Patient reported outcome measures in microtia surgery

Evaluation of the Reproducibility of Auricular Subunit Markers Based on Three-Dimensional Computed Tomography

BACKGROUND

As a facial feature, the auricle plays an important role in the integrity and aesthetics of the whole face. Auricular subunits are associated with patient satisfaction in auricular reconstruction, but there are few studies on auricular subunits. We want to evaluate the reproducibility of auricular subunits by measuring the coordinates of the marker points of auricular subunits, accordingly provide a reference for the improvement of auricular reconstruction and the aesthetics of auricular injection.

METHODS

Mimics 19.0 was used to carry out three-dimensional (3D) reconstruction of the computed tomography (CT) scan data of patients' brains; measure the three-dimensional coordinates of the 13 auricular subunit markers, the morphological auricle length and width, and the physiological auricle length and width; and analyze the reproducibility as well as the differences between group.

RESULTS

Reproducibility of auricle subunit markers: There are 1124 (58.82%) high reproducibility, 580 (30.35%) moderate reproducibility, and 207 (10.83%) low reproducibility. The superior tragus notch, tragus, and antitragus had the highest reproducibility. There was no significant difference between the groups in the marking points on the helix, and there were no statistically significant differences in the measurement values of the auricles on the two sides. The physiological ear length and width and the morphological ear length of males were larger than those of females. These showed significant differences between the age groups.

CONCLUSION

Most auricular subunit markers have high reproducibility. The subunits with higher reproducibility are the structures that need to be optimized during auricle reconstruction surgery or auricle injection in the future.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Patient factors associated with novel EAR-Q appearance, psychosocial, and social scales: A cross-sectional study and regression analysis

INTRODUCTION

The EAR-Q is a rigorously validated patient-reported outcome measure, which evaluates ear appearance and health-related quality of life (HRQL) in patients with congenital or acquired ear conditions. The aim of this study was to conduct an exploratory analysis to examine the factors associated with EAR-Q appearance and HRQL scale scores.

METHODS

In this study, 862 participants, aged 8-29 years, with congenital or acquired ear conditions, completed the EAR-Q as part of an international field-test study. Patients responded to demographic and clinical questions as well as the EAR-Q. Univariable and multivariable linear regression analyses were used to determine factors that were significant predictors for the scores on the EAR-Q Appearance, Psychological, and Social scales.

RESULTS

Most participants were men (57.4%), awaiting treatment (55.0%), and had a microtia diagnosis (70.4%), with a mean age of 13 (±4) years. Worse ear appearance scores (p < 0.02) were associated with male gender, microtia, no history of treatment, ear surgery within 6 months, unilateral involvement, and greater self-reported ear asymmetry. Decreased psychological scores (p < 0.01) were associated with increasing participant age, no treatment history, recent ear surgery, and dissatisfaction with ears matching or overall dissatisfaction. Lower social scores (p ≤ 0.04) were associated with no treatment history, those awaiting surgery, ear surgery within the last 6 months, bilateral involvement, and self-reported ears matching or overall appearance.

CONCLUSION

This analysis identified patient factors that may influence ear appearance and HRQL scale scores. These findings provide evidence of patient factors that should be adjusted for when undertaking future observational research designs using the EAR-Q in this patient population.

Porous Polyethylene Versus Autologous Costochondral Reconstruction for Microtia: Incidence and Analysis of Secondary Procedures

OBJECTIVE

To examine the frequency of autologous and alloplastic ear reconstructions for patients with microtia in the United States, and describe post-index procedure rates associated with each method.

DESIGN

Retrospective cohort study.

SETTING

Claims data from 500 + hospitals from IBM® MarketScan® Commercial and Multi-State Medicaid databases.

PATIENTS/PARTICIPANTS

A total of 649 patients aged 1 to 17 years with International Classification of Diseases, ninth/tenth revision (ICD-9/10) diagnoses for microtia, congenital absence of the ear, or hemifacial microsomia.

INTERVENTIONS

Alloplastic or autologous ear reconstruction between 2006 and 2018.

MAIN OUTCOME MEASURE

Post-index procedures performed within 1 year following the index repair, analyzed across the study period and separately for each half of the study period (2006-2012, 2012-2018).

RESULTS

A total of 486 (75%) qualifying patients received autologous and 163 (25%) received alloplastic reconstruction. Secondary procedure rates were significantly higher in the autologous group at 90 days (P = .034), 180 days (P < .001), and at 365 days (P < .001). Alloplastic reconstruction accounted for 23.2% of reconstructions in the first half of the study period compared with 26.7% in the second half (P = .319). One-year secondary procedure rates in the autologous group were not significantly different between both halves of the study period (69.7% vs 67.1%, P = .558), but were significantly lower in the second half for the alloplastic group (44.9% vs 20.2%, P = .001).

CONCLUSIONS

In these databases, autologous reconstruction is more common than alloplastic reconstruction. Autologous reconstruction is staged, with most undergoing a secondary procedure between 3 months and 1 year postoperatively. Secondary procedure rates decreased over time in patients undergoing alloplastic reconstruction.

Reconstructive Techniques in Pediatric Congenital Microtia: A Systematic Review and Meta-analysis

Autografts and allografts are commonly used in microtia reconstruction. We aimed to systematically review and compare these reconstructive materials in pediatric congenital microtia reconstruction. A systematic review of the literature was performed. MEDLINE, Embase, PubMed, Web of Science, and CINAHL databases were searched for original studies on congenital microtia reconstruction in pediatric patients since database inception to 2021. Microtia grade was stratified as high or low. Meta-analysis of pooled proportions and continuous variables was performed using inverse variance weighting with a random effects model to compare between the autograft and allograft groups. Sixty-eight studies with a total of 5,546 patients used autografts (n = 5,382) or alloplastic implants (n = 164). Four other studies used prosthesis, cadaveric homografts, or tissue engineering. The allograft group was on average younger than the autograft group (8.4 vs. 11.1 years). There were no syndromic patients in the allograft group, compared to 43% in the autograft group. Patients treated with allografts had higher microtia grade than those treated with autograft (98 vs. 72%). Autografts were more commonly utilized by plastic surgeons and allografts by otolaryngologists (95 vs. 38%). No autografts and 41% of allografts were done concurrently with atresiaplasty or bone conduction implant. Satisfaction rates were similarly high (>90%) with similar complication rates (<10%). Microtia reconstruction using autografts and allografts had similar satisfaction and complication rates. Allografts were preferred for younger patients and concurrent hearing restoration. Further large-scale studies are required to evaluate the long-term efficacy of these reconstructive techniques.

Secondary ear reconstruction based on the Nagata method after unsatisfactory microtia surgery outcomes

BACKGROUND

Follow-up studies on auricular reconstruction procedures have reported postoperative complications; some of which can only be reversed with revision surgery. This study aims to provide a feasible surgical strategy based on the Nagata method for patients requiring secondary revision and verify mid-term aesthetic outcomes.

METHODS

Secondary auricular reconstructions based on the Nagata method were performed on seven patients seeking secondary revision between 2017 and 2021. Scores of a five-point Likert scale and artificial intelligence ratings based on convolutional nerve networks were used as outcome measures.

RESULTS

Five patients underwent complete two-stage ear reconstruction, and the other two patients underwent the first-stage microtia procedure only. Few complications were observed, except in Case 4; this patient required an additional minor surgery after frame exposure 6 weeks after the first-stage procedure. All revised ears showed clear anatomical structures, and all patients were satisfied with the aesthetic results. Statistical analysis showed a significant increase in postoperative versus preoperative scores by convolutional neural network models (p < 0.05). Cases 5 and 6, which involved projection surgeries only, had decreased artificial intelligence appearance scores postoperatively.

CONCLUSION

After adequate preoperative evaluation, secondary auricle reconstruction based on the Nagata method can achieve reliable aesthetic outcomes with few complications.

CLINICAL TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov ID: NCT05604456.

Objective quantitative methods to evaluate microtia reconstruction: A scoping review

Background

Commonly used methods to evaluate auricles are subjective and are therefore not specific, comprehensive, and precise nor effective in the assessment of microtia reconstruction outcomes. This scoping review aimed to summarize the objective methods for the accurate evaluation of microtia reconstruction.

Methods

We performed a scoping review of publications that used objective measurement methods to evaluate outcomes of microtia reconstruction according to the PRISMA-ScR guidelines. A systematic literature search was conducted in the Embase, PubMed, Cochrane, CNKI, and VIP databases, and literature references were screened for additional records. Studies that evaluated auricles after microtia reconstruction using quantitative anthropometric methods were included, and data on these methods were collected.

Results

Twenty-five publications reported on quantitative objective outcome measurements. Thirteen studies evaluated auricular protrusion, three articles assessed the position or symmetry, and twelve studies reported on auricle size. The quantitative measurements of fine structures, such as the tragus and concha, were described in three studies. All described measurements used manual landmarking, where fifteen studies described well-defined landmarks, fifteen studies described poorly defined landmarks, and four studies used a combination of well and poorly defined landmarks.

Conclusion

The objective evaluation of microtia reconstruction outcomes is hindered by significant heterogeneity of measurement methods. The measurement methods used for general auricular measurements (auricular protrusion, auriculocephalic angle, and size) used in microtia reconstruction were abundant, while measurements of auricular position and the fine structures of the auricle were limited. Three-dimensional imaging combined with computer analyses poses promising future alternatives.

Management Strategy of Local Subcutaneous Effusion After Auricle Reconstruction

OBJECTIVES

Microtia is a severe congenital malformation of the external ear, and auricular reconstruction is still a challenge for plastic surgeons because of the complicated procedures and rare conditions. This study aimed to describe the location of subcutaneous effusion after auricular reconstruction and explore the clinical efficacy of the indwelling needle puncture drainage method in the treatment of local subcutaneous effusion.

METHODS

From January 2017 to December 2019, 1240 patients (1296 affected sides) who underwent auricular reconstruction using autogenous cartilage framework in the Plastic Surgery Hospital of Chinese Academy of Medical Science and Peking Union Medical College were selected. The local subcutaneous effusion occurred within 5 days after the drainage tube was removed, and the indwelling needle was used for puncture and drainage in the postoperative treatment.

RESULTS

A total of 55 patients had subcutaneous effusion after the operation, including 24 cases with Nagata's method and 31 cases with the expanded single-flap method. One patient showed no obvious reduction after puncture and drainage by indwelling needle and improved after the secondary operation. Two patients had slight cartilage absorption. The remaining patients had good results.

CONCLUSIONS

The method of the indwelling needle for puncture and drainage is easy to operate. The problem of local subcutaneous effusion after auricular reconstruction can be solved and good efficacy can be obtained.

Psychosocial and Health-Related Experiences of Individuals With Microtia and Craniofacial Microsomia and Their Families: Narrative Review Over 2 Decades

This paper describes 20 years of microtia and craniofacial microsomia (CFM) psychosocial and healthcare studies and suggests directions for clinical care and research.

A narrative review of papers January 2000 to July 2021 related to psychosocial and healthcare experiences of individuals with microtia and CFM and their families.

Studies (N = 64) were mainly cross-sectional (69%), included a range of standardized measures (64%), and were with European (31%), American (27%), or multinational (23%) samples. Data were generally collected from both patients and caregivers (38%) or patient self-report (35%). Sample sizes were 11 to 25 (21%), 26 to 50 (19%), 51 to 100 (22%), or over 100 (38%). Studies addressed 5 primary topics: (1) Healthcare Experiences, including Medical Care, Hearing Loss/Amplification, Diagnostic Experiences, and Information Preferences; (2) Psychosocial Experiences, including Teasing, Behavioral Adjustment, Psychosocial Support, and Public Perception; (3) Neurocognitive Functioning and Academic Assistance; (4) Pre- and Post-Operative Psychosocial Outcomes of Ear Reconstruction/Canaloplasty; and (5) Quality of Life and Patient Satisfaction.

Care involved multiple specialties and was often experienced as stressful starting at diagnosis. Psychosocial and neurocognitive functioning were generally in the average range, with possible risk for social and language concerns. Coping and resiliency were described into adulthood. Satisfaction and positive benefit of ear reconstruction/canaloplasty were high. Care recommendations include increasing: hearing amplification use, microtia and CFM knowledge among providers, efficient treatment coordination, psychosocial support, academic assistance, and advances to minimize surgical scarring. This broad literature overview informs clinical practice and research to improve psychosocial outcomes.

Dual Option Microtia Clinic: A Comparison of Outcomes in Microtia Reconstruction Using Autologous Rib or Porous Polyethylene Implant

Introduction: Auricular reconstruction techniques most frequently utilize either autologous costal cartilage or alloplastic porous polyethylene (PPE) implant. Objectives: To compare the aesthetic outcomes, number of surgeries, and complications in children who underwent microtia reconstruction with either rib or PPE implant by blinded photograph review. Methods: This retrospective cohort study included consecutive pediatric patients who underwent auricular reconstruction with either autologous cartilage or PPE between November 2017 and February 2022. Blinded observers rated each postoperative ear through a web-based survey. Data on patient characteristics, operative time, length of admission, and complications were collected, bivariate analyses were performed using chi-square or Fisher's exact tests for categorical variables and Wilcoxon rank-sum test for continuous variables. Results: Forty-four ears were included, 28 of which (63.6%) were reconstructed with cartilage. Median patient age was 8 years (range 4-18 years) and 29 (65.9%) were male. The cartilage group had more surgeries (median 2.5 vs. 1.0, p < 0.001), and total operating time across all surgeries did not differ significantly. Conclusion: The two groups in our study had similar rates of complications and aesthetic scores, and aesthetic scores were worse for ears with wound complications requiring unplanned revisions.

Quality of Life After Modified Rambo Ear Canal Closure in Pediatric and Adult Patients

OBJECTIVE

To present the surgical and quality of life (QOL) outcomes of patients who underwent blind sac closure of the external auditory canal (EAC) via a modified Rambo approach.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary academic referral center.

METHODS

All patients who underwent EAC closure with a modified Rambo approach between 2015 and 2021 were evaluated. Complication rates, QOL estimations from a validated survey, and subjective cosmetic reports were analyzed.

RESULTS

Thirty-five ears were closed in 31 patients. The most common indication for surgery was related to cochlear implantation and cochlear malformation or cholesteatoma (31.4%). No case involved an immediate complication requiring revision surgery, and 4 ears (11.4%) were suspected of having cholesteatoma within the surgical cavity at a mean 28.6-month follow-up. Adults (≥18 years) had significantly higher QOL scores than children in the medical resource subscale of the Chronic Ear Survey (P < .01), and patients undergoing concurrent EAC closure and skull base tumor removal scored higher than others (P = .04). Females reported higher cosmetic scores than males (P = .04). QOL and cosmetic scores compared favorably to previously published data involving the management of otologic disease.

CONCLUSIONS

Ear canal closure can be a useful technique for select adult and pediatric patients. Patient and surgeon concerns regarding QOL and cosmesis in ear canal closure should be explored prior to employing this surgical technique, though the present data suggest that the modified Rambo approach to closure is generally associated with reasonable outcomes in both areas.

The psychosocial impact of microtia and ear reconstruction: A national data-linkage study

Introduction

Children with visible facial differences are believed to be at increased risk of negative psychosocial behaviours which may manifest as affective disorders. The aim of this study was to determine whether a diagnosis of microtia, and the associated surgical intervention, is associated with psychosocial implications including impaired educational attainment and a diagnosis of an affective disorder.

Methods

A retrospective case-control study was conducted using data linkage to identify patients in Wales with a diagnosis of microtia. Matched controls were sought on the basis of age, gender and socioeconomic deprivation status to yield a total sample size of 709. incidence was calculated using annual and geographic birth rates. Surgical operation codes were used to classify patients into those that had no surgery, autologous reconstruction or prosthetic reconstruction. Educational attainment at 11 years of age, plus a diagnosis of depression or anxiety were used as markers of adverse psychosocial outcomes and the relative risk was attained using logistic regression analyses.

Results

There were no significant associations between a diagnosis of microtia and an increased risk of adverse educational attainment or a risk of an affective disorder diagnosis. Male gender and higher deprivation scores were significantly associated with poorer educational attainment, irrespective of a diagnosis of microtia. Surgical intervention of any nature was also not associated with any increased risk of adverse educational or psychosocial outcomes in microtia patients.

Discussion

Microtia patients in Wales do not appear to be at greater risk of developing affective disorders or impaired academic performance as a result of their diagnosis or associated surgical intervention. Whilst reassuring, the need for appropriate support mechanisms to maintain positive psychosocial wellbeing and academic achievement in this patient cohort is reinforced.

The Use of Auricular Cartilage Grafts in Septorhinoplasty: A Dual-Centre Study of Donor Site Patient-Reported Outcome Measures

Objectives

The use of autologous grafts is a key aspect of contemporary septorhinoplasty. When septal cartilage is deficient, auricular cartilage serves as a biocompatible, readily accessible alternative. Our study aimed to assess donor site patient-reported outcome measures (PROMs) where auricular cartilage has been harvested for use in septorhinoplasty, adding to the limited existing literature on this topic.

Design

A dual-centre, single-surgeon retrospective analysis of patients undergoing septorhinoplasty surgery with augmentation using auricular cartilage grafts was conducted. Grafts were harvested using an anterior anti-helical approach. Patients were followed up at one week, three months and 12 months post-operatively. Donor site outcomes were assessed across several physical and psychological domains by adapting the EAR-Q questionnaire, which was administered via telephone consultation. Responses were quantified using a Likert scale.

Results

A total of 22 patients met our inclusion criteria. Four were lost to follow-up, five were non-responders and one case was excluded due to documentation of body dysmorphic disorder. A significant proportion of patients reported no reduction in quality of life (QOL) or confidence attributed to donor site cosmesis. High satisfaction was noted with anti-helical donor site scars. Although noticeable differences in shape and symmetry were reported, these had negligible effects across psychological domains.

Conclusions

Preliminary results suggest high levels of patient satisfaction, with minimal physical and psychological donor site sequelae following auricular cartilage harvest in septorhinoplasty. Subsequent studies should involve the use of validated questionnaires, coupled with larger patient cohorts in order to provide further data for statistical analysis.

Patient-Reported Satisfaction After Autologous Auricular Reconstruction in Patients with Microtia: A Systematic Review

Importance: In a patient-centered field such as plastic surgery, patient-reported satisfaction can measure the success and value of surgery, since it is not uncommon for patient and surgeon assessments to differ. Currently, there is no standard for evaluating patient-reported satisfaction postauricular reconstruction. Objective: To systematically review the literature regarding patient-reported satisfaction postauricular reconstruction in microtia patients. Evidence Review: The databases MEDLINE, EMBASE, Cochrane, and Scopus were searched and preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Studies documenting patient-reported satisfaction postauricular reconstruction in microtia patients were included. All techniques for ear reconstruction have been included in this review. Findings: Nineteen studies utilizing autologous reconstruction technique, comprising 3694 patients, met inclusion criteria. No standardized patient satisfaction assessment was used throughout the studies, indicating criteria variability to measure outcomes. Auricular substructure analysis highlighted lower patient satisfaction with the tragus and antitragus compared with the upper units. In addition, satisfaction depended on patient perception, not on a low surgical complication rate. Conclusions: There is a clear need to incorporate a standardized validated surgery-specific questionnaire related to patient satisfaction in the auricular reconstruction protocol.

An international study to develop the EAR-Q patient-reported outcome measure for children and young adults with ear conditions

BACKGROUND

There is currently a lack of patient-reported outcome measures for ear reconstruction. We developed the EAR-Q to measure ear appearance and post-operative adverse effects from the patient perspective.

METHODS

Field-test data were collected from children and young adults in eight countries between 13 May 2016 and 12 December 2019. Rasch measurement theory (RMT) analysis was used to refine the scales and to examine their psychometric properties.

RESULTS

Participants had microtia (n = 607), prominent ears (n = 145) or another ear condition (n = 111), and provided 960 assessments for the Appearance scale (e.g., size, shape, photos), and 137 assessments for the Adverse Effects scale (e.g., itchy, painful, numb). RMT analysis led to the reduction of each scale to 10-items. Data fit the Rasch model for the Appearance (X2(80) = 90.9, p = 0.19) and Adverse Effects (X2(20) = 24.5, p = 0.22) scales. All items in each scale had ordered thresholds and good item fit. There was no evidence of differential item function for the Appearance scale by age, gender, language, or type of ear condition. Reliability was high for the Appearance scale, with person separation index (PSI) and Cronbach alpha values with and without extremes ≥0.92. Reliability for the Adverse Effects scale was adequate (i.e., PSI and Cronbach alpha values ≥0.71). Higher scores (liked appearance more) correlated with higher scores (better) on Psychological, Social and School scales.

INTERPRETATION

The EAR-Q can be used in those 8-29 years of age to understand the patient perspective in clinical practice and research, and in addition, can be used to benchmark outcomes for ear reconstruction internationally.

Long-term aesthetics, patient-reported outcomes, and auricular sensitivity after microtia reconstruction: A systematic review

BACKGROUND

Auricular reconstruction for microtia is most frequently performed using autologous costal cartilage (ACC) or porous polyethylene (PPE) implants. Short-term results are generally promising, but long-term results remain unclear. Long-term outcomes were explored in this systematic review, and minimal reporting criteria were suggested for future original data studies.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included if postsurgical follow-up was at least 1 year. Outcome reporting was split into separate publications, and results on complications were reported previously. This publication focused on long-term aesthetic, patient-reported, and sensitivity outcomes.

RESULTS

Forty-one publications reported on these outcomes. Both materials led to aesthetically pleasing results and high rates of patient satisfaction. ACC frameworks grew similarly to contralateral ears, and the anterior surface of auricles regained sensitivity. Furthermore, postoperative health-related quality of life (HRQoL) outcomes were generally good. Data synthesis was limited due to considerable variability between studies and poor study quality. No conclusions could be drawn on the superiority of either method due to the lack of comparative analyses.

CONCLUSION

Future studies should minimally report (1) surgical efficacy measured using the tool provided in the UK Care Standards for the Management of Patients with Microtia and Atresia; (2) complications including framework extrusion or exposure, graft loss, framework resorption, wire exposure and scalp/auricular scar complications and (3) HRQoL before and after treatment using the EAR-Q patient-reported outcome measure (PROM).

Long-term complications of microtia reconstruction: A systematic review

BACKGROUND

Microtia is a rare disorder characterized by malformation or even complete absence of the auricle. Reconstruction is often performed using autologous costal cartilage (ACC) or porous polyethylene implants (PPE). However, the long-term outcomes of both methods are unclear.

OBJECTIVE

This systematic review aimed to analyze long-term complications and suggest minimal reporting criteria for future original data studies.

METHODS

A systematic literature search was conducted in MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials from inception through October 14, 2020. Articles on auricular reconstruction in patients with microtia using ACC or PPE were included provided that the follow-up period was at least one year. This publication focused on long-term complications reported in patients with a postoperative follow-up period of at least one year.

RESULTS

Twenty-nine publications reported on complications during long-term follow-up. Overall long-term complication rates were not reported. The incidence of individual complications during long-term follow-up was less than 10% after ACC reconstruction and less than 15% in PPE reconstruction. Framework resorption and wire exposure were reported even after an extended follow-up of more than five years after ACC reconstruction, while reports on the extended long-term results of PPE reconstruction are limited. Data synthesis was limited due to heterogeneity and poor study quality.

CONCLUSIONS

Future studies should report on long-term complications including framework exposure or extrusion, graft loss, framework resorption, wire exposure and scalp and auricular scar complications. We recommend a surgical follow-up of at least five years.

A Single Surgeon's Experience of Starting a New Ear Reconstruction Service in the UK

ABSTRACT

Autologous ear reconstruction is known as one of the most difficult types of reconstruction to perform in plastic surgery. Very rarely is a trainee exposed to the level of complexity and variety of cases they will treat as a sole care provider in a tertiary care setting. This is because the learning curve is steep and those few surgeons that already perform ear reconstruction are limited in what technical experience they can offer trainees due to the plethora of factors competing against the surgeon. These include patient expectations, level of experience, length of anesthetic and accountability for results and complications. For this reason, once a plastic surgeon is nominated to provide autologous ear reconstruction, they face the daunting prospect of not only performing what is a very complex surgery with a very steep learning curve but also the judgment of their patients and colleagues. This paper charts the endeavors of the senior author to provide a service over the last 5 years. It will hopefully provide insight and context on setting up a service, dealing with complications, patient and peer expectations, and finally acknowledgment from both alike as experience is gained and excellence is reached.

Microtia: A Data Linkage Study of Epidemiology and Implications for Service Delivery

Introduction: Previous studies of microtia epidemiology globally have demonstrated significant geographical and ethnic variation, cited broadly as affecting 3-5 in 10,000 live births. The aim of this study was to determine the incidence of microtia in a largely homogeneous ethnic population in the United Kingdom (Wales) and to identify factors, such as distance and socioeconomic status, which may influence the access to surgical intervention. Materials and Methods: A retrospective cohort study was conducted using data linkage to identify patients born between 2000 and 2018 with a diagnosis of microtia. Microtia incidence was calculated using annual and geographic birth rates. Surgical operation codes were used to classify patients into those that had no surgery, autologous reconstruction or prosthetic reconstruction. Sociodemographic attributes were compared using descriptive statistics to determine differences in access to each type of surgical intervention. Results: A total of 101 patients were identified, 64.4% were male and the median age was 12 (8-16). The mean annual incidence was 2.13 microtia cases per 10,000 births over the 19-year study period. Both temporal and geographic variation was noted. The majority of patients undergoing surgery opted for autologous reconstruction (72.9%) at a median age of 9 (7-10) compared to 7 (5-8) for prosthetic reconstruction. Autologous reconstruction had a higher median number of surgeries (2, 1-3) than prosthetic (1.5, 1-2) and a higher median socioeconomic status of 3 (2-4) compared to 2 (1-4) for the prosthetic cohort. There were no statistically significant differences in the distance traveled for surgery. Discussion: This study highlights a role for data linkage in epidemiological analyses and provides a revised incidence of microtia in Wales. Although the majority of patients opted for autologous reconstruction, demographic disparities in socioeconomic status warrant further investigation, emphasizing the importance of striving for equity in accessibility to surgical intervention.

Modification of the cartilaginous framework for autologous ear reconstruction: Construction of a stable complete ring framework with grander highs and lows

BACKGROUND

Successful microtia reconstruction involves fabrication of a framework with well-defined ear subunits. Tragal definition and deep conchal bowl are key elements to produce a natural well-defined and contoured ear. We describe a modification in the cartilage framework with the purpose of increasing framework stability, tragal definition and conchal bowl depth.

METHODS

The tragus is placed on two cartilaginous bars (L-shaped), which are fixed to the framework base block creating a complete ring. These increase tragal projection and conchal depth. The tragus is carved angled posteriorly to have a shadowing effect on the absent auditory canal. Aesthetic outcome was assessed, at least 6 months after the second stage, on a 5-point ordinal scale (1-5) using the scoring system published in the UK microtia care standards and agreed on by the International Society for Auricular Reconstruction (ISAR).

RESULTS

A total of 406 auricular reconstructions were performed in 363 patients (206 right, 114 left, 43 bilateral). After excluding cases who did not have second stage and those without complete photographs, 290 cases were assessed. The described modification in the framework carving was performed in 255 ears out of these 290 ears. The mean aesthetic score before and after the modification was 2.4 and 3.09 respectively for the tragus (p < 0.001), 2.2 and 2.95 for the intertragal notch (p < 0.001) and 2.77 and 3.49 for the concha (p < 0.001).

CONCLUSIONS

This technical refinement has resulted in increased permanence and definition of the tragus and deeper and more aesthetic concha.

"Auricular reconstruction: A sociocultural, surgical and scientific perspective"

The functional and sociocultural role of the auricle has been prevalent in art, literature and history for millennia. It is no surprise, therefore, that auricular anomalies can be associated with affective disorders and impaired academic performance in children. The challenge of auricular reconstruction has captured the attention of surgical innovators for millennia with the earliest records of auricular reconstruction documented in the Edwin Smith Surgical Papyrus dating back to 3000 BCE. Since the 19th century, however, the interest in the ambition partial and total auricular reconstruction witnessed a rebirth, with refinements in frame construction, projection and skin coverage improving exponentially over the last two centuries. The gold standard auricular reconstruction practices today have their roots in these historical milestones, and form a solid foundation for the introduction of technological advancements such as 3D bioprinting and composite tissue allotransplantation into future auricular reconstruction practice. The aim of this review is to outline the sociocultural role of the auricle, the history and evolution of auricular reconstruction surgery and to provide an insight into potential future avenues of restoring auricular form and function.

A Review of Best Practices for Monitoring and Improving Inpatient Pediatric Patient Experiences

CONTEXT

Achieving high-quality patient-centered care requires assessing patient and family experiences to identify opportunities for improvement. With the Child Hospital Consumer Assessment of Healthcare Providers and Systems Survey, hospitals can assess performance and make national comparisons of inpatient pediatric experiences. However, using patient and family experience data to improve care remains a challenge.

OBJECTIVE

We reviewed the literature on best practices for monitoring performance and undertaking activities aimed at improving pediatric patient and family experiences of inpatient care.

DATA SOURCES

We searched PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsychINFO.

STUDY SELECTION

We included (1) English-language peer-reviewed articles published from January 2000 to April 2019; (2) articles based in the United States, United Kingdom, or Canada; (3) articles focused on pediatric inpatient care; (4) articles describing pediatric patient and family experiences; and (5) articles including content on activities aimed at improving patient and family experiences. Our review included 25 articles.

DATA EXTRACTION

Two researchers reviewed the full article and abstracted specific information: country, study aims, setting, design, methods, results, Quality Improvement (QI) initiatives performed, internal reporting description, best practices, lessons learned, barriers, facilitators and study implications for clinical practice, patient-experience data collection, and QI activities. We noted themes across samples and care settings.

RESULTS

We identified 10 themes of best practice. The 4 most common were (1) use evidence-based approaches, (2) maintain an internal system that communicates information and performance on patient and family experiences to staff and hospital leadership, (3) use experience survey data to initiate and/or evaluate QI interventions, and (4) identify optimal times (eg, discharge) and modes (eg, print) for obtaining patient and family feedback. These correspond to adult inpatient best practices.

CONCLUSIONS

Both pediatric and adult inpatient best practices rely on common principles of culture change (such as evidence-based clinical practice), collaborative learning, multidisciplinary teamwork, and building and/or supporting a QI infrastructure that requires time, money, collaboration, data tracking, and monitoring. QI best practices in both pediatric and adult inpatient settings commonly rely on identifying drivers of overall ratings of care, rewarding staff for successful implementation, and creating easy-to-use and easy-to-access planning and QI tools for staff.

A Survey of Aesthetic Standards of the Ear

BACKGROUND

The aesthetic standards of the ear are very important for evaluation of auricular surgery. Few studies have previously assessed ear aesthetics, especially in China. This study aimed to investigate aesthetic standards of the ear in a Chinese population.

MATERIALS AND METHODS

A questionnaire was administered to Chinese individuals, which included assessment of the general impressions of the ear and other facial aesthetic units, the individual aesthetic subunits of the ear, the effects of different ear subunits on ear symmetry and the degree of the subunits to which the participants wanted to change. Answers were recorded on a five-point Likert-style scale. Statistical analysis was performed using SPSS ver. 17.0.

RESULTS

A total of 319 responses were received, 50.3% women and 49.7% men. The external ear received the lowest degree of attention either on the front or on the lateral view of the face in both genders. Among the individual aesthetic units, the earlobe received the most attention and the fine structures the lowest. The helix had the greatest effect on the ear symmetry. The structure that participants most wanted to change was the earlobe in males and the helix in females. There were significant differences on the evaluation of the helix and crus of helix among the groups divided according to educational background (P < 0.001).

CONCLUSION

The results showed that the structures that people were most concerned about were the helix and earlobe. There were gender differences in the results which were also influenced by education background.

Standardized measurement of auricle: A method of high-precision and reliability based on 3D scanning and Mimics software

Objective measurement is important for diagnosing congenital or acquired auricular abnormalities and the evaluation of therapeutic efficacy. However, methods applied in the past were mostly inaccurate and unreliable. The present study aimed to introduce five standardized indices for auricle measurement and present a highly precise and reliable methodology combining three-dimensional (3D) scanning techniques and the Materialise Mimics software for the evaluation of auricle sizes. A total of 20 normal ears were measured independently by four surgeons using the standardized digital method with 3D scanning technique and the traditional manual method. Parameters of the auricle, including the length and width, arc length, cranioauricular height and angle were measured using the Mimics software. Paired t-test, Wilcoxon signed rank test and intra-class correlation coefficients (ICC) were performed on the data to assess the precision, uniformity and observer independence of the method. Pearson's product moment correlation was calculated to assess the correlation between auricle length and width in addition to the correlation between cranioauricular height and angle. No significant differences were indicated between measurements of five auricular parameters made by two surgeons using the digital method. However, significant differences were found using the manual method (P<0.01). ICC values derived from digital measurements ranged from 0.901 to 0.987, whereas those derived from manual measurements ranged from 0.526 to 0.807. These results suggested that the standardized digital method was replicable and reliable compared with the traditional manual method. Pearson's coefficient analysis showed that there was a significant correlation between cranioauricular height and angle (P<0.05), but no correlations were found between the height and width of the auricle (P>0.05). Taken together, data from the present study suggested that measurements of the length and width, arch length, and cranioauricular height and angle of auricles using the standardized digital method combining 3D scanning with the Mimics software were comprehensive, precise, convenient, repeatable and reliable.

Recommendations for the Development and Reform of Microtia and Atresia Services

BACKGROUND

The initial step in setting up standardized microtia-atresia service is investigating the current status of the service and comparing this to internationally recognized guidelines or care standards. In many countries, documented information about microtia care is lacking. This study is an initiative to guide reform efforts of national microtia service in any country. The UK care standards for microtia-atresia can be a useful model to help set up a comprehensive microtia-atresia service.

METHODS

The authors conducted a survey to investigate different aspects of microtia service in Egypt. The major plastic surgery centers (n = 22) were surveyed by a structured questionnaire. The results were compared with the UK care standards for microtia-atresia to identify the aspects that need improvement. Thorough analysis of the main problems in microtia-atresia service is presented.

RESULTS

The authors found that microtia service is fragmented between the surveyed centers with 65% of the centers treating less than 10 microtia cases annually. Multiple surgeons are responsible for ear reconstruction in 90% of centers and only 25% of them practise a multidisciplinary team approach. None of the centers uses validated tools of aesthetic or psychological patient-reported outcome measures.

RECOMMENDATIONS

These 5 recommendations are the keys to reforming microtia service in any country:(1) Establishing nationally designated centers to concentrate the required expertise.(2) Assigning fewer high-volume surgeons to optimize the surgical outcomes.(3) Providing treatment by experienced multidisciplinary teams.(4) Using validated tools of patient-reported outcome measures.(5) Collecting and keeping standardized records for regular audit and intercenter studies.

New methods for specialized subjective and high-precision objective evaluation of constricted ears: A pilot study

The effects of therapy on constricted ears are evaluated subjectively and objectively. However, previous methods are not specific, comprehensive, precise, or effective in diagnosing and predicting surgical outcomes. This study aimed to present a personalized, subjective evaluation scale and new objective indices utilizing a digital method for the accurate evaluation of constricted ears.Nine consecutive patients with constricted ears were selected. To perform subjective evaluations, the patients' parents were contacted by telephone within 3 to 6 months after surgery and asked to answer questions using a scale. To perform objective evaluations, the constricted and normal ears of each patient were scanned using a 3-dimensional scanner before and 14 days after surgery. The vertical height of the auricle (VHA), transverse diameter of the auricle, minimum length of the helix (MLH), length of the inner auricle (LIA), and transverse diameter of the inner auricle were calculated using Mimics software. The Wilcoxon matched pairs signed-rank test was used for data analysis.High satisfaction scores were reported. The folds of the ear and helix had the highest median scores, whereas the crus of the antihelix had the lowest. The difference in LIA and postoperative MLH was greater than that in VHA and preoperative MLH. The mean values of the 5 indices of the normal ear were greater than those of the indices of the preoperative constricted ear (P < .05).The specialized subjective scale reported in this study allows comprehensive and personalized assessment of constricted ears. The new objective indices are more effective than existing methods and the digital measurement method is precise and reliable. These methods will allow the treatment of constricted ears to be better evaluated, leading to improvements in patient management and treatment selection.

Development of a New Patient-reported Outcome Measure for Ear Conditions: The EAR-Q

Background:

Patient-reported outcome measures are widely used to improve health services and patient outcomes. The aim of our study was to describe the development of 2 ear-specific scales designed to measure outcomes important to children and young adults with ear conditions, such as microtia and prominent ears.

Methods:

We used an interpretive description qualitative approach. Semi-structured qualitative and cognitive interviews were performed with participants with any type of ear condition recruited from plastic surgery clinics in Canada, Australia, United States, and United Kingdom. Participants were interviewed to elicit new concepts. Interviews were audio-recorded, transcribed, and coded using the constant comparison approach. Experts in ear reconstruction were invited to provide input via an online Research Electronic Data Capture survey.

Results:

Participants included 25 patients aged 8–21 years with prominent ears (n = 9), microtia (n = 14), or another condition that affected ear appearance (n = 2). Analysis of participant qualitative data, followed by cognitive interviews and expert input, led to the development and refinement of an 18-item ear appearance scale (eg, size, shape, look up close, look in photographs) and a 12-item adverse effects scale (eg, itchy, painful, numb).

Conclusions:

The EAR-Q in currently being field-tested internationally. Once finalized, we anticipate the EAR-Q will be used in clinical practice and research to understand the patient’s perspective of outcomes following ear surgery.

Autologous Ear Reconstruction

Since the pioneering use of autologous rib cartilage for the reconstruction of microtia, there have been significant advances in surgical technique that have helped to ameliorate the psychological burden of microtia. To date, the use of rib cartilage for auricular reconstruction is one of the most enduring and ubiquitous techniques for microtia reconstruction as it provides excellent aesthetic results with lasting durability. In this review, the authors outline the most common methods of microtia reconstruction with a comparison of each technique and illustrative case examples.