[Management of patients with complex ear deformities]. / Prise en charge des patients présentant des déformations complexes du pavillon de l'oreille.

Complex ear reconstruction requires specialized multidisciplinary care. Most patients present with microtia, often associated with hearing disorders. The management of these disorders is a priority, and reconstruction of the external ear remains optional. Nowadays, auricular reconstruction is based on the subcutaneous implantation of either autologous cartilage or an allogeneic implant. Autologous reconstruction requires highly specialized surgical expertise and involves harvesting rib cartilage but carries a lower risk of exposure compared to allogeneic implants. Both techniques yield good results with a high success rate and have a positive impact on the social functioning and daily life of patients.

La reconstruction complexe du pavillon auriculaire nécessite une prise en charge multidisciplinaire spécialisée. La majorité des patients nécessitant ce geste présentent une microtie, souvent associée à des troubles de l'audition. La prise en charge de ceux-ci est prioritaire et la reconstruction du pavillon reste facultative. Aujourd'hui, la reconstruction du pavillon se base sur l'implantation sous-cutanée d'une maquette de cartilage autologue ou d'un implant allogène. La reconstruction autologue demande une expertise chirurgicale hautement spécialisée et nécessite un prélèvement de cartilage costal mais présente un risque d'exposition inférieur par rapport à l'implant allogène. Les deux techniques permettent d'atteindre de bons résultats avec un taux de réussite élevé et un effet positif sur le fonctionnement social et le quotidien des patients.

Personalised 3D printed respirators for healthcare workers during the COVID-19 pandemic.

Widespread issues in respirator availability and fit have been rendered acutely apparent by the COVID-19 pandemic. This study sought to determine whether personalized 3D printed respirators provide adequate filtration and function for healthcare workers through a Randomized Controlled Trial (RCT). Fifty healthcare workers recruited within NHS Lothian, Scotland, underwent 3D facial scanning or 3D photographic reconstruction to produce 3D printed personalized respirators. The primary outcome measure was quantitative fit-testing to FFP3 standard. Secondary measures included respirator comfort, wearing experience, and function instrument (R-COMFI) for tolerability, Modified Rhyme Test (MRT) for intelligibility, and viral decontamination on respirator material. Of the 50 participants, 44 passed the fit test with the customized respirator, not significantly different from the 38 with the control (p = 0.21). The customized respirator had significantly improved comfort over the control respirator in both simulated clinical conditions (p < 0.0001) and during longer wear (p < 0.0001). For speech intelligibility, both respirators performed equally. Standard NHS decontamination agents were able to eradicate 99.9% of viral infectivity from the 3D printed plastics tested. Personalized 3D printed respirators performed to the same level as control disposable FFP3 respirators, with clear communication and with increased comfort, wearing experience, and function. The materials used were easily decontaminated of viral infectivity and would be applicable for sustainable and reusable respirators.

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.

"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.

Bio-Alcamid complications: A 10 year review.

This article is a follow up to "Early and late complications of polyalkimide gel (Bio-Alcamid)".1 It is a summary of late complications that have developed in patients treated with Bio-Alcamid for HIV lipoatrophy following extended follow up of 10 years.

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.

Patient reported outcome measures in microtia surgery.

BACKGROUND: Autologous ear reconstruction for microtia is a complex, multi-stage procedure. The success of the procedure is dependant on how the patient perceives the outcomes of surgery and their overall experience. Patient reported measures are therefore crucial to developing the technique and improving the patient journey. AIM: The aim of this study was to use two reproducible patient reported outcome tools as an objective measure of microtia reconstructive surgery. METHODS: A retrospective cohort study was performed at Great Ormond Street Hospital (GOSH), London and the Royal Hospital for Sick Children (RHSC), Edinburgh. Two questionnaires were posted to patients with congenital microtia who underwent an autologous ear reconstructive procedure. The first questionnaire - designed by the authors at Great Ormond Street Hospital - measured the patient's perspectives of: ear appearance, the individual aesthetic units and the donor site. The second questionnaire - created by the authors at the Royal Hospital for Sick Children - collected demographic information; and asked general questions regarding ear surgery including psychosocial considerations and satisfaction scores of individual aesthetic units. RESULTS: The majority of patients were very satisfied with their reconstructed ear (83% at GOSH and 85% at RHSC). High patient satisfaction scores were reported for the lobe of ear and size of the ear. Low satisfaction scores were reported for the antitragus and projection of ear. CONCLUSION: The measures used in this study provide an objective assessment of patient reported experience and outcome that in the future can be used as a means of targeted quality improvement and to benchmark care nationally.

Identification of factors that predict outpatient utilisation of a Plastic Dressing Clinic. A retrospective review of 287 paediatric burn cases.

INTRODUCTION: This study investigated aetiology of burn cases presenting to the Royal Hospital for Sick Children in Edinburgh to identify factors that influence the number of outpatient visits patients make to the Plastic Dressing Clinic (PDC) following discharge. METHODS: A retrospective review was performed of all paediatric burn cases presenting between January 2009 and July 2012. Information gathered included patient demographics, burn aetiology, details of inpatient admission and outpatient PDC attendance. RESULTS: 287 cases were identified, mean age 2.79 years (range 0-15), gender ratio 1.52:1 (M:F). Scald was the most common aetiology, n=172 (59.9%). Most burns were superficial thickness, n=173 (60.3%). One-way ANOVA showed that full thickness burn, skin graft and pressure garment therapy significantly increased the number of PDC appointments (p<0.05). Pearson correlation coefficient found that length of stay in hospital and time spent in theatre were positively correlated to the number of PDC appointments (p<0.01). CONCLUSION: Outpatient utilisation of the PDC can be predicted from burn characteristics. Full thickness burn, skin graft and pressure garment therapy are identified to significantly increase the number of PDC appointments following paediatric burn.

Does the degree of ptosis predict the degree of psychological morbidity in bariatric patients undergoing reconstruction?

BACKGROUND: There is proven therapeutic benefit in bariatric surgery for obese patients. Successful bariatric surgery will result in massive weight loss and ptotic skin, which can cause significant functional and psychological problems. As the incidence of bariatric surgery increases, so will the demand for plastic surgery. Currently, there is no evidence-based indication for massive weight loss body contouring, and therefore there is no standardized provision. METHODS: A prospective, multicenter, observational study of outcomes in 75 patients undergoing bariatric and plastic surgery procedures at two clinical sites was performed to determine whether the degree of ptosis can be determined by the type (malabsorptive or restrictive) of bariatric surgery and if the extent of disfigurement has an impact on psychological morbidity. RESULTS: Massive weight loss body contouring is not purely aesthetic surgery, but it leads to functional and psychosocial benefits. This study has given preliminary data on which anthropometric measurements and their thresholds lead to the greatest benefit from massive weight loss body contouring. From this study, the fourth quartiles of the anthropometric measurements xiphisternum to pubic symphysis (≥91 cm), umbilicus to pubic symphysis (≥38 cm), and hip circumference (≥143 cm) were statistically significant in crossing the psychometric tolerances from within the normal range to pathological psychology. CONCLUSIONS: This study demonstrates that there is a statistically significant, quantifiable correlation among type of bariatric surgery, degree of ptosis, and psychological morbidity in patients who have undergone bariatric surgery. This pilot study could provide the basis for evidence-based guidelines for plastic surgery referral.

A preliminary report on the development of a validated tool for measuring psychosocial outcomes for massive weight loss patients.

AIM: To validate the newly developed patient report outcome measure (PROM): the Post Bariatric Outcome Tool (PBOT). The tool is designed and developed for massive weight loss patients seeking body contouring procedures. METHOD: The PBOT was piloted with three cohorts: massive weight loss patients seeking body contouring; massive weight loss patients who have had body contouring; and healthy, non-obese subjects as controls matched for age and gender. Each cohort completed two PROMS at week one, and then for a second time at week three. The PROMS used were the new Post Bariatric Outcome Tool (PBOT) and the Derriford Appearance Scale 24 (DAS24). CONCLUSION: The PBOT was shown to be reliable both in terms of its internal consistency and test-retest reliability. Comparison to the DAS24 demonstrated the PBOT to be valid. However, the cohorts were small and responsiveness was not tested. This needs to be tested in further larger validation studies, ideally, with comparison to functional scales such as the SF-36 or other validated massive weight loss body contouring PROMs; such as the Body Q.

Preoperative implant selection for two stage breast reconstruction with 3D imaging.

Implants used for two-stage breast reconstruction are selected exclusively on the basis of the directly measured linear parameters. Therefore, the relevant implant is not always chosen despite the wide range of available products. The aim was to analyze the clinical usefulness of three-dimensional (3D) imaging in the breast implant selection. In 50 patients after unilateral two-stage breast reconstruction, height, width, projection and total volume of both breasts were triply obtained with measuring tape (anthropometric method), thermoplastic casting (thermoplastic method) and 3D imaging (optical method). We measured skin fold thickness with skin caliper. In the optical method, we subtracted the covering tissues and calculated the parameter - "estimated breast implant volume" (EBIV), together with the corresponding "anthropometrically estimated breast implant volume" (aEBIV) in the anthropometric method. Reliability of the three methods was described as repeatability and accuracy, both quantified with parameters: "technical error measurement" (TEM) and "reliability factor" (R). Repeatability showed variation among the repeated measurements. Accuracy determined variability between the real volume of the implant used for reconstruction and the obtained volumetric parameters. Repeatability was the highest for the optical method, comparing to anthropometric and thermoplastic methods (p<0.0001). Accuracy was the highest in the optical method for EBIV, comparing to aEBIV in the anthropometric method and the total volume in three methods (p<0.0001). Level of accuracy for EBIV was in the range of variability among the commercially available implants (p>0.05). In conclusion, implants for breast reconstruction are precisely selected with the 3D scanning method, in comparison to widely used direct measurements or thermoplastic casting.

Treatment of infantile hemangiomas with propranolol: clinical guidelines.

BACKGROUND: Infantile hemangioma is a vascular tumor and requires treatment in lesions manifested by potentially dangerous symptoms. Several publications have reported that involution of infantile hemangioma could be accelerated by propranolol but have used only invalidated subjective measures of assessment. The authors aimed to objectively validate the aesthetic results after propranolol treatment for infantile hemangioma, and to produce a therapy protocol, including optimal timing for introduction, pretreatment preparation, dosage, frequency of visits, duration, and patient safety. METHODS: For the nonrandomized comparative cohort study, the authors enrolled 60 patients treated with propranolol. Medical two-dimensional photographs, taken before and after treatment, were subjectively analyzed by three plastic surgery consultants and objectively analyzed with a computer program. Aesthetic results were analyzed using the following parameters: subjective overall outcome, subjective color fading, and objective color fading. Reliability of subjective and objective methods was quantified and compared, as described with accuracy and repeatability. Volumetric parameters were obtained from three-dimensional scans taken before and after treatment and objectively analyzed with a computer program. Numerous patients' data were recorded from the medical notes. RESULTS: This study proved high efficiency of propranolol in treatment of infantile hemangioma, as assessed with the objective measures for the first time. The authors outlined an optimal treatment protocol, including introduction, dosage, duration, and cessation of therapy. CONCLUSIONS: Propranolol is an effective, well-tolerated, and safe first-line treatment for proliferative hemangioma. Therapy should begin early, continue with the target dosage of 2 mg/kg/day in three divided doses through the proliferative phase of infantile hemangioma, and be stopped gradually. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Quantitative method for evaluation of aesthetic results after laser treatment for birthmarks.

Subjective assessment of results after laser treatment for birthmarks does not provide a validated method for clinicians. Previous reports concerning objective evaluation using L*a*b color coordinates were only partially successful due to difficulties in standardizing and comparing colors from pre- and posttreatment photographs. The study aimed to present a reliable and clinically applicable method of aesthetic result assessment after laser treatment for birthmarks. All 48 patients, included in the study, were treated for birthmarks on the face or neck using laser. Each pre- and posttreatment photograph was subjected to triple objective comparative assessment of color fading with use of a computer program, as well as to subjective evaluation by three core physicians and three laypeople. Objective analysis was based on an innovative method using combined L*a*b and hue saturation value color coordinates. Accuracy was higher between objective assessment with the computer program and subjective evaluation by core physicians than by laypeople. Repeatability of results was higher with the use of the computer program than among core physicians or among laypeople. In conclusion, our method may be considered for objective assessment of the results after laser treatment of vascular and pigmented birthmarks.

Breast reconstruction with the denervated latissimus dorsi musculocutaneous flap.

OBJECTIVE: To analyze clinical implications of the thoracodorsal nerve division in the latissimus dorsi musculocutaneous flap breast reconstruction. PATIENTS AND METHODS: Prospective cohort study was conducted on 29 patients. Breast reconstruction with latissimus dorsi musculocutaneous flap was performed unilaterally in 20 patients or bilaterally in 9 women (38 breasts). Thoracodorsal nerve was divided during reconstruction of 20 breasts (group 1) and was preserved for 18 breasts (group 2). Height, width, projection, area of the covering skin and volume of the reconstructed and healthy breasts were measured on the 3D images of the anterior chest wall, taken 6 weeks and 6 months postoperatively with the Di3D 3D camera. Data regarding tissue consistency, painfulness and animation of the reconstructed breast, symmetry of both breasts and overall satisfaction after the surgery were collected at 6 months. RESULTS: The reconstructed and healthy breasts decreased in volume in group 1 (-45.85 cm(3) ± 48.41 cm(3), p = 0.0004; -29.13 cm(3) ± 14.98 cm(3), p = 0.0009) and in group 2 (-31.5 cm(3) ± 25.35 cm(3), p = 0.0001; -15.4 cm(3) ± 21.96 cm(3), p = 0.0537). There were no differences in decrease in volume between groups 1 and 2 (p > 0.05). Respondents in group 1 in comparison to group 2 showed similar satisfaction of the tissue consistency of the reconstructed breast (p > 0.05) and the level of symmetry between both breasts (p > 0.05), gave lower scores for painfulness (p < 0.0001), animation (p < 0.0001) and higher scores for the overall satisfaction about the reconstructed breast (p = 0.0001). CONCLUSION: We suggest that division of the thoracodorsal nerve during latissimus dorsi musculocutaneous flap breast reconstruction is a useful undertaking to minimize unnatural animation of the reconstructed breast.

Comparison of cartilage scoring and cartilage sparing techniques in unilateral otoplasty: a ten-year experience.

We identified the optimal operative technique of unilateral otoplasty among cartilage-scoring or posterior-suturing methods. All unilateral otoplasties repaired in South East Scotland in 10 years were analyzed. Using visual analog scale, outcomes were scored by blinded professional panel and by patients. Case notes were interrogated for postoperative complications. Of 81 patients, 40 with full photographic records were included in the study. Cosmetic outcomes and symmetry scores in patients who underwent posterior suturing with fascial flap were significantly better than cartilage scoring and posterior suturing without fascial flap. Early complications were significantly more common in cartilage-scoring and posterior-suturing techniques without fascial flap than posterior suturing with fascial flap. In conclusion, posterior suturing with fascial flap represents cosmetically superior technique in unilateral otoplasty. It allows for intraoperative adjustment of posterior sutures, resulting in symmetric ears. The technique seems to be associated with fewer short-term complications, often responsible for pediatric patient distress.