Microtia: Rib and Medpor Philip A Young, MD Aesthetic Facial Plastic Surgery, PLLC Face to Face Ho Chi Minh City, Vietnam 2014

Microtia: Medpor ReconstructionPhilip A Young, MDAesthetic Facial Plastic Surgery, PLLCFace to FaceHo Chi Minh City, Vietnam2014

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Microtia:Spectrum of congenital malformations:Grade 1 slightly smaller ear with the majority of structures presentGrade 2 greater deficiency of ear structures (absent lobule, helix)Grade 3 classic peanut deformityGrade 4 Anotia complete abscense

Etiology:Not well understood3rd week of gestation: hillocks of His develop around otic placodeThalidomide and Accutane have caused microtiaEthane Dimethanesulfonate dose dependent changes

Epidemiology:2-3 births in 10000 increased rates in Asians, HispanicsNavajo 1 in 1200More commonly male, unilateral 90%, right sidedRisk Factors: higher altitudes, high birth order, increased paternal age, prenatal drug exposre

Grade 1:

Grade 1 majority structures are present, ear is slightly smaller3

Grade 1 majority structures are present, ear is slightly smaller

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Grade 2:

Grade 2 greater deficiency with possible absent helix, lobule5

Grade 2 greater deficiency with possible absent helix, lobule

Grade 3:

Grade 3 Classic Peanut ear

To Grade 4 Anotia complete absence of the ear7

Grade 3 Classic Peanut ear

To Grade 4 Anotia complete absence of the ear

Microtia:Options:Prosthesis: Using 3 titanium screws or use of adhesives, prosthesis usually needs to be replaced every 3 years. Costs (3000-7000) and moreMedpor: Use of Tpf flap contralateral skin graft, abdominal skin graft, excellent biocompatibility, stability, tissue integration (150 micrometer pore size), resistance to infection, supports secondary intention healingCostal Cartilage: Ribs 6-8, and floating 9th rib, Contralateral,

Medpor:Age:Classically age 5-6 is the earliestEar can grow up until 15, Cartilage remnant has been shown to grow, Medpor is an alloplastPoints:Medpor 2 component is around 2000 The operation can take 6-7 hoursIncludes: marking the position, identifying the ST artery with doppler, Elevating the sptf skin flap not the actual flap with remnant removal (save), harvesting contralateral ear skin graft, harvesting abdominal skin graft, Covering ear with abdominal skin graft, implant construction, implant placement, Complete sptf elevation and coverage of implant, coverage of implant with ear skin graft, drain placement, watertight closure,

Medpor:Marking the Ear Position:Lateral Canthus, Alae, Oral Lateral Commisures Visual Inspection from multiple angles from frontal aspect

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Medpor:Marking the Ear Position:Close up of the radiograph

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Here is the ear drawn out.I like to orient the ear anteriorly to see how it will rest at the right angleThat is why there are 2 pictures ears drawn out13

Here is the ear drawn out.I like to orient the ear anteriorly to see how it will rest at the right angleThat is why there are 2 pictures ears drawn out

Medpor:Track the Course of the Superficial Temporal Artery - Doppler:Becomes more superficial around the helix anterior superior attachment about 1 cm anteriorlyBranch point approximately 4-6 cm superiorly

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Medpor:Track the Course of the Superficial Temporal Artery - Doppler:

Here is the artery marked outI couldnt reliably find the other branchThe incisions are zigzagged to avoid incisions over the spta16

Here is the artery marked outI couldnt reliably find the other branchThe incisions are zigzagged to avoid incisions over the spta

This diagram shows where the incisions would be and the path of the arteryNotice how the incisions cross over the artery minimally18

This diagram shows where the incisions would be and the path of the arteryNotice how the incisions cross over the artery minimally

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Medpor:Elevate the Superficial Temporal Artery Flap:

The elevation is in the subcutaneous plane just superficial to the superficial temporal fasciaUsually the plane is clear, make sure to do it bluntlyExtra bleeding means your likely in the wrong plane20

The elevation is in the subcutaneous plane just superficial to the superficial temporal fasciaUsually the plane is clear, make sure to do it bluntlyExtra bleeding means your likely in the wrong plane

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Medpor:Taking out the Remnant:

Here is the dissection of the remnant cartilageAt this point you can also get the earlobe ready for transposition based on inferiorly22

Here is the dissection of the remnant cartilageAt this point you can also get the earlobe ready for transposition based on inferiorly

Medpor:Harvesting the Contralateral ear skin graft:

You can wait to see how much skin you need but the larger the better The more you have the same skin on one side the betterYou can pretty much use the whole post auricular area and up to the hairline as shown24

You can wait to see how much skin you need but the larger the better The more you have the same skin on one side the betterYou can pretty much use the whole post auricular area and up to the hairline as shown

Medpor:Harvesting the Contralateral ear skin graft:

The ear is pinned forward with 2-0 nylonAnd as you can see the whole post auricular surface is taken26

The ear is pinned forward with 2-0 nylonAnd as you can see the whole post auricular surface is taken

Medpor:Harvesting the abdominal skin graft:

The length is based on (the way I choose to do this is) how the long the ear is times two and the widthIs based on the distance from the helix to the hairline approximately28

The length is based on (the way I choose to do this is) how the long the ear is times two and the widthIs based on the distance from the helix to the hairline approximately

Medpor:Harvesting the abdominal skin graft:

I use permanent sutures to close the deep layers staggered with non absorbables3-0 nylon, 3-0 biosynThen 4-0 nylon and 5-0 prolene30

I use permanent sutures to close the deep layers staggered with non absorbables3-0 nylon, 3-0 biosynThen 4-0 nylon and 5-0 prolene

Medpor:Defat the grafts:

Defat the graft to help with survival as well as contour refinement of the implant32

Defat the graft to help with survival as well as contour refinement of the implant

Medpor:The abdominal skin graft goes over the post auricular defect:

Here is the abdominal skin graft being placed34

Here is the abdominal skin graft being placed

Medpor:Apply the Bolster:Xeroform and 2-0 nylons

I use xeroform and 2-0 nylon36

I use xeroform and 2-0 nylon

Medpor:Post Operatively:

Post operativelyNot the prettiest resultBut I have not done any resurfacing to improve this and this is at the one month post procedure time point38

Post operativelyNot the prettiest resultBut I have not done any resurfacing to improve this and this is at the one month post procedure time point

Medpor:Implant Reconstruction:I use 4-0 nylon, cautery option, mersilines option

Bacitractin in a 60 cc syringeVacuum suctioned negative pressure to pull air out and pull in the bacitracin4-0 nylon to reconstruct versus mersiline or cautery (reinisch)Dr. Reinisch cuts out the segment where the incisura connects to the base to create a bigger concha?This is harder than it looks40

Bacitractin in a 60 cc syringeVacuum suctioned negative pressure to pull air out and pull in the bacitracin4-0 nylon to reconstruct versus mersiline or cautery (reinisch)Dr. Reinisch cuts out the segment where the incisura connects to the base to create a bigger concha?This is harder than it looks

Medpor:Implant Reconstruction:The bottom helix and base is cut off

The bottom helix and base are cut offAllows the earlobe to be softerKept if there is no earlobe remnantYou can control how big the ear is with this part of the procedureI think I left too much for this particular patient but can go back and take off more42

The bottom helix and base are cut offAllows the earlobe to be softerKept if there is no earlobe remnantYou can control how big the ear is with this part of the procedureI think I left too much for this particular patient but can go back and take off more

Medpor:Earlobe Transposition and preparing the earlobe to accept bottom of the implant:

You may need to dissect the earlobe in half to accept the lower portion of the implant44

You may need to dissect the earlobe in half to accept the lower portion of the implant

Medpor:Finding the right position for the implant:

I then use both drawings that I made earlier to find the right position and verify it visually from mutliple angles even sitting patient up and getting opinions from others in the room46

I then use both drawings that I made earlier to find the right position and verify it visually from mutliple angles even sitting patient up and getting opinions from others in the room

Medpor:I fix the implant with 4-0 nylon as well

I fix the implant with 4-0 nylon as well48

I fix the implant with 4-0 nylon as well

Medpor:Now we elevate the flap, usually the dimensions are 10 x 5 cm but you need to verify that it will completely cover the implant

I fix the implant with 4-0 nylon as wellVideo 87May need to reinject this will bleed a lot50

I fix the implant with 4-0 nylon as wellVideo 87May need to reinject this will bleed a lot

Medpor:-superficial plane is subcutaneous deep to hair follicles-deep plane is just above deep temporalis fascia

Video 8952

Medpor:Here is another picture of the superficial and deep layers

Video 8953

Medpor:-Here the drains have been placed one under implant, one under donor site-The suction is tested for contour-The flap has been sewn around the implant

Video 10054

Medpor:-The Earlobe is being sewn into place

Video 10255

Medpor:-The skin graft is being sewn into place

Video 10456

Medpor:-More of the finished product

Video 10457

Medpor:Results from this patient:

At first the contours are not as distinct due to the swellingThis was gradual over the first monthWe had some skin graft loss and were worried about sptf deathSome exposures can be fixed with local flaps, occipital artery flap, or loss of the implant58

At first the contours are not as distinct due to the swellingThis was gradual over the first monthWe had some skin graft loss and were worried about sptf deathSome exposures can be fixed with local flaps, occipital artery flap, or loss of the implant

Medpor:Results from this patient:

The ear looks lower partly because of the superior pole being more medializedYou can elevate the whole ear and there are approaches that you can do based on a superior flap of the superficial temporal artery system

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The ear looks lower partly because of the superior pole being more medializedYou can elevate the whole ear and there are approaches that you can do based on a superior flap of the superficial temporal artery system

Rib:-Most people wait until the child is at least 5-6 years old-Harvest from the 6-9 rib contralateral side-synchondrosis of 6,7,8 and floating portion of 9th rib

The ear looks lower partly because of the superior pole being more medializedYou can elevate the whole ear and there are approaches that you can do based on a superior flap of the superficial temporal artery system

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The ear looks lower partly because of the superior pole being more medializedYou can elevate the whole ear and there are approaches that you can do based on a superior flap of the superficial temporal artery system