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Surgical Versus Prosthetic Reconstruction of Microtia: the Case for Prosthetic Reconstruction Gregory G

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Surgical Versus Prosthetic Reconstruction of Microtia: the Case for Prosthetic Reconstruction Gregory G CLINICAL CONTROVERSIES IN ORAL AND MAXILLOFACIAL SURGERY: PART ONE J Oral Maxillofac Surg 64:1639-1654, 2006 Surgical Versus Prosthetic Reconstruction of Microtia: The Case for Prosthetic Reconstruction Gregory G. Gion, BA, BS, MMS, CCA* The auricular prosthesis and the autogenous recon- collaboration with university implant teams in Dallas, struction must ultimately be judged on their ability to Texas. This article suggests that the prosthetic option free the patient from the stigmatization of their con- has historically been poorly represented, even misrep- dition. Excellent esthetic results are key in providing resented for various reasons, and that more should be patients with the confidence that their correction will published in the future to give a more complete go undetected. There are other technical and psycho- picture of the prosthetic option to help with this logical issues that impact prostheses success in par- decision of treatment selection. It is hoped that the ticular, but the wide variability in esthetic quality author’s experience, not as plastic surgeon, implant available historically and around the world today surgeon, or prosthodontist, but as the silicone ear might still be unnecessarily complicating if not bias- specialist of 25 years, will add a different perspective ing the treatment selection process. The thrust of this to help guide future decisions. article is to provide current advantages and future Treatment options for children with absence or potential of prostheses, along with demonstration of other malformation of the pinna remain; no treat- esthetic results that are possible with ear prostheses. ment, autogenous reconstruction, or prosthetic re- The hope is that readers will come away more en- construction. The literature provides guidance in the lightened, more optimistic, and more confident in area of selection criteria for choosing between autog- sharing information on prostheses with colleagues, enous and prosthetic reconstruction1-3 and several parents, or patients. This might be helpful to those team studies help to add quantity and experiential patients with an ambiguous prognosis who, for lack insight to the information pool on this topic.4-6 Some of knowledge, might otherwise undergo fruitless at- of the articles have been coauthored by the autoge- tempts at autogenous reconstruction. nous surgical and prosthetic representatives at large Surgeons and others involved in the decision-mak- centers that can evaluate patients, make a recommen- ing process with parents of children with microtia are dation on the preferred treatment, and offer treat- encouraged to become familiar with the important ment of either kind at the center. The situation where references. The criteria for treatment selection be- a patient would receive the very best results for either tween surgical and prosthetic approaches are well- treatment type from the same institution is rather 1,2 developed and supported in Wilkes and Thorne. unusual in the author’s experience. The idea of offer- However, the question for the patient or parent will ing such comprehensive excellence under one roof is always remain prior to treatment; what will the final attractive, but parents should feel free to consult result really look like? This article is written from the independent anaplastologists as well. As a private point of view of a medical artist/anaplastologist that anaplastologist based 21 years in Dallas, the author has practiced full time for 25 years creating and pro- has enjoyed the professional enrichment of close col- viding silicone auricular, nasal, and orbital prostheses. laboration and cross-referring of patients with maxil- The initial 4 years were in hospital-based positions lofacial surgeons and prosthodontists at Baylor Col- and the last 21 years have been in private practice in lege of Dentistry, Medical City Dallas, and the University of Texas Southwestern Medical Center. *Private Practice, Dallas, TX, and Madison, WI. Some anaplastologists would agree that this experi- Address correspondence and reprint requests to Mr Gion: 10501 ence of professional autonomy has invested them N Central Expressway, Ste 314, Dallas, TX 75231; e-mail: more deeply in their patient and thereby elevated [email protected] final prosthetic results and long-term care. © 2006 American Association of Oral and Maxillofacial Surgeons The general opinion gleaned from the main refer- 0278-2391/06/6411-0012$32.00/0 ences seems to be that autogenous reconstruction is doi:10.1016/j.joms.2006.03.050 the preferred method, if there exists a reasonable 1639 1640 TREATMENT OF MICROTIA: THE CASE FOR PROSTHETIC RECONSTRUCTION chance for an esthetically acceptable result. What is nonstudent of long-term autogenous sequelae, the judged to be esthetically acceptable is a question author must defer to the selection criteria posed in worthy of much more study, both for surgical and the major articles. However, in the author’s 25 years prosthetic results. There seems to be general agree- of creating ear prostheses, many have been for pa- ment that surgical results are improving because of tients with hemifacial microsomia, Goldenhar syn- the refinement of the techniques pioneered by Tanzer drome, etc, who presented with histories of repeated and further refined by truly gifted and experienced unsuccessful attempts at reconstruction. Given that specialists like Brent, Firmin, Nagata, and very few there is some component of cases of unremitting others around the world. Many surgical outcomes are family pressure to reconstruct even in light of the characterized as “suboptimal” or “not entirely suc- surgeon’s caution, so there must be a component of cessful” indicating results continue to be unpredict- overzealousness or other motivation that prompts able. some surgeons to operate. There also is very likely a On the other hand, prosthetic results are also im- component of experienced pediatricians and others proving in terms of stability, anatomical accuracy, and who have steadfastly eschewed the idea of a prosthe- esthetics. With over 2 decades of experience in sis based, probably in part, on long-term patient dis- craniofacial implantology in the United States, and the satisfaction with adhesives and/or very poor esthetic continual refinement of implant techniques to retain results or unfamiliarity with the recent advances in ear prostheses, patients now enjoy predictable and the ear prosthesis option. The author believes that, repeatable attachment of the prosthesis with the generally, patients with microtia should be evaluated promise of even more stable, secure, and sophisti- by only the very best dedicated ear reconstructive cated designs to come. The application of advanced surgeons. The present level of prosthetic outcome digital technologies plays an increasingly important success must become more visible so that selection role in planning and guiding endosseous implant criteria are based on accurate offerings for each treat- placement for bone-anchored prostheses as well as in ment type. In particular, it is incumbent on anaplas- several phases of ear prosthesis fabrication where tologists specializing in ear (and facial) prostheses to anatomical fit and bilateral symmetric accuracy ap- present and publish the results of their university or proach perfection. Perhaps as important has been the private practice experience. profound maturing of the field of anaplastology; spe- Patients must be referred only to surgeons such as cifically, facial prosthetics, in which truly dedicated Brent, Nagata, or the handful of similarly successful artist/clinicians have provided as their specialty es- ear reconstructive surgeons worldwide, who, with thetic silicone auricular prostheses that often eclipse their great experience, would be more likely to pre- those from nonspecialized dental labs where they are dict the outcome as well as most likely to provide a treated as incidental or ancillary services. The “pro- successful result. It is crucial that the initial attempt fessionalization” of anaplastology and the dedicated be in the hands of one of the few experts. Perhaps specialization in silicone ear and facial prosthetics in these individuals would be less likely to undertake particular has raised the bar considerably over the last cases with poor prognoses for the sake of gaining two decades. In view of these developments and the more experience. Also of concern in the author’s collaboration between anaplastologist, implant sur- experience is the notion that patients should be di- geon and other team members, the prosthetic option rected to major “centers” where they can make their should be considered equally with autogenous recon- treatment selection and obtain successful results uti- struction in borderline cases. lizing either the surgical option or the prosthetic option within the center. As with referral to an expert ear reconstructive surgeon where location and hospi- The Anaplastologist’s Opinion tal affiliation are secondary, so too should be the In the author’s opinion, children with microtia mode of referral to the expert anaplastologist or team should be provided the best chance to have their ears that includes a highly regarded anaplastologist. successfully surgically reconstructed, which means The anaplastologist, like the reconstructive sur- they should be evaluated and treated only by the best geon, is charged with the formidable task of restoring in the specialty. The author recognizes the major the delicate beauty of the human ear. Differently
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