Long-Term Follow-Up of Osseointegrated Orbital Prosthetic Reconstruction.

BACKGROUND: Osseointegrated implants have been used for craniofacial prosthetic reconstruction since 1979. The authors sought to review long-term outcomes of osseointegrated orbital reconstruction at the Institute for Reconstructive Sciences in Medicine (iRSM). METHODS: Twenty-six patients have undergone osseointegrated orbital prosthetic (OOP) reconstruction at iRSM since 1991. A retrospective chart review was performed and patient satisfaction assessed through a questionnaire used in previous osseointegration studies. Multivariate binary logistic regression analysis was performed to assess the relationship between smoking, age, sex, and previous radiation treatment with the occurrence of skin reactions and implant failures. A χ test was used to assess the relationship between implant position within the orbit and development of a skin reaction or implant failure. RESULTS: Patients received an average of 5.8 implants during the course of treatment. Follow-up ranged from 6 months to 24 years (mean = 10.6 years). A statistically significant correlation was found between skin reaction and age (P = 0.022), with younger patients more likely to develop a reaction. No variables in our model were significant for predicting implant failure. Overall, there were 39 failures of 155 osseointegrated implants, for a success rate of 74.8%. There was no relationship between skin reaction and implant failure compared to implant position within the orbit. Survey responses were received from 11 of 19 patients (58% response rate). Ninety-one percent of patients were overall satisfied with their prosthesis. CONCLUSIONS: There are minimal contraindications for consideration of OOP reconstruction. Patients find their prosthesis comfortable, report increased self-confidence, and are happy to have undergone reconstruction.

Clinical Outcomes of Osseointegrated Prosthetic Auricular Reconstruction in Patients With a Compromised Ipsilateral Temporoparietal Fascial Flap.

Patients with major ear deformities and associated compromise of the superficial temporal artery are poor candidates for autogenous ear reconstruction because of a tenuous ipsilateral temporoparietal fascial flap (TPFF). Osseointegrated prosthetic auricular reconstruction (OPAR) is an alternative to contralateral free TPFF microsurgical and autogenous reconstruction, but data on clinical outcomes are limited. The records of patients with ear loss or major deformity and a compromised ipsilateral TPFF who underwent OPAR from 1989 to 2013 were reviewed. Satisfaction was assessed using a questionnaire based on a 5 point Likert scale. Thirty-two patients (8 women, 24 men) with mean age 43.0 years (range, 10-70 years) underwent OPAR. The ipsilateral TPFF was compromised due to major trauma (13 patients), cancer extirpation (9), burn injury (4), previous harvest (4), arteriovenous malformation (1), or infection (1). All but 2 patients had an associated craniofacial defect, such as soft tissue deformity (87.5%), hearing loss (46.9%), or bony deformity (31.3%). The overall implant success rate was 88.6% at mean follow-up time of 7.6 years post-OPAR. Prosthesis wear averaged 12.2 hours/day and 6.6 days/week (80.5 hours/week). All 5 patients who experienced implant failures had received prior head and neck irradiation. With their prosthesis, 76.2% (16 patients) stated that their self-consciousness and self-esteem were "better" or "much better," whereas 85.7% (18 patients) stated that their self-image was "better" or "much better." All patients declared that they would undergo the treatment again. Osseointegrated prosthetic auricular reconstruction is a reliable option in this challenging population with high patient satisfaction. Patients with prior radiotherapy may have a higher chance of implant failure and would benefit from extended annual follow-up.

Teaching ear reconstruction using an alloplastic carving model.

BACKGROUND: Ear reconstruction is challenging surgery, often with poor outcomes. Our purpose was to develop a surgical training model for auricular reconstruction. METHODS: Silicone costal cartilage models were incorporated in a workshop-based instructional program. Trainees were randomly divided. Workshop group (WG) participated in an interactive session, carving frameworks under supervision. Nonworkshop group (NWG) did not participate. Standard Nagata templates were used. Two further frameworks were created, first with supervision then without. Groups were combined after the first carving because of frustration in the NWG. Assessment was completed by 3 microtia surgeons from 2 different centers, blinded to framework origin. Frameworks were rated out of 10 using Likert and visual analog scales. Results were examined using SPSS (version 14), with t test, ANOVA, and Bonferroni post hoc analyses. RESULTS: Cartilaginous frameworks from the WG scored better for the first carving (WG 5.5 vs NWG 4.4), the NWG improved for the second carving (WG 6.6 vs NWG 6.5), and both groups scored lower with the third unsupervised carving (WG 5.9 vs NWG 5.6). Combined scores after 3 frameworks were not statistically significantly different between original groups. A statistically significant improvement was demonstrated for all carvers between sessions 1 and 2 (P ≤ 0.09), between sessions 1 and 3 (P ≤ 0.05), but not between sessions 2 and 3, thus suggesting the necessity of in vitro practice until high scores are achieved and maintained without supervision before embarking on in vivo carvings. Quality of carvings was not related to level of training. CONCLUSIONS: An appropriate and applicable surgical training model and training method can aid in attaining skills necessary for successful auricular reconstruction.

Learning to perform ear reconstruction.

Learning how to perform ear reconstruction is very difficult. There are no standardized teaching methods. This has resulted in many ear reconstructions being suboptimal. Learning requires a major commitment by the surgeon. Factors to be seriously considered by those considering performing this surgery are (1) commitment, (2) aptitude, (3) training methods available, (4) surgical skills and experience, and (5) additional equipment needs. Unless all these factors are addressed in a surgeon's decision to perform this form of reconstruction, the end result will be compromised, and patient care will not be optimized. It is hoped that considering these factors and following this approach will result in a higher quality of aesthetic result. The future of ear reconstruction lies in the use of advanced digital technologies and tissue engineering.

Advanced Training and Job Satisfaction Among Recent Canadian Plastic Surgery Graduates.

BACKGROUND: In order to increase one's competitiveness in the current job market, Canadian plastic surgery graduates may complete additional degrees and multiple fellowships. The authors sought to determine the impact of this additional training on the practice profile of recent graduates and determine the current state of job satisfaction among this group. METHODS: An anonymous cross-sectional online survey was created and sent to all 250 graduates of Canadian plastic surgery residencies from 2005 to 2015. Demographics were collected and questions grouped into clinical, teaching, research, and administrative components. Questions pertaining to job satisfaction were also included. RESULTS: The response rate to the survey was 39%. Sixty-nine (71%) respondents had permanent attending positions at the time of survey completion, while the remaining 28 respondents did not. Among those with permanent positions, 59 (86%) completed at least one fellowship and 30 (43%) have an advanced degree. Of those who did fellowship training, 76% practice primarily in their area of subspecialty. Having an advanced degree showed a trend to a higher percentage of practice dedicated to research (5.6% vs 1.9%; P = .074) and more publications per year were seen among this group (1.31 vs 0.30; P = .028). Eighty-six percent of respondents are satisfied with their current attending position. CONCLUSIONS: The majority of recent Canadian plastic surgery graduates are undergoing fellowship training and are practicing primarily in their fields of subspecialty training. Having a postgraduate degree was associated with a higher number of publications per year as an attending surgeon. Job satisfaction is high among recent graduates.

HISTORIQUE: Afin d'accroître leur compétitivité sur le marché du travail, les diplômés canadiens en chirurgie plastique peuvent obtenir d'autres diplômes et de multiples postdoctorats. Les auteurs ont cherché à établir les retombées de cette formation supplémentaire sur le profil de pratique des récents diplômés ainsi que la satisfaction au travail des membres de ce groupe. MÉTHODOLOGIE: Les 250 diplômés d'une résidence en chirurgie plastique au Canada entre 2005 et 2015 ont reçu un sondage transversal anonyme en ligne. Les chercheurs ont recueilli les données démographiques et ont regroupé les questions dans les volets de la clinique, de l'enseignement, de la recherche et de l'administration. Il y avait également des questions sur la satisfaction au travail. RÉSULTATS: Le taux de réponse au sondage s'élevait à 39 %. Soixante-neuf répondants (71 %) occupaient un poste permanent au moment du sondage, contrairement aux 28 autres. Chez ceux qui occupaient un poste permanent, 59 (86 %) avaient effectué au moins un postdoctorat et 30 (43 %) possédaient un diplôme avancé. Parmi ceux qui avaient fait un postdoctorat, 76 % exerçaient surtout dans leur domaine de surspécialité. Un diplôme avancé s'associait à une tendance vers un pourcentage plus élevé de pratiques vouées à la recherche (5.6 % par rapport à 1.9 %; P = .074), qui suscitaient plus de publications annuelles (1.31 par rapport à 0.30; P = .028). Quatre-vingt-six pour cent des répondants étaient satisfaits de leur poste. CONCLUSIONS: La majorité des récents diplômés en chirurgie plastique au Canada étudient au postdoctorat et exercent surtout dans leur domaine de surspécialité. Le postdoctorat s'associait à un plus grand nombre de publications par année de la part des chirurgiens. La satisfaction au travail était élevée chez les récents diplômés.

Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: A literature review.

Facial reanimation provides patients affected by chronic facial paralysis a chance to regain basic human functions such as emotional expression, verbal communication, and oral competence for eating and swallowing, but there is still no consensus as to the best way to measure surgical outcomes. We performed a literature review to investigate the different functional outcomes that surgeons use to evaluate facial function after reanimation surgery, focusing on outcomes other than facial expressions such as speech, oral competence, and patient quality of life/satisfaction. A total of 37 articles were reviewed, with the majority reporting outcomes through subjective facial expression ratings and only 15 dealing with other functional outcomes. In particular, outcomes related to oral competence and speech were reported inconsistently. Facial reanimation patients would benefit from a unified movement to create and validate through consensus, an outcomes reporting system incorporating not only facial expression, but also oral competence, speech, and patient-reported quality of life, to enable global patient assessment.

Microtia reconstruction.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to understand: 1. The epidemiology and genetics of microtia. 2. Refinements in surgical technique for microtia. 3. Outcomes of treatment. 4. Challenges in treatment selection, hearing restoration, surgical training, and tissue engineering. SUMMARY: Microtia reconstruction is both challenging and controversial. Our understanding of the epidemiology and genetics of microtia is improving. Surgical techniques continue to evolve, with better results. Treatment selection continues to be controversial. There are strong proponents for reconstruction with costal cartilage, Medpor or a prosthesis. More realistic models for teaching surgeons how to do the procedures are becoming available. Our approach to hearing rehabilitation is changing. Better solutions using percutaneous and implantable devices are under evaluation to help both unilateral and bilateral microtia patients. Tissue engineering will offer some exciting new treatment possibilities in the future.

Auricular reconstruction for microtia: A review of available methods.

Several surgical techniques have been described for auricular reconstruction. Autologous reconstruction using costal cartilage is the most widely accepted technique of microtia repair. However, other techniques have certain indications and should be discussed with patients and families when planning for an auricular reconstruction. In the present review, the authors discuss the main surgical techniques for auricular reconstruction including autologous costal cartilage graft, Medpor (Stryker, USA) implant and prosthetic reconstruction. To further elaborate on the advantages and disadvantages of each technique, the authors invited leaders in this field, Dr Nagata, Dr Park, Dr Reinisch and Dr Wilkes, to comment on their own technique and provide examples of their methods.

Plusieurs techniques chirurgicales de reconstruction auriculaire ont déjà été décrites. La reconstruction autologue à l'aide de cartilage costal est la technique la plus acceptée pour la réparation des microties. Cependant, d'autres techniques sont parfois indiquées et devraient être proposées aux patients et à leur famille au moment de planifier une reconstruction auriculaire. Dans la présente analyse, les auteurs traitent des principales techniques chirurgicales de reconstruction auriculaire, y compris la greffe de cartilage costal autologue, l'implant Medpor (Stryker, États-Unis) et la reconstruction prosthétique. Pour traiter des avantages et inconvénients de chaque technique, les auteurs ont invité les docteurs Nagata, Park, Reinish et Wilkes, chefs de file dans ce domaine, à commenter leur propre technique et à donner des exemples de leurs méthodes.

Helical rim reconstruction using two bi-pedicled tube flaps.

Thermal injury can result in substantial auricular deformity and subsequent psychosocial morbidity. Helical rim repair, in particular, poses formidable challenges to the reconstructive surgeon. Bi-pedicled tube flaps are one option that have the potential to restore much of the helix's natural contours. This case report discusses the unique strengths and weaknesses of the flap, as well as the reasoning that must be implemented when deciding which situations are appropriate for its utilization. Superior outcomes resulting in a high degree of patient and surgeon satisfaction are possible when the techniques of this report are employed appropriately.

Ear deformities, otoplasty, and ear reconstruction.

LEARNING OBJECTIVES: After reviewing this article, the participant should be able to: 1. Evaluate patient's ears for needed adjustments to size, shape, prominence, and symmetry. 2. Identify common ear deformities and describe methods to repair them. 3. Avoid or manage common complications associated with otoplasty and ear reconstruction. SUMMARY: The essentials of otoplasty will be described/illustrated for the following conditions: Prominent ears, underdeveloped helical rims (shell ear), macrotia, Stahl's ear, constricted ear, cryptotia, and question mark ear.

Long-term follow-up of osseointegrated auricular reconstruction.

BACKGROUND: Auricular deformity presents a formidable challenge for the reconstructive surgeon, and osseointegrated auricular reconstruction provides a safe and reliable option. The authors sought to review long-term results of osseointegrated auricular reconstruction at the Institute for Reconstructive Sciences in Medicine. METHODS: A chart review examining demographics, skin reactions (defined by a modified Holgers classification), and complications at the Institute for Reconstructive Sciences in Medicine was completed. A multivariate binary linear logistic regression analysis was performed to determine whether there was a correlation between the likelihood of a skin reaction and certain patient demographics. A survey was then developed to assess patient satisfaction. RESULTS: Seventy-five osseointegrated auricular reconstructions were performed on 69 patients at the Institute for Reconstructive Sciences in Medicine from 1989 to 2007; mean patient age was 39 years (range, 9 to 76 years). The most common indication for reconstruction was posttraumatic, then congenital and oncologic. The frequency of Holgers reactions was as follows: no reaction, 69 percent; red tissue, 15 percent; excessive tissue, 10 percent; red and moist tissue, 3 percent; granulation tissue, 2 percent; and soft-tissue necrosis, 1 percent. Multivariate binary linear logistic regression analysis found that smoking, younger age, and female gender were associated with the occurrence of a reaction. The overall failure rate of osseointegration in the mastoid region was 2 percent. Survey results found generally satisfied patients willing to undergo the same procedure again, although 55 percent felt that they had had a skin reaction. CONCLUSION: The authors present long-term results showing both success and complications of the osseointegrated prosthetic ear reconstruction for a variety of different etiologies and age groups.

Rhinoplasty: a hands-on training module.

BACKGROUND: Rhinoplasty is a complex surgical procedure with a steep learning curve and a small margin for error. The authors present a hands-on, anatomically correct, silicone training model designed specifically for learning the technical aspects of rhinoplasty. METHOD: Computed tomographic data were acquired and used to create a plaster mold. Silicone was cast into this mold to create an operable, realistic, three-dimensional silicone model. RESULTS: The prototype created an anatomically accurate rhinoplasty training model. The silicone materials simulate the properties and behavior of the anatomical structures of the nose. CONCLUSION: A realistic three-dimensional silicone nasal model has the potential to be used as a hands-on training module for learning rhinoplasty and assessing surgical competency.

Lateral pharyngeal wall and velar movement and tailoring velopharyngeal surgery: determinants of velopharyngeal incompetence resolution in patients with cleft palate.

BACKGROUND: After primary palatoplasty, patients with cleft palate may still require secondary surgical procedures to correct residual velopharyngeal incompetence. This study evaluated speech outcomes of patients who underwent differential velopharyngeal surgery based on degree of lateral pharyngeal wall movement and velar movement. METHODS: In this retrospective cohort study, 31 patients with cleft palate from 1992 to 2003 underwent tailor-made velopharyngeal surgery with complete preoperative and postoperative speech assessments. All patients were evaluated postoperatively for velopharyngeal incompetence resolution, persistent velopharyngeal incompetence, and hyponasality. RESULTS: Velopharyngeal incompetence was resolved in 90 percent of patients. Severe hyponasality occurred as a complication in 16 percent, requiring subsequent division of the pharyngeal flap. Patients with lateral pharyngeal wall movement greater than 25 percent had a significantly greater chance of incompetence resolution compared with those with lateral pharyngeal wall movement less than 25 percent (p < 0.001). Regarding combined lateral pharyngeal wall movement plus velar movement, all groups showed significantly lower velopharyngeal competence scores following surgery (p < 0.001). Patients with lateral pharyngeal wall movement less than 25 percent and velar movement greater than 50 percent had the least successful speech outcome. The data also showed that various types of surgical operations performed on patients with similar combined degrees of lateral pharyngeal wall movement and velar movement can result in equally successful speech outcomes. This finding indicated flexibility in following the treatment algorithm for tailoring velopharyngeal surgery. CONCLUSION: The degree of lateral pharyngeal wall movement and velar movement, rather than type of surgical procedure chosen, is a more important determinant of velopharyngeal incompetence resolution in patients with cleft palate.