Discussion: Polyethylene Ear Reconstruction
The field of ear reconstruction has come remarkably far since Tagliacozzi’s description of the use of a pedicled arm flap to reconstruct a monk’s ear in 1597. Such improvements and refinements over 420 years may not be surprising, but microtia reconstruction consistently represents one of the most difficult surgical challenges in plastic surgery. This difficulty is attributable to the fine detail and complex architecture of the cartilaginous auricular framework and its relationship with the thin soft-tissue envelope. For these reasons, recreation of the total ear remained an elusive goal until Tanzer’s detailed descriptions of a staged, autologous costal cartilage–based reconstruction1 ushered in the modern era of ear reconstruction. Autologous cartilage-based reconstruction has since been the definitive standard for microtia reconstruction, with exceptional results obtained by surgeons experienced in the technique.2 However, this technique has several well-documented limitations, including a requirement for multiple staged procedures, creation of a thick and relatively inflexible ear, potential asymmetry, suboptimal ear projection, long operative times, donor-site morbidity, inconsistent aesthetic outcomes, and a steep learning curve because of the technical skill required. In addition, surgery is often delayed until later in the first decade of life to ensure availability of an adequate amount of costal cartilage, which can have significant psychosocial consequences associated with carrying a significant physical deformity during a child’s early school years.3 To address these shortcomings, new techniques were developed that used alloplastic materials as frameworks. Cronin and Ascough4 and Ohmori and Sekiguchi5 achieved promising initial aesthetic outcomes using a silicone framework, but high rates of implant exposure on long-term follow-up ultimately led to its abandonment in ear reconstruction. Dr. Reinisch has long been an advocate of porous polyethylene implants6 because of their minimal tissue reactivity and the allowance of soft-tissue ingrowth, but initial reports demonstrated similarly high rates of exposure.7,8 However, refinements to the procedure—specifically, the use of a temporoparietal fascia flap to envelop the implant and ensure adequate vascular supply—have dramatically reduced the exposure rate with polyethylene implants.9 The initial failures of alloplastic ear reconstruction may have discouraged widespread acceptance of polyethylene implants, as their use remains vastly underrepresented relative to cartilage-based constructs despite multiple advantages and the minimization of exposure risk.10
Limited reports exist comparing outcomes of cartilage-based reconstructions with those using polyethylene, particularly from the same surgeon and institution, but autologous microtia repair is considered by many to be the “gold standard.”11 However, Dr. Reinisch makes a convincing case for alloplastic implants, detailing their many advantages and importantly emphasizing that the key to success is less the framework itself and more the meticulous harvest of a well-vascularized temporoparietal fascia flap to provide soft-tissue coverage and a robust blood supply. The authors also importantly highlight special considerations in bilateral ear reconstruction and in treating patients with Treacher Collins syndrome. The procedure described in this article represents the culmination of decades of technical refinement, for which Dr. Reinsisch should be commended. Although the debate of autologous versus alloplastic reconstruction is long-standing and will certainly continue, the minimal complication and exposure rates reported by Dr. Reinisch and his technique appear to improve the risk-to-benefit ratio of alloplastic implants.