return to: Reconstructive Procedures Protocols

Note: last updated before 2013

GENERAL CONSIDERATIONS (FIRST STAGE)

1. A major commitment is needed from the patient and the health care team to successfully manage alloplastic reconstruction of facial deformities with osseointegrated implant support. Counseling should include discussion between the patient, their family, and the reconstructive team composed of a surgeon, a prosthodontist, and a maxillofacial prosthetics expert (anaplastologist). The presentation that follows is directed from the surgeon's perspective and therefore emphasizes the operation, which represents a small portion of the total effort that needs to be expended to perform a successful reconstruction.
2. Indications
   1. Major tissue loss affecting the eye, ear, nose, or midface in a patient motivated to expend significant time and energy to establish and then maintain osseointegrated implants and the prosthetic device they support
   2. A tissue deficit resulting from trauma, tumor resection, or that is congenital
   3. A defect that is not better reconstructed with autogenous tissue (ie, free flap, etc)
   4. A defect that is not better reconstructed with a glue-on prosthesis
3. Contraindications
   1. A patient unable or unwilling to provide the time and effort required
   2. Active cancer recurrence
   3. Irradiated tissue is only a relative contraindication; hyperbaric oxygen administered before and after placement of the implants improves success to acceptable levels
   4. Inadequate bone support for the implants

PREOPERATIVE PREPARATION (FIRST STAGE)

1. Surgeon's Consultation With Patient
   1. Discuss reconstructive options including staged auricular reconstruction with autogenous tissue, a "glue-on" prosthesis, and a prosthesis secured with osseointegrated implants.
   2. Describe procedure: "A staged procedure involving prosthetic specialists as well as surgeons to place titanium screws (fixtures) into bone, followed three to six months later by placement of a post (abutment) protruding through the overlying skin, followed by fabrication of a prosthesis that attaches to the posts. The skin about the posts may need to be modified with a skin graft to permit appropriate placement of the prosthesis."
   3. Describe potential complications not limited to: "Bleeding, infection, reaction to the anesthesia and damage to adjacent structures. The most common complication is the development of a proliferative healing response about the posts (abutments) that may require treatment with aggressive cleaning, antibiotics, and possibly further surgery with skin grafting."
2. Surgeon's Consultation With a Maxillofacial Prosthodontist or Anaplastologist (prosthetics expert)
   1. Confer regarding sacrifice of unwanted tissue (ie, previous unsatisfactory auricular reconstruction may leave unwanted tissue best dealt with by complete removal).
   2. Confer regarding location, orientation, and number of implants to be placed. Until an established working relationship is developed, it is best to have the anaplastologist in the operating room at the time of implant placement.
3. Surgeon's Consultation With Operating Room Nursing Personnel
   1. Ensure they are comfortable with equipment (a dry run may be helpful).
   2. Provide them with copies of this protocol.
4. Evaluations
   1. CT to assess bone thickness and abnormalities of underlying bone.
   2. In cases of auricular reconstruction, obtain audiogram.

NURSING CONSIDERATIONS (FIRST STAGE)

1. Room Setup
   1. See Basic Soft Tissue Room Setup
   2. Instead of the Basic Soft Tissue Supply Pack, use the ENT Supply Pack
   3. Osseointegration motors (nonsterile)
2. Instrumentation and Equipment
   1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Osseointegration Fixture Installation Instrument Tray, Stage I
   2. Special
      1. Arthroscopy camera drape, small x 3 (for the drill and motor)
      2. Cassette cover
      3. Instrument pouch
      4. Concept micro bipolar forceps, 4-1/8 in w/ cord
      5. Richards adjustable double fork retractor, 6-3/8 in
      6. Polyethylene tourniquet, 6 in x 2 (used to cover Frazier suction tube)
      7. 20 cc syringes with 18-gauge blunt needles x 2 to use for irrigation while drilling
3. Medications (specific to nursing)
   1. 1% lidocaine with 1:100,000 epinephrine
   2. Bacitracin ointment
4. Prep and Drape
   1. Standard prep, 10% providone iodine
   2. Drape
      1. Head drape
      2. Square off face with towels; exclude contaminated region (nose, mouth) as much as possible from the field
      3. Split sheet
5. Drains and Dressings
   1. Adaptic, small, 3 x 3 in
   2. Fluffs, 5-pack x 3
   3. Kling wrap, 4 in
6. Special Considerations
   1. Check to ensure that implants and instrumentation are available before intubation and prepping for procedure.
   2. Never touch the titanium implant or anything that will touch the titanium implant with fingers. Materials in titanium box should not be touched with gloves. Lift from box with special titanium pincette.
   3. Drills are in a stainless steel cup; titanium instruments are in a titanium cup. During change of instruments from stainless steel to titanium, the suction tip used during flap reflection should also be changed to one with its tip protected by a plastic guard.
   4. The fast-speed drill is used for the drill and the countersink. The slow-speed drill is used for the tap (do not irrigate while tapping) and the implant.
   5. Anything used with the slow-speed drill is titanium and should not be touched with anything but titanium (including hands). Anything used with the fast-speed drill is stainless steel and should be placed in the stainless steel cup.
   6. Order two each of the following: guide drills, fixed depth, drill countersink, screw tap flange fixture. Sizes will depend on the request of the surgeon.

ANESTHETIC CONSIDERATIONS (FIRST STAGE)

1. General Anesthesia
   1. Heavy sedation is usually sufficient, although general anesthesia may also be used.
2. Preoperative Systemic Medications
   1. Antibiotics are administered only if the implant is to be placed in or near an infected or contaminated region (see Antibiotic Prophylaxis in Head and Neck Surgery protocol).
   2. No medications are needed other than those required by the anesthesiologist.
3. Positioning
   1. Modified according to the site of implant placement
   2. Head of bed elevated 15 to 30°

OPERATIVE PROCEDURE (FIRST STAGE) (Details are directed toward auricular reconstruction)

1. Incision for Auricular Prosthesis
   1. Curvilinear incision 10 to 15 mm from the intended implant sites
   2. Sharp dissection to periosteum
   3. Incise periosteum separately and elevate as flap
   4. Careful subperiosteal dissection with identification of specific anatomic landmarks (in ear cases: linea temporalis, suprameatal spine, foramen mastoideum)
   5. Self-retaining retractor
2. Primary Hole (Initial Drilling)
   1. Fixture-site preparation carried out at a speed of 1800 rpm (maximum 3000 rpm) with abundant room-temperature saline solution irrigation. Bone chips to be removed frequently from the drill flutes.
3. During drilling, the burr is moved up and down in the preparation hole so that the saline solution may reach down to the cutting edge facilitating removal of cut bone tissue.
4. A depth guide allowing only 3 mm of penetration is slipped over the shank of the round cutting burr. Repeatedly check the bottom of the hole with blunt dissector as drilling goes on. It is possible to penetrate the wall of the sigmoid sinus or expose dura. If there is adequate bone thickness, the 4 mm depth guide is attached to the cutting burr and drilling is continued.
5. Widen Hole
   1. Repeat drilling using spiral drills of 3 to 4 mm, respectively. A depth guide is again used to limit the depth of the resultant hole that also acts as a countersink to allow flange of titanium fixture to have maximum contact with the bone surface.
6. Tap Hole
   1. Switch to low-speed contra-angle piece (15 to 20 rpm).
   2. Screw tap is titanium and should not be touched by anything but titanium-coated pincettes. Continue abundant saline irrigation.
   3. Take great care to orient the tap in the correct direction. If not, the threads will be ruined. The taps must be cleaned with a special titanium needle before being used in the next fixture site.
   4. If bone tissue in the prepared site does not bleed spontaneously, some bleeding should be provoked. Do not aspirate or flush away this blood with saline, but leave it in place.
7. Fixture Installation
   1. Continue with low-speed contra-angle piece (15 to 20 rpm).
   2. Fixture installed without cooling until the small grooves in the distal end of the fixture are well within the canal.
   3. Remaining portion of fixture installation is carried out under abundant irrigation. If there is great resistance during fixture installation, one may convert to manual installation with the ratchet wrench. Even if no problem with advancing the fixture, use ratchet to check the final tightening of the fixture. This is also performed under abundant irrigation.
   4. When tightening the fixture, stoppage should occur when bone comes through the small holes of the flange.
   5. Strike fixture and fixture mount with dissector for sound of percussion; nature of the sound will indicate the quality of fixture connection with the bone tissue.
8. Remove Fixture Mount
   1. Accomplish with a screwdriver attached to the low-speed contra-angle handpiece with the handpiece running in reverse direction (or manually with a screwdriver).
   2. With both methods, use open-ended wrench as a counterforce so that the fixture does not rotate.
   3. Check hexagonal fixture head for possible damage resulting from installation; then install the cover screw on the fixture to protect internal threads of the fixture.
9. Replace Periosteal Flap
   1. Suture with 4-0 dexon.
   2. Significant subcutaneous and muscle tissue is then removed from the skin flap (final thinning may be done during the second surgical stage).
   3. Suture skin with interrupted 4-0 polyamid suture.

POSTOPERATIVE CARE (FIRST STAGE)

1. Mastoid dressing
2. Antibiotics not prescribed
3. Change dressing day after surgery and replace with small dressing.
4. Protect wound from water and contamination for seven days (when sutures are removed).

GENERAL CONSIDERATIONS (SECOND STAGE)

1. A waiting period of approximately three months is recommended between the first and second stages to permit the titanium implants to become integrated. For cases with unpredictable healing (previous irradiation, poor bone stock identified during implant placement), a longer wait up to six months may be reasonable.

PREOPERATIVE PREPARATION (SECOND STAGE)

1. Consultation with Patient
   1. Discuss procedure: "Expose the screws previously placed into bone to place abutments projecting above adjacent skin; may require skin graft."
   2. Potential complications: "Bleeding, infection, reaction to the anesthetic. Most common complication is a proliferative healing response about the abutments requiring aggressive wound care and occasionally revision surgery, possibly with skin grafting."
2. Refer to previous photos and diagrams demonstrating location of implants.
3. Consider obtaining plain film radiographs to help localize implants; not necessary for auricular reconstruction, but of potential benefit for implants placed elsewhere.

NURSING CONSIDERATIONS (SECOND STAGE)

1. Room Setup
   1. See Basic Soft Tissue Room Setup
   2. Instead of the Basic Soft Tissue Supply Pack, use the ENT Supply Pack
2. Instrumentation and Equipment
   1. Standard
      1. Minor Instrument Tray, Otolaryngology
      2. Osseointegration Fixture Installation Instrument Tray, Stage I
      3. Concept micro bipolar forceps, 4-1/8 in w/ cord
   2. Special
      1. Abutments and large plastic healing caps specified for patient
      2. Richards adjustable double fork retractor, 6-3/8 in
      3. Polyethylene tourniquet, 6 in x 2 (used to cover Frazier suction tube)
3. Medications (specific to nursing)
   1. 1% lidocaine with 1:100,000 epinephrine
   2. Bacitracin ointment
4. Prep and Drape
   1. Standard prep, 10% providone iodine
   2. Drape
      1. Head drape
      2. Square off face with towels
      3. Split sheet
5. Drains and Dressings
   1. Adaptic, small, 3 x 3 in
   2. Fluffs, 5-pack
   3. Kling wrap, 4 in x 2
   4. Telfa, large
6. Special Considerations
   1. Check to ensure that implants and instrumentation are available before intubation and prepping for procedure.
   2. Never touch the titanium implant or anything that will touch the titanium implant with fingers. Change the suction used during flap reflection when instruments are changed.
   3. Procedure may require skin graft.

ANESTHESIA (SECOND STAGE)

1. Heavy sedation is generally satisfactory, although general anesthesia may be used in selected cases.
2. Local infiltration with 1% lidocaine with 1:100,000 epinephrine

OPERATIVE PROCEDURE (SECOND STAGE)

1. Elevation of Soft Tissue
   1. Generally performed through scar from previous incision with elevation of flap leaving periosteum down.
   2. Cover screw is identified with soft tissue about screw (implant, fixture) removed overlying the screw. Bone overgrowth of the flanges of the implant is commonly seen and may require minimal curettage to remove to permit placement of the post (abutment).
   3. Before proceeding with abutment placement, ensure that the screw (implant, fixture) is well integrated without movement or sign of infection.
2. Abutment Placement
   1. Prior to placing abutment, the skin flap is redraped over the screw (implant, fixture) after removal of cover screw. A "cookie cutter" is used with a central probe and surrounding sharp cylinder to remove a small circle of skin overlying the screw.
   2. The skin flap is reflected, and a 4 mm (preferably) or 3 mm post (abutment) is secured to the integrated screw (implant, fixture) with clockwise rotation of the screw located in the center of the abutment into the hollow implanted titanium implant. Care is taken to ensure that the hexagonal projection from the implant coapts flush with the hexagonal depression within the abutment to prevent motion about this connection.
3. Soft Tissue Considerations
   1. Attention to the soft tissue about the abutment is critical to the success of the reconstruction. Proliferative granulation tissue may develop about the posts (abutments) if there is any skin mobility about the posts, especially in the younger patients. Aggressive thinning of the overlying skin flap in a wide area (up to 3 or 4 cm) is therefore essential if the skin flap is to be used to cover the area adjacent the posts.
   2. A low threshold should be held for complete sacrifice of the skin flap with placement of a thin (non-hair-bearing) skin graft overlying thin periosteum.
4. Stenting the Soft Tissue
   1. Bacitracin and adaptic are placed over the thin skin flap or skin graft.
   2. Either three or four layers of Telfa are used to cover the adaptic with holes cut to accommodate the posts projecting through the Telfa.
   3. Large plastic healing caps are screwed onto the posts to secure the bolster. The bolster is secured circumferentially to adjacent skin with either staples or 3-0 nylon sutures.

POSTOPERATIVE CARE (SECOND STAGE)

1. One week postoperative: The second stage is generally done as an outpatient with follow-up one week later to remove the dressing overlying the implants. Wound care is instituted with cleanings with Q-tips, peroxide, and Bacitracin. The wound is generally left open at this stage.
2. Two weeks postoperative: The wound is rechecked in clinic in consultation with the prosthodontist or anaplastologist (facial prosthetics expert) with a date set for fitting of the prosthesis, usually four weeks after the procedure.
3. Routine follow-up every four to six months with the prosthetics service for cleaning of abutments and evaluation of surrounding tissues and prosthesis.
4. Daily cleaning of the abutments and surrounding soft tissue should be performed by the patient using cotton swabs and a 50/50 mixture of hydrogen peroxide (3%) and water.

REFERENCES

Arcuri M, LaVelle W, Fyler A, Hoffman H. Midface reconstruction with osseointegrated implants. J Prosthodontics. 1992.

Arcuri M, LaVelle W, Higuchi KW, Hoffman H. Combined percutaneous-permucosal titanium implants for retention of a maxillary prosthesis: a clinical report. J Prosthet Dent. 1993;7:288-290.