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Comparison of Thinning vs Non-Thinning Techniques for Placement of Ponto
Osseointegrated Auditory Implants in Children
Kay W. Chang Associate Professor of Otolaryngology
Stanford University
December 11, 2014 14th Symposium on Cochlear Implants
in Children Nashville, TN
Disclosure
• Oticon - consultant, speaker
Evolution in skin technique
• Rectangular scalp flap -‐ manually thinned • Dermatome
• Linear incision – De Wolf et al (2008) Nijmegen, Netherlands -‐ 129 implants in children. 28 (22%)
Holgers grade 2-‐4 skin reactions. Revision surg to reduce subcut scar tissue in 22 (17%)
• No skin thinning – Lanis & Hultcrantz (2013) St. Louis, Missouri -‐ 33 children
23 skin thinning -‐ 56 min -‐ 36% infection rate -‐ 4 implant losses 10 without skin thinning -‐ 34 min -‐ 11% infection rate -‐ 1 implant loss
Evolution in skin technique
• Free skin transplant with thinning (4 h)
• Flaps with thinning (1.5 h)
• Dermatome with thinning (45 m) • Vertical incision with thinning (30 m)
• Vertical incision, no thinning (15-20m)
Malou Hultcrantz, Copenhagen 2014
BAHA Design 1978-‐1998 1998-‐2010
Abutment Design History
O3con Medical (2009 -‐ 2014 -‐)
BIA300 (6, 9 mm)
BIA400 (6, 8, 10, 12 mm)
BIA210 (5.5, 8.5 mm)
Cochlear designs 2009 2010-‐ 2012 2012 -‐
Ponto (6, 9, 12, 14 mm)
Abutment Sizes for Differing Skin Thickness
Abutment size
Ponto 6 mm Ponto 9 mm Ponto 12 mm Ponto 14 mm
Natural skin thickness
< 3 mm 3 – 6 mm 6 – 9 mm 9 – 12 mm
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More programs using 1-‐stage rather than 2-‐stage surgeries in pediatric patients
• Saliba et al (2012) Montreal – 26 1-‐stage implants (mean age 8.5 yo) mean OR time 54 min
– 29 2-‐stage implants, mean OR time 79 min
– No diff in complications
• Ali et al (2009) Glasgow, UK – 30 children, all 1-‐stage. No failures of osseointegration. 2 lost fixtures due to trauma,
subseq reimplanted. Adverse skin reaction in only 2.
• Kohan et al (2008) NYU – 18 children (6-‐13 yo), 14 adults, all 1-‐stage. 4 (13%) revision surgery. 3 pediatric cases
(16.7%) with adverse skin reactions.
Tissue Preservation First clinical study by Prof. Hultcrantz, 2011
• Findings • BeKer cosme3cs • Less numbness and pain • Quicker healing • Minimal scar 3ssue. Intact skin with good blood supply
• Quicker surgery • No increase in skin infec3ons
KEY FINDING DATA
Tissue Preservation
Dermatome
NO OF PATIENTS 7 persons 7 persons
ABUTMENT SIZE 8,5 – 12 mm 5,5 mm
MEAN SURGERY TIME
28,1 min 44,6 min
INFECTION1 1 patient 3 patients
NUMBNESS2 1 patient 6 patients
HEALING TIME 100%: 10 days 74%: <60 days 1Holger score 1-‐ 3, 2At 12 month control
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Comparison of new tissue preservation vs older thinning/dermatome techniques in pediatric patients at Stanford University
• 14 children with Ponto performed with dermatome or linear incision with thinning from 2010-‐2012
• 9 children with Ponto performed with non-‐thinning technique from 2012-‐2013
• Data obtained on: Mean surgical time, Skin reaction as assessed by Holgers Grade, Absence/presence of numbness, Healing time
Holger's Grading Scale for the Classification of Skin Reactions
Tissue Preservation Thinning techniques
Number of patients 9 14 (10 linear w/ thinning, 4 dermatome)
Age 8.52 ± 1.66 9.26 ± 2.98
Mean surgery time 19 min 41 min
Holgers 0 - no irritation 8 (89%) 7 (50%)
1 - slight redness 1 3
2 - red and slightly moist 1
3 - granulation 2
4 - infection 1
Numbness 0 6 (43%)
Healing time 100% at 10d 57% < 30d, 79% < 60d
Comparison of new tissue preservation vs older thinning/dermatome techniques in pediatric patients at Stanford University
The benefits of Tissue Preservation Summary
• Better cosmetics • Less numbness and pain
• Quicker healing • Minimal scar tissue • Quicker surgery • Fully reversible
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Thank You!
