with autogenous rib cartilagegrafts: Two decades of experience with 600 cases. Plast.Reconstr. Surg. 90: 355, 1992.

9. Firmin, F. Ear reconstruction in cases of typical micro-tia: Personal experience based on 352 microtic earcorrections. Scand. J. Plast. Reconstr. Surg. Hand Surg.32: 35, 1998.

10. Nagata, S. A new method of total reconstruction of theauricle for microtia. Plast. Reconstr. Surg. 92: 187, 1993.

11. Brånemark, P. I., Hansson, B. O., Adell, R., etal. Osseointegrafted implants in the treatment of theedentulous jaw: Experience from a 10-year period.Scand. J. Plast. Reconstr. Surg. Suppl. 16:1, 1977.

12. Letterman, G. S., and Harding, R. L. The managementof the hairline in ear reconstruction. Plast. Reconstr.Surg. 18: 199, 1956.

13. Yotsuyanagi, T., Yokoi, K., Nihei, U., et al. Managementof the hairline using a local flap in total reconstructionfor microtia. Plast. Reconstr. Surg. 104: 41, 1999.

14. Gillies, H. Plastic Surgery of the Face. London: Frowde,Hodder and Stonghton, 1920. P. 381.

15. Tanzer, R. C. Total reconstruction of the external ear.Plast. Reconstr. Surg. 23: 1, 1959.

16. Tanzer, R. C. Total reconstruction of the auricle: Theevolution of a plan of treatment. Plast. Reconstr. Surg.47: 523, 1971.

17. Tanzer, R. C. Microtia. Clin. Plast. Surg. 5: 317, 1978.

Self-Assessment Examination follows onpage 1252.


Self-Assessment Examination

Auricular Reconstruction: Indications for Autogenous and ProstheticTechniquesby Charles H. Thorne, M.D., Lawrence E. Brecht, D.D.S., James P. Bradley, M.D., Jamie P. Levine, M.D.,Paul Hammerschlag, M.D., and Michael T. Longaker, M.D.

1. THE IDEAL INDICATION FOR PROSTHETIC RECONSTRUCTION OF AN AURICULAR DEFECT ISA) A child with microtiaB) A child with complications from autogenous reconstruction of microtiaC) An adult with a helical rim defect related to resection of a basal cell carcinomaD) An elderly adult who has undergone removal of an ear for a cutaneous malignancy

2. WHICH OF THE FOLLOWING ARE FAVORABLE SOFT-TISSUE CHARACTERISTICS FOR PROSTHETICRECONSTRUCTION OF THE AURICLE? (MORE THAN ONE MAY BE CORRECT.)A) Loose, unscarred, thick soft tissue around the transcutaneous abutmentsB) Thin, immobile soft tissue or scar adherent to the underlying skullC) Presence of a tragusD) Absence of a tragus

3. WHICH OF THE FOLLOWING REPRESENT RELATIVE INDICATIONS FOR PROSTHETIC RECONSTRUCTIONIN CHILDREN WITH MICROTIA?A) Failed autogenous reconstructionB) Severe soft-tissue/skeletal hypoplasiaC) Low or unfavorable hairlineD) All of the above

4. PROSTHETIC RECONSTRUCTION OF AURICULAR DEFECTS IS SUBSTANTIALLY EASIER AND REQUIRESLESS TIME AND SKILL THAN AUTOGENOUS RECONSTRUCTION.A) TrueB) False

5. PROSTHETIC RECONSTRUCTION OF MICROTIA IN A CHILD IS CHEAPER IN THE LONG RUN THANAUTOGENOUS RECONSTRUCTION.A) TrueB) False

6. IMPLANT-RETAINED PROSTHETIC RECONSTRUCTION OF THE AURICLE HAS BEEN AVAILABLE IN THEUNITED STATES ONLY SINCE 1995.A) TrueB) False

7. THE DAILY HYGIENE AND MAINTENANCE REQUIRED OF AN IMPLANT-RETAINED PROSTHETICRECONSTRUCTION OF THE AURICLE IS MINOR AND IS EASY FOR CHILDREN.A) TrueB) False

8. AN AUTOGENOUS RECONSTRUCTION DOES NOT “BURN THE BRIDGE” FOR LATER PROSTHETICRECONSTRUCTION, BUT AN IMPLANT-RETAINED PROSTHETIC RECONSTRUCTION DOES “BURN THEBRIDGE” FOR LATER AUTOGENOUS RECONSTRUCTION.A) TrueB) False

To complete the examination for CME credit, turn to page 1329 for instructions and the response form.

Documents

CME Auricular Reconstruction: Indications for Autogenous ... · for prosthetic ear reconstruction is the acquired total or subtotal auricular defect, most often traumatic or ablative