Holgers Classification Research Articles

Complicaciones en osteointegración percutánea: ¿es necesario un cambio de paradigma?

Introduction: Percutaneous bone conduction implants are the standard osseointegration model used to provide an alternative treatment option for conductive and mixed hearing loss. In recent years, the indications for these implants have increased, despite concerns about their use because of local complications. The aim of this study was to describe the complications of percutaneous osseointegrated devices implanted at our hospital. Material and methods: A retrospective longitudinal study was conducted in 57 consecutive patients who received a Baha®-type percutaneous bone conduction implantation. The main clinical indications were chronic otitis media and ear malformations. Local periimplant complications were described using the Holgers classification. Results: After a mean follow-up of 12 months (range: 4-48 months), 26.31% of patients had some type of peri-implant soft tissue complication. Only one patient (1.75%) had major reactions requiring removal of the implant. Complications in the paediatric age group were notably higher, affecting 42.85% of the children. Conclusions: The local complication rate in our study was at the lower end of the range described in the literature, which reports a very wide range of rates, even reaching 70%. Most complications are minor and resolve with topical antibiotic treatment. However, the rate is higher in children.

Reliability of Postsurgical Soft Tissue Reaction Grading Scales for Bone-anchored Hearing Implants.

This study aims to assess and compare the reliability of the Holgers, the IPS, and the Tullamore scales for skin tolerability assessment of postoperative bone-anchored hearing implant images. A survey study and retrospective review of percutaneous osseointegrated auditory implant images for scoring using three skin classification scales. McGill University Health Center, Montreal, Quebec, Canada. Healthcare workers experienced and inexperienced with osseointegrated auditory implant skin classification scales. Participation involved completing: 1) survey questionnaires assessing experience with osseointegrated auditory implants and related skin reactions and 2) scoring postoperative osseointegrated auditory implant with surrounding skin images using the Holgers Classification, the IS (of the IPS) scale, and the Tullamore Classification. Participants were asked to rate 12 images of postoperative osseointegrated auditory implant and surrounding soft tissue. This process was repeated until participants scored all images using the three scales; each rater graded 36 images in total. The order in which scales were presented occurred at random. Intraclass correlation coefficients were calculated to assess reliability. Thirty-one participants were recruited to the study. Fourteen (45.2%) had experience with at least 1 osseointegrated auditory implant skin classification scale, while 17 (54.8%) did not have experience. The wide and overlapping 95% confidence intervals of the intraclass correlation coefficients results do not provide us with enough evidence to define a well-established degree and hierarchy of reliability when comparing the scales. Among experienced raters, all scales presented moderate to good reliability. The Holgers Classification, the IPS scale, and the Tullamore Classification all present moderate to good reliability when used by experienced raters to assess skin reactions following surgical implantation of an osseointegrated hearing device. As a result, clinicians should use these scales with a degree of caution. The findings of this study do not provide us with enough evidence to single out one of the scales as a standard to follow, but more extensive studies are required to assess the reliability of the scales.

Post-operative infection rates in linear vs. punch technique for bone anchored hearing systems.

This study investigates the post-operative infection rates between two surgical approaches: linear incision and the punch technique for bone anchored hearing systems. Secondarily, it investigates the impact of smoking, comorbid disease, and operative conditions on post-operative skin reactions and infections. A retrospective study was conducted at a single tertiary care institution. A single surgeon completed either of the two techniques on adult patients with mixed, conductive hearing loss, or single sided-deafness. Patients included had at least 6months follow-up, and were evaluated for preexisting illnesses, perioperative complications, length of surgery, and post-operative complications including infection after surgery. Post-operative soft tissue around the abutment was assessed with Holgers Classification scale. Fifty-one patients were included in this study, 28 female and 23 males with an average age of 68.8. Thirty-three patients underwent linear incision surgery and 18 had the punch technique. Overall 9 patients (17.6%) had post-operative infections requiring topical or oral antibiotic treatment. Six (18.2%) were in the linear group and 3 (16.7%) in the punch group. There was no statistically significantly difference (p=1). A multivariate analysis compared age, sex, obesity, DM, operative time, skin thickness, and abutment size to post-operative skin infection rates requiring treatment. Only DM was statistically correlative with infection (p=0.02). No significant differences in post-operative infections were identified comparing linear incision and the punch techniques. Patients with diabetes had a higher incidence of post-operative skin infections rates.

Inter-rater Reliability and Validity of Holgers Scores for the Assessment of Bone-anchored Hearing Implant Images.

This study aims to review the utility and interassessor reliability of Holgers classification by simultaneously testing various professionals of the bone-anchored implant team for their impression of a series of randomized images. Retrospective review of a randomized series of bone-anchored implant fixture clinical photographs from the database at a tertiary referral university hospital. Raters were blinded to the contemporaneous Holgers grading assigned by the Clinical Nurse Specialist at initial assessment. Multivariate analysis was performed for correlation between scores for assessors and between grades of assessor. Queen Elizabeth Hospital, Birmingham, UK a tertiary center for BAHIs. Patients implanted from May 2012 until November 2014. Photographs of fixture sites of adult patients were taken following bone-anchored hearing implant surgery using either a tissue reduction (a split skin graft or linear incision technique was used) or tissue preservation approach, at 1 week, 6 months, and 12 months postoperatively. On a single occasion 263 images were reviewed by 10 assessors (2 consultants, 2 higher surgical trainees, 3 junior doctors, and 3 audiologists). Images were displayed at 10-second intervals and were scored by each assessor. Assessors were blinded to patient identity, time points and to each other's scores. Results were then compared against the real-time scoring of Holgers grades done by the BAHI specialist nurse to compare scores. Overall 227 (86.2%) images were with tissue reduction technique of which 110 (41.8%) were with linear incision and 117 (44.4%) were with a split skin graft (SSG); and 36 (13.6%) were with tissue preservation technique. Of these 263 images, 104 were at 1 week (39.5%), 70 were at 6 months (26.6%), and 89 were at 12 months (33.9%). The cumulative scores for each grade scored by blinding the time points were: 0 = 1132 (43.04%), total 1 = 995 (37.83%), total 2 = 346 (13.15%), total 3 = 141 (5.36%), total 4 = 16 (0.6%). 2630 data points had a variance of only 0.6415 for each nominal. Multivariate correlation between all assessors was r =0.7230 (Pearson's R). Correlations between consultants r=0.6317, higher surgical trainees r=0.7351, junior doctors r=0.7599, and audiologists r=0.7981.There is a good correlation (r=0.89) with no statistically significant differences between the SSG and linear incision groups (p>0.05), possibly suggesting Holgers score is comparable within both these tissue reduction techniques.There is a moderate correlation (r=0.58) with statistically significant differences between tissue preservation versus tissue reduction groups (p<0.05), possibly suggesting tissue preservation gives better results with lower Holgers scores than tissue reduction. Holgers scoring system is a reliable tool with respect to inter-rater variability across all levels of experience. Correlation was closer with audiologists and lesser experienced assessors.

Three-year Outcomes of a Randomized Controlled Trial Comparing a 4.5-mm-Wide to a 3.75-mm-Wide Titanium Implant for Bone Conduction Hearing.

Objective:To compare 3-year implant stability, survival, and tolerability of a 4.5-mm-wide (test) and a 3.75-mm-wide (control) percutaneous titanium implant for bone-conduction hearing, loaded with the sound processor after 3 weeks.Methods:Sixty implants were allocated in a 2:1 ratio (test-control) in 57 adult patients included in this prospective randomized controlled clinical trial. Follow-up visits were performed at 7, 14, 21, and 28 days; 6 and 12 weeks; 6 months; and at 1, 2, and 3 years after implantation. During these visits, the implant stability quotient (ISQ) was measured by means of resonance frequency analysis (RFA). The peri-abutment soft tissue status was assessed according to the Holgers classification. Skin height around the abutment was evaluated.Results:The mean area-under-the-curve (AUC) of ISQ-low was statistically significantly higher for the test implant (65.7 versus 61.4, p = 0.0002). Both implants showed high survival rates (97.4% versus 95.0%, p = 0.6374). Adverse soft tissue reactions were observed sporadically, with no significant inter-group differences. Skin thickening was seen in the majority of the patients, but no correlation with adverse soft tissue reactions or implant type was observed.Conclusion:The 4.5-mm-wide implant provides significantly higher ISQ values during the first 3 years after surgery compared with the previous generation 3.75-mm-wide implant. Both implants showed high survival rates and good tolerability. These long-term results indicate that the wider implant, loaded with a sound processor at 3 weeks, is a safe and well-performing option for hearing rehabilitation in specific types of hearing loss.

Findings from the experience with the punch technique for auditory osseointegrated implants: A retrospective single center comparative study

ObjectiveTo compare the punch technique and linear incision with soft tissue reduction for the placement of auditory osseointegrated implants (AOI) and analyze results of osseointegration obtained with the punch technique as measured with the Implant Stability Quotient (ISQ). MethodsCase review of 34 patients who received auditory osseointegrated implants between January 2010 and July 2015 and were divided into two groups according to the surgical technique: 18 with the punch technique (PT) and 16 with the linear incision technique (LI). Minimum follow-up was four months (mean: 24 months; range 4–64 months). Included in the analysis were patient profiles and records of the demographic data, surgical indications, surgical technique, implant placement, surgical time, intraoperative complications, as well as postsurgical complications (Holgers classification) and implant stability quotients (ISQ). ResultsUse of larger abutments was significantly greater in the PT group (PT, 10mm; LI, 6mm, p<0.001). The PT technique resulted in a shorter procedure than the LI (PT, 20min; LI, 45min, p<0.001). Holgers classification scores identified significantly fewer skin complications one week after surgery for the PT group; however, only small differences were seen between the two groups at the one- and three-month control visits. ConclusionsAs shown for our cohort, the punch technique for surgical placement of AOI is faster and presents fewer immediate postoperative complications when compared to the linear incision technique. The clinical application of the ISQ is a useful, easy method to demonstrate the status of osseointegration and, thus, the stability of the device.

Findings from the experience with the punch technique for auditory osseointegrated implants: A retrospective single center comparative study

ObjectiveTo compare the punch technique and linear incision with soft tissue reduction for the placement of auditory osseointegrated implants (AOI) and analyze results of osseointegration obtained with the punch technique as measured with the Implant Stability Quotient (ISQ). MethodsCase review of 34 patients who received auditory osseointegrated implants between January 2010 and July 2015 and were divided into two groups according to the surgical technique: 18 with the punch technique (PT) and 16 with the linear incision technique (LI). Minimum follow-up was four months (mean: 24 months; range 4–64 months). Included in the analysis were patient profiles and records of the demographic data, surgical indications, surgical technique, implant placement, surgical time, intraoperative complications, as well as postsurgical complications (Holgers classification) and implant stability quotients (ISQ). ResultsUse of larger abutments was significantly greater in the PT group (PT, 10mm; LI, 6mm, p<0.001). The PT technique resulted in a shorter procedure than the LI (PT, 20min; LI, 45min, p<0.001). Holgers classification scores identified significantly fewer skin complications one week after surgery for the PT group; however, only small differences were seen between the two groups at the one- and three-month control visits. ConclusionsAs shown for our cohort, the punch technique for surgical placement of AOI is faster and presents fewer immediate postoperative complications when compared to the linear incision technique. The clinical application of the ISQ is a useful, easy method to demonstrate the status of osseointegration and, thus, the stability of the device.

Retrospective analysis of skin complications related to bone-anchored hearing aid implant: association with surgical technique, quality of life, and audiological benefit.

IntroductionThe bone-anchored hearing aid is an effective form of auditory rehabilitation. Due to the nature of the implant, the most common complications are skin related. A number of alternative surgical implantation techniques have been used to reduce the frequency and severity of skin complications, including the U-shaped graft and the linear incision.ObjectiveTo assess skin complications and their association with surgical technique, quality of life, and audiological benefit in patients with bone-anchored hearing aids.MethodsThis was a retrospective study conducted in a tertiary referral center in Bogotá, Colombia. Patients who had been fitted with a bone-anchored hearing aid implant (unilaterally or bilaterally) for at least 6 months were included in the study. The Holgers classification was used to classify skin complications (Grade 0 = none; Grade 1 = erythema; Grade 2 = erythema and discharge; Grade 3 = granulation tissue; and Grade 4 = inflammation/infection resulting in the removal of the abutment). The Glasgow Benefit Inventory questionnaire was used to determine quality of life, and the Abbreviated Profile of Hearing Aid Benefit questionnaire was used to determine the subjective audiological benefit.ResultsA total of 37 patients were included in the study (30 with unilateral implants and 7 with bilateral implant). Of the 44 implants evaluated, 31 (70.3%) were associated with skin complications (7 [15.9%] Grade 1; 4 [9.1%] Grade 2; 15 [34.1%] Grade 3, 5 [11.4%] Grade 4). The U-shaped graft was statistically associated with major complications (Grades 3 and 4) compared with the linear incision technique (p = 0.045). No statistically significant differences were found between Abbreviated Profile of Hearing Aid Benefit scores and severity of complications. Similarly, no differences were found between Glasgow Benefit Inventory physical health questions and skin complications.ConclusionDespite the high frequency, skin complications did not seem to affect quality of life or subjective audiological benefits of patients with bone-anchored hearing aids.

Erratum to: Stability, survival, and tolerability of a 4.5-mm-wide bone-anchored hearing implant: 6-month data from a randomized controlled clinical trial

The objective of this study was to compare the stability, survival, and tolerability of 2 percutaneous osseointegrated titanium implants for bone conduction hearing: a 4.5-mm diameter implant (test) and a 3.75-mm diameter implant (control). Fifty-seven adult patients were included in this randomized controlled clinical trial. Sixty implants were allocated in a 2:1 (test-control) ratio. Follow-up visits were scheduled at 7, 14, 21, and 28 days; 6 and 12 weeks; and 6 months. At every visit, implant stability quotient (ISQ) values were recorded by means of resonance frequency analysis (RFA) and skin reactions were evaluated according to the Holgers classification. Implants were loaded with the bone conduction device at 3 weeks. Hearing-related quality of life was evaluated using the Abbreviated Profile of Hearing Aid Benefit (APHAB), the Glasgow Benefit Inventory (GBI), and the Glasgow Health Status Inventory (GHSI). ISQ values were statistically significantly higher for the test implant compared to the control implant. No implants were lost and soft tissue reactions were comparable for both implants. Positive results were reported in the hearing-related quality of life questionnaires. These 6-month results indicate that both implants and their corresponding hearing devices are safe options for hearing rehabilitation in patients with the appropriate indications. Loading at 3 weeks did not affect the stability of either implant.

Punch and Drill

To compare 2 surgical techniques for implantation of a percutaneous bone anchored hearing device: (1) a minimal skin punch incision without additional skin incision or soft tissue reduction and (2) implantation with an epidermal flap and soft tissues reduction. Prospective study. Tertiary care referral center. Forty patients consecutively implanted (18 males and 22 females). Twenty patients underwent implantation by means of epidermal flap and soft tissues reduction (dermatome group), and 20 patients underwent skin punch resection without soft tissues reduction (punch group). surgical adverse events, surgical time, skin healing, skin tolerance (Holgers classification), and skin appearance and implant failure. The surgical time was shorter with the punch technique (P < .05). The postoperative healing was satisfactory in both groups. All implants were loaded after the healing period. The skin tolerance was good in both groups by Holgers classification (punch, 85.7%/dermatome, 86%) with no significant difference. There were no severe adverse skin events in the punch group. The appearance of the skin around the implant was improved by the punch technique. The implantation of the currently available percutaneous bone anchored hearing implants with a minimal skin punch skin resection without additional skin incision or soft tissue reduction shortens the surgery and improves the postoperative appearance. The skin tolerance is at least as good as with techniques with that include soft tissue reduction.

Stability, survival, and tolerability of a 4.5-mm-wide bone-anchored hearing implant: 6-month data from a randomized controlled clinical trial.

The objective of this study was to compare the stability, survival, and tolerability of 2 percutaneous osseointegrated titanium implants for bone conduction hearing: a 4.5-mm diameter implant (test) and a 3.75-mm diameter implant (control). Fifty-seven adult patients were included in this randomized controlled clinical trial. Sixty implants were allocated in a 2:1 (test–control) ratio. Follow-up visits were scheduled at 7, 14, 21, and 28 days; 6 and 12 weeks; and 6 months. At every visit, implant stability quotient (ISQ) values were recorded by means of resonance frequency analysis (RFA) and skin reactions were evaluated according to the Holgers classification. Implants were loaded with the bone conduction device at 3 weeks. Hearing-related quality of life was evaluated using the Abbreviated Profile of Hearing Aid Benefit (APHAB), the Glasgow Benefit Inventory (GBI), and the Glasgow Health Status Inventory (GHSI). ISQ values were statistically significantly higher for the test implant compared to the control implant. No implants were lost and soft tissue reactions were comparable for both implants. Positive results were reported in the hearing-related quality of life questionnaires. These 6-month results indicate that both implants and their corresponding hearing devices are safe options for hearing rehabilitation in patients with the appropriate indications. Loading at 3 weeks did not affect the stability of either implant.

Orbital implant placement using a computer-aided design and manufacturing (CAD/CAM) stereolithographic surgical template protocol

Surgical implant placement in the orbital region for the support of a prosthesis is challenging due to the thin orbital rim and proximity to vital structures. This article reports the use of a computer-aided design and manufacturing (CAD/CAM) stereolithographic surgical template protocol for orbital implant placement in four patients, who were followed-up for about 7 years. A total of 11 orbital implants were inserted, eight of these in irradiated bone. No intraoperative complications were noted in any of the patients and the implants were all inserted in the planned positions. The survival rate of implants placed in irradiated bone that received hyperbaric oxygen therapy was 62.5% (5/8). One implant failed in a burns injury patient at 74 months after functional loading. The overall survival of implants in the orbital region and the cumulative survival at 7 years was 63.6%. With regard to skin reactions around the abutments, 85% were grade 0, 13% were grade 1, and 2% were grade 2 according to the Holgers classification. The mean survival time of the first prosthesis was 49 months. High patient satisfaction was achieved with the implant-retained orbital prostheses.

Complicaciones cutáneas en los implantes oseointegrados: comparación entre la técnica clásica y la de preservación de tejido

Introduction and objectivesThe standard surgical technique for osseointegrated hearing aids involves removing a large area of subcutaneous tissue down to the periosteum. Recently, the industry has designed a new range of abutment lengths for less invasive surgery with soft tissue preservation. This study compared and evaluated the complications in the standard and the tissue preservation techniques. Material and methodsThis was a prospective study including 29 adult patients that underwent single-stage osseointegrated hearing aids insertion between February 2009 and February 2013. We performed the standard technique in 14 patients, and the tissue preservation technique in 15. Soft tissue complications were graded according to the Holgers classification. ResultsNo patient required removal of implant or revision surgery. Although the Holgers grade was always worse in the standard technique (reaction score of 3 or higher was 28% versus 7% at a month), the complication rate was not statistically significant between the 2 groups at any postoperative time a week (p=0.233), a month (p=0.470) and a year (p=0.401). ConclusionIn our experience the tissue preservation technique, without soft tissue reduction, is the procedure of choice for bone anchored implant surgery. The preservation technique is easier, faster and possible with local anaesthesia and has similar postoperative outcomes.

Soft tissue reactions in patients with bone anchored hearing aids.

To establish the incidence and correlation between the degree of soft tissue reaction and the body mass index (BMI) according to age and gender after a bone anchored hearing aid (BAHA) implant. We did a 1-9-year follow-up for the all the patients who underwent surgery in our department with BAHA implant system. Soft tissue reactions were classified in accordance with the Holgers classification on regular patient visits. BMI was calculated for each patient, and changes were recorded at least once a year. 47 patients were evaluated. 58% were operated on for chronic otitis with mixed or conductive hearing loss; 20% had unilateral or bilateral atresia and 16% had single sided deafness (SSD); other indications were otosclerosis and syndromic patients. The grade of Holgers classification significantly correlated at a 0.001 level with BMI (Spearmans rho 0.452). Holgers grade also differed significantly between the sexes-skin reactions in females were less frequent. An ANOVA test did not reveal any statistical difference between patients with dissimilar indications for BAHA. If performed carefully, BAHA surgery produces a favorable outcome. The Holgers grade may change as time passes. If skin reactions appear, they can be treated through local or systemic therapy, and they may turn into a normal grade. Adipose patients should be treated with special care because they are more prone to soft tissue reactions.

A Minimally Invasive Technique for the Implantation of Bone‐Anchored Hearing Devices

To describe and evaluate a novel technique for the implantation of bone conduction hearing devices as compared with a common, conventional technique. Case series with chart review. Tertiary referral otology and neurotology practice. Individuals who underwent the implantation of bone-anchored hearing devices between January 1, 2004, and December 31, 2011, were identified. Demographic data, surgical indications, surgical technique used, surgical time, and complications were recorded. Soft tissue complications were graded on the Holgers classification scheme. Group 1 was defined as those undergoing a traditional technique using a dermatome with subcutaneous tissue reduction. Group 2 was defined as those undergoing the described technique for implantation of the coupling hardware with minimal subcutaneous soft tissue reduction. Forty patients underwent the procedure, with 11 patients comprising group 1 and 29 patients comprising group 2. Group 2 required a shorter operative time (32.3 vs 56.1 minutes, P < .0001). Of patients in group 1, 2 of 11 developed soft tissue complications, whereas 5 of 29 in group 2 developed soft tissue complications (P = 1.000). Most soft tissue complications were reversed with conservative wound care. Surgery was performed faster with similar postoperative outcomes in individuals undergoing implantation of bone-anchored hearing devices using the described technique that necessitated minimal soft tissue reduction.

Stability, Survival, and Tolerability of a Novel Baha Implant System

Determination of the difference in implant stability between a novel Baha implant system (test) and the previous-generation implant system (control). In an open, randomized, prospective multicenter clinical investigation, 77 adult patients with Baha implants were included. Test and control implants were randomly assigned in proportions of 2:1. Implant stability quotient (ISQ) values were recorded using resonance frequency analysis at the time of implantation and at 10 days, at 4, 6, 8, and 12 weeks, and at 6 months after surgery. Skin reactions were evaluated according to the Holgers classification. Sound processor fitting was performed from 6 weeks after implantation. Significantly higher mean ISQ values, measured between 0 and 6 months, were obtained for test compared to control implants (70.4 versus 65.4, p < 0.0001). Statistically significant differences were obtained for the study population as a whole and for the subgroup of patients loaded at 6 ± 1 weeks after implant surgery (63.6% of patients). Up to 12 weeks, Holgers rates were comparable, whereas at 6 months, more skin reactions (Grades 1 and 2) were observed in the control implant group. No reduction in mean ISQ values was observed after implant loading. The test implant showed higher mean ISQ values at the time of placement and over time. The level of osseointegration reached with the implants in adults as early as 6 weeks after implantation was sufficient to support the sound processor. The test implant system is expected to provide additional benefits related to the improvement of the degree of osseointegration, especially for patients with thin or compromised bone.

Long-Term Follow-Up of Osseointegrated Auricular Reconstruction

Auricular deformity presents a formidable challenge for the reconstructive surgeon, and osseointegrated auricular reconstruction provides a safe and reliable option. The authors sought to review long-term results of osseointegrated auricular reconstruction at the Institute for Reconstructive Sciences in Medicine. A chart review examining demographics, skin reactions (defined by a modified Holgers classification), and complications at the Institute for Reconstructive Sciences in Medicine was completed. A multivariate binary linear logistic regression analysis was performed to determine whether there was a correlation between the likelihood of a skin reaction and certain patient demographics. A survey was then developed to assess patient satisfaction. Seventy-five osseointegrated auricular reconstructions were performed on 69 patients at the Institute for Reconstructive Sciences in Medicine from 1989 to 2007; mean patient age was 39 years (range, 9 to 76 years). The most common indication for reconstruction was posttraumatic, then congenital and oncologic. The frequency of Holgers reactions was as follows: no reaction, 69 percent; red tissue, 15 percent; excessive tissue, 10 percent; red and moist tissue, 3 percent; granulation tissue, 2 percent; and soft-tissue necrosis, 1 percent. Multivariate binary linear logistic regression analysis found that smoking, younger age, and female gender were associated with the occurrence of a reaction. The overall failure rate of osseointegration in the mastoid region was 2 percent. Survey results found generally satisfied patients willing to undergo the same procedure again, although 55 percent felt that they had had a skin reaction. The authors present long-term results showing both success and complications of the osseointegrated prosthetic ear reconstruction for a variety of different etiologies and age groups.

Bone-Anchored Hearing Aid Implant Location in Relation to Skin Reactions

To evaluate the effect of implant location and skin thickness on the frequency and degree of adverse skin reactions around the abutment. Retrospective multivariate analysis of implant position related to skin thickness and clinical variables. Tertiary referral center. Random sample of 248 patients with bone-anchored hearing aids. Bone-anchored hearing aid implant placement by means of the linear incision technique. Type and number of skin reactions and implant loss. The mean (SD) distance from the external auditory ear canal to implant was 48.8 (8.0) mm (range, 29-84 mm). The mean skin thickness was 5.5 (1.9) mm. Severe skin reactions (Holgers classification, 2-4) were seen in 46 of the 248 patients (18.5%). Implant loss occurred in 4 patients (1.6%). Three implants were lost owing to failed osseointegration (1.3%), and another implant was removed because of deterioration of cochlear function (0.9%). No implant was lost as a result of infection. Implant location and skin thickness were not correlated with implant loss or the frequency or degree of adverse skin reactions around the abutment.