The Finer Points of Microtia Ear Surgery

[Dr. Gopi Shah]
Okay. Then this is [laughs] a silly question, but are you always doing ipsilateral ribs? Do you ever?

[Dr. Mai Thy Truong]
Always.

[Dr. Gopi Shah]
Okay. Always. In your field as well, are y'all harvesting rib first or making your ear? You have a two-surgeon team. How do y'all get to play together?

[Dr. Mai Thy Truong]
First, let me just clarify, Burt Brent's technique is opposite rib. That is advantageous for two-surgeon teams because you're not in each other's way. Dr. Firmin liked the shape of having the rib from the same side because what happens is the curve of that cartilage is perfect for the curve of the ear, the base plate of the ear. That means that we're all on the same side, which is a little challenging. We started out a two-surgeon team, helping each other on the rib and then helping each other on the skin pocket. That way, Dr. Chang and I learned the surgery well together, but that took a long time. That was a long surgery.

Now we're really efficient because one person harvests rib, the other does the skin pocket. We work at the same time. Then when the rib is done, the remaining skin pocket area is dealt with, the part that couldn't get done because the surgeon was standing there.

[Dr. Gopi Shah]
Okay. In terms of rib harvest, it sounds like you and Dr. Chang go back and forth of who's going to harvest rib and then who's going to do the skin pocket, and then the grafting, or do you all have the same person doing the rib every time and the same person doing the pocket every time?

[Dr. Mai Thy Truong]
In the past, we took turns. For efficiency's sake, we have now at this point in our partnership, which I call my work marriage-- Yes, absolutely.

[Dr. Gopi Shah]
Absolutely. Those are important.

[Dr. Mai Thy Truong]
Yes. Right now, he's harvesting the rib and I'm doing the skin pocket. I'm so obsessive about the skin pocket. He probably prefers it because then he doesn't have me in his ear.

[Dr. Gopi Shah]
Okay. Let's just quickly talk about the rib harvest and then we'll get into creating the framework because that's a very important part of the surgery, as is the rib. You said you normally do the ipsilateral side for the Firmin technique. Is the incision, a couple of finger breadths below the nipple? Where's the incision usually?

[Dr. Mai Thy Truong]
The incision is along the costal margin. You have a costal margin and then two-finger breadths above that margin. Now, many surgeons approach this differently. There's two things you need to be able to do. One is you have to be able to get very close to that xiphoid to release the cartilage up near the xiphoid, which is really challenging because you don't want a pneumothorax and it's quite tight up there, but you also have to be able to access the floater because the floating rib is the helical rim and it's so important for how the ear looks.

Some surgeons like to put it right in the middle. Some like to favor near the xiphoid because that part is really challenging to get out. Some people like a 4-centimeter incision. We personally don't want to struggle and so we decide on a 5 to 7-centimeter incision.

[Dr. Gopi Shah]
At the end of the day, you have a scar there and beats a pneumo and beats not having enough ribs.

[Dr. Mai Thy Truong]
That's right.

[Dr. Gopi Shah]
Would you say it's similar to harvesting rib for airway surgery?

[Dr. Mai Thy Truong]
No.

[Dr. Gopi Shah]
Okay.

[Dr. Mai Thy Truong]
A rhinoplasty is very, very different. Because that you're identifying a single rib. It's very easy to go right subperichondrially, underneath, which is really safe. You're never going to get a pneumo. Whereas this, you're really harvesting this giant chunk of rib and you're releasing it at the bony cartilaginous junction at each rib and so I would say there's nothing like it.

[Dr. Gopi Shah]
In terms of when you're harvesting the rib and you're getting some of the muscle off of the rib, are you just using straight-up Bovie? Are you using coblations? Are you worried about the heat? What are some of the tricks you've learned in terms of rib harvesting?

[Dr. Mai Thy Truong]
It's mostly Bovie. Although, I just recently watched a bunch of surgeons, actually Kathy Sie and the Seattle group. They do a lot more cold dissection. I really liked it. I think either way, but you still have to use a Bovie to get some of those muscles off, the intercostal muscles.

[Dr. Gopi Shah]
You're talking about distinguishing the bone and the cartilage, which to me always felt a little hard. Sometimes--

[Dr. Mai Thy Truong]
The junction.

[Dr. Gopi Shah]
Yes. Is it visually pretty clear to you because you've seen so many or do you use a needle? How do you find that junction?

[Dr. Mai Thy Truong]
I remember as a fellow being freaked out because I was like, "I can't see the junction." Really being scared. Yes, using a needle and trying to differentiate the two. Now I really rely on cleaning the surface. If there's a little blood around the area, just washing it away and wiping it with a wet four-by-four. You can really clearly see that light purplish blue of that junction.

[Dr. Gopi Shah]
Okay. If you do end up having to check it with a needle or when you do use it, what gauge do you usually use?

[Dr. Mai Thy Truong]
I think we use, I don't know, 25 gauge.

[Dr. Gopi Shah]
Okay. Something small.

[Dr. Mai Thy Truong]
Something small, yes. Boy, that I'd have to ask Kay.

[Dr. Gopi Shah]
[laughs]

[Dr. Mai Thy Truong]
We haven't done it in a while.

[Dr. Gopi Shah]
Then in terms of Dr. Chang's instruments or your instruments for a rib harvest, do you have a special elevator that you like to use?

[Dr. Mai Thy Truong]
Yes, we do.

[Dr. Gopi Shah]
What do you like to use?

[Dr. Mai Thy Truong]
I knew you were going to ask the name of this instrument.

[Dr. Gopi Shah]
[laughs]

[Dr. Mai Thy Truong]
Because we call it the bone scraper.

[Dr. Gopi Shah]
Girl, the podcast is called BackTable, girl. We got to have something relevant to the back table besides my chattering.

[Dr. Mai Thy Truong]
Okay. Because it is the best instrument. I was so happy to hear-- I had just had a chance to operate with Kathy Sie, which is one of my dream come trues. We were just at a medical mission in Cambodia and we did microtia surgery together. I swear there was a moment in the operating room where the sun was shining on us both. You know what I mean? As we were holding an ear together. She liked it, this instrument. We call it the bone scraper.

The classic instrument is a Doyen. This Doyen is this lovely curled instrument that you can imagine curling under the rib and pulling it up in a safe way. It's a thin mini version with just a little curve to it for baby ribs. I love using that instrument to do the first dissection under the rib in a nice subperichondrial plane, maybe subperichondrial, but it's called the rib scraper.

[Dr. Gopi Shah]
Okay. When you dissect down on the rib, you take the muscle off, superiorly/inferiorly. You find your junction and then you start with the Doyen or the bone scraper and create a plane.

[Dr. Mai Thy Truong]
That's right. Yes.

[Dr. Gopi Shah]
Okay. Then how do you know how far laterally you're going to go and where your cartilage and its cuts are going to be to take off?

[Dr. Mai Thy Truong]
We go as far as we can. A helical rim is best when it's 10 centimeters, no matter what the ear is. Now, we don't always get 10 centimeters, but that's the goal, and so as far back as possible.

[Dr. Gopi Shah]
Okay. Are you using just a 15-blade? What do you like to use in terms of when you take that rib? Are you doing–

[Dr. Mai Thy Truong]
An angled cut. We like to have the rib scraper or the Doyen under the rib to protect. We get a 10-blade or a malleable. A malleable is also quite lovely because you can gently put it under and then cut onto the metal of the instrument.

[Dr. Gopi Shah]
Okay. That makes sense.

[Dr. Mai Thy Truong]
Beveled.

[Dr. Gopi Shah]
Beveled. Okay. Do you take a couple of like going a few millimeters at a time or do you feel pretty confident and it's in one or two swipes and that cut is released?

[Dr. Mai Thy Truong]
I think really the key is that I like to bovie above and below the rib. That really takes care of the blood vessels. There's always some on both sides, the superior and inferior edge of the rib. Really free those margins. Then as soon as you have that malleable under, the cut is pretty easy. Then someone is lifting it up.

[Dr. Gopi Shah]
Okay. Now we've put our framework together, and I think I went a little bit out of order, but let's go back to the skin pocket because it seems like, "Oh, you just make a little pocket," but there's obviously more to it. Tell me about the incision and creating the skin pocket.

[Dr. Mai Thy Truong]
I would say that there are multiple hard parts of microtia and this is one of them because that skin pocket will be the home of the new framework and its vascular supply. If you made little holes in it, if you bruised it, if you were rough on it, there's nothing like stretching that skin over something inert with no blood supply that will prove to you how delicate you were with that skin pocket. I'm pretty militant about that skin pocket because I've learned the hard way, if you accidentally bovied it or bipolared it or scraped it or held it with your Bishop, then after that stretch of the suction, then you'll have small dehiscences.

There are some principles on this skin pocket. Once you draw your ear where it should go and you look at the baby remnant, you have to decide, is that remnant going to give me a lobule? If it's a grade 3, is that lobular remnant in the perfect location that it can be transposed and rotated to be part of the lobule of the new ear? If the answer is yes, then you try to decide where that incision is. If the answer is no, then you're going to divide the ear and make a lobule out of your framework.

[Dr. Gopi Shah]
It's going to be a little bit different every time, just depending on what you get. In terms of the size of your pocket, do you ever worry that it's too big? I would imagine if it's too small, that's okay. You can always make it bigger. Is it ever an issue if the pocket is just too big?

[Dr. Mai Thy Truong]
You actually have to dissect a pocket that is at least 1 centimeter beyond the line of the ear, where the ear goes, because of the skin draping. You need to know where your superficial temporal artery is. The goal is not to ding it.

[Dr. Gopi Shah]
That's going to be so painful because we don't want any bipolaring or Bovie. We want to try to keep it as dry.

[Dr. Mai Thy Truong]
It's a disaster. Yes, it's all. Especially if it's an atypical placement and the artery goes under the remnant, then it's just super stressful. You look at where the artery is, you make the pocket. After learning how to make your skin incisions, the next challenge is the thickness of the skin. Because you want it thin so that you see all of the framework and it looks nice, but if it's too thin, it all dies. You want it thick so it has a nice blood supply, but if it's too thick, you have what I call a teddy bear ear.

[Dr. Gopi Shah]
That makes sense because you can't see any of the defined cartilage under the teddy bear. This might sound like a silly comparison, is it like when you're doing a parotid and you're raising your skin fat up, fat down kind of thing, or?

[Dr. Mai Thy Truong]
Extremely similar. What makes it challenging is you removed a remnant with cartilage in it. The microtia ear had a cartilage remnant. After removing it, there's all these muscular fascial planes that had enveloped that ear that give you a false sense of where that plane is.

[Dr. Gopi Shah]
Oh, okay. How do you find the plane that you need to be in?

[Dr. Mai Thy Truong]
I like to look for it inferiorly near the mastoid, away from the remnant. Because then we could do it like a parotid, where it's light, transilluminating. My co-surgeon, or at Stanford, I have this amazing nurse practitioner, Charlie, who works with me and knows exactly how to guide me. I move from there and then I move towards where the remnant was, where it gets challenging.

[Dr. Gopi Shah]
That makes sense. Now, any tips or tricks when you're actually putting the framework in the pocket?

[Dr. Mai Thy Truong]
We made the pocket, we made the framework. We love it. It's a little perfect ear. We're about to go put it in.

[Dr. Gopi Shah]
Does it just slide in or is this like doing a posterior?

[Dr. Mai Thy Truong]
No.

[Dr. Gopi Shah]
Graph for the-- Is it like putting an ear tube in, where it just pops in, one of those Armstrong grommets?

[Dr. Mai Thy Truong]
No. I actually call it phase three so that mentally no one thinks that the surgery is almost over.

[Dr. Gopi Shah]
I love that.

[Dr. Mai Thy Truong]
Because it is so hard. First, you put a drain in. You put the drain in because you need that suction to create the skin coaptation. Then I call it the Cinderella moment, where you remember in Cinderella when the sisters were trying to put the shoe in and they're like, "I'll make it fit."

[Dr. Gopi Shah]
Yes.

[Dr. Mai Thy Truong]
You got to get that framework in. Then something that really always amazed me with Dr. Firmin was that she already knew where skin was going to lie even before putting the framework in. I'm trying to get a sense of that now, and I think I'm getting much better with more experience. Once you put the framework in and you have that lobule translocated, there's always excess skin. Knowing where to safely cut the skin is the battle.

That battle can take hours. Because you don't want to lose your anterior blood supply. That's the most robust blood supply, which comes from that superficial temporal artery, but your remnants from that microtic ear is what makes the ear ugly, which I call the nubbin. The more nubbins you have, the uglier the ear is. I've thought a lot about this when I look at our previous dehiscences and our previous wins and losses, and what I've learned is, it's better to delay removal of nubbins for safety of the flap, then deal with it at the next surgery.