The Branemark-type Bone-anchored Ear Prosthesis: The Untold Story
Ibby Younis, MBBCh, MRCS, Walid Sabbagh, FRCS, (Plast), David Gault, FRCS, (Plast), and Norbert Kang, MD, FRCS, (Plast).
INTRODUCTION: The absence of an ear due to congenital abnormality, trauma or cancer surgery poses an unusual and difficult reconstructive challenge. The Branemark-type osseointegrated ear prosthesis is regarded as an acceptable alternative (Figures 1 & 2) when autologous reconstruction (Figures 3 & 4) is technically impossible or declined by the individual (1). However, there is paucity of data in the literature with regards to patient satisfaction, complication rates and long term follow up relating to these ear retention devices (2).
Figure1. Two Branemark implants in theFigure 2. Prosthetic ear retained by a
mastoid with percutaneous abutments Branemark implant
Figure 3. Congenital absence of ear Figure 4. Autolougous reconstructed ear
METHODS: A twenty point postal questionnaire examining patient outcomes using likert rating scales was sent to all individuals who had undergone this procedure over a 16 year period in a national plastic surgery tertiary referral centre (n=28). A comprehensive case note review was also conducted.
RESULTS: A questionnaire response rate of 54% (15) was achieved. A high mean aesthetic satisfaction score of 2.33 (95% CI = 2.3 1.7-3.0) was obtained where 1 indicated excellent and 5 terrible (Figure 5). However, 88% (12) of the respondents had experienced skin problems around the abutments such as infection, bleeding and build up of granulation tissuewith a mean severity score of 2.8 (95%CI = 2.07-3.59) where 1 represented very mild skin problems and 5 very severe skin problems (Figure 6). Interestingly 67% (10) reported they were still having ongoing skin complications (Figure 7) with a higher mean severity score of 3.1(95%CI = 2.42-3.78). Despite these chronic skin problems as many as 67% (10) of respondents indicated they would undergo the same procedure again or would recommend it to others (Figure 8). Over a third, 40% (6) were frustrated by the prosthesis detaching too easily from the Branemark implant! From the case note review (n=28), it was found that 32% (9) had developed over-granulation around the abutments (Figure 9), all of which were successfully treated with the CO2 laser (Figure 10). Additionally, 29% (8) patients had developed signs of clinical infection (Figure 11) and 25% (7) patients found their abutments became loose regularly and fell out in 14% (4) of cases (Figure 12).
Figure 5. Aesthetic appearance scores Figure 6. Past ‘skin problems’ scores
Figure 7. Current ‘skin problems’ scores Figure 8. Proportion of respondents who would consider undergoing procedure again
Figure 9. Granulation tissue around abutments Figure 10. Granulation tissue treated with CO2 laser
Figure 11. Loosened abutment Figure 12. Low grade infection
CONCLUSION: The Branemark device appears to offer patients a good aesthetic outcome but the frequency and severity of skin complications associated with this was significantly and surprisingly high. We suggest this is largely due to an incomplete seal at implant-skin interface and propose a modification of the implant design that may reduce the prevalence of chronic skin complications. Additionally the CO2 laser to be very effective in treating over-granulation around the abutments without significantly raising the temperature of the titanium implants (3). We advocate further investigation and more extensive patient follow up for the Branemark ear prosthesis as this may have wider implications in other craniofacial bone-anchored prosthesis reconstruction.
REFERENCES
1. Wilkes GH, Wolfaardt J. Auricuar defect: treatment options. Branemark P-I, Tolman DE (ed). Osseoinegration in Craniofacial Reconstruction. Illinois, Quintessence Publishing Co, Inc, 1998. Pp141-154.
2. Westin T, Tjellstrom A, Hammerlid E, Bergstrom K, Rangert B. Long-term study of quality and safety of osseointegration for the retention of auricular prostheses.Otolaryngol Head Neck Surg 121(1):133-43,1999.
3. Mouhyi J, Sennerby L, Nammour S, Guillaume P, Van Reck J. Temperature increases during surface decontamination of titanium implants using CO2 laser. Clin Oral Implants Res 10(1):54-61, 1999.