The psychological, social and educational impact of prominent ears: A systematic review

Results of Modified Stenströms Technique Otoplasty and Patients' Satisfaction at King Fahad Armed Forces Hospital (KFAFH)

Background Globally, the prevalence of protruding ears is relatively frequent. Ear deformities manifest due to underdevelopment of the antihelical fold, conchal hypertrophy, and/or an obtuse conchoscaphal angle. The availability of multiple approaches proves that there isn't a single optimal accepted procedure. The Modified Stenström otoplasty technique supports the surgeon in the management of underdeveloped antihelix fold, conchal hypertrophy, and obtuse conchoscaphal angle among other deformities. We are the first to evaluate the clinical effects and measure the satisfaction rate post-otoplasty using the modified Stenström technique with a case series study. Methods Six patients were included in the study with a total of 12 ears operated on between February 2021 and July 2022. Utilizing the modified Stenström technique for bilateral protruding ears. All patients had six postoperative follow-up visits with fixed intervals; one week, three weeks, six weeks, three months, six months, and one year. During their one-year postoperative follow-up appointment, all patients completed the satisfaction survey questions. Results Six individuals were studied, three males and three females with a mean age of 23.1 (range, 7-53 years old). There were no complications or recurrences observed. Based on the responses we collected, all patients reported a high satisfaction rate at one-year postoperative follow-up. Conclusion The modified Stenström technique yields good naturally appearing ears. It is an easy and safe technique to apply. It has a short recovery period, and no hospital stay is required. All contribute to a high satisfaction rate among studied patients.

A Different Approach for Protruding Earlobe Correction-Modified Fish-tail Technique

BACKGROUND

Protruding ears are the most common auricular abnormalities seen in children (1). Protruding ears are a condition that has social and psychological consequences due to its physical appearance and one of the main causes of peer bullying at young ages (2). While various surgical methods exist to address prominent ears, the options for correcting the lobule are relatively scarce. In this study, we are aimed to present the modified fish-tail technique that we have developed and to compare it with other techniques in the literature.

METHODS

The patients were selected from the cases that underwent otoplasty for prominent ear correction in our clinic between 2020 and 2022. A total of 21 cases that required protruded lobule correction during otoplasty were included in our study. Keloid and hypertrophic scar formation, wound dehiscence, hematoma, infection and recurrence in the lobule were evaluated. The patients were followed up for at least 1 year for early and late complications.

RESULTS

Each patient in the study underwent bilateral prominent ear correction, including bilateral modified fish-tail technique. All cases were followed for at least 12 months. There was no wound dehiscence, infection, recurrence in lobule prominence or hematoma during the follow-up period. No hypertrophic scar or keloid was observed in any case.

CONCLUSIONS

Our method stands out for its ability to achieve both adjustable vertical height and effective lobule correction with a reduced need for skin excision. We recommend the modified fish-tail technique as an alternative technique for prominent lobule surgery.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. 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 .

Pediatric Otoplasty and Auricular Molding

With the advent of widespread use of commercial ear molding products, the literature addressing the indications for and timing of perinatal intervention in auricular deformations and malformations has increased significantly. Although the rationale for perinatal ear molding seems to be hormonally mediated, the common assertion that breastfeeding may prolong the window of effective intervention remains without convincing evidence. The common auricular anomalies as well as indications, timing, and methodology of effective intervention including ear molding or surgical otoplasty are reviewed herein.

Objective evaluation of nonsurgical treatment of prominent ears: A systematic review

Background

The prominent ear is a type of congenital ear deformity that can be corrected by a variety of nonsurgical treatments, such as splinting and the taping method. However, there is no objective evaluation method that is universally accepted. The aim of this review is to evaluate objective measurement methods that are used in the available literature to analyze nonsurgical treatment of prominent ears.

Methods

A systematic review was performed in the MEDLINE and Embase databases in December 2022 and updated on April 2023 according to Preferred Reporting Items for Systematics and Meta-Analyses (PRISMA) guideline. Any study using objective measurements (continuous variables such as distance and angle) to evaluate the effect of nonsurgical treatment of prominent ears was included. The Joanna Briggs Institute (JBI) critical appraisal for case series was used for quality assessment.

Results

A total of 286 studies were screened for eligibility, of which five articles were eligible for inclusion. All of the included studies were case series. The helix mastoid distance (HMD) is the most commonly used parameter to measure treatment outcome. Pinna and cartilage stiffness, length, and width were also used, but without clear statistical relevance. HMD was classified into grading groups (i.e. good, moderate, and poor) to evaluate the treatment's effect.

Conclusion

Based on the included studies, objective measurements are rarely used, and when used, they are largely heterogeneous. Although HMD was the most frequent measurement used, all studies used different definitions for the measurement and grouped subsequent outcomes differently. Automated algorithms, based on three-dimensional imaging, could be used for object measurements in the nonsurgical treatment of prominent ears.

A Retrospective Analysis of Pinnaplasty Outcomes: The Welsh Experience

Prominent ears (PEs) are the most frequent congenital external ear deformity, occurring in ∼5% of the population. Although the deformity does not usually cause functional difficulties, it can significantly affect the patient's psychological and social health. The authors aim to present the Welsh experience of pinnaplasty, reviewing our outcomes and complications. A retrospective cross-sectional study was performed of all patients undergoing pinnaplasty in Morriston Hospital, Swansea, Wales. We represent the tertiary plastic surgery referral unit across Wales. We included all patients undergoing pinnaplasty between 2015 and 2022 inclusive. We excluded patients undergoing revision procedures or those who had no follow-up. Over the 7-year period, 236 pinnaplasties were performed and 203 were included in the analysis. Ninety-six percent of cases were performed using a cartilage-sparing approach, which represents the mainstay in our unit. The mean follow-up length for our cases was 12 months. Revision procedures were required in 4% of cases. Three hematomas (1.5%) and one (0.5%) wound dehiscence due to infection were recorded and required a return to the operating room. Suture extrusion was noted in 5% of cases (10 patients); 4.5% (9) cases were affected by either hypertrophic or keloid scarring. Across the United Kingdom, cosmetic procedures have come under scrutiny, namely, because of a difficult economic climate. In the era of tight fiscal control in health care, it is pertinent to analyze the outcomes and performance metrics of our operations regularly, thus aiding in the development of an established evidence base to advocate for our respective patients.

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.

Correction of Darwin's Tubercle with Plasma Exeresis

Darwin’s tubercle (DT) is a congenital outer ear deformity characterized by a posterior thickening of the auricular helix. It is particularly common in certain ethnic groups, with reports ranging between 10% and 58% of the specific populations. Despite being common, this vestigial trait is poorly known. It carries no clinical significance, except in the cases where it might be hypertrophic, potentially causing psychological distress and significant social impairment. DT has been traditionally treated with surgical resections where part of the helical cartilage is removed. More recently, cartilage reshaping has been envisioned without cutting, suturing, or scars, using laser irradiation. Surgical resection, laser ablation and plasma exeresis are different tools in the surgeon’s armamentarium which may all be used successfully. Nevertheless, the first may cause noticeable scarring while the second may cause relevant laser-related complications. We present a noninvasive aesthetic medicine procedure based on plasma exeresis, which combines the benefits of a noninvasive procedure with the advantage of not requiring lasers for the correction of this cartilage defect. We present the case of a 28-year-old woman with right-sided hypertrophic DT, who requested a correction of the outer ear deformity. Two sessions were required, pain intensity during treatment was low, no complications were reported, and the patient was satisfied with the result at 6 months from the last session. Although plasma exeresis has been described in the past for several other non-invasive procedures of the skin, this is the first report of its kind for the correction of minor cartilage reshaping.

Noninvasive ear molding in the correction of ear anomalies: A systematic review and meta-analysis

OBJECTIVE

Ear molding has been used for the treatment of congenital external ear anomalies. The purpose of this study is to systematically review ear molding therapy and perform a meta-analysis to determine its efficacy.

METHODS

A systematic review and meta-analysis of the literature was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The PubMed and Embase databases from January 2009 to April 2021 were searched. Individual studies were eligible for inclusion if they evaluated noninvasive ear molding for congenital ear anomalies, featured at least 50 ears, and were published in English.

RESULTS

15 studies (one RCT and 14 clinical series) with a total of 1729 children undergoing molding of 2508 ears were identified and included in the meta-analysis. Meta-analysis of the eight studies with reported success rates as determined by clinician assessment showed an overall success rate in 87.4% of ears. Meta-analysis of the three studies with reported efficacy as assessed by laypersons showed an overall success rate of 92%. All studies reported a variety of minor skin-related complications in the ear, such as eczema, excoriation, infection, irritation, rash (allergic or nonallergic), and ulceration. Generally, complications were not reported to be serious and were noted to resolve with minimal to no intervention.

CONCLUSION

To the authors' knowledge, this study represents the largest modern systematic review and meta-analysis analyzing the efficacy of ear molding. A review of the 15 studies included suggests that ear molding is an effective and safe treatment for congenital ear anomalies with a high success rate. However, the strength of this body of evidence is reduced by a lack of comparative studies, heterogeneous patient populations, treatment protocols, and ear assessment scales.

Performance-optimized otoplasty

Objectives

This study proposes a new surgical alternative for the most common deformity in the ears, the so-called "protruding/prominent ears", which is a condition that affects 5% of the Caucasian population (Goulart et al. in Rev Bras Cir Plast 26:602–607, 2011). This technique comes with the benefits of reduced surgical time, shallow learning curve, and a low revision rate.

Methods

We studied a total of 213 patients with an indication for otoplasty from January 2020 to January 2021. Women made up 65% of the study population, while men made up 35%, with an average age of 21 years, the youngest being 7 years of age. The technique presented here corrects all the deformities that cause protruding ears and can be performed together with other ear surgeries, such as surgical treatment of macrotia and lobuloplasty. All surgeries were performed in an outpatient setting under local anesthesia and sedation.

Results

All surgeries followed a performance-optimized protocol, with an average total surgical time of 45 min for a bilateral approach. Revision surgery was needed in 2% of cases, with the most frequent complaint being asymmetry in the upper third of the ears. The complication rate was approximately 7.5%, with 1 case of hematoma, 1 case of mild infection, 2 cases of altered ear sensitivity, 3 cases of keloid scar formation, 6 cases of asymmetry in the upper third of the ears, and 3 cases of irregularities or spikes in the antihelix cartilage. Patient satisfaction was measured using the McDowell/Wright Objectives and Outcome Index (McDowell in Plast Reconstr Surg 41:17–27).

Conclusion

The proposed performance technique is a viable alternative to optimize the surgical time of otoplasty in an outpatient setting. This technique can be performed together with other corrective ear surgeries, has a shallow learning curve, and has a low revision rate.

Level IV: Evidence obtained from multiple time series with or without the intervention, such as case studies.

Algorithm-Assisted Decision Making in Otoplasty

INTRODUCTION

Ear congenital deformities represent an aesthetical concern in adult patients and a social matter in children. An accurate assessment of ear defects should be made preoperatively in order to plan surgery adequately.

MATERIALS AND METHODS

In order to correctly assess the ear preoperatively the authors have considered four different subunits: helical and scaphal region (A), antihelical region (B), conchal region (C) and lobule region (D). Surgical planning should start from sub-unit A evaluation, ending with sub-unit D, in a concentric fashion. When sub-unit A defects have to be corrected, an anterior approach is preferred.

DISCUSSION

A correct evaluation of ear defects prior to surgery is of dramatic importance. Sub-unit A ear defects are often disregarded, and surgical techniques for their correction are rarely considered. Correcting helical and scaphal defects requires an anterior approach, influencing the technique employed for the correction of subunits B and C defects. Sub-unit B defects should be evaluated and corrected before sub-unit C defects in order to avoid overcorrection of ear protrusion.

CONCLUSION

Several surgical techniques have been described in the literature for correcting ear defects. After many years of experience, we outlined a schematic flowchart that prevents from leaving areas of the ear untreated, providing the best possible result for the patient.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. 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 .

Adolescents' perception of malocclusion, their motivations, and expectations concerning the orthodontic treatment. Is it all about attractiveness? A qualitative study

INTRODUCTION

In addition to essential clinical parameters, orthodontic treatment outcomes should also consider patients' opinions and perceptions, which could be comprehensively clarified with a qualitative scientific approach. Considering that the information on younger patients' views is scarce, the objective of this study was to investigate how adolescent orthodontic patients perceive malocclusion, and their motivations and expectations concerning orthodontic corrective treatment.

METHODS

In this descriptive qualitative study, 12 adolescents aged 12 to 14 years and of both genders, covering a heterogeneous collection of malocclusions, were recruited from the waiting list of an Orthodontics Graduate Course. They were individually interviewed before the appliance insertion by an experienced researcher using an interview guide and photographic records to stimulate patients' self-perception of their oral condition. The interviews proceeded simultaneously with transcription analyses until saturation. After the transcription evaluation, the framework analysis technique was performed.

RESULTS

Data derived from the transcription analyses were grouped into 3 major themes: perceptions concerning the concepts of normality and abnormality regarding oral health; self-perceptions regarding malocclusion and other discrepancies; and motivations for seeking orthodontic treatment and expectations related to the results.

CONCLUSIONS

Attractiveness was exceptionally relevant among adolescent patients. Most interviewees seemed to focus their attention on esthetically upsetting dentofacial traits, which they expected to be corrected by orthodontic treatment. In addition to self-oriented appearance-driven motivations, parents, other health professionals, friends, and peers also influenced adolescents' perception of their need for treatment. The achievement of a normal dentofacial status seems to be closely attached to social and individual aspirations.