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BackTable / ENT / Podcast / Transcript #104
Podcast Transcript: Microtia Surgery in Children
with Dr. Mai Thy Truong
In this episode of BackTable ENT, Dr. Gopi Shah discusses microtia repair techniques with Dr. Mai Thy Truong, fellowship director of pediatric otolaryngology at Stanford University. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) Comprehensive Care for Microtia: From Initial Consultation to Surgical Decision-making
(2) Microtia Surgery: Enhancing Precision through 3D Printing and Modeling
(3) Technical Insights into Rib Harvesting in Pediatric Microtia Surgery
Pleural Defect Management in Pediatric Microtia Surgery
(5) Auricular Reconstruction in Microtia Surgery: Proportions and Techniques
(6) Carving and Suturing Techniques in Ear Reconstruction Surgery
(7) Crafting the Ideal Skin Pocket for Microtia Surgery
(8) Drain Choices in Microtia Ear Surgical Procedure
(9) Surgical Closure Techniques in Microtia Ear Surgery
(10) Antibiotic Protocols Following Microtia Ear Surgery
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[Dr. Gopi Shah]
Hello, everyone. Welcome to the BackTable ENT podcast, where we discuss all things ENT. We bring you the best and brightest in our field with a hope that you can take something from our show to your practice. My name is Gopi Shah. I'm a pediatric otolaryngologist, and I have an awesome guest and a great episode for us today. I have Dr. Mai Thy Truong. She is a Clinical Associate Professor and pediatric otolaryngologist practicing at Stanford Children's in California, where she is the Clinical Chief and the Fellowship Director for pediatric otolaryngology.
I had the awesome opportunity to get to work with Mai Thy on the fellowship committee for ASPO, the American Society of Pediatric Otolaryngology, so I feel super excited. It's my great pleasure to have her here today to talk about something she's so passionate about, which is microtia surgery in children. We're going to focus on surgical tips and tricks. Welcome to the show, Mai Thy. How are you?
[Dr. Mai Thy Truong]
I'm good. Thank you so much for having me.
[Dr. Gopi Shah]
I'm so glad that we finally got to do this [crosstalk] Before we get into it, I do want to tell you thank you. In Paris, I've been able to get to know Dr. Charlotte Célerier from Necker Children's. A quick shout-out to Charlotte. Thank you for that introduction.
[Dr. Mai Thy Truong]
Hi, Charlotte. I wish I could round with you guys at Necker. So fun.
[Dr. Gopi Shah]
It's a great hospital. Before we get into microtia, can you tell our audience a little bit about yourself and your practice?
[Dr. Mai Thy Truong]
I practice at Stanford Children's. I went to undergrad at UCLA and I went to medical school at UC Irvine, and I did my residency at Stanford. I did my general surgery internship and my otolaryngology residency there. I also did my pediatric otolaryngology fellowship. It's there that I fell in love with microtia surgery with my attending at that time, and now my colleague, Dr. Kay Chang. After being in practice for a bit, we had a chance to train in Paris with Dr. Francoise Firmin to learn her technique for microtia. That's a little bit about my training.
[Dr. Gopi Shah]
That's amazing. In fellowship at Stanford, you got really good microtia training there, and then you were able to do even more training in Paris.
[Dr. Mai Thy Truong]
Yes. The history of it is actually quite typical for an American microtia surgeon, which is that Kay Chang was trained in the Brent technique, which is three stages or three surgeries to complete a microtia, and a lot of the world was switching over to two-stage techniques. When I joined him, he was really ready to switch to a two-stage technique for the advantages that it has. We had the opportunity to visit Dr. Firmin and have a chance to see what it was like, and then realize that I needed to spend more time with her to really learn it.
(1) Comprehensive Care for Microtia: From Initial Consultation to Surgical Decision-making
[Dr. Gopi Shah]
Before we get into the surgical techniques, when do you usually meet these families? Do you ever have any prenatal visits, or do you meet them in their first six months of life? When is your first meeting with some of these kids?
[Dr. Mai Thy Truong]
That's a great question. I would say the majority of families don't get the prenatal diagnosis. That's because if you look at an ultrasound, the way the ear is shaped, it's very hard to catch the ear in a single plane. A microtia ear, unless there's an anotia, even then it's just too hard to see. I think if you get a 3D ultrasound, maybe you'll catch it, but most families don't know. Usually, it's like a surprise at delivery. My heart goes out to these parents, especially the moms. It's like the surprise that you weren't expecting, so we like to consult when they're born. That initial consultation is in the hospital, or if they're born in another hospital, after their newborn hearing screening, I'll see them in their infancy.
[Dr. Gopi Shah]
Okay. Then when you meet the family, I find that that first conversation can be really difficult in terms of explaining everything that's going on and the trajectory of it. What is your conversation like?
[Dr. Mai Thy Truong]
First, I really want to design it well, so the first thing is, these patients get extra long visits. It's not my standard new patient visit. We double-team it, Dr. Kay Chang and I. We're a two-surgeon team. We're like mom and dad in the OR and in consultation. We're a really good balance. We sit down with the parents. I really like to get a feel on emotionally where they are, because if they're just not there, then our first visit is just to hold their hands and really remind them that their kid is going to grow up and be awesome, no matter what they choose.
We purposefully divide the conversation into hearing topics, and then ear reconstructive topics. We ask the parents, "Where would you like to go with this conversation?"
[Dr. Gopi Shah]
How do you usually follow them? What's your follow-up plan until you start considering surgery?
[Dr. Mai Thy Truong]
We see them initially as a newborn until a hearing status is decided. If it's very straightforward, we fit them with a hearing device, which is called the Baha on a soft band. As soon as that's ready, then we see them once a year.
[Dr. Gopi Shah]
When you see them once a year, are you getting audios as well on your good ear? I find that initially when I first started practicing, sometimes I would be so focused on the microtic ear, but I would feel like, "Wait a second, that good ear needs to be extra specially taken care of." Meaning this is your ear where if we're starting to get ear infections or fluid, or if there's any concerns in school and where the child should sit, do y'all talk preferential seating and talk to the families about some of that?
[Dr. Mai Thy Truong]
Yes. I think every year our goal is like, "Are they wearing their hearing aid, their Baha Softband?" If not, are we doing an FM system at school? Are they getting their preferential seating? How are they coping with it? We always like to talk to them about advances in hearing devices and hearing implants, the ear health of the other ear, any obvious genetic syndromes that may be more apparent and other consults that may be needed, and then a check-in with the parents, like, "Hey, how are you guys doing? Any speech delay? What are you guys thinking about surgery?" All the surgical options.
For me, it's really important, whatever surgical option they choose, I want to help them coordinate the care. That it's very planned.
[Dr. Gopi Shah]
Absolutely. Then on those check-ins, the yearly check-ins, are you getting just an audiogram usually, a behavioral audio?
[Dr. Mai Thy Truong]
I get an audiogram, then two things that we like to do is we like to measure their normal ear and measure their chest frame. Measuring their normal ear gets us a sense of when the ear stops growing. After doing this for many years, it becomes very apparent there are growth spurts in the ear where we'll see them, we're like, "Your ear grew 5 millimeters."
Then when we're trying to decide, "Is this a good age to do surgery?" "Your other ear has stopped growing." It's just nice to know.
[Dr. Gopi Shah]
I feel like the textbook teaching is about six to seven years old of when it's about 80%. Is that a good number or do you find with the measurements, there's a wider range or it could be younger or much older even? What have you found?
[Dr. Mai Thy Truong]
I think that five to six is 80% is about right, but seven to nine, that growth is pretty stable. 7 to 10, that's a preferable age.
[Dr. Gopi Shah]
When you take the chest measurements, where exactly are you placing the measuring tape? I would imagine the chest would probably continue to still grow. Is there a certain cutoff? What are you looking for in that measurement?
[Dr. Mai Thy Truong]
This is not perfect. The idea is we're trying to see if the chest frame is robust enough for surgery. Something that's very standard is at the xiphoid. We take it at the xiphoid, we go all the way around. It's not a perfect measurement. If the child is obese, it's not a good reflection of their chest frame, but it's something. We have a standard goal of 60 centimeters. We've learned that if there's 60 centimeters circumference, then in general, we'll have enough cartilage to make an entire ear.
[Dr. Gopi Shah]
Okay. Sorry to jump back to the ear measurements. Are we doing length, width, projection? Is it with one of those measuring tapes? Are you getting a protractor out? What's happening?
[Dr. Mai Thy Truong]
This is awesome because it's weird. If you look at an ear, no matter what, there's at one point, the longest point. We just pick the longest point. I have this special caliper. I got it from Dr. Fee. My old head and neck attending. He called it the golden rule. It has a little clasper, so it can pretty accurately measure the ear.
[Dr. Gopi Shah]
That's from bottom of the earlobe to the--
[Dr. Mai Thy Truong]
To the very tippy top.
[Dr. Gopi Shah]
Okay. Got it.
[Dr. Mai Thy Truong]
Wherever along the ear it's longest.
[Dr. Gopi Shah]
Okay.
[Dr. Mai Thy Truong]
Which I call the ear access. Ears have an access. Some people have really turned ears, and some people have ears that are really straight up and down.
(2) Microtia Surgery: Enhancing Precision through 3D Printing and Modeling
[Dr. Gopi Shah]
Okay. That's also very good to know. All right. Let's get into the surgical details because unless, like you said, you really have had a lot of training in microtia or that's what you plan to do, I would say most of us aren't going to be doing microtia surgery, but we do have to understand how it works. Also, again, what is our screening process for the other ear? Which we were able to touch on. I wanted to talk to you, Thy, about the surgery, given your expertise and experience.
Let's say the child is seven years old. You feel that the growth in the chest is, it's the robust 60 plus centimeters. The ear, the last year or two, has hit its maybe peak or that 80% to 90% of what we normally think. We're talking about grade 3 microtia. We can focus on that, I think, first. For your preparation, are you using 3D printing? Is that part of your preparation? Tell us how you start kind of planning your surgery.
[Dr. Mai Thy Truong]
Okay. The first thing is we get a CT scan for all kids. That allows us to understand the temporal bone anatomy. Make sure we know if they're a good candidate for ear canal reconstruction. Make sure there's no cholesteatoma or anything happening behind the little ear, the underdeveloped ear that we can't see. That gives us information about the other ear.
I meet with a company that takes that really fine detail of the other ear. We make it into a mirror image. We have what we call a planning session. We take it and we design each individual segment that I would actually carve during surgery, which is the helix, the antihelix, the tragus-antitragus complex, and then make an actual 3D printed model. The thing that's different about this than other people who say they use models is that it's high fidelity. Our CT scans are 0.25 millimeter thickness. It's printed in a sterilizable material. You know how some 3D prints are just globby? This is really a perfect ear.
We've learned how to design it in a way that really matches the surgery, which means it actually has to be a little bit smaller than the regular ear to account for the skin envelope. You have to design it in a way that's similar to how you carve it. For every surgery, I have this ear that I'm holding in my hands to help me carve. When you first start carving an ear, it's so complex, the three-dimensionality of it. The traditional surgeon uses photos that are posted on the wall of the patient, and then a flat drawing on an X-ray film.
It's very hard to know the peaks and the troughs and how things relate to each other, so as an early carver, having this ear in my hands, I've really learned a lot about the relationship of each thing. I just think anyone who's starting out doing microtia surgery, I think they should have this 3D model. By the end, it's so funny because I showed Dr. Firmin my 3D model and I was just so proud of myself. I was like, "Look, Dr. Firmin, what we're doing now." She looked at it and she was like, "I don't need this." She didn't.
[Dr. Gopi Shah]
Then in terms of the Firmin technique, you have your CT scan, your 3D model, and now the patient is in the OR, are there measurements that you take or anything that you do before, the prep and all that stuff? Are these measurements in the office, the OR? Let's get into that.
[Dr. Mai Thy Truong]
The weirdest thing about prep for this surgery, as opposed to other reconstructive surgeries that we do, is that we're trying to match something to the other side, which happens to be on the other side of the head, which is not always in your field of view. Then there's all these things about the ear, how tall it is, how front or back it is, and then how turned it is. Surgeons have tried many different ways to do this and it's quite challenging. Some surgeons will leave the whole head prepped, in view for the surgery, so that they can constantly refer back to the other ear.
I worry constantly about sterility because the nose and the mouth and the eyes and the hair, we're putting a cartilage framework into a pocket. I just don't want any risks of infection. This 3D modeling that I do, the amazing thing is I can work with a computer programmer and we can place it perfectly in place on a picture. The way we do it is we use the actually skull landmarks. We line up the orbits and line up all the mastoid suture lines and actually the bony landmarks instead of the soft tissue. Then we place the ear.
Before surgery, I have a picture of where the new ear should go relative to the microtia ear. At the end, when I draw my drawings, I have this comparison. It's not perfect, but it's really nice to know, "Hey, this looks very similar to my 3D printing." That's really upped our game in terms of size and placement.
[Dr. Gopi Shah]
Do you use that to help you decide where your incisions are made or in relation to what level of the eye you're putting it, the angle? Tell me exactly how the drawing and the details of that help you. How do you apply it, I guess, when you're operating?
[Dr. Mai Thy Truong]
You do some measurements from the canthus to where the new ear should go, both the oral and the ocular canthus. Then you take measurements relative to the nasal dorsum. Then you draw where your ear should go. Then to decide on your incision, you say, if this is where the new ear should go, how do I make the skin of the microtia ear go there? Then decisions are made on incision.
[Dr. Gopi Shah]
Wow. Okay. At this point, the patient is not prepped and draped. Your markings are giving you an idea and a measuring. Patient is asleep, your bed is 180, all that, but this is the pre-marking everything out.
[Dr. Mai Thy Truong]
Yes. I really do think the time spent for that stage is really, really important. That 3D picture that I get from the company ahead of time, I actually do that in my mind. I have decided on the incision from that 3D modeling session.
[Dr. Gopi Shah]
Then you have the model with you in the OR and you do your measurements, figure out your landmarks, and then you can also place the model and then see how that then is, how you want to do your incisions based on that. That's very cool. Okay. Then are you tegaderming the eyes and then prepping everything out? Are you covering the mouth with your towels? I think these details are important.
[Dr. Mai Thy Truong]
The classic Firmin approach is that once you do your drawings, the most important drawing on the face near the ear is the angle of the ear, the axis of the ear. On the cheek, there's going to be an arrow that will guide you to which axis the ear should be placed once it's in its pocket. That drawing is left on the cheek near the ear and will be in the field. I cover it with a Tegaderm so that it doesn't get washed away with the surgery. Then I have my drawing of where the ear should go, and I cover everything else up.
[Dr. Gopi Shah]
Okay. You're not using the contralateral ear at this point. You don't need to because you have your models and your measurements.
[Dr. Mai Thy Truong]
Yes, and my drawings.
(3) Technical Insights into Rib Harvesting in Pediatric Microtia 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.
Pleural Defect Management in Pediatric Microtia Surgery
[Dr. Gopi Shah]
Then let's say, got the rib out, how do you check for a pneumothorax or some sort of pleural injury? Do you usually do Valsalva? Tell me about that.
[Dr. Mai Thy Truong]
This is good because it's such a huge excision. It's really important to me that it's not a single Valsalva. We fill the cavity up with water and then we do a Valsalva. If you just do a single Valsalva, then those little openings can actually just be a little tamponaded and you could miss it. I actually was just with a surgeon who I liked the way he said it. He's like, "You got to burp the wound." I don't know if you've ever heard that before.
[Dr. Gopi Shah]
I don't think I have. Explain that one.
[Dr. Mai Thy Truong]
Scott Bevans. He's like, "You got to burp it." I was like, "Okay." Where he had the anesthesiologist breathe in and out.
[Dr. Gopi Shah]
Ah, okay.
[Dr. Mai Thy Truong]
To let little air bubbles out. I really liked that. We would just do it a couple of times. That's a great way to find little openings in the pleura.
[Dr. Gopi Shah]
If you do have a pleural defect, what do y'all do?
[Dr. Mai Thy Truong]
We repair it. The repair is with a 4/0 Vicryl and a taper. The biggest thing is to not be scared about it because small pleural openings are no big deal. I learned that with Dr. Firmin because they used to freak me out. She would say, "I did this for you so you can see nothing to be scared of." It's really key. I like purse string closures of these small openings. I like to put a red Rob Nel catheter to suction out the air as you're closing. Because if you will get a chest X-ray, you will see the air otherwise. The small amount of air, but you have to decide what you want to do about the air that you see. If you're going to chase it or leave it. Then I like to cover it with a little bit of muscle. If there's a big defect, I'll do a purse string closure and then rotate a little bit of that muscle to cover it as a second layer.
[Dr. Gopi Shah] When you close that incision, are you leaving a drain in on top of the muscle then? Now let's say you've repaired the pleural defect. You've used the-- What did you call the catheter? The red Rob Nel.
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
Sorry. You've closed over that and you slowly remove that as you've closed that to get as much air out.
[Dr. Mai Thy Truong]
It's kind of that one, two, three, pull. You connect the red Rob Nel to suction and then you pull it out, and as you pull it out, you close the closure.
[Dr. Gopi Shah]
Okay. You're not leaving Penroses or anything like those types of drains in.
[Dr. Mai Thy Truong]
I just operated with a bunch of surgeons who leave no drains in their chest wounds. Neither did Dr. Firmin. At Stanford, we place something called an ON-Q pump, which is like a little bulb that gives a constant drip of bupivacaine. We've learned that that really helps with the post-op pain. That's placed at the layer of the muscle. It can be quite a bit of fluid, so at the other end of the wound in a different plane, we do leave a JP bulb just so that we can collect excess fluid.
[Dr. Gopi Shah]
Okay. In terms of the rib incision, seromas and those kinds of things aren't as common.
[Dr. Mai Thy Truong]
No, because we put a JP in.
(5) Auricular Reconstruction in Microtia Surgery: Proportions and Techniques
[Dr. Gopi Shah]
Got it. Okay. Now we've done the rib harvest, let's talk about what you're doing at the back table and creating the framework. You have this rib, I assume that's what you also use the 3D model that you have.
[Dr. Mai Thy Truong]
Yes. It's interesting. I prepare all the surgeons in the room for the three phases of microtia surgery. That's to mentally prepare them. Phase one is two teams harvesting the rib and preparing the skin pocket. The preparation of the skin pocket is probably the most important for the outcome of the surgery. There's two main battles. You must make a nice framework because nothing is hidden under the auricular skin. That's a commandment from Dr. Firmin. She has 10 commandments.
It's so true. You can have a beautiful skin pocket, but if your framework at the end of the day is not harmonious or not nice, it will be evident. It may not be evident in the first post-op week, but in four months when the skin edema is all gone, then you'll see it. Skin pocket is important and it's all about planning your skin approach. That's done and then we go to the back table. Then we have our 3D model. We use that model to then draw X-ray film to cut it out to decide which piece of rib goes to what.
[Dr. Gopi Shah]
Is it the same floating for the helix every time or do you re-look at everything that you have in terms of the rib you have and then decide?
[Dr. Mai Thy Truong]
You look at the rib that you have and then decide. There are some classic patterns. One branch point is, is that floater big enough for a helical rim? Yes or no? On a smaller kid like age seven, a lot of times the answer is no. When it's not, at the harvest, we go for the next rib. We actually harvest bigger rib. That's decided intra-op while the rib is being harvested often.
[Dr. Gopi Shah]
You talked about the five microtia subunits, I think. You talked about creating the helix. Can you go through those? Are you creating those subunits separately first? Does it all carve out as one piece? How does that work?
[Dr. Mai Thy Truong]
No. I definitely draw each piece on all the ribs that's harvested and I plan it before any cut is made. That used to stress me out because once you cut that's all the rib you get. The most important for me is having a good base plate because that's the ear itself. Then I think the antihelix is the next important thing. There's two worlds of thought. The antihelix or the Y piece is either a single piece that you cut right in half and you split or a wide piece of rib that you cut out in between. I can look at a surgeon and their work or their ears and I'll know which they did. Of course, what I'm looking at is probably not what anyone else is looking at, but deciding where those pieces come from is the next step, and inking it out.
[Dr. Gopi Shah]
Then after you've inked it out and you feel good with the subunits you have, I assume you look at the model-- I just see myself walking in circles, second-guessing myself. Anyway. Then what's your next step? Then what do you do?
[Dr. Mai Thy Truong]
The inking it out is actually quite a big deal.
[Dr. Gopi Shah]
Are you just using one of those purple skin marking pens, they have it on the back table for you, or is there a special cartilage inking pen?
[Dr. Mai Thy Truong]
Dr. Firmin and Dr. Nagata use this amazing damping paper. They would dip it in ink. They would cut it out and then they would literally stamp on the cartilage. It was the most amazing thing. It was this beautiful stamp of the ear. That ink that they used is not FDA-approved, so we can't use it. I just use a purple marker. You end up going through quite a few markers because it doesn't last, but they're only $2. It's okay. Then drawing it out. There's like a little art to it because you have to dot around but draw on the inside. It's all about proportions. If you aren't aware of where you cut relative to the inside or the outside of your drawing, your proportions will be all wrong.
[Dr. Gopi Shah]
You're talking about the width of the actual ink or the mark?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
Because we're talking about millimeters at this point. Do you always do it the same way where, okay, I know that my outside is going to be bigger than my inside and the inside of the dot is more consistent with the framework and the model, or?
[Dr. Mai Thy Truong]
I know that because I'm using a cut-out piece of X-ray to draw onto the rib and then I'm dotting around it, so then I remove it and I draw on the inside of that line and then I'll cut on the line.
(6) Carving and Suturing Techniques in Ear Reconstruction Surgery
[Dr. Gopi Shah]
What do you use to carve? What kind of blade do you like?
[Dr. Mai Thy Truong]
I'm really particular. We always need to have an 11-blade, a 10-blade, a 15-blade, and a 2, 3, and 4-hole punch, as well as some carving tools. The punches, I learned, are always sharp because they're disposable. They're amazing to carve out the scapha. Dr. Firmin has these lovely carvers to scoop out those pieces. What I learned over time is that there are these really curved places that you're carving and the best way to get those curves are with an 11-blade because it's very sharp.
You're going to get through these really amazing curves with the 11-blade, but what you're going to realize is that it's very hard to get full thickness with an 11-blade. You'll start to curve but you won't be full thickness. If you try to go back with the 11-blade, then you'll cut into your original curve and so people are scared to use the 11-blade. I always say in my carving sessions that you start with the 11-blade to get those beautiful curves but you finish with the 15 because the 15 is small and then can follow the curves without re-cutting into it. Does that make sense?
[Dr. Gopi Shah]
Yes, it does. You're not scraping or cutting into the piece that you actually need. You want to have a clean through and through cut.
[Dr. Mai Thy Truong]
Exactly, yes.
[Dr. Gopi Shah]
Okay. I need to take one of these carving courses. What are you holding the cartilage with? What kind of forcep? I would imagine you have in the other hand, or are you holding the cartilage–
[Dr. Mai Thy Truong]
Fingers.
[Dr. Gopi Shah]
Your own hands?
[Dr. Mai Thy Truong]
Yes. I have all these memories of watching Dr. Firmin carve because it's an amazing thing to watch. She would often cut herself, every surgery, because we were using needles and knives. Changing gloves is just have 30 sets of gloves. I wouldn't say that I cut myself that often, but I'm really big into haptics. I love how my fingers feel, how the instruments feel. I really feel like feeling it is important.
[Dr. Gopi Shah]
Are you using loops?
[Dr. Mai Thy Truong]
Loops.
[Dr. Gopi Shah]
Loops. Okay. Then what if you break it or it bends, what do you do?
[Dr. Mai Thy Truong]
I cry? No, I'm just kidding.
[laughter]
[Dr. Gopi Shah]
What if something happens, what do you do in those situations? Let's say just I can imagine the cartilage in some places it's just getting too thin to manipulate, right?
[Dr. Mai Thy Truong]
This is why carving is so stressful and it's not one of those things we're like, "Hey, try it." You know what I mean? You've got to practice. I practiced on foam. Foam because that's what Dr. Firmin chose. I love it. It's very similar. You just can't make that mistake. I think that's why the helical rim is so stressful too. We spend a lot of time on the helical rim. Actually, while one person is carving the base plate and the antihelix, one person is doing the helical rim. Because it's really thin, one wrong move and it will break.
[Dr. Gopi Shah]
That's probably the one part that everybody looks at, right? The most visual part of the repair. Tell me about putting the parts together now. What kind of sutures do you use for that?
[Dr. Mai Thy Truong]
Okay. There's two worlds to do this. One is with monofilament sutures, clear sutures. The other is steel sutures. Nagata and Firmin are classically steel sutures.
[Dr. Gopi Shah]
What O is that?
[Dr. Mai Thy Truong]
5/0. 5/0 steel. I personally believe in it. Originally we started with sutures, Dr. Chang and I, because we didn't have the steel. It's really hard to get unless you know how to get it. I have two reasons. One is we use steel sutures on straight needles. That allows you to pin the framework in place onto a block. That really sets the shape. The other thing is when you're spinning a wire–
[Dr. Gopi Shah]
I was so bad at it, but I remember spinning the wire.
[Dr. Mai Thy Truong]
Remember spinning the wires?
[Dr. Gopi Shah]
It wasn't always tight enough or it would spin on itself. I was really bad at it.
[Dr. Mai Thy Truong]
Do you remember how there's a lot of tension in the wire? Did you have them pre-tighten the wire? Do you remember your scrub tech doing that?
[Dr. Gopi Shah]
I don't remember that as well.
[Dr. Mai Thy Truong]
There's something about wire that has tension in it that there's more or less that you have a sense of. There's something about how you can spin a wire and not actually place that much tension on these two pieces of cartilage. Whereas tying a knot down and keeping that tension so that the knot doesn't move, in my mind, always places tension on that cartilage. With cartilage ears, you always worry about resorption. When there's resorption, you're trying to figure out why.
There was this brilliant study by a Chinese group that did consecutive microtia repairs with monofilament sutures and then with wires. They happened to use titanium wires, but titanium and steel I think are probably similar. They showed that the wire had less resorption. When I say consecutive, I mean hundreds. Their practice is so robust. Their study of their outcomes was so robust also. We use wires. We spin them.
[Dr. Gopi Shah]
Okay. You spin them. This might be a dumb question, but you use your needle driver to help you spin them, you're spinning them with your hands? I don't remember. Maybe having something with my needle driver and using that initially just to see how far down I wanted it to go.
[Dr. Mai Thy Truong]
It's a wire spinner actually, made for wires. This natural grip that you spin. Then you see the loops and then you feel the tension in the wire as you spin.
[Dr. Gopi Shah]
Okay. Can use regular suture scissors or do you have to use a wire cutter?
[Dr. Mai Thy Truong]
Wire cutters.
[Dr. Gopi Shah]
Okay.
[Dr. Mai Thy Truong]
Literally, there's this little pile of wires in the back table when you're done.
[Dr. Gopi Shah]
Then after you've cut, do you have to curl them down the edge?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
How long is your tail?
[Dr. Mai Thy Truong]
2 to 3 millimeters.
[Dr. Gopi Shah]
Okay. Then you [unintelligible] just a single bend or something so it doesn't stick out?
[Dr. Mai Thy Truong]
Yes. We used to obsess about cutting a little edge with the wires. Honestly, the framework gets enveloped in a capsule. As long as it's flush, it's been good, but it does have to be flush against the framework. I always laugh when we're doing this wiring because it's intimate because we're both holding the ear, me and my co-surgeon, which is usually Dr. Chang unless I'm on a medical mission. I'm not even thinking about it, but I'm actually holding their hand.
[Dr. Gopi Shah]
To make sure that it's stable, you need all hands on deck, if you will.
[Dr. Mai Thy Truong]
Yes. I'm holding the framework and I'm holding their hands while I'm spinning because I'm just trying to get a sense. I had someone tell me recently, oh, I was holding their hand. I was like, "I was?"
[Dr. Gopi Shah]
[laughs] What's the order of putting the subunits together?
[Dr. Mai Thy Truong]
There is an order.
[Dr. Gopi Shah]
What is it?
[Dr. Mai Thy Truong]
Absolutely.
[Dr. Gopi Shah]
Because I can imagine it's got to turn and twist a little bit, right?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
There's going to be a little rotation as--
[Dr. Mai Thy Truong]
That's right. If something is off, the ear is not harmonious. You have a base plate and then it's always the antihelix because that little Y, if it's pointing in the wrong direction, everything is off. It's the base plate and then the antihelix. Then after the antihelix, it is the support, which Dr. Firmin calls the P1. That is a support under the base plate, which then supports the root of the helix and the tragus. It helps make the ear a complete circle. It's base plate, antihelix, P1, helical rim, tragus, anti-tragus.
(7) Crafting the Ideal Skin Pocket for Microtia Surgery
[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.
(8) Drain Choices in Microtia Ear Surgical Procedure
[Dr. Gopi Shah]
That makes sense. What size drains do you use?
[Dr. Mai Thy Truong]
Seven.
[Dr. Gopi Shah]
Are these like the JP?
[Dr. Mai Thy Truong]
No. It's like facelift drains.
[Dr. Gopi Shah]
Okay.
[Dr. Mai Thy Truong]
I think the 10 French.
[Dr. Gopi Shah]
Are these–
[Dr. Mai Thy Truong]
Round.
[Dr. Gopi Shah]
Okay. Two of them? One of them?
[Dr. Mai Thy Truong]
We used to do two, but I've learned that you can get away with one and most microtia surgeons use one.
[Dr. Gopi Shah]
Okay. Is it just like a bulb suction? I've seen it attached to a test tube before.
[Dr. Mai Thy Truong]
Test tubes are great because it's a little amount of suction. The amount of suction in the test tube, it's like a 5cc, right? 5cc test tube gives you that amount of suction, but it has to be changed every four hours. That is the classic Burt Brent technique, but it was very labor-intensive for the nurses and quite stress-inducing. Because they have to stab the test tubes.
[Dr. Gopi Shah]
Yes. They get clogged. I remember them getting clogged. You're-- What is it called? Trying to milk it a little bit to get the clot out.
[Dr. Mai Thy Truong]
We switched to a ConstaVac.
[Dr. Gopi Shah]
What is that?
[Dr. Mai Thy Truong]
I'm embarrassed because it's so fancy.
[Dr. Gopi Shah]
It's Stanford, girl. Y'all can do that.
[Dr. Mai Thy Truong]
We're fancy.
[Dr. Gopi Shah]
Yes, absolutely.
[Dr. Mai Thy Truong]
It's this box-based drain that has a lower amount of suction than your wall suction. It's really nice because it allows you to turn the suction up, turn it down and have this almost equivalent to your 5cc test tube amount of suction, but you never lose it because it's based on a battery, so it's nice.
[Dr. Gopi Shah]
That stays in for how long?
[Dr. Mai Thy Truong]
By the way, a JP bulb is probably fine. Many surgeons use just a JP bulb and it works great because that bulb in itself isn't that much suction either. It stays in. This part I just do because I did what Dr. Firmin did. You know what I mean? For about three days.
[Dr. Gopi Shah]
Are your kids in the hospital for all three?
[Dr. Mai Thy Truong]
Yes.
[Dr. Gopi Shah]
They are. Okay.
[Dr. Mai Thy Truong]
That is the disadvantage of a cartilage technique. I don't always see it as disadvantageous because--
[Dr. Gopi Shah]
It's got to hurt, the rib graft part, right? It's got to hurt.
[Dr. Mai Thy Truong]
I like being able to take care of the kids and supporting the families and giving them pain medicine so that by the time they go home that rib pain is mostly resolved. Also to help take care of the ear. I think it's hard to go home right after a big surgery.
(9) Surgical Closure Techniques in Microtia Ear Surgery
[Dr. Gopi Shah]
I jumped ahead with the drains, but in terms of suture for your closure, what do you like to use when you're closing the skin?
[Dr. Mai Thy Truong]
Every surgeon does this differently.
[Dr. Gopi Shah]
Are you tacking anything down? Do you have any quill-type tackings? How does that work?
[Dr. Mai Thy Truong]
Let's talk about the closure first. Because we're always taught for layer closure, right? Two-layer closure. A dermal layer and a subcutaneous layer. I always say that microtia is different because we are stretching the skin over something without a blood supply, over a block of an inert object, so I don't want anything that compromises blood flow. I was amazed to see that Dr. Firmin closed the wound in a single-layer closure. That's with a 5-0 or a 6-0 ETHILON. That is not perfectly subcutaneous. It's like this in-between thickness. That's what I've learned. It's like a little bit into the dermis.
It's light. It's not a tight closure. There are no deep dermals that will strangulate. That skin is so thin. I don't know if you've ever closed a preauricular pit. That skin is really thin, you know what I mean? I love DERMABOND for those. DERMABOND is not going to work for this closure. Single-layer monofilament, that's my optimal closure. It's very Nagata to have these little bolsters that you bolster into place. I'm not brave enough yet.
[Dr. Gopi Shah]
That's tacking just the skin down or actually tacking like Xeroform down, using something to bolster?
[Dr. Mai Thy Truong]
Firmin would do this too, roll up little tiny Xeroforms, tuck them into corners and then secure them down so that the skin will co-op that way. I'd rather just get it with suction and then not do anything more traumatic to the skin.
[Dr. Gopi Shah]
Do you do mastoid dressing or fluff in one of those mastoid bands, or do you leave the ear open to air? What kind of dressing do you use?
[Dr. Mai Thy Truong]
All right. There are two worlds, Glasscock or no Glasscock, right?
[Dr. Gopi Shah]
Yes.
[Dr. Mai Thy Truong]
Ear cup, ear McMuffin, wherever you want to call it, or none. When I first joined Kay Chang, he was using the Glasscock. I think that's what a lot of surgeons use. What I learned was that it moves. For kids with hemifacial microsomia, it's not perfect. It's all over their eye. Then finally we had a patient that slept on their ear with the Glasscock, putting pressure on it and there was a wound. I talked to Dr. Firmin about it and she was like, "Why don't you use my dressing?"
[Dr. Gopi Shah]
[laughs]
[Dr. Mai Thy Truong]
So we switched. Her dressing has a name at Stanford, I call it death by white tape because it's a little silly, but it's basically bacitracin, Vaseline gauze strips cut to cover the ear and the incisions, and then fluffs and then white tape taping those fluffs into a square around the ear.
[Dr. Gopi Shah]
A silk tape, paper tape, that kind of stuff?
[Dr. Mai Thy Truong]
It's paper tape. 1-inch paper tape. It's so much paper tape, watching you place it is absurd. You think she's insane. You're like, "She can't possibly put more tape on."
[Dr. Gopi Shah]
Oh, it's so funny.
[Dr. Mai Thy Truong]
It's just enough pressure without a lot of pressure.
[Dr. Gopi Shah]
Then if it comes off, you can always retape it.
[Dr. Mai Thy Truong]
It never comes off. It's mastisoled down.
[Dr. Gopi Shah]
Oh. How long does that stay on for?
[Dr. Mai Thy Truong]
For the three days. The classic Firmin thing would be to pour the Mastisol into the cup and she'd have everybody sniff it in the room.
[Dr. Gopi Shah]
[laughs]
[Dr. Mai Thy Truong] Because you know the smell of Mastisol.
[Dr. Gopi Shah]
Yes.
[Dr. Mai Thy Truong]
Then you paint the area. Actually, I always feel like it's a very French dressing to cover the ear.
[Dr. Gopi Shah]
It's efficient, has a lot of red tape, but perfect.
[Dr. Mai Thy Truong]
Exactly.
[Dr. Gopi Shah]
Oh goodness.
(10) Antibiotic Protocols Following Microtia Ear Surgery
[Dr. Gopi Shah]
Then afterwards, antibiotics?
[Dr. Mai Thy Truong]
I do. I give antibiotics.
[Dr. Gopi Shah]
While they're in the hospital, home? What's your protocol?
[Dr. Mai Thy Truong]
It's really hard to have evidence-based medicine for antibiotics for this case. I've had a lot of meetings with infectious disease about it because we want to be evidence-based. My argument is, is that you have cartilage as a donor in a wound that is by hair, especially if there's an ear canal. If the child has an ear canal, there's a couple of things that I do ahead of time, but they are on antibiotics until they go home while there's a drain in.
[Dr. Gopi Shah]
Okay. Then when the drain's out, they're ready to go home. They're not on another four days or something like that.
[Dr. Mai Thy Truong]
They do have a couple more days just to complete a week's course.
[Dr. Gopi Shah]
Okay. Are you just doing Keflex, if no penicillin sensitivity?
[Dr. Mai Thy Truong]
I don't like Keflex because it's four times a day and I think it's hard on families, so I do Augmentin. I feel bad that my infectious disease colleagues, they're so good, and I know-- Here's one thing, when we operate near hair and near ear canals, it's hard to attain the same sterility as just skin. We are not scrubbing those ear canals. Do you know what I mean? My rule with kids with ear canals are, one, they always get their ears cleaned before surgery. We clean them at pre-op. Then they always get a couple of drops of Floxin because nothing will destroy your framework more than Pseudomonas.
Last thing is sometimes the little microtia ears have little pits in them, those little pits. Those have debris and bacteria in them that can't be sterilized.
[Dr. Gopi Shah]
Do you take those pits out at the time of the repair?
[Dr. Mai Thy Truong]
If I think it's going to compromise the skin flap, I try to leave them. If it's full of debris, then I take them out.
[Dr. Gopi Shah]
Okay. I didn't even think about the pits and how that might play a role.
[Dr. Mai Thy Truong]
Yes, it's the pits.
[Dr. Gopi Shah]
Yes. [laughs] All right. As we round this out, I know we stayed with grade 1 surgery with rib graft. Do you get a chest X-ray afterwards-
[Dr. Mai Thy Truong]
We do.
[Dr. Gopi Shah]
-in that post-op? Okay. Then what other final pearls, tips, or tricks do you want to leave our audience with? Because we're just coming around that time.
[Dr. Mai Thy Truong]
People who are obsessed with microtia surgery like you're obsessed. I think of the surgery in pockets of, everything is hard with microtia. Just finishing the surgery is like a win. Like, "I finished." Once you get to that stage, you want to make sure your skin pocket and your framework are excellent. Those take two different skills. Practice carving and look at different models and really challenge yourself that your framework is nice. Then once you get that, think about different skin approaches for your skin pocket. Both battles are equally important to have a good-looking ear.
[Dr. Gopi Shah]
Thank you so much, Mai Thy. I learned so much. I love picking your brain about this. For our listeners that might want to get more information about you or your technique, I know the Stanford website has a lot of information. Y'all have done an excellent job discussing your program. Are you on any social media or anything like that?
[Dr. Mai Thy Truong]
Yes. I have an Instagram, Dr. Truong Microtia. I have an atlas that has all my drawings from my time with Dr. Firmin. If you look up the Stanford Atlas, it's a step-by-step for her technique, with wonderful drawings. Then finally, I invite all microtia surgeons to come visit. I think that it's a hard surgery and we shouldn't all learn it all on our own. Just like Dr. Firmin had visiting surgeons every week, I think we should collaborate, so come visit. I can talk about microtia for hours.
[Dr. Gopi Shah]
Awesome. Thank you so much, Mai Thy. It was a pleasure to get to hang out and talk to you and geek out with you on this topic. For our listeners, thank you for stopping by. I think it's a wrap.
[Dr. Mai Thy Truong]
Thank you so much.
Podcast Contributors
Cite This Podcast
BackTable, LLC (Producer). (2023, April 11). Ep. 104 – Microtia Surgery in Children [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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