Letters OBSERVATION
Prosthetic Reconstruction of Complicated Auricular Defects: Use of a Hybrid Prosthetic Fabrication Technique A multidisciplinary rehabilitative approach to patients treated for head and neck malignant neoplasms aims to address both the surgical defects and functional deficits. Free tissue transfer for reconstruction of large facial defects is considered the gold standard for many defects.1 Prosthetic facial restoration can be useful when surgical reconstruction is precluded by medical comorbidities, defect size or location, or patient preference.2 We reviewed the traditional methods of prosthetic fabrication and introduce digital methods that, when used in conjunction with traditional methods, allow the creation of a prosthesis with greater accuracy in shape and positioning. A man fitted with a prosthesis created through hybrid technology will be discussed. Report of a Case | A 55-year-old man with T3N2aM0 squamous cell carcinoma of the left side of the scalp, parotid, and neck underwent a left total parotidectomy, total auriculectomy, lateral temporal bone resection, condylectomy, and extended radical neck dissection. The defect was repaired with a large cervicofacial flap and skin graft, followed by uncomplicated adjuvant radiotherapy (Figure). He was deemed a candidate for a prosthetic recon-
struction owing to skin quality from the radiation and surgery, need for tumor surveillance, and desire for an ear restoration. Traditional Methods of Prosthesis Fabrication | The traditional method for prosthesis fabrication consists of 4 steps.3 An impression of the defect is taken and cast in dental stone. A wax model is sculpted onto this cast to resemble the missing anatomy. The final mold for the prosthesis is made from the finished wax sculpture. Pigmented silicone is layered onto the prosthesis to match the skin color and texture.4 This intrinsic color of the prosthesis is perfected with extrinsic coloring before final sealing and hair placement.5 Digital Methods of Prosthesis Fabrication | Digital design and fabrication offers several advantages over the traditional method. The impression stage can be bypassed or quickened using computed tomographic or magnetic resonance imaging scans for digital defect acquisition. A 3-dimensional model is made from the scans, and the unaffected side can be mirrored digitally to create an exact template for the defect side.6 The result can then be outputted using rapid prototyping technology, which greatly reduces fitting time. A 2-hour fitting appointment replaces the traditional 3 halfday appointments. Color matching remains a challenge for digital automation. The silicone material needs to be mixed and applied by hand, but commercial systems can match the patient's skin
Figure. A 55-Year-Old Man With Squamous Cell Carcinoma of the Scalp, Parotid, and Neck A
B
A, Patient after his surgery prior to prosthesis fabrication. B, Patient after prosthetic placement. jamafacialplasticsurgery.com
JAMA Facial Plastic Surgery March/April 2014 Volume 16, Number 2
Copyright 2014 American Medical Association. All rights reserved.
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153
Letters
color. The anaplastologist measures the skin tones with a spectrometer and chooses from the various premixed pigmented silicones. The longevity of the prosthesis is improved when more accurate intrinsic color is used, limiting the extrinsic coloring process (which can degenerate). Hybrid Digital Method | A hybrid technique for prosthesis fabrication is based on the same steps as traditional methods but blends digital technology. The ear prototype was produced using a digital scanner and an additive rapid prototyping machine. Traditional impressions of both the defect and unaffected ear were made. The cast of the unaffected ear was scanned, mirrored, and a model of the left ear was printed 3-dimensionally. The left ear was cast in wax and accurately positioned on the defect mold using digital photographs. When the patient returned for fitting, the ear was already positioned correctly. Texture and hair were added, and adhesives were used for fixation. By following the traditional methods and using digital tools, the prosthesis retention, comfort, aesthetics, and durability were excellent. This hybrid method seems to be quicker than traditional methods and includes the accuracy of digital technology. Conclusions | Facial prosthetics are viable options for some facial defects. This hybrid fabrication process facilitates an efficient workflow and accurate prostheses. Future developments in prosthesis retention, 3-dimensional modeling, and
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rapid prototyping technology will improve the ease of the prosthesis fabrication. Levi G. Ledgerwood, MD Janet Chao, MS Travis T. Tollefson, MD, MPH Author Affiliations: Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento (Ledgerwood, Tollefson); Phillip A. Danz and Associates Inc, Sacramento, California (Chao). Corresponding Author: Travis T. Tollefson, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, Facial Plastic and Reconstructive Surgery, University of California, Davis Medical Center, 2521 Stockton Blvd, Ste 7200, Sacramento, CA 95817 ([email protected]). Published Online: December 5, 2013. doi:10.1001/jamafacial.2013.2058. Conflict of Interest Disclosures: None reported. 1. Sakuraba M, Miyamoto S, Kimata Y, et al. Recent advances in reconstructive surgery: head and neck reconstruction. Int J Clin Oncol. 2013;18(4):561-565. 2. Mello MC, Piras JA, Takimoto RM, Cervantes O, Abraão M, Dib LL. Facial reconstruction with a bone-anchored prosthesis following destructive cancer surgery. Oncol Lett. 2012;4(4):682-684. 3. Huband M. Prosthetic rehabilitation. Dermatol Clin. 2011;29(2):325-330, x. 4. Erb RA. Intrinsic and extrinsic coloration of prostheses. In McKinstry RE, ed. Fundamentals of Facial Prosthetics. Arlington, VA: ABI Professional Publications; 1995:161-168. 5. McKinstry RE, ed. Fundamentals of Facial Prosthetics. Arlington, VA: ABI Professional Publications; 1995. 6. Schepers RH, Raghoebar GM, Vissink A, et al. Fully 3-dimensional digitally planned reconstruction of a mandible with a free vascularized fibula and immediate placement of an implant-supported prosthetic construction. Head Neck. 2011;35(4):109-114.
JAMA Facial Plastic Surgery March/April 2014 Volume 16, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a New York University User on 05/26/2015
jamafacialplasticsurgery.com
Prosthetic Reconstruction of Complicated Auricular Defects: Use of a Hybrid Prosthetic Fabrication Technique A multidisciplinary rehabilitative approach to patients treated for head and neck malignant neoplasms aims to address both the surgical defects and functional deficits. Free tissue transfer for reconstruction of large facial defects is considered the gold standard for many defects.1 Prosthetic facial restoration can be useful when surgical reconstruction is precluded by medical comorbidities, defect size or location, or patient preference.2 We reviewed the traditional methods of prosthetic fabrication and introduce digital methods that, when used in conjunction with traditional methods, allow the creation of a prosthesis with greater accuracy in shape and positioning. A man fitted with a prosthesis created through hybrid technology will be discussed. Report of a Case | A 55-year-old man with T3N2aM0 squamous cell carcinoma of the left side of the scalp, parotid, and neck underwent a left total parotidectomy, total auriculectomy, lateral temporal bone resection, condylectomy, and extended radical neck dissection. The defect was repaired with a large cervicofacial flap and skin graft, followed by uncomplicated adjuvant radiotherapy (Figure). He was deemed a candidate for a prosthetic recon-
struction owing to skin quality from the radiation and surgery, need for tumor surveillance, and desire for an ear restoration. Traditional Methods of Prosthesis Fabrication | The traditional method for prosthesis fabrication consists of 4 steps.3 An impression of the defect is taken and cast in dental stone. A wax model is sculpted onto this cast to resemble the missing anatomy. The final mold for the prosthesis is made from the finished wax sculpture. Pigmented silicone is layered onto the prosthesis to match the skin color and texture.4 This intrinsic color of the prosthesis is perfected with extrinsic coloring before final sealing and hair placement.5 Digital Methods of Prosthesis Fabrication | Digital design and fabrication offers several advantages over the traditional method. The impression stage can be bypassed or quickened using computed tomographic or magnetic resonance imaging scans for digital defect acquisition. A 3-dimensional model is made from the scans, and the unaffected side can be mirrored digitally to create an exact template for the defect side.6 The result can then be outputted using rapid prototyping technology, which greatly reduces fitting time. A 2-hour fitting appointment replaces the traditional 3 halfday appointments. Color matching remains a challenge for digital automation. The silicone material needs to be mixed and applied by hand, but commercial systems can match the patient's skin
Figure. A 55-Year-Old Man With Squamous Cell Carcinoma of the Scalp, Parotid, and Neck A
B
A, Patient after his surgery prior to prosthesis fabrication. B, Patient after prosthetic placement. jamafacialplasticsurgery.com
JAMA Facial Plastic Surgery March/April 2014 Volume 16, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a New York University User on 05/26/2015
153
Letters
color. The anaplastologist measures the skin tones with a spectrometer and chooses from the various premixed pigmented silicones. The longevity of the prosthesis is improved when more accurate intrinsic color is used, limiting the extrinsic coloring process (which can degenerate). Hybrid Digital Method | A hybrid technique for prosthesis fabrication is based on the same steps as traditional methods but blends digital technology. The ear prototype was produced using a digital scanner and an additive rapid prototyping machine. Traditional impressions of both the defect and unaffected ear were made. The cast of the unaffected ear was scanned, mirrored, and a model of the left ear was printed 3-dimensionally. The left ear was cast in wax and accurately positioned on the defect mold using digital photographs. When the patient returned for fitting, the ear was already positioned correctly. Texture and hair were added, and adhesives were used for fixation. By following the traditional methods and using digital tools, the prosthesis retention, comfort, aesthetics, and durability were excellent. This hybrid method seems to be quicker than traditional methods and includes the accuracy of digital technology. Conclusions | Facial prosthetics are viable options for some facial defects. This hybrid fabrication process facilitates an efficient workflow and accurate prostheses. Future developments in prosthesis retention, 3-dimensional modeling, and
154
rapid prototyping technology will improve the ease of the prosthesis fabrication. Levi G. Ledgerwood, MD Janet Chao, MS Travis T. Tollefson, MD, MPH Author Affiliations: Department of Otolaryngology-Head and Neck Surgery, University of California, Davis, Sacramento (Ledgerwood, Tollefson); Phillip A. Danz and Associates Inc, Sacramento, California (Chao). Corresponding Author: Travis T. Tollefson, MD, MPH, Department of Otolaryngology–Head and Neck Surgery, Facial Plastic and Reconstructive Surgery, University of California, Davis Medical Center, 2521 Stockton Blvd, Ste 7200, Sacramento, CA 95817 ([email protected]). Published Online: December 5, 2013. doi:10.1001/jamafacial.2013.2058. Conflict of Interest Disclosures: None reported. 1. Sakuraba M, Miyamoto S, Kimata Y, et al. Recent advances in reconstructive surgery: head and neck reconstruction. Int J Clin Oncol. 2013;18(4):561-565. 2. Mello MC, Piras JA, Takimoto RM, Cervantes O, Abraão M, Dib LL. Facial reconstruction with a bone-anchored prosthesis following destructive cancer surgery. Oncol Lett. 2012;4(4):682-684. 3. Huband M. Prosthetic rehabilitation. Dermatol Clin. 2011;29(2):325-330, x. 4. Erb RA. Intrinsic and extrinsic coloration of prostheses. In McKinstry RE, ed. Fundamentals of Facial Prosthetics. Arlington, VA: ABI Professional Publications; 1995:161-168. 5. McKinstry RE, ed. Fundamentals of Facial Prosthetics. Arlington, VA: ABI Professional Publications; 1995. 6. Schepers RH, Raghoebar GM, Vissink A, et al. Fully 3-dimensional digitally planned reconstruction of a mandible with a free vascularized fibula and immediate placement of an implant-supported prosthetic construction. Head Neck. 2011;35(4):109-114.
JAMA Facial Plastic Surgery March/April 2014 Volume 16, Number 2
Copyright 2014 American Medical Association. All rights reserved.
Downloaded From: http://archfaci.jamanetwork.com/ by a New York University User on 05/26/2015
jamafacialplasticsurgery.com
