F A C I A L P L A S T I CS U R G E R Y C L I N I C S

O F N O R T H A M E R I C A

Facial Plast Surg Clin N Am 14 (2006) 129–136

129

Medpor Alternative forMicrotia RepairThomas Romo III, MD

a,b,c,*, Paul M. Presti, MDa,

Haresh R. Yalamanchili, MDa

& Cartilage reconstruction & Postoperative care

& Medpor alternative& Microtia repair with Medpor& Surgical technique

a Department of Otolaryngology–Head and Neck SurgeryNew York Eye and Ear Infirmary, 310 East 14th Street, Nb Division of Facial Plastic Reconstructive Surgery, ManhaNew York, NY, USAc Division of Facial Plastic and Reconstructive Surgery, LNY 10021, USA* Corresponding author. Division of Facial Plastic and R74th Street, New York, NY 10021.E-mail address: docromo@aol.com (T. Romo III).

1064-7406/06/$ – see front matter © 2006 Elsevier Inc. All rightsfacialplastic.theclinics.com

& Complications& Summary& References

The auricle is arguably the most challenging anat-omy to construct or reconstruct. The nuances of theear—the subtle crests and precipitous drops castinga spectrum of shadows—are not easily mimicked.Moreover, the facial plastic surgeon frequently ispresented with the daunting task of constructing asymmetric replica of a model, the perfect, naturalcontralateral ear.The task is, however, more complex than sheer

aesthetics. A child with microtia requires a con-structed auricle that endures throughout his orher lifetime. To this end, one must consider thecrux of the problem: the lack of an auricular frame-work. Determining the most suitable material forthat framework has been a century-long endeavor.Attempts to reconstruct with simple local flaps pro-duced disappointing results, lacking appropriateshape, size, and contour [1,2]. It was not until thelate nineteenth century that total auricular recon-struction was even conceived as feasible [1]. Overthe century attempts were made to reconstruct withbone (tibial, iliac, mastoid), xenogenous materials(ox, calf cartilage), autogenous cartilage, and allo-

genous cartilage sources. Eventual success camewith the honing of technique and discerningsuitable materials. The culmination of success andfailures has produced the few options presentlyaccepted and practiced in auricular reconstruction.

Cartilage reconstruction

Although autologous costal cartilage is not the idealframework material, it is the most widely used inmicrotia repair. The results have been time-testedand the nature of the material has inherent merits.Costal cartilage is durable, autogenous, and is asso-ciated with a low infection rate [3,4]. Tanzer [3]described his experience with microtia repair usingcostal cartilage in 44 patients. After a follow-upranging from 6 to 19 years, there was no incidenceof extrusion even after mild trauma. Except for ex-trusion of sutures, chest wall deformity, and lossof auricular definition, no long-term complica-tions were reported.Brent’s [4] extensive experience with 1200 cases

of auricular reconstruction using costal cartilage

, Division of Facial Plastic and Reconstructive Surgery,ew York, NY 10003, USAttan Eye, Ear & Throat Hospital, 210 East 64th Street,

enox Hill Hospital, 135 East 74th Street, New York,

econstructive Surgery, Lenox Hill Hospital, 135 East

reserved. doi:10.1016/j.fsc.2006.01.006

130 Romo et al

echoes the success of Tanzer. In his series, 70 recon-structed ears were involved in major trauma, andnone of them failed. Of the 508 patient surveyed,he further reported no instance of shrinkage orsoftening of the cartilage framework.While meritous, auricular reconstruction with

costal cartilage has notable drawbacks. The processdescribed by Tanzer and Brent requires multiplesurgical procedures, which may have significantassociated morbidity. Moreover, aesthetically ac-ceptable results are hard to reproduce [5–9]. Thereconstruction of a symmetric auricle from blockcostal cartilage is predicated on the artistic capacityof the surgeon. Even when the results initially arefavorable, with time appearances may differ. Theautologous rib framework is subject to resorptionwith subsequent loss of contour and detail. Tanzer[3] reported an 11% incidence of blurred frame-work definition. Finally, costal cartilage is not afeasible option for all cases of auricular reconstruc-tion, namely reconstruction in adults with ossifiedcostal cartilage.Concerns inherent with costal cartilage auricular

reconstruction are not limited to varied aestheticresults. Harvesting costal cartilage presents the riskof pneumothorax, postoperative pain, and splint-ing with subsequent atelectasis. These risks aremagnified by the potential for revision and multi-ple harvests. Thomson and colleagues [5] describedtheir experience with 88 costal cartilage harvests forauricular reconstruction. A total of 19 patients(22%) experienced pleural perforations, with twopatients requiring chest tubes. A number of patients(25%) were left with retrusion of their chest. All ofthe patients were left with some remarkable defect.A similar experience was described by Ohara and

colleagues [6] in Japan. Of 18 patients (32 grafts),half had appreciable deformity, ranging from bow-ing of the ribs to ‘‘severe deformity of the thorax.’’

Fig. 1. Example of the chest wall deformity after costalcartilage harvesting for auricular reconstruction.

Postoperative thoracic scoliosis was observed in4 of 16 cases, although this finding could not bedefinitively attributable to costal cartilage harvest-ing. Nonetheless, the morbidity of this process isclearly measurable. The unavoidable chest scar isalso not inconsequential [Fig. 1]. One third of Brent’s500 patients described their chest wound as nota-ble after auricular reconstruction [4]. Tanzer [3]noted chest wall depression in 16% of his patients.

Medpor alternative

Hence the search continues for a durable, sizable,and tolerable framework to construct an auriclewhile obviating the need for further deformity orpotential morbidity. Surgical implants intended tomimic human tissue have failed in the past for oneof the following reasons: lack of biocompatibility,inherent instability in structure with eventual deg-radation, and finally, failure of integration. The ad-vent of porous high-density polyethylene (PHDPE),Medpor (Porex Surgical, Inc., College Park, Georgia),has provided an effective alternative for construct-ing an auricular framework because it is a stable,inert substance, which integrates with human softtissue. Implanted Medpor integrates with host tis-sue (including bone), providing a durable complexthat is relatively resistant to infection and morecapable of enduring exposure [9–13].Medpor is a sintered form of particulate PHDPE.

The relatively noncompressible, porous producthas thermoplastic properties [9]. Once heated inan aqueous bath (82° to 100°C), Medpor becomesmalleable and can be contoured easily. Whencooled, it maintains its new form. It is, on average,50% porous by volume with an average pore size of150 μm. The implant is stable, nonresorbable, andelicits minimal foreign body response.Medpor is highly tissue compatible as its capacity

for rapid tissue ingrowth has been demonstratedin animal and human studies. Shanbag and col-leagues [10] evaluated the host response of Medpordiscs of varied thickness in the external ear of eightbaboons. After 9 weeks, histologic evaluation re-vealed minimal foreign body reaction along withsignificant connective tissue and blood vessel in-growth. Sclafani and colleagues [11] described simi-lar findings with 1.5- mm Medpor implanted intothe dorsal skin of 12 rats. After 14 days the PHDPEimplants were infiltrated with fibrovascular tissue.The implants demonstrated the capacity to tolerateexposure without extrusion and support skin grafts.Medpor’s stability in the face of exposure and

infection was further investigated over the pastdecade. Williams and colleagues [12] examinedthe soft tissue response to exposed PHDPE inNew Zealand rabbits. Medpor was implanted into

131Medpor Alternative for Microtia Repair

defects created on rabbit ears and then exposedover varied time intervals post implantation. The36 exposed specimens revealed uniform fibrousingrowth by day 24 and only one specimen ex-truded. Split thickness skin grafts were applied to19 of the exposed porous polyethylene (PPE) im-plants, 17 of which had a 100% graft survival. Themajority of exposed, ungrafted implants eventu-ally reepithelialized.When challenged with induced infection Medpor

proved also to be resilient. Sclafani and colleagues[13] inoculated Staph aureus into PHDPE surgicallyimplanted on the dorsum of 28 rats. Ultimately itwas shown that PHDPE resistance to infection iscorrelated with the extent of soft tissue infiltration.The low rate of extrusion and infection reported

in animal studies is echoed in clinical experience[14–21]. polyethylene has been used since the1940s as a cartilage and bone replacement with30-year follow-up [14]/ PHDPE has been availablesince 1985 as a facial implant. Romano and col-leagues [14] reported success with Medpor use inmaxillofacial trauma. Of 140 patients implanted,only 3 required re-operation (1 required removalfor infection) and there was no incidence of migra-tion or exposure.These findings are further evidenced by two dis-

tinct published case series. Wellisz [17] recounts inhis experience with 116 implants for facial recon-struction and augmentation only 7 exposed im-plants. All of the auricular reconstructions withPHDPE (41 of the 116 cases) were successful. Ex-posed grafts healed without removal. Frodel andLee’s [18] review of 38 cases using Medpor forskeletal facial deformities revealed a low incidenceof exposure and infection. One infection and 2 expo-sures were noted over a 6- to 40-month follow-up.Specific experience using Medpor for auricular

reconstruction has found equally impressive re-sults. Medpor has been used effectively to recon-struct burned external ears. Wellisz [19] publishedhis results of 26 ear reconstructions using Medpor.Neither of the two exposed implants reportedover a 2-year follow-up necessitated removal. Formany of these patients, costal cartilage was not areconstructive option as their costal cartilage hadbeen calcified.

Fig. 2. Porous high-density polyethylene (PHDPE) frame-work for auricular reconstruction.

Microtia repair with Medpor

Patients with grade II and III microtia, as well asthose with failed costal cartilage grafts, are suitablecandidates for Medpor reconstruction. The authorsbase their echnique for auricular reconstructionon a prefabricated porous polyethylene auricularframework. A temporoparietal facial (TPF) flap is

elevated and draped over the implant. The upperone-third of the TPF flap is then covered with a full-thickness skin graft harvested from bilateral ingui-nal skin. The lower two-thirds of the framework/TPF combination is covered by local native skin.The process is a two-stage reconstruction. Implan-tation is followed by lobular transposition afterapproximately 3 months, although the timing iscustomized for each individual. Since harvestingof cartilage is not a factor, the surgery can be per-formed regardless of a patient’s age and body size.However, our preference is to proceed with thesurgery after the child is 5 years of age (when theauricle has reached ~85% of adult size.) Children ator above this age are typically more willing tocooperate with postoperative care, which is criticalduring the immediate post-reconstruction period.Before surgical evaluation each microtia patient

receives a full otologic work up. This includes anaudiometric battery and a temporal bone CT scanto evaluate the middle ear status. A final third stageof the process, atresia repair and middle ear recon-struction, may be an option depending on patientpreference and favorable audiologic and anatomicparameters. Bone conducting hearing aids are avail-able in addition to more easily concealed boneanchored hearing aids (BAHA) for hearing rehabili-tation. Our patients have increasingly opted for theBAHA for hearing restoration with a generally highlevel of satisfaction.

Surgical technique

To construct and refine a natural appearing earfrom a PHDPE prefabricated frame [Fig. 2], a tem-

Fig. 4. Porous high-density polyethylene (PHDPE) frame-work inset into a pocket made within the tempo-ral scalp.

132 Romo et al

plate of the contralateral ear is made with exposedradiographic film. In cases of bilateral microtia thetemplate is modeled after a parent’s ear. The tem-plate is further scaled to compensate for the bulk ofsoft tissue, which will cover the framework. Using asurgical marker, the template is outlined over theplanned implantation site. The authors positionthe outline using the following landmarks: theanterior helix is positioned approximately 6 cmfrom the lateral canthus and is angled 20° fromthe vertical axis. The horizontal position relates tothe level of the brow, with the lobule approximat-ing the height of the nasal columella.In preparation for harvesting an ipsilateral tem-

poroparietal facial flap, a handheld doppler is usedto delineate the course of the superficial temporalartery superiorly, toward its bifurcation. Once iden-tified and outlined, a Y-shaped incision is markedon the temporal/parietal scalp. The superior extentof the temporal dissection is 10 cm above theplanned helical rim. The posterior extent of dissec-tion is marked 5 cm posterior to the planned posi-tion of the helix.Before incision, the area described is infiltrated

with 0.5% lidocaine with 1:200,000 epinephrine.The skin graft donor site (full thickness bilateralinguinal skin) is also injected. A #10 blade is usedto incise and initially raise a subpapillae flap, tak-ing care not to damage the subdermal plexus ofvessels [Fig. 3]. As this is not an anatomic plane,dissection is performed with the cutting motion ofdull-tipped Stevens scissors up to the 10-cm mark.The dissection is then advanced anteriorly to non-hair-bearing temporal skin and carried 5 cm poste-rior to the planned helical rim. Hemostasis is

Fig. 3. Harvesting of the temporoparietal facial flap.

achieved with bipolar cautery. With the temporal/parietal scalp elevated, attention is turned to elevat-ing the postauricular skin with a metzenbaum scis-sor. This flap is elevated posteriorly 5 cm and downaround the vestigial cartilage, ending 1 cm anteriorto the lobule. The vestigial cartilage is delicatelydissected free from the surrounding soft tissueand removed.The PHDPE framework is then sized with a

#10 blade, modeled from the fabricated template.

Fig. 5. The temporoparietal facial (TPF) flap is drapedover the entire porous high-density polyethylene(PHDPE) framework.

Fig. 6. The upper one third of the framework andtemporoparietal facial (TPF) flap combination is cov-ered with full thickness skin grafts harvested frominguinal skin.

133Medpor Alternative for Microtia Repair

3-0 Monocryl sutures are used to bind the helixand base components together. After bathing inantibiotic solution, the composite is inset into theoutlined temporal pocket. To accommodate forlateralization of the framework and suturing, aposterior cut back can be made. Once correctlypositioned, the frame is sutured in place with 3-0Prolene sutures [Fig. 4].The vertical and horizontal limbs of the tempo-

ralis facia flap are then incised with cutting electro-

Fig. 7. Example of a reconstructed auricle using aporous high-density polyethylene (PHDPE) frameworkat the completion of stage 1.

cautery. Every surface of the PHDPE frameworkis now covered with the temporoparietal facia[Fig. 5]. A suction drain is placed between thehelical rim and the facial flap. The scalp flaps areclosed over a #10 french barreled suction drain.Previously harvested defatted skin grafts cover theexposed TPF flap [Fig. 6].Lobular reconstruction and scar revision, if needed,

follows within the proceeding 3 months. A simpletransposition flap is used to relocate the lobuleinto a natural, contiguous position [Fig. 7].

Postoperative care

Protecting the newly formed ear is critical duringthe immediate postoperative time period. Thisallows for sufficient soft tissue ingrowth to stabilizethe structure. A solid plastic cup dressing is wornover the ear constantly for 2 to 4 weeks. Patient andparental cooperation is crucial during this post-operative period to prevent compression ischemiato the newly constructed ear.

Complications

The spectrum of complications ranges from simplewound infection to necrosis of the facial flap andexposure of the underlying Medpor framework.Fortunately the hearty nature of the properly ele-vated TPF flap and PHDPE’s capacity to meld withthe surrounding tissue affords some buffer. Despiteincidents of exposure of the implant and subse-quent infection, rarely is removal of the implant

Fig. 8. Example of an early complication: exposedporous high-density polyethylene (PHDPE) frameworksecondary to necrosis of the full thickness skin grafts.

Fig. 9. (A) cPre- and postoperative pictures. (B) Postoperative picture.

134 Romo et al

required. The authors have experienced a complica-tion rate of 4% in 11 years (250 cases) of microtiareconstruction. Early complications, which are themost common, present in the first 3 months aftersurgery. Compression ischemia with loss of skin orskin and TPF flap most commonly presents duringthis period [Fig. 8]. The cause typically relates toundetected compression of the newly reconstructedear by the cap dressing [Figs. 9–11].

Fig. 10. (A) Preoperative picture. (B) Postop

If integration with the surrounding soft tissue ispresent and the defect is less than 1 cm, then the earcan be salvaged via local rotation advancementflaps. In contrast, a defect larger than 1 cm withno integration present may result in a total loss ofthe framework. We have seen this in only twopatients over the last 11 years.Late complications, greater than 3 months after

surgery, are usually traumatic excoriations to the re-

erative picture.

Fig. 11. (A) Preoperative picture. (B) Postoperative picture.

135Medpor Alternative for Microtia Repair

constructed ear. These are treated with local woundcare or possible local skin flaps. No total losses ofreconstructed ears have occurred in this group.

Summary

The chemical and biologic properties of PHDPEmake it an ideal material for a framework in au-ricular reconstruction. It is a ready-to-use allo-pastic material that has distinguished itself fromother implants via its durability, tensile strength,biocompatibility, and malleability. Clinical expe-rience and bench research support this claim. Theonce formidable task of auricular reconstructionis feasible without the risk, morbidity, and de-formation entailed with costal cartilage harvest-ing. More importantly the aesthetic results withMedpor frameworks have profoundly enhancedthe lives of microtia patients with minimal post-operative complications.

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