Osseointegrated Implants for Auricular Defects:Operative Techniques and Complication Management

*Daniel J. Rocke, *Debara L. Tucci, †Jeffrey Marcus, ‡Jay McClennen,and *David Kaylie

*Department of Surgery, Division of Otolaryngology, Head and Neck Surgery, ÞDepartment of Surgery, Divisionof Plastic, Maxillofacial, and Oral Surgery, and þThe Anaplastology Clinic, Duke University Medical Center,

Durham, North Carolina, U.S.A.

Objective: Auricular defects are challenging to reconstruct withnative tissue. We describe operative techniques and complica-tion management for patients undergoing osseointegrated im-plants for auriculectomy defects and microtia.Setting: Tertiary referral center.Patients: All patients at Duke University Medical Center withauricular defects treated with osseointegrated implants forprosthetic (OIP) auricles from January 1, 2010, until September16, 2013.Interventions: Osseointegrated implantation for auricular defects.Main Outcome Measure: Description of operative techniques,complications, and complication management.Results: Sixteen patients met inclusion criteria. Five patientshad microtia and atresia. Two of these patients had bilateralmicrotia and atresia and underwent bilateral simultaneous im-plantation of both OIP and osseointegrated hearing implants(OHIs). Two other microtia/atresia patients underwent simul-taneous unilateral OIP and OHI. Eleven patients had unilateral

defects from either trauma or skin cancer resection. Three pa-tients received adjuvant radiation before implantation. Compli-cations included tissue overgrowth requiring revision surgery(two patients), inadequate bone stock requiring split calvarialbone graft and later implantation, loss of implant secondary toosteoradionecrosis requiring hyperbaric oxygen therapy, andskin infection requiring antibiotic therapy.Conclusion: Reconstruction of auriculectomy defects and microtiais difficult to accomplish using native tissue. Complications arecommon, and these complications can have devastating conse-quences on the final result. Osseointegrated implantation offersan outstanding alternative for reconstructing these defects. Wedescribe our multidisciplinary team approach, examine operativetechniques, and focus on the unique challenges of simultaneousand bilateral simultaneous OIP and OHI implantation. Key Words:Osseointegrated implantsVAuricular defectsVMicrotiaVAtresia.

Otol Neurotol 35:1609Y1614, 2014.

Defects of the auricle, whether acquired or congenital,can be a significant disability to patients from psycho-logical, social, and functional perspectives. This is espe-cially true in the context of microtia with atresia, but it isalso seen in those with acquired defects. Multiple authorshave examined the psychosocial ramifications of defectsof the auricle and have found associations with depres-sion, social difficulties, anxiety, low quality of life, andaggression (1,2). After reconstruction, however, mostpatients report an increase in self-confidence and manyreport an improved social life (3).

Unfortunately, these defects are extremely difficult torehabilitate with native tissue (4Y9). Typically, this requires

harvesting costal cartilage and multiple stages before thereconstruction is complete. Repairs of this type are oftenaesthetically unsatisfying unless performed by highly ex-perienced surgeons (5,6). Across time, some initially satis-factory results will undergo cartilage resorption, blurring thedefinition of the reconstruction (8). In addition, rib cartilageharvest is associated with chest wall depression in somepatients (4,7,8). In cases with concomitant atresia, repairof this component is itself a multistage procedure fraughtwith complications and challenges and, in some cases, isnot possible (10Y13).

Osseointegrated implants for prosthetic (OIP) auriclesoffer an alternative to traditional methods of rehabilitatingdefects of the auricle. These surgeries are technicallysimple; however, the preoperative planning is verycomplex. Complications are manageable and typically donot affect the final result. Cosmetic outcomes are arguablysuperior to traditional reconstructive procedures. Also, these

Address correspondence and reprint requests to David Kaylie, M.D.,M.S., Department of Surgery, Division of Otolaryngology, Head &Neck Surgery, DUMC Box 3805, Durham, NC 27710, U.S.A.; E-mail:david.kaylie@dm.duke.eduThe authors disclose no conflicts of interest.

Otology & Neurotology35:1609Y1614 � 2014, Otology & Neurotology, Inc.

1609

Copyright © 2014 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

implants can be combined with osseointegrated hearing im-plants (OHIs) to rehabilitate single-sided hearing loss incases of concomitant atresia. This study describes ourmultidisciplinary team approach and examines operativetechniques and complication management for osseointe-grated implants with a focus on the challenging situationof simultaneous implantation of OIPs and OHIs eitherunilateral or bilateral.

MATERIALS AND METHODS

After institutional review board approval was granted, theDuke University Health System medical records were searchedfor any patient who had undergone osseointegrated implantationfor rehabilitation of an auricular defect between January 1, 2010,and September 16, 2013. Sixteen patients were identified, and aretrospective chart review was conducted. Demographic infor-mation was collected, along with indications for the procedure,operative details, medical comorbidities, complications, and com-plication management. We used Vistafix for our OIPs and Bahafor our OHIs (Cochlear Americas, Centennial, CO, USA).

Operative techniqueBefore implantation, patients are seen by our anaplastologist

for consultation and prosthesis planning. The anaplastologist

makes an impression of the auricular region to have a detailedmodel of the treatment area. This is used to plan implant placementso that the prosthesis position matches that of the opposite normalear. In case of bilateral prostheses, the implant sites are planned sothat the prostheses will sit on anatomically appropriate and sym-metric positions. An acrylic template is made that fits preciselyover the auricular area and has predrilled holes that mark theideal spots for placement of the implants that secure the pros-thesis (Fig. 1). A wax model is then made of the prosthesis andadjusted based on patient preference, and this is used to makethe final prosthesis to be loaded onto the implants (Fig. 2).Intraoperatively, the implantation site is shaved and the ideal

implantation sites are marked using the acrylic template, withmethylene blue injected at the level of the periosteum (Fig. 3). Ifthere is an auricular remnant to be removed, this is routinelydone at the same surgery as the placement of the implants. Theremnant is removed first to create a flat surface with thin skin foroptimal prosthesis fitting.For patients with thick skin or thick reconstruction flap, our

technique involves raising a thin posteriorly based skin flap anddebriding the subcutaneous tissues to minimize the tissue be-tween the bone and the skin. The implantation sites are thenidentified and overlying periosteum immediately surroundingthe site is removed. The titanium implants are then drilled intoplace in the usual fashion. In patients with thin skin or thin re-construction flaps,we use a percutaneous technique. The thicknessof the skin is measured using a needle to gauge the depth. Theappropriate size abutments are then selected. A 1-cm incision ismade over the previously marked site, and the implant is placed.In the single-stage technique, the abutments are placed

through a 4-mm skin punch hole in the skin flap or closed in theincision if a flap is not elevated. The skin flap is then suturedwith absorbable suture. A healing cap and a bolster are placed.The implants are allowed to osseointegrate for 3 months; if thereis no evidence of failure to integrate, then the prosthetic auricleis loaded.In the two-stage approach, sleeper caps are placed on the

implants. After osseointegration for 3 months, a second proce-dure is performed to place the abutments. The flap is raisedagain, and the implants are identified. The sleeper caps are re-moved, and the abutments are placed through a 4-mm skinpunch hole in the flap. More recently, we have palpated thelocation of the sleeper caps and made only a skin punch over-lying it. The cap is then removed, and the abutment is placed.After 2 weeks of healing, the prosthetic auricle is loaded.

FIG. 1. Acrylic template.

FIG. 2. Impression of treatment area and wax model. FIG. 3. Placement of template and marking of implant sites.

1610 D. J. ROCKE ET AL.

Otology & Neurotology, Vol. 35, No. 9, 2014

Copyright © 2014 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

RESULTS

Sixteen patients were identified who had undergoneosseointegrated implantation to rehabilitate an auriculardefect. Table 1 displays patient demographic information,as well as etiology of auricular defect and follow-up. Themajority of the patients were male (69%), and the medianage was 56.5 years. The most common etiologies for theauricular defect were skin cancer (50%) and congenitalcauses (31%). Median follow-up was 7 months.

Three patients were current smokers, and three patientswere former smokers. Two patients had undergone pre-implantation radiation therapy, and one patient had un-dergone preimplantation chemoradiation therapy. Tenpatients underwent unilateral placement of OIP. Fourpatients received OIP and OHI, and three of these weresimultaneous. Two patients underwent bilateral simulta-neous implantation of OIPs and OHIs. These data areshown in Table 2.

Of the 16 total patients, four experienced complica-tions. Patient 14 had granulation tissue and skin flapovergrowth, which required revision in the operatingroom. Patient 3 had cellulitis postoperatively, which re-solved with oral and topical antibiotics.

Patient 8 had bilateral simultaneous OIP and OHIs. Weplanned to place two OIP implants and one OHI implanton each side. She had a thin cortical bone, and there wasnot adequate bone stock for one of the OIP implants. BothOHI implants were placed without difficulty. Both of theOIP implants on the left were placed and the superior oneon the right. An inferior OIP was placed on the right andhad poor purchase but was left in place after subsequentpilot holes demonstrated inadequate cortical bone to sup-port additional implants. These holes were filled withdemineralized bone matrix. After 8 months, reimplantationwas attempted. The implants that had been placed werewell integrated, and abutments were placed. A small cir-cular hole was drilled in the cortex of the mastoid wherethe inferior implant should be placed. A split calvarialbone graft was harvested and secured in the defect with

plates. Six months later, the calvarial bone graft had com-pletely integrated, allowing placement of the inferior im-plant and abutment in a single stage (Fig. 4).

Patient 11 had undergone total auriculectomy andpostoperative radiation therapy for basal cell carcinoma.He was a current smoker. Two implants and abutmentsfor prosthesis were placed in a single stage. The patientwas doing well 6 weeks later, and the prosthetic auriclewas loaded. He did well for another 5 months but, at thattime, had delayed nonintegration of both implants. Acomputed tomography scan of the temporal bone wasconsistent with osteoradionecrosis. The patient quit smokingand underwent 30 treatments with hyperbaric oxygen. Hethen underwent reimplantation with two implants and iscurrently awaiting his second stage after 6months of healing.

DISCUSSION

Osseointegrated implantation is an excellent option forrehabilitation of auricular defects. The procedure itself istechnically simple, and the postoperative care for patientsis minimal. The results are predictable and arguably aes-thetically superior to the best native tissue reconstruc-tion. Moreover, unlike native tissue reconstruction, thecomplications are manageable and do not typically affectthe final result. Other options for patients, such as alter-native hairstyles or prosthetics secured with adhesive, arecumbersome or not ideal long-term solutions (14,15).Although others have published similar case series ontheir results using these implants (16Y20), to our knowl-edge, none have focused on unique situations such as

TABLE 1. Patient information

Patient Age (yr) Gender EtiologyFollow-up

(mo)

1 57 M Congenital microtia/atresia 272 61 M Basal cell carcinoma 63 17 F Burn 174 28 F Traumatic avulsion 35 64 M Melanoma 66 49 M Basal cell carcinoma 187 57 M Traumatic avulsion 168 12 F Congenital microtia/atresia 199 62 M Basal cell carcinoma 810 61 M Basal cell carcinoma 611 65 M Basal cell carcinoma 1012 11 F Congenital microtia/atresia 313 56 M Squamous cell carcinoma 314 66 M Squamous cell carcinoma 615 9 M Congenital microtia/atresia 1416 7 F Congenital microtia/atresia 4

TABLE 2. Comorbidities, procedures, and complications

PatientMedicalhistory Smoker Radiation Procedures Complications

1 None Former No OIP/OHI None2 HL Former No OIP None3 None No No OIP Skin

overgrowth4 None Yes No OIP None5 HTN No No OIP None6 HTN Former No OIP None7 DM No No OIP None8 None No No Bilateral

OIP/OHIInadequatebone stock

9 HTN Yes No OIP None10 None No No OIP None11 HL Yes Yes OIP ORN12 None No No OIP/OHI None13 CML, IPF,

PE, CRINo Yesa OIP None

14 CAD, HL,sarcoidosis

No Yes OIP/OHI Cellulitis

15 None No No OIP/OHI None16 None No No Bilateral

OIP/OHINone

aChemoradiation therapy.CAD indicates coronary artery disease; CML, chronic myelogenous

leukemia; CRI, chronic renal insufficiency; DM, diabetes mellitus; HL,hyperlipidemia; HTN, hypertension; IPF, idiopathic pulmonary fibrosis;OHI, osseointegrated hearing implants; OIP, osseointegrated implants forprosthetic; PE, pulmonary embolus.

1611OSSEOINTEGRATED IMPLANTS FOR AURICULAR DEFECTS

Otology & Neurotology, Vol. 35, No. 9, 2014

Copyright © 2014 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

simultaneous implants for prostheses and hearing aids orbilateral simultaneous implantation.

The limiting factor for this procedure is the supportstructure necessary for excellent results. We work closelywith an anaplastologist who has extensive experience inprosthetic production, and he consistently achieves out-standing aesthetic results. Moreover, the anaplastologistconstructs an acrylic template, which is vital for accuratepreoperative planning and placement of the implants. Inmany cases, the anaplastologist is present in the operating

room for implant placement. This collaboration allows foradjustments in placement based on unexpected intraoperativeanatomyVfor example, inadequate bone stock at the pro-posed implant site. In both unilateral and bilateral recon-struction, it is essential to achieve not only an anatomicallyaccurate placement of the prosthesis but also symmetrywith the contralateral ear or prosthesis.

The importance of symmetry is highlighted in the caseof bilateral OIPs. Once the patient is prepped and draped,normal landmarks are lost. The absence of an ear canal inmany of these patients further complicates accurate place-ment. This again shows the importance of the anaplast-ologist. The acrylic template, which is made to preciselylocate the ideal sites for implantation, is essential for ac-curate placement. Although there is some degree of flex-ibility in the site of implantation, allowing intraoperativedeviations from these ideal sites based on anatomy, somedeviations may not be compatible with a symmetric out-come or would require redesign of the prosthesis. Collab-oration with the anaplastologist can greatly aid in findingalternate sites that will best accommodate the prosthesis.Indeed, we plan backup sites preoperatively to allow forflexibility in implant placement. This collaboration hasallowed for excellent cosmetic results (Fig. 5). There arelimited areas in the prosthesis that can adequately hide theunderlying implant and abutment. The helical rim ofthe prosthesis is the thickest part and is ideal for hiding theclips for the bars between abutments. When alternativesites for implants need to be used, it is important that thesurgeon has a good understanding of the final prosthesisdesign, so as to not place the implant in a site that cannotbe hidden in the prostheses.

The case of simultaneous OIP and OHI deserves spe-cial mention. This is an ideal option in the case of microtiawith atresia. The traditional repair of atresia is notoriouslydifficult, with potential for complications including facialnerve injury, and even when successful, the repair re-quires a lifetime of maintenance (10Y13). In some cases,this repair is virtually impossible and hearing results can

FIG. 5. Postoperative result.FIG. 6. Use of intraoperative image guidance to identify areaswith adequate bone stock.

FIG. 4. Bone graft and healed implants with attached bar andhearing aid.

1612 D. J. ROCKE ET AL.

Otology & Neurotology, Vol. 35, No. 9, 2014

Copyright © 2014 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

be unpredictable (11,13). In contrast, simultaneous OHIand OIP provide predictable hearing and cosmetic out-comes (21).

When placing OIP and OHI simultaneously, it is im-portant to plan the placement of the implants very carefully.The OHI must be placed a sufficient distance posterior tothe prosthetic implants so that the placement of the pros-thesis will not interfere with the placement of the hearingaid. Again, the template is invaluable in planning theposition of these implants (Fig. 3).

A relatively infrequent complicating factor is inade-quate bone stock to support an implant, which was seen inPatient 8. Other authors have noted the increased risk ofimplant loss in children (22,23), which may be caused bydecreased cortical bone. One solution to this problem is asplit calvarial bone graft, as was done in Patient 8 (Fig. 4).This graft may not be possible in younger children, re-quires a separate procedure, and can be associated withdonor site morbidity (24), but it should be considered forpatients in whom this is a problem. We typically use ourplastic surgery colleagues to perform this procedure.

Another solution to the problem of inadequate bonestock is to use image navigation to find sites with ade-quate bone stock. This was done with Patient 13 becausehe had undergone chemoradiation therapy before im-plantation and had free tissue reconstruction to cover theresection site (Fig. 6).

Staging of the implantation process is also an importantconsideration. We always stage these implants in youngchildren, as it is unrealistic to expect them to protect theabutment to allow osseointegration. Staging should alsobe considered in cases where the ability to osseointegrateis a concern. Based on literature that supports implanta-tion in radiated patients (15,25,26), we typically do notstage patients who have undergone prior radiation therapynor do we give preoperative hyperbaric oxygen. However,we allow 6 months for osseointegration in patients whohave undergone preoperative radiation. We did, however,lose both implants in Patient 11, and he is currently awaitinghis second stage after undergoing hyperbaric oxygen therapy.

It is important to be able to manage possible compli-cations. One relatively frequent complication is cellulitis,which was seen in Patient 3. These infections are typicallymild and can usually be treated with a topical antibioticointment like bacitracin, although some may require oralantistaphylococcal antibiotics as well.

Tissue overgrowth is another possible complication, asseen in Patient 14. This is seen frequently in OHI patientsand can often be managed, in the case of granulationtissue, with silver nitrate cauterization. Some cases mayrequire minor revisions, as in the case of Patient 14. Thiscomplication can also be minimized by adequate debulkingof subcutaneous tissues when placing the implant. Wehave begun using implants coated externally with hy-droxyapatite, which is designed to encourage skin in-growth into the implant. Use of this technique alongwith longer implants may limit the need for significantdebulking of the subcutaneous tissue, as other authors havedescribed (27,28).

This study is limited by its retrospective nature, lownumber of patients, and relatively short follow-up in certainpatients. However, our goal in this study was not to mea-sure outcomes but rather to highlight management in dif-ficult cases like bilateral simultaneous OIP and OHI.

CONCLUSION

Osseointegrated implants are an excellent alternative tonative tissue reconstruction of auricular defects. The pro-cedure is technically simple, but it does require severalclinicians with specialized skill sets. The complicationsaremanageable and do not typically threaten the end resultVthis offers an advantage over native tissue reconstruction.These implants are an especially good option in patientswith atresia who will need an OHI and in patients whohave undergone adjuvant radiation. We highlight the dif-ficulties associated with unilateral and bilateral simulta-neous placement of OIPs and OHIs.

REFERENCES

1. Li D, Chin W, Wu J, et al. Psychosocial outcomes among microtiapatients of different ages and genders before ear reconstruction.Aesthetic Plast Surg 2010;34:570Y6.

2. Lim SY, Lee D, Oh KS, et al. Concealment, depression and poorquality of life in patients with congenital facial anomalies. J PlastReconstr Aesthet Surg 2010;63:1982Y9.

3. Horlock N, Vogelin E, Bradbury ET, Grobbelaar AO, Gault DT.Psychosocial outcome of patients after ear reconstruction: a retro-spective study of 62 patients. Ann Plast Surg 2005;54:517Y24.

4. Brent B. Technical advances in ear reconstruction with autogenousrib cartilage grafts: personal experience with 1200 cases. Plast ReconstrSurg 1999;104:319Y34.

5. Yanai A, Fukuda O, Yamada A. Problems encountered in contouringa reconstructed ear of autogenous cartilage. Plast Reconstr Surg1985;75:185Y91.

6. Eavey RD, Ryan DP. Refinements in pediatric microtia recon-struction. Arch Otolaryngol Head Neck Surg 1996;122:617Y20.

7. Ohara K, Nakamura K, Ohta E. Chest wall deformities and thoracicscoliosis after costal cartilage graft harvesting. Plast Reconstr Surg1997;99:1030Y6.

8. Tanzer RC. MicrotiaVa long-term follow-up of 44 reconstructedauricles. Plast Reconstr Surg 1978;61:161Y6.

9. Thomson HG, Kim TY, Ein SH. Residual problems in chest donorsites after microtia reconstruction: a long-term study. Plast ReconstrSurg 1995;95:961Y8.

10. Manolopoulos L, Papacharalampous GX, Yiotakis I, Protopappas D,Vlastarakos PV, Nikolopoulos TP. Congenital aural atresia recon-struction: a surgical procedure with a long history. J Plast ReconstrAesthet Surg 2010;63:774Y81.

11. Jahrsdoerfer RA, Yeakley JW, Aguilar EA, Cole RR, Gray LC.Grading system for the selection of patients with congenital auralatresia. Am J Otol 1992;13:6Y12.

12. Shonka DC Jr, Livingston WJ III, Kesser BW. The Jahrsdoerfergrading scale in surgery to repair congenital aural atresia. ArchOtolaryngol Head Neck Surg 2008;134:873Y7.

13. Tollefson TT. Advances in the treatment of microtia. Curr OpinOtolaryngol Head Neck Surg 2006;14:412Y22.

14. Jacobsson M, Tjellstrom A, Fine L, Jansson K. An evaluation ofauricular prosthesis using osseointegrated implants. Clin OtolaryngolAllied Sci 1992;17:482Y6.

15. Schoen PJ, Raghoebar GM, van Oort RP, et al. Treatment outcomeof bone-anchored craniofacial prostheses after tumor surgery. Cancer2001;92:3045Y50.

16. Wright RF, Zemnick C, Wazen JJ, Asher E. Osseointegrated im-plants and auricular defects: a case series study. J Prosthodont2008;17:468Y75.

1613OSSEOINTEGRATED IMPLANTS FOR AURICULAR DEFECTS

Otology & Neurotology, Vol. 35, No. 9, 2014

Copyright © 2014 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.

17. Granstrom G, Bergstrom K, Odersjo M, Tjellstrom A. Osseointegra-ted implants in children: experience from our first 100 patients.Otolaryngol Head Neck Surg 2001;125:85Y92.

18. Nishimura RD, Roumanas E, Sugai T, Moy PK. Auricular pros-theses and osseointegrated implants: UCLA experience. J ProsthetDent 1995;73:553Y8.

19. Benscoter BJ, Jaber JJ, Kircher ML, Marzo SJ, Leonetti JP.Osseointegrated implant applications in cosmetic and functional skullbase rehabilitation. Skull base 2011;21:303Y8.

20. Korus LJ, Wong JN, Wilkes GH. Long-term follow-up of osseointe-grated auricular reconstruction. Plast Reconstr Surg 2011;127:630Y6.

21. Cass SP, Mudd PA. Bone-anchored hearing devices: indications,outcomes, and the linear surgical technique. Oper Tech Otolarngol-Head Neck Surg 2010;21:197Y206.

22. Roman S, Nicollas R, Triglia JM. Practice guidelines for bone-anchored hearing aids in children. Eur Ann Otorhinolaryngol HeadNeck Dis 2011;128:253Y8.

23. McDermott AL, Williams J, Kuo M, Reid A, Proops D. The BirminghamPediatric Bone-anchored Hearing Aid Program: a 15-year experience.Otol Neurotol 2009;30:178Y83.

24. David L, Argenta L, Fisher D. Hydroxyapatite cement in pediatriccraniofacial reconstruction. J Craniofac Surg 2005;16:129Y33.

25. Brogniez V, Lejuste P, Pecheur A, Reychler H. Dental prostheticreconstruction of osseointegrated implants placed in irradiated bone.Int J Oral Maxillofac Implants 1998;13:506Y12.

26. Niimi A, Ueda M, Keller EE, Worthington P. Experience withosseointegrated implants placed in irradiated tissues in Japan andthe United States. Int J Oral Maxillofac Implants 1998;13:407Y11.

27. Hawley K, Haberkamp TJ. Osseointegrated hearing implant sur-gery: outcomes using a minimal soft tissue removal technique.Otolaryngol Head Neck Surg 2013;148:653Y7.

28. Lanis A, Hultcrantz M. Percutaneous osseointegrated implant sur-gery without skin thinning in children: a retrospective case review.Otol Neurotol 2013;34:715Y22.

1614 D. J. ROCKE ET AL.

Otology & Neurotology, Vol. 35, No. 9, 2014

Copyright © 2014 Otology & Neurotology, Inc. Unauthorized reproduction of this article is prohibited.