[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.

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.

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.

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.

International trends in the treatment of microtia.

BACKGROUND: Microtia is a well-known craniofacial malformation treatable with numerous different treatment strategies and techniques. The purpose of this study was to analyze the current international trends in microtia repair. METHODS: All surgeons attending the fourth International Ear Reconstruction Congress in Edinburgh received a questionnaire by e-mail about their current surgical practice in microtia care. RESULTS: Thirty-one questionnaires were received. Most primary reconstructions are performed at ages 8 to 10 years using autologous cartilage from the ipsilateral sixth to eighth ribs. Most surgeons make a multilayer framework, leaving a subcutaneous pedicle. Suction drainage was used in all patients. On average, the second stage was performed more than 6 months later using a mastoid flap. Most surgeons do not reconstruct the middle ear. CONCLUSIONS: Microtia reconstruction is performed in many different ways, with numerous treatment and postoperative possibilities.

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.

Early treatment with prednisolone or acyclovir in Bell's palsy.

BACKGROUND: Corticosteroids and antiviral agents are widely used to treat the early stages of idiopathic facial paralysis (i.e., Bell's palsy), but their effectiveness is uncertain. METHODS: We conducted a double-blind, placebo-controlled, randomized, factorial trial involving patients with Bell's palsy who were recruited within 72 hours after the onset of symptoms. Patients were randomly assigned to receive 10 days of treatment with prednisolone, acyclovir, both agents, or placebo. The primary outcome was recovery of facial function, as rated on the House-Brackmann scale. Secondary outcomes included quality of life, appearance, and pain. RESULTS: Final outcomes were assessed for 496 of 551 patients who underwent randomization. At 3 months, the proportions of patients who had recovered facial function were 83.0% in the prednisolone group as compared with 63.6% among patients who did not receive prednisolone (P<0.001) and 71.2% in the acyclovir group as compared with 75.7% among patients who did not receive acyclovir (adjusted P=0.50). After 9 months, these proportions were 94.4% for prednisolone and 81.6% for no prednisolone (P<0.001) and 85.4% for acyclovir and 90.8% for no acyclovir (adjusted P=0.10). For patients treated with both drugs, the proportions were 79.7% at 3 months (P<0.001) and 92.7% at 9 months (P<0.001). There were no clinically significant differences between the treatment groups in secondary outcomes. There were no serious adverse events in any group. CONCLUSIONS: In patients with Bell's palsy, early treatment with prednisolone significantly improves the chances of complete recovery at 3 and 9 months. There is no evidence of a benefit of acyclovir given alone or an additional benefit of acyclovir in combination with prednisolone. (Current Controlled Trials number, ISRCTN71548196 [controlled-trials.com].).

"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.

Equilibrium isotope effects in the preparation and isothermal decomposition of ternary hydrides Pd(HxD1-x)y (0 < x < 1 and y > 0.6).

A Sieverts' apparatus coupled with a residual gas analysis is used to measure the concentration variations of hydrogen isotopes in the gas and solid phases during exchange and isothermal decomposition of mixed hydrides. beta-phase palladium hydrides with known ratios of H:D, Pd(H x D 1- x ) y (0 < x < 1, y > 0.6), are prepared by H 2 with PdD y or D 2 with PdH y exchange, and their desorption isotherms are reported here at 323 K. A higher equilibrium pressure in isothermal desorption of mixed hydrides is associated with a higher ratio of D/H in the initial mixed hydrides in beta-phase. The composition of the gas desorbed from a mixed hydride varies; i.e., the ratio of D/H in gas decreases with the sum of (H + D) in Pd. The values of the separation factor alpha during desorption at 323 K and during H-D exchange at 248 K are discussed and compared with those in the literature. Desorption isotherms of mixed isotope hydrides are between those of the single isotope hydrides of H-Pd and D-Pd, however, plateaus slope more than those of pure isotope hydrides. The origin of the plateau sloping in the mixed hydrides can be attributed to the compositional variations during desorption, i.e., the equilibrium pressure is greater when D/H ratio in solid is greater. A simple model is proposed in this study that agrees well with experimental results.

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.

The tip of the iceberg: a giant pelvic atypical lipoma presenting as a sciatic hernia.

BACKGROUND: This case report highlights two unusual surgical phenomena: lipoma-like well-differentiated liposarcomas and sciatic hernias. It illustrates the need to be aware that hernias may not always simply contain intra-abdominal viscera. CASE PRESENTATION: A 36 year old woman presented with an expanding, yet reducible, right gluteal mass, indicative of a sciatic hernia. However, magnetic resonance imaging demonstrated a large intra- and extra-pelvic fatty mass traversing the greater sciatic foramen. The tumour was surgically removed through an abdomino-perineal approach. Subsequent pathological examination revealed an atypical lipomatous tumour (synonym: lipoma-like well-differentiated liposarcoma). The patient remains free from recurrence two years following her surgery. CONCLUSION: The presence of a gluteal mass should always suggest the possibility of a sciatic hernia. However, in this case, the hernia consisted of an atypical lipoma spanning the greater sciatic foramen. Although lipoma-like well-differentiated liposarcomas have only a low potential for recurrence, the variable nature of fatty tumours demands that patients require regular clinical and radiological review.

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 donor cause of death affect the outcome of lung transplantation?

BACKGROUND: Accumulating evidence suggests that the donor's cause of death may influence posttransplantation allograft function. We conducted a retrospective analysis of our adult lung transplant experience to investigate the influence of donor traumatic brain injury versus nontraumatic brain injury on posttransplantation outcome. METHODS: We retrospectively reviewed donor records and recipient medical charts for 500 consecutive lung transplants performed between July 1988 and December 1999. Recipient follow-up was complete, with a minimum follow-up of 1 year of survival. RESULTS: There were 295 and 205 donors in the traumatic and nontraumatic brain injury groups, respectively. Young male donors predominated in the traumatic brain injury group. Recipients receiving donor lungs from the traumatic and nontraumatic brain injury groups did not differ by age, sex, diagnosis, type of transplant (single-lung versus double-lung) or requirement for pretransplantation mechanical ventilatory assistance. Recipients did not differ in immediate or 24-hour PaO (2)/inspired oxygen ratio, ventilation time, hospital stay, hospital mortality, or overall survival. Recipients of organs from donors who died of traumatic brain injury showed a higher severity and frequency of rejection episodes during the first year after transplantation. Freedoms from bronchiolitis obliterans syndrome at 5 years were 34.5% and 50.8% for recipients of organs from donors who died of traumatic and nontraumatic brain injury, respectively (P =.002). CONCLUSIONS: The cause of donor brain death does not appear to influence early results of lung transplantation. Traumatic brain injury, or some phenomenon associated with it, may predispose a transplanted lung and its recipient toward more severe early rejection episodes and subsequent development of bronchiolitis obliterans syndrome.

Proinflammatory cytokines are not released in the circulation following acute pulmonary thromboembolism in pigs.

Histological examination of acute lung injury associated with sepsis often revealed thromboembolic lesions in the pulmonary microcirculation. Several inflammatory mediators such as platelet activating factor, thromboxane, and endothelins have also been implicated in the pathogenesis of acute pulmonary thromboembolism (APTE). In the present study we examined the roles of three proinflammatory cytokines, tumor necrosis factor-alpha (TNF-alpha), interleukin 1beta (IL-1beta), and IL-8, in the early phase of APTE. APTE was induced in 13 anesthetized piglets (22+/-4 kg) by injecting thrombin-induced blood clots directly into the left lower lobar pulmonary artery. Five animals that received only warm sterile saline served as controls. Arterial plasma samples were collected regularly over 8 h so that cytokine levels could be measured later by enzyme-linked immunosorbent assay (ELISA). Administration of clots doubled the mean pulmonary arterial pressure (from 13+/-5 to 26+/-7 mm Hg) and caused significant decrease in arterial oxygen tension (PaO2 from 390+/-85 to 256+/-89 mm Hg while the FiO2 was maintained at 1.0). Mean arterial blood pressure and cardiac output remained comparable throughout the experiments after initial fluid resuscitation. Plasma levels of TNF-alpha, IL-1beta, and IL-8 were not significantly increased in the APTE group when compared with their baseline values or the control group. Our results thus show that APTE is associated with pulmonary hypertension and deterioration of gas exchange but not with the systemic release of TNF-alpha, IL-1beta, or IL-8. We conclude that these cytokines have minimal impact on the systemic circulation during APTE.

Periocular Mohs micrographic surgery: Results of a dual-site day-surgery service.

PURPOSE. To assess the feasibility of day-surgery Mohs Micrographic Surgery (MMS) at dual sites. METHODS. MMS now has an established position for the management of skin tumour removal. The literature reports excellent results in terms of tissue preservation, complete tumour excision and recurrence rate. MMS involves an initial stage undertaken by dermatologists. The subsequent reconstructive phase can be undertaken either by the dermatologist or by an oculoplastic surgeon in cases of extensive defects. In the latter cases, special expertise is needed in order to achieve satisfactory cosmetic results. Centres offering MMS are few and are usually located in tertiary referral hospitals. In a large city of 12 million inhabitants like London there is only one centre offering MMS on the National Health Scheme. We have set up a dual-site day-surgery service since 1997, whereby a Mohs trained dermatologist in the first unit undertakes the initial ablative stage. The patient is then transferred to the second location, which is approximately three miles away; a trained oculoplastic surgeon then undertakes the reconstruction the same day. Rarely, defects are deemed too large for reconstruction and the patient discharged on the same day; patients are then admitted as inpatients for reconstruction the following day with oculoplastic, plastic, craniofacial and facio-maxillary services at hand. RESULTS. To date we have operated on 59 patients for removal of basal cell carcinomas (BCC). All patients had a biopsy-proven diagnosis of BCC before being referred to the dermatologist. Following liaison with the Dermatology Unit, surgery was scheduled so that the reconstruction could be undertaken in the Oculoplastic Unit at the second hospital on the same day. All patients' defects were reconstructed successfully. With the longest follow-up being 39 months so far, tumour recurrence has been 0%. CONCLUSIONS. A dual-site day-surgery service seems to be a feasible option where a MMS dermatologist is not present onsite. The logistic problem can be easily overcome with a proper liaison between the departments. A dual-site day-surgery MMS service provides a superior service compared with the 2 mm tumour-free margin excision and delayed surgical repair following histological examination advocated by other authors where MMS is not available on site. It is only with MMS that one can ensure complete tumour excision. Day-surgery is the preferred choice, both for patients and for financial considerations. We would therefore support the establishment of dual-site day-surgery MMS services where the reconstruction is undertaken in hospitals located away from the MMS dermatology unit, provided close collaboration exists between the two units to ensure the smooth transfer of patients.

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.