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The avoidance and treatment of scalp flap complications in cochlear implant surgery
Operative Techniques in Otolaryngology (2005) 16, 149-153
The avoidance and treatment of scalp flap complications in cochlear implant surgery Erik H. Waldman, MD, John K. Niparko, MD From the Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. KEYWORDS Complications; Cochlear implant; Scalp flap; Management
Successful cochlear implantation produces a durable, reaction-free surgical site that allows the patient to use his/her implant system comfortably with a cosmetically acceptable appearance. The most frequently reported major and minor complications after cochlear implantation are those related to the incision and postauricular scalp flap. Ideal flap design that considers vascularity of the postauricular area, skull anatomy, device design, and proper surgical principles will prevent most complications from occurring. When complications do occur, treatment requires thoughtful and aggressive therapy to avoid further patient discomfort, morbidity, surgery, and dreaded device explantation. It cannot be stressed enough that prevention is the key. © 2005 Elsevier Inc. All rights reserved.
Successful cochlear implantation produces a durable, reaction-free surgical site that allows the patient to use his/her implant system comfortably with a cosmetically acceptable appearance. Successful surgery also enables the patient to use an implant system to its fullest potential for accessing the sounds of speech and those of the environment. First steps in achieving an optimal surgical result require a plan of precisely locating the prospective implant site to facilitate interaction with the system’s processor and microphone. Adequate exposure of the surgical site requires that the surgeon develop a pedicled “flap” of skin and subcutaneous tissue. A well-planned flap provides exposure that facilitates safe mastoidectomy, and eliminates the risk of subsequent skin loss and device exposure. To ensure long-term coverage and device durability, the flap should be able to withstand the effects of pressure from the underlying device and compression from the overlying magnetically retained headset. The most frequently reported major and minor complications after cochlear implantation are those related to the incision and postauricular scalp flap.1 Problems range in severity from minor wound dehiscences or infections to major loss of tissue necessitating removal of the device. In Address reprint requests and correspondence: John K. Niparko, MD, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2005.03.006
a study by Hoffman and Cohen,2 the overall rate of flap complications was 4.5%. Fifty-five percent of all flap complications were considered major and required follow-up surgery. Ideal flap design that considers vascularity of the postauricular area, skull anatomy, device design, and proper surgical principles will prevent most complications from occurring. When complications do occur, treatment requires thoughtful and aggressive therapy to avoid further patient discomfort, morbidity, surgery, and dreaded device explantation. It cannot be stressed enough that prevention is the key.
Prevention of scalp flap complications Prevention of scalp flap complications after cochlear implantation begins with good incision and flap design. Ideally, the flap should have adequate blood supply and venous drainage, allow enough exposure of the operative site, and sufficiently cover the device. Blood supply to the postauricular area involves mainly 2 branches off the external carotid artery: the postauricular artery and the occipital artery (Figure 1). Venous drainage parallels the arterial supply. Various incisions have been advocated for insertion of the cochlear implant (Figures 2 and 3). All have advantages and disadvantages. Classically, the anteriorly based, C-shaped flap has the advantage of providing complete
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Operative Techniques in Otolaryngology, Vol 16, No 2, June 2005
Figure 3
Figure 1 Vascular supply to the postauricular area involves the postauricular and occipital arteries branching from the external carotid artery. The superficial temporal artery is shown anterior to the external ear.
coverage of the internal receiver-stimulator with borders that do not cross the implant. One disadvantage of this flap design is that it does not allow gravity based venous drainage, and flap edema may occur. Often associated with complications,3 anteriorly based flaps are contraindicated when there is a previous postauricular incision.4 Inverted U-shaped and J-shaped flaps take advantage of the posterior arterial supply from the occipital artery. Because these flaps have the disadvantage of the incision crossing the electrode lead as it enters the mastoid cavity, it
Figure 2 Various incisions described for cochlear implant surgery. (A) Anterior based, C-shaped incision. (B) “Lazy S” incision. (C) Inverted U-shaped incision. (D) A 3-cm oblique “keyhole” incision.
Recommended incision.
is necessary to create an anteriorly based musculofascial flap (ie, Palva flap) under the scalp to bolster electrode coverage. The patient may have postoperative numbness of an area of scalp superior to the horizontal arm.3 Other incisions include straight, the “lazy S” incision,5 and the extended endaural incision.6 Gibson et al3 developed a 7-cm vertical entry route found to minimize scalp infection and device extrusion. The minimal access surgical route created by O’Donoghue and Nikolopoulos7 is a 3-cm oblique incision. Both offer the advantage of a minimal (or no) hair shave and a smaller incision. The 3-cm “keyhole” operation is limited to the use of a selected stimulator and may be more difficult to perform safely. Shorter incisions and less hair shave do seem to be beneficial in the pediatric population because it improves the esthetic quality of the procedure and reduces the psychologic trauma of the intervention. A recent retrospective study showed no evidence that minimal hair shave adversely affects the rates of wound complications.8 However, the value of any modification of wound preparation procedures should be considered carefully when a prosthetic device is to be placed. Flap thickness must be incorporated in surgical planning. As Hoffman and Cohen2 warn, flaps that are too thick will impede transmission of electrical signals, while flaps that are too thin may erode under magnetic pressure. In younger children who have a thin scalp, elevation of the postauricular tissue in continuity with the skin flap may protect the flap from necrosis secondary to magnet pressure.9 Flap thinning is unnecessary in the pediatric population.10 Although children were indeed once thought to be at higher risk for major and minor complications from cochlear implantation, past studies, in fact, suggested no significantly heightened risk in children.10 As for all otologic surgery in children, the surgeon should remember that the lack of development of the mastoid tip, narrow tympanic ring, and lack of subcutaneous tissue in infants and young toddlers place the trunk of the facial nerve just below the skin. An incorrectly placed incision or aggressive deep dissection of the inferior postauricular tissue may injure the facial nerve when it is unprotected by the mastoid tip. Design of the postauricular skin flap should be tailored to the child’s head shape. In older children, the lateral skull is usually thick enough to permit creation of an adequate well for the receiver-stimulator. In younger children in whom the
Waldman and Niparko
The Avoidance and Treatment of Scalp Flap Complications in Cochlear Implant Surgery
Figure 4 Early wound infection displaying erythema of incision site. (Color version of figure is available online.)
skull is much thinner, the bone is often drilled to the level of the dura, or a mobile island of thin bone can be created over the dura in the center of the well for protection. Alternatively, many surgeons make attempts to thin the skull to approximate, but not reach, the level of the dura. Such a conservative approach may reduce the likelihood of dural neovascularization and the risk of bacterial translocation as a precursor to meningitis. Retention sutures are often placed between the bone and dura. Careful handling of the flap with proper moisture and hemostasis, and suture placement away from the surface of the implant are especially important. The wound should be closed in layers without undue tension, and a pressure dressing should be applied at the conclusion of the operation. Because of their high reactivity, chromic sutures should be avoided in closure. Intraoperative flap design and plans for device positioning are assisted by the use of a mock implant and mock behind-the-ear processor. The planned position for the receiver-stimulator may be marked through skin to bone using methylene blue in a medium bore needle. The flap is elevated to expose landmarks of the mastoid cortex (ie, the spine of Henle, linea temporalis, and the mastoid tip), and at least 3 cm of bone above and beyond the mastoid for locating the well to accommodate the device.
151
resolve. Luetje and Jackson11 labeled these the “nonsurgical” complications when they concerned the scalp flap. They are less frequently reported than major complications. Signs of flap infection should be immediately recognized and treated. Local symptoms and signs include erythema, warmth, and drainage and crusting at the incision site (Figure 4), which may be treated with topical and/or oral antibiotics. In adults, oral cephalosporins or fluoroquinolones are used. More persistent cases of infection should be treated with intravenous antibiotics, with consultation from infectious disease specialists to ensure that the blood prosthesis barrier is penetrated by the antibiotic. Aggressive therapy should be administered to prevent wound necrosis, which would then constitute a major complication requiring surgical intervention. Wound dehiscence and/or delayed healing is rare but may occur more frequently in patients with underlying problems with healing (e.g., diabetics, smokers, immunosuppressed). When dehiscence occurs, meticulous wound care and aggressive antibiosis should be administered to prevent exposure of the device. Stitch abscess treatment involves local wound care, including possible incision and drainage with removal of the suture (Figure 5). Seroma/hematoma treatment depends on the size and rate of formation. Small collections that are not expanding may be treated conservatively with pressure and observation, and usually abate (Figure 6). Large or expanding lesions may need to be drained.
Treatment of major scalp flap complications Flap necrosis is often the result of poorly planned and executed incisions or flap designs. Patients with previous
Treatment of minor scalp flap complications According to Cohen et al,1 minor scalp flap complications are those that require minimal treatment or no treatment to
Figure 5 online.)
Stitch abscess. (Color version of figure is available
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Operative Techniques in Otolaryngology, Vol 16, No 2, June 2005
Figure 6 Mild seroma/hematoma treated conservatively with pressure and observation resolved. A mastoid/pressure dressing was worn at all times. (Color version of figure is available online.)
postauricular or face-lift incisions should not be implanted using an anteriorly based, C-shaped flap because the blood supply to the flap may be inadequate. A “lazy S,” straight, or inverted U-flap or J-flap will allow survival of the flap. Infection and/or underlying inflammatory conditions (e.g., vasculitides) may also predispose to flap necrosis and problems with wound healing. There have been case reports praising the use of hyperbaric oxygen to speed recovery and healing, and even to “prepare” the bed for rotational flap.12 Extrusion of the device (Figure 7) can result from local flap necrosis and infection transmitted from the mastoid. Paying particular attention to flap thickness intraoperatively and aggressively treating infection and minimizing comorbid conditions before surgery are ef-
fective preventative strategies. In cases in which adequately mobile, vascularized soft tissue in the postauricular area is unavailable, a rotation of the device or coverage with an extended flap, usually to a more superior location, may prevent device explantation.9 Other situations may require a rotational pericranial flap to fill the defect and enhance implant coverage.9 Explantation is warranted when antibiosis and locoregional flap coverage fail to address a gathering wound infection. Reimplantation requires considerable attention to flap design. The skin over the anticipated implant site is often atrophic and must be handled carefully. The skin incision is through the original scar, and the flap is raised, with an attempt to maintain maximal thickness. The internal device well should be considered carefully. Often relocation
Waldman and Niparko
The Avoidance and Treatment of Scalp Flap Complications in Cochlear Implant Surgery
153
Acknowledgment We wish to thank Brian Dunham, MD, for his assistance in generating images used in this article.
REFERENCES
Figure 7 online.)
Device extrusion. (Color version of figure is available
of the device well is needed to provide coverage with adequate soft tissue.
Conclusion The success of cochlear implantation has rested on its ability to enhance communication abilities of a large number of patients, while at the same time having minimal morbidity associated with the procedure. Major problems still occur, and scalp flap complications dominate these difficulties. Attention to detail, surgical planning and execution to prevent known mistakes, and aggressive treatment and recognition of postoperative complications may substantially reduce the risk of flap complication.
1. Cohen NL, Hoffman RA, Stroschein M: Medical or surgical complications related to the Nucleus multichannel cochlear implant. Ann Otol Rhinol Laryngol Suppl 135:8-13, 1988 2. Hoffman RA, Cohen NL: Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol Suppl 166:420-422, 1995 3. Gibson WP, Harrison HC, Prowse C: A new incision for placement of cochlear implants. J Laryngol Otol 109:821-825, 1995 4. Harris JP, Cueva RA: Flap design for cochlear implantation: Avoidance of a potential complication. Laryngoscope 97:755-757, 1987 5. Telian SA, El-Kashlan HK, Arts HA: Minimizing wound complications in cochlear implant surgery. Am J Otol 20:331-334, 1999 6. Franz BK, Kuzma JA, Lehnhardt E, et al: Implantation of the Melbourne/Cochlear multiple-electrode extracochlear prosthesis. Ann Otol Rhinol Laryngol 98:591-596, 1989 7. O’Donoghue GM, Nikolopoulos TP: Minimal access surgery for pediatric cochlear implantation. Otol Neurotol 23:891-894, 2002 8. Howard NS, Antonelli PJ: Complications of cochlear implant placement with minimal hair shave. Am J Otolaryngol 25:84-87, 2004 9. Wang RC, Parisier SC, Weiss MH, et al: Cochlear implant flap complications. Ann Otol Rhinol Laryngol 99:791-795, 1990 10. Miyamoto RT, Young M, Myres WA, et al: Complications of pediatric cochlear implantation. Eur Arch Otorhinolaryngol 253:1-4, 1996 11. Luetje CM, Jackson K: Cochlear implants in children: What constitutes a complication? Otolaryngol Head Neck Surg 117:243-247, 1997 12. Schweitzer VG, Burtka MJ: Cochlear implant flap necrosis: Adjunct hyperbaric oxygen therapy for prevention of explantation. Am J Otol 12:71-75, 1991
The avoidance and treatment of scalp flap complications in cochlear implant surgery Erik H. Waldman, MD, John K. Niparko, MD From the Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland. KEYWORDS Complications; Cochlear implant; Scalp flap; Management
Successful cochlear implantation produces a durable, reaction-free surgical site that allows the patient to use his/her implant system comfortably with a cosmetically acceptable appearance. The most frequently reported major and minor complications after cochlear implantation are those related to the incision and postauricular scalp flap. Ideal flap design that considers vascularity of the postauricular area, skull anatomy, device design, and proper surgical principles will prevent most complications from occurring. When complications do occur, treatment requires thoughtful and aggressive therapy to avoid further patient discomfort, morbidity, surgery, and dreaded device explantation. It cannot be stressed enough that prevention is the key. © 2005 Elsevier Inc. All rights reserved.
Successful cochlear implantation produces a durable, reaction-free surgical site that allows the patient to use his/her implant system comfortably with a cosmetically acceptable appearance. Successful surgery also enables the patient to use an implant system to its fullest potential for accessing the sounds of speech and those of the environment. First steps in achieving an optimal surgical result require a plan of precisely locating the prospective implant site to facilitate interaction with the system’s processor and microphone. Adequate exposure of the surgical site requires that the surgeon develop a pedicled “flap” of skin and subcutaneous tissue. A well-planned flap provides exposure that facilitates safe mastoidectomy, and eliminates the risk of subsequent skin loss and device exposure. To ensure long-term coverage and device durability, the flap should be able to withstand the effects of pressure from the underlying device and compression from the overlying magnetically retained headset. The most frequently reported major and minor complications after cochlear implantation are those related to the incision and postauricular scalp flap.1 Problems range in severity from minor wound dehiscences or infections to major loss of tissue necessitating removal of the device. In Address reprint requests and correspondence: John K. Niparko, MD, Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, 601 North Caroline Street, Baltimore, MD 21287. E-mail address: [email protected]. 1043-1810/$ -see front matter © 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.otot.2005.03.006
a study by Hoffman and Cohen,2 the overall rate of flap complications was 4.5%. Fifty-five percent of all flap complications were considered major and required follow-up surgery. Ideal flap design that considers vascularity of the postauricular area, skull anatomy, device design, and proper surgical principles will prevent most complications from occurring. When complications do occur, treatment requires thoughtful and aggressive therapy to avoid further patient discomfort, morbidity, surgery, and dreaded device explantation. It cannot be stressed enough that prevention is the key.
Prevention of scalp flap complications Prevention of scalp flap complications after cochlear implantation begins with good incision and flap design. Ideally, the flap should have adequate blood supply and venous drainage, allow enough exposure of the operative site, and sufficiently cover the device. Blood supply to the postauricular area involves mainly 2 branches off the external carotid artery: the postauricular artery and the occipital artery (Figure 1). Venous drainage parallels the arterial supply. Various incisions have been advocated for insertion of the cochlear implant (Figures 2 and 3). All have advantages and disadvantages. Classically, the anteriorly based, C-shaped flap has the advantage of providing complete
150
Operative Techniques in Otolaryngology, Vol 16, No 2, June 2005
Figure 3
Figure 1 Vascular supply to the postauricular area involves the postauricular and occipital arteries branching from the external carotid artery. The superficial temporal artery is shown anterior to the external ear.
coverage of the internal receiver-stimulator with borders that do not cross the implant. One disadvantage of this flap design is that it does not allow gravity based venous drainage, and flap edema may occur. Often associated with complications,3 anteriorly based flaps are contraindicated when there is a previous postauricular incision.4 Inverted U-shaped and J-shaped flaps take advantage of the posterior arterial supply from the occipital artery. Because these flaps have the disadvantage of the incision crossing the electrode lead as it enters the mastoid cavity, it
Figure 2 Various incisions described for cochlear implant surgery. (A) Anterior based, C-shaped incision. (B) “Lazy S” incision. (C) Inverted U-shaped incision. (D) A 3-cm oblique “keyhole” incision.
Recommended incision.
is necessary to create an anteriorly based musculofascial flap (ie, Palva flap) under the scalp to bolster electrode coverage. The patient may have postoperative numbness of an area of scalp superior to the horizontal arm.3 Other incisions include straight, the “lazy S” incision,5 and the extended endaural incision.6 Gibson et al3 developed a 7-cm vertical entry route found to minimize scalp infection and device extrusion. The minimal access surgical route created by O’Donoghue and Nikolopoulos7 is a 3-cm oblique incision. Both offer the advantage of a minimal (or no) hair shave and a smaller incision. The 3-cm “keyhole” operation is limited to the use of a selected stimulator and may be more difficult to perform safely. Shorter incisions and less hair shave do seem to be beneficial in the pediatric population because it improves the esthetic quality of the procedure and reduces the psychologic trauma of the intervention. A recent retrospective study showed no evidence that minimal hair shave adversely affects the rates of wound complications.8 However, the value of any modification of wound preparation procedures should be considered carefully when a prosthetic device is to be placed. Flap thickness must be incorporated in surgical planning. As Hoffman and Cohen2 warn, flaps that are too thick will impede transmission of electrical signals, while flaps that are too thin may erode under magnetic pressure. In younger children who have a thin scalp, elevation of the postauricular tissue in continuity with the skin flap may protect the flap from necrosis secondary to magnet pressure.9 Flap thinning is unnecessary in the pediatric population.10 Although children were indeed once thought to be at higher risk for major and minor complications from cochlear implantation, past studies, in fact, suggested no significantly heightened risk in children.10 As for all otologic surgery in children, the surgeon should remember that the lack of development of the mastoid tip, narrow tympanic ring, and lack of subcutaneous tissue in infants and young toddlers place the trunk of the facial nerve just below the skin. An incorrectly placed incision or aggressive deep dissection of the inferior postauricular tissue may injure the facial nerve when it is unprotected by the mastoid tip. Design of the postauricular skin flap should be tailored to the child’s head shape. In older children, the lateral skull is usually thick enough to permit creation of an adequate well for the receiver-stimulator. In younger children in whom the
Waldman and Niparko
The Avoidance and Treatment of Scalp Flap Complications in Cochlear Implant Surgery
Figure 4 Early wound infection displaying erythema of incision site. (Color version of figure is available online.)
skull is much thinner, the bone is often drilled to the level of the dura, or a mobile island of thin bone can be created over the dura in the center of the well for protection. Alternatively, many surgeons make attempts to thin the skull to approximate, but not reach, the level of the dura. Such a conservative approach may reduce the likelihood of dural neovascularization and the risk of bacterial translocation as a precursor to meningitis. Retention sutures are often placed between the bone and dura. Careful handling of the flap with proper moisture and hemostasis, and suture placement away from the surface of the implant are especially important. The wound should be closed in layers without undue tension, and a pressure dressing should be applied at the conclusion of the operation. Because of their high reactivity, chromic sutures should be avoided in closure. Intraoperative flap design and plans for device positioning are assisted by the use of a mock implant and mock behind-the-ear processor. The planned position for the receiver-stimulator may be marked through skin to bone using methylene blue in a medium bore needle. The flap is elevated to expose landmarks of the mastoid cortex (ie, the spine of Henle, linea temporalis, and the mastoid tip), and at least 3 cm of bone above and beyond the mastoid for locating the well to accommodate the device.
151
resolve. Luetje and Jackson11 labeled these the “nonsurgical” complications when they concerned the scalp flap. They are less frequently reported than major complications. Signs of flap infection should be immediately recognized and treated. Local symptoms and signs include erythema, warmth, and drainage and crusting at the incision site (Figure 4), which may be treated with topical and/or oral antibiotics. In adults, oral cephalosporins or fluoroquinolones are used. More persistent cases of infection should be treated with intravenous antibiotics, with consultation from infectious disease specialists to ensure that the blood prosthesis barrier is penetrated by the antibiotic. Aggressive therapy should be administered to prevent wound necrosis, which would then constitute a major complication requiring surgical intervention. Wound dehiscence and/or delayed healing is rare but may occur more frequently in patients with underlying problems with healing (e.g., diabetics, smokers, immunosuppressed). When dehiscence occurs, meticulous wound care and aggressive antibiosis should be administered to prevent exposure of the device. Stitch abscess treatment involves local wound care, including possible incision and drainage with removal of the suture (Figure 5). Seroma/hematoma treatment depends on the size and rate of formation. Small collections that are not expanding may be treated conservatively with pressure and observation, and usually abate (Figure 6). Large or expanding lesions may need to be drained.
Treatment of major scalp flap complications Flap necrosis is often the result of poorly planned and executed incisions or flap designs. Patients with previous
Treatment of minor scalp flap complications According to Cohen et al,1 minor scalp flap complications are those that require minimal treatment or no treatment to
Figure 5 online.)
Stitch abscess. (Color version of figure is available
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Operative Techniques in Otolaryngology, Vol 16, No 2, June 2005
Figure 6 Mild seroma/hematoma treated conservatively with pressure and observation resolved. A mastoid/pressure dressing was worn at all times. (Color version of figure is available online.)
postauricular or face-lift incisions should not be implanted using an anteriorly based, C-shaped flap because the blood supply to the flap may be inadequate. A “lazy S,” straight, or inverted U-flap or J-flap will allow survival of the flap. Infection and/or underlying inflammatory conditions (e.g., vasculitides) may also predispose to flap necrosis and problems with wound healing. There have been case reports praising the use of hyperbaric oxygen to speed recovery and healing, and even to “prepare” the bed for rotational flap.12 Extrusion of the device (Figure 7) can result from local flap necrosis and infection transmitted from the mastoid. Paying particular attention to flap thickness intraoperatively and aggressively treating infection and minimizing comorbid conditions before surgery are ef-
fective preventative strategies. In cases in which adequately mobile, vascularized soft tissue in the postauricular area is unavailable, a rotation of the device or coverage with an extended flap, usually to a more superior location, may prevent device explantation.9 Other situations may require a rotational pericranial flap to fill the defect and enhance implant coverage.9 Explantation is warranted when antibiosis and locoregional flap coverage fail to address a gathering wound infection. Reimplantation requires considerable attention to flap design. The skin over the anticipated implant site is often atrophic and must be handled carefully. The skin incision is through the original scar, and the flap is raised, with an attempt to maintain maximal thickness. The internal device well should be considered carefully. Often relocation
Waldman and Niparko
The Avoidance and Treatment of Scalp Flap Complications in Cochlear Implant Surgery
153
Acknowledgment We wish to thank Brian Dunham, MD, for his assistance in generating images used in this article.
REFERENCES
Figure 7 online.)
Device extrusion. (Color version of figure is available
of the device well is needed to provide coverage with adequate soft tissue.
Conclusion The success of cochlear implantation has rested on its ability to enhance communication abilities of a large number of patients, while at the same time having minimal morbidity associated with the procedure. Major problems still occur, and scalp flap complications dominate these difficulties. Attention to detail, surgical planning and execution to prevent known mistakes, and aggressive treatment and recognition of postoperative complications may substantially reduce the risk of flap complication.
1. Cohen NL, Hoffman RA, Stroschein M: Medical or surgical complications related to the Nucleus multichannel cochlear implant. Ann Otol Rhinol Laryngol Suppl 135:8-13, 1988 2. Hoffman RA, Cohen NL: Complications of cochlear implant surgery. Ann Otol Rhinol Laryngol Suppl 166:420-422, 1995 3. Gibson WP, Harrison HC, Prowse C: A new incision for placement of cochlear implants. J Laryngol Otol 109:821-825, 1995 4. Harris JP, Cueva RA: Flap design for cochlear implantation: Avoidance of a potential complication. Laryngoscope 97:755-757, 1987 5. Telian SA, El-Kashlan HK, Arts HA: Minimizing wound complications in cochlear implant surgery. Am J Otol 20:331-334, 1999 6. Franz BK, Kuzma JA, Lehnhardt E, et al: Implantation of the Melbourne/Cochlear multiple-electrode extracochlear prosthesis. Ann Otol Rhinol Laryngol 98:591-596, 1989 7. O’Donoghue GM, Nikolopoulos TP: Minimal access surgery for pediatric cochlear implantation. Otol Neurotol 23:891-894, 2002 8. Howard NS, Antonelli PJ: Complications of cochlear implant placement with minimal hair shave. Am J Otolaryngol 25:84-87, 2004 9. Wang RC, Parisier SC, Weiss MH, et al: Cochlear implant flap complications. Ann Otol Rhinol Laryngol 99:791-795, 1990 10. Miyamoto RT, Young M, Myres WA, et al: Complications of pediatric cochlear implantation. Eur Arch Otorhinolaryngol 253:1-4, 1996 11. Luetje CM, Jackson K: Cochlear implants in children: What constitutes a complication? Otolaryngol Head Neck Surg 117:243-247, 1997 12. Schweitzer VG, Burtka MJ: Cochlear implant flap necrosis: Adjunct hyperbaric oxygen therapy for prevention of explantation. Am J Otol 12:71-75, 1991