Dr. Lewin’s Complication Rates for Porous Implant Ear Reconstruction

Posted by on Mar 14, 2016 in Dr. Lewin's Blog | No Comments

Honesty is ALWAYS the best policy.

I am a firm believer in closely tracking and consistently publishing my Microtia ear surgery complication rates with the Porous Implant Ear Reconstruction (PIER) technique. This may be considered “taboo” to some, but my whole philosophy stems from the question:

If I had a child with microtia, what would I want to know?

One of the things I would most want to know is the likelihood that something could “go wrong”. I would want to know “the good, the bad, the ugly”. Yet, it appears that this information is incredibly hard for a parents to find.

Microtia ear surgery is not an ‘ideal’ surgery. In fact, many plastic surgeons would agree that it is actually one of the most complex and difficult procedures we do. There are risks involved, and results can never be “guaranteed”. But those risks need to be put into perspective.

Complication rates for a particular procedure are SURGEON DEPENDENT. Generally speaking, the more experience a surgeon has, the lower their complication rates. This has certainly been the case in my practice performing PIER surgery over the past 11 years.

Dr Lewin complication rates 2013-2015

Here is a very detailed account of the risks of PIER, including my own complication rates over the past 3 years (and the DETAILS about the numbers):

Exposure is a “hole” where the implant is visible.  All of the patients that had surgery to correct the exposure have had a successful outcome while maintaining the aesthetics of the ear. These exposures are not easy to fix. I use a wide variety of techniques that I have developed over years and years of challenging cases. Solving the problem is one thing, but if it compromises the appearance of the ear, that is not a success in my book. So achieving a beautiful reconstruction AFTER an exposure is my goal. In a few cases, more than one surgery was required to get there.

Nerve Injury occurs when the nerve that powers the eyebrow is injured when the flap that covers the porous implant is obtained. It is usually an anatomy issue, where the nerve is too close to the artery that is needed for the flap. The result is either a complete or a partial inability to raise the eyebrow. I’ve had a few patients with a complete nerve injury (no movement) right after the surgery, but who gained normal or near normal motion 6 months after surgery. Others never regained motion.

Infection: Of the 4 patients who had an infection, all of them were successfully treated with just medication. One patient had a “deep” infection that required IV antibiotics for treatment, and 3 were “superficial” infections that were treated with a topical antibiotic to the ear and oral antibiotics. Surgery is rarely needed if the infection is detected quickly and proper treatment started at the very first sign. That is why I require patients to stay in L.A. for 2 weeks (for US patients) or 4 weeks (for international patients). Over my career, I have had a few patients with infections that were so advanced or so difficult to treat that we lost the ear reconstruction. Thankfully, that hasn’t occurred in the past 3 years. I believe this is in part due to new anti-infection measures that I have adopted.

Bleeding is quite rare in these cases, but it does occur occasionally. I can only recall one child in my career that had bleeding of the ear itself. More likely is bleeding in the scalp, or where the skin grafts are taken from (the abdomen or the arm). Only 2 patients required surgery to remove the blood. One patient had bleeding of the arm, but we were able to fix the problem in the office and surgery wasn’t needed. Just a month ago (so not reflected in the slide above), I had an unusual complication of a late bleed of the abdominal skin graft site after the patient returned home. This is the only time I have seen such a late bleeding complication. (The patient was treated locally and issue was resolved.)

Fracture of Implant: I am not aware of any fractures of either Medpor or SuPor implants that I have created in the past 3 years. Since January 2013, I have used my modified technique to make the implant that has resulted in a significantly stronger ear. Prior to this modification, I had several patients with Medpor fractures, usually of the helical rim. I first noted this in 2010. All of these patients needed a surgery to remove the fractured implant and replace it with a new one.  Though still a theoretic risk, I believe I have solved this one with my new implant technique.

Injury to Flap Artery: I have never injured the primary flap artery (called the “pedicle”) in my career. If this artery were inadvertently injured during surgery, the flap would fail. However, it can often be fixed in surgery using a special technique to repair the vessel.

Failure: Earlier in my career, 1 to 2 patients per year would have a complication that led to failure of the ear reconstruction. Either an infection that couldn’t be treated or a vascular problem with flap. I am very thankful that my failure rate has decreased significantly as I have gained experience. In the past 3 years, I have not had any failed ears. It is important for parents to know that even if a failure occurs, it is still possible to redo the surgery and have an excellent PIER using a different flap. This alternative flap is how I can correct patients with failed ear reconstructions and give them a second chance to have an ear.

Families shouldn’t focus on the fact that complications can occur, but more so on the ABILITY of the surgeon to properly treat the complication in a timely and aesthetic manner so that a beautiful outcome can still be obtained. There is no surgeon manual explaining how to handle complications – it is learned by trial and error over years of experience.

ASK!! When researching and interviewing potential Microtia ear reconstruction surgeons, ASK for the good, the bad, the ugly. ASK for their complication rates. All surgeons should have this data, but few, if any, make it readily available to all their potential patients.

Questions? Please email us at info@lewinmd.com

*The above complication rates do not include those patients that had previous failed Microtia ear reconstruction surgeries with Porous Implants or Rib Graft. Overall, their complication rates are higher in all areas. Surgery is significantly more challenging in these cases as the anatomy is more difficult. 

 

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