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BackTable / ENT / Article
Microtia Ear Surgery Closure Technique & Antibiotic Protocols
Dana Schmitz • Updated Jul 8, 2024 • 65 hits
Pediatric Otolaryngologist Dr. Mai Thy Truong walks through her microtia ear surgery techniques, offering insight into the finishing details that lead to successful outcomes. From outlining the choices of drainage systems (ConstaVac drain) to detailing her preferred strategy behind skin closure and dressing, Dr. Truong's methods showcase the evolution of care in microtia ear reconstruction surgery. Furthermore, her approach to antibiotic use, tailored to the specific needs of microtia ear surgery near hair and ear canals, highlights the importance of customizing care to prevent postoperative complications.
This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.
The BackTable ENT Brief
• The ConstaVac drain, 5cc test tube, or JP bulb are drainage options often used during microtia ear surgery, each with their own strengths and disadvantages.
• Surgical drains typically stay in place for three days while the patient’s pain is adequately controlled in an inpatient setting.
• While traditional training involves a two-layer closure during microtia surgery, Dr. Troung recommends a single-layer monofilament closure, which is optimal for stretching thin skin over an inert object without compromising blood supply.
• Glasscock ear dressings are often used in the postoperative wound management of microtia ear reconstruction surgery, but Dr. Troung has found the ‘death by white tape’ dressing to provide the most consistent amount of pressure against the surgical site. This dressing involves a protective layer of bacitracin, followed by Vaseline gauze strips, fluffs, and an abundant amount of 1-inch paper tape.
• Due to concerns of maintaining sterility while operating near hair and possible ear canals, a seven day course of antibiotics is generally recommended following surgery.
• Pits in microtia ears may harbor debris and bacteria, and may be removed during surgery if there is concern over pits compromising the integrity of the skin flap.
Table of Contents
(1) Microtia Ear Surgery Drain Choices
(2) Microtia Ear Surgery Closure Techniques
(3) Antibiotic Protocols Following Mictoria Ear Surgery
Microtia Ear Surgery Drain Choices
Dr. Truong elaborates on the strengths and limitations of drain options in microtia ear surgery. A small test tube provides desired suction levels but this technique is labor intensive for nursing staff, as it can get clogged. A ConstaVac drain is a box-based drain that has a lower amount of suction than wall suction. It can be adjusted to be equivalent to the 5cc test tube amount of suction, but as it’s on a battery the suction remains constant. A JP bulb is also an option used by many surgeons. All three drainage methods require a multiple day postoperative hospital stay, during which time the patient’s pain is adequately managed. By the time the drains are able to be removed, surgical pain has typically resolved.
[Dr. Gopi Shah]
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 drain.
[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.
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Microtia Ear Surgery Closure Techniques
While the traditional training encourages a two-layer closure, both dermal and subcutaneous, microtia ear surgeries can be unique given the skin's thin nature and the challenges of stretching it over an inert object without blood supply. Instead of the conventional layered closure, Dr. Truong recommends a single-layer monofilament method to minimize skin trauma. While there are multiple post-surgical dressing options, the 'death by white tape' dressing, a protective layer of bacitracin, Vaseline gauze strips, fluffs, and ample amount of 1-inch paper tape, provides just enough pressure without excessive force on the ear.
[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 ear dressing or no Glasscock ear dressing, 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 ear dressing. 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.
Antibiotic Protocols Following Mictoria Ear Surgery
Dr. Mai Thy Truong argues for a seven day course of antibiotics such as Augmentin following microtia ear surgery due to the surgical site’s proximity to hair, possible ear canals and associated pits, and the presence of surgical drains. Children with distinct ear canals may have them cleaned before surgery with antibiotics drops, but the debris is hard to sterilize before surgery when there are pits involved with the small microtia ears. These pits may or may not be removed at time of microtia ear reconstruction 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.
Podcast Contributors
Dr. Mai Thy Truong
Dr. Mai Thy Truong is the fellowship director of pediatric otolaryngology at Stanford University in California.
Dr. Gopi Shah
Dr. Gopi Shah is a pediatric otolaryngologist and the co-host of BackTable ENT.
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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