Keywords cephaloauricular sulcus - ear projection - microtia - customized splints
Introduction
Maintaining ear projection is essential after second-stage microtia reconstruction.[1 ] Preservation of cephaloauricular sulcus from obliteration following graft contracture
is a challenge.[2 ] An effective splint should maintain the necessary auricular projection. Essentially,
it should be self-retaining over a period of time. Various splints used have limited
application owing to issues with compliance, cost-effectiveness, and the necessity
to replace daily under supervision. Some are bulk and cumbersome, making it reasonably
difficult to be retained in place and socially embarrassing for children. The authors
have designed simple, effective, and easy-to-use splints using conventional moulds
in a more feasible manner to improve aesthetic outcomes and patient compliance.
Aim
Our aim is to evaluate the efficacy of our customized splints in defining cephaloauricular
angle and maintaining ear projection.
Materials and Methods
This prospective clinical study was conducted over a period of 3 years and included
six patients of both sexes aged 6 to 12 years. Outcomes were analyzed following Brent's
stage II reconstruction for lobular type of microtia. Custom-made ear splints were
designed separately for females and males. Splints were prepared using conventional
dental moulds in order to snugly fit in the retroauricular space. Splints were anchored
using various innovative means as per individual needs. Designs included spectacles,
anchorage splints, thin hair bands camouflaged in the hair in males, and fancy-looking
hair bands in females. Prior consent for the splint application was obtained by the
patients/parents. For females who desired to wear earrings, a new splint was designed
in the form of chain (mattal in Tamil) and ear stud (jhumkis in Hindi). The mould was incorporated on the posterior aspect of the chain, which
was concealed by hair. These moulds were also painted in skin tone fabric colors for
better aesthetic results. Ear piercing was performed under aseptic precautions. These
splints were designed very similar to the traditional earrings worn by the local population.
Procedure
A dental mould was placed in hot water for few minutes till it softened. It was then
taken out and cooled. A softened mold was fashioned in a desired wedge (C) shape to
snugly fit the created retroauricular space. The mould was wrapped around over a solid
framework of thin stainless steel wire attached to the band ([Fig. 1a, b ]), spectacle frame ([Fig. 2a, b ]), or fancy bands ([Fig. 3a, b ]) for firm anchorage. An anterior extension of the splint was given in superior aspect
for a better hold. No other tape or bandage was used. In case of the earring-type
splint ([Fig. 4a, b ]), it was incorporated on the posterior link chain (mattal ) of the jewelry.
Fig. 1 (a ) Splint with thin wire band framework. (b ) Splint with thin wire band application.
Fig. 2 (a ) Splint with spectacle framework. (b ) Splint with spectacle framework application.
Fig. 3 Splint with fancy hair band framework.
Fig. 4 (a –d ) Splint with mattal earring framework application.
The splint was placed at the back of the elevated ear framework (cephaloauricular
sulcus) after applying an antibiotic cream over the grafted skin ([Fig. 5 ]). The splint was applied 1 week after surgery once the graft had taken well. The
patient was asked to use the splint constantly except during bathing.
Fig. 5 (a–c) Postsplint application ear projection.
Ear projection was measured postoperatively and at follow-up using a goniometer documentation
using photography. Patients were reviewed at 1 month after surgery and every 2 months
for 1 year thereafter. Splint was continued for 6 to 8 months postsurgery. Outcome
was assessed in terms of cephaloauricular angle, conchal depth, pain, cost-effectiveness,
splint retention period, and aesthetics as perceived by two independent observers.
A scoring scale (1–5) was used. Statistical analysis was performed using the Student
t -test, and p < 0.05 was considered to be statistically significant.
Discussion
Numerous splints have been described for maintaining the retroauricular space after
ear framework elevation in microtia surgery.[2 ] These range from simple conventional dental moulds,[1 ] acrylic based resins,[2 ] silicon Foleys catheter,[3 ] and thermoplastic materials, to dressing techniques[4 ] and spectacle frames.[5 ] These have limited application owing to scarce availability, difficult compliance,
cost, and the necessity to replace daily under supervision. Some are bulk and cumbersome,
making it difficult to retain in place and socially embarrassing for children. The
literature has limited reports of splints used for the maintenance of the desired
position of the elevated ear.[3 ]
[6 ]
Nagata's technique uses cartilage block for ear elevation and a temporoparietal fascial
flap cover.[7 ] Other techniques include expanded retroauricular skin and fascial flap,[8 ] retroauricular fascial flap and wrapping of the wedge of autogenous costal cartilage,[9 ] and modifications.[10 ] Inspite of these, the ear projection is lost due to secondary graft contracture.
The authors have designed simple, effective, and easy-to-use splints using conventional
moulds to facilitate better aesthetic outcomes and patient compliance. These customized
splints have proved to be superior in terms of projection and patient satisfaction.
Though dental moulds have been routinely used in various studies for the same purpose,
firm long-term anchorage of the mould in the retroauricular space was not accomplished,
which led to frequent falling and breakage of the splint.[1 ] This problem was not seen with these customized splints. Silicon foley catheter
splints could be used only in patients with intact external auditory meatus.[3 ] Besides, these are easily visible and may be less aesthetically acceptable. Nevertheless,
these are good for maintaining meatal patency in case of stenosis.
Dressing techniques used for splintage require frequent dressing changes and are cumbersome.
These are not suitable for long-term use.[4 ]
Though ethylene-vinyl acetate custom-made ear splint can be used for long term with
good results, these are still not completely camouflaged and seen as transparent splints
and can fall off.[11 ]
2-Octyl-cyanoacrylate skin adhesive has been used as an auricular splint[12 ] after prominent ear surgery, but its use after microtia reconstruction is not described
yet.
The splints described by authors (1) are aesthetically acceptable and are incorporated
in readily used hair and ear accessories, (2) are painted to get a close match to
patients‘ skin tone, (3) are easily camouflaged by hair, (4) are cost-effective as
readily available materials are used to make the splint, (5) are non alleregenic,
(6) reduce number of postoperative visits, and (7) give excellent patient satisfaction
as they give the perception of a naturally worn earring.
Conclusion
These customized splints are self-retaining, easy to fabricate, concealable, inexpensive,
lightweight and maintain the required auricular projection and definition. They also
satisfy the patient's need for psychological and social acceptability. These splints
have excellent patient compliance and help in minimizing adhesions. We anticipate
that this simple innovative technique would provide a prospective solution to some
of the difficulties that may arise with otoplastic reconstruction.
