The Social Perception of Microtia and Auricular Reconstruction

Establishing an International Interdisciplinary Research Network in Craniofacial Microsomia: The CARE Program

OBJECTIVE

Craniofacial microsomia (CFM) is a broad clinical term used to describe a congenital condition most commonly involving the underdevelopment of the external ear, mandible, soft tissues, and facial nerve. Despite medical advances, understanding of the psychological health and healthcare experiences of individuals with CFM and their caregivers remains limited. This article describes a research program designed to address these knowledge gaps, and identify opportunities for psychosocial intervention and improved healthcare provision.

DESIGN

The Craniofacial microsomia: Accelerating Research and Education (CARE) research program aims to: 1) Conduct up to 160 narrative interviews with individuals and caregivers to validate a conceptual framework; 2) Administer an online international survey of up to 800 individuals with CFM and caregivers to identify predictors of psychological distress; 3) Perform up to 60 semi-structured interviews with healthcare providers and advocacy leaders to examine the extent to which current healthcare provisions address identified patient needs; and 4) Establish a participant registry to build a longitudinal database and develop an international community.

RESULTS

Teams in the USA and UK have been established, alongside an international, interdisciplinary Advisory Committee. Data analysis for Aim 1 is ongoing and informing the delivery of Aims 2-3. Aim 4 is also in development. A dedicated website serves as a recruitment tool, educational resource, and mechanism for engaging with the CFM community.

CONCLUSIONS

The CARE program provides a comprehensive approach to understanding the experiences of individuals with CFM and their caregivers. Challenges encountered and lessons learned are shared for the benefit of the community.

The Ideal Proportion of the Auricle Exposure via a Morphometric Analysis in Asian Women

BACKGROUND

Ears are an important aesthetic feature that is vital to the overall attractiveness of the face. Although there have been many studies on the aesthetics of the auricle, there is currently a lack of consensus on the ideal proportion of auricle exposure for Asian women in frontal view.

OBJECTIVES

This study aimed to investigate ideal proportion of auricle exposure in Asian women.

METHODS

An observational study was carried out on the photographs of 84 women on the list of the 100 most beautiful faces in Asia (published by TCC Asia in 2020). The proportion of the distance between the outer canthus and the outermost point of auricle to the distance between the inner canthus and the outermost point of auricle was calculated as the auricle exposure proportion. Evaluators were asked to rank a set of photographs of the volunteer with varying auricle exposure proportions from most attractive to least attractive.

RESULTS

Measurements of the photographs of the 84 women showed a mean ear exposure proportion of 0.600. With 487 questionnaire responses received, the proportion of auricle exposure that the evaluators considered most attractive was 0.600. People with aesthetic experience considered 0.625 the most attractive proportion, while the general group considered 0.600 the most attractive.

CONCLUSIONS

The ideal proportion of the auricle exposure for Asian women is in the range of 0.60-0.625, which may help surgeons reconstruct aesthetically pleasing ears.

LEVEL OF EVIDENCE V

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 .

Gaze Patterns of Normal and Microtia Ears Pre- and Post-Reconstruction

OBJECTIVES

To understand attentional preferences for normal and microtia ears.

METHODS

Eye-tracking technology was used to characterize gaze preferences. A total of 71 participants viewed images of 5 patients with unilateral microtia. Profile images of patient faces and isolated ears including normal, microtia, and post-reconstruction microtia ears were shown. Total time of fixation in predefined areas of interest (AOI) was measured. Inferential statistics were used to assess significance of fixation differences between AOIs within and between facial or auricular features.

RESULTS

The ear received most visual attention in lateral view of the face (1.91 s, 1.66-2.16 s) [mean, 95% CI], followed by features of the "central triangle"-the eyes (1.26 s, 1.06-1.46), nose (0.48 s, 0.38-0.58), and mouth (0.15 s, 0.15-0.20). In frontal view, microtia ears received less attention following surgical reconstruction (0.74 s vs. 0.4 s, p < 0.001). The concha was the most attended feature for both normal (2.97 s, 2.7-3.23) and reconstructed microtia ears (1.87 s, 1.61-2.13). Scars on reconstructed ears altered the typical visual scanpath.

CONCLUSION

The ear is an attentional gaze landmark of the face. Attention to microtia ears, both pre- and post-reconstruction, differs from gaze patterns of normal ears. The concha was the most attended to subunit of the ear. Attentional gaze may provide an unbiased method to determine what is important in reconstructive surgery.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:3136-3142, 2024.

Remaining microtia tissue as a source for 3D bioprinted elastic cartilage tissue constructs, potential use for surgical microtia reconstruction

The absence of ears in children is a global problem. An implant made of costal cartilage is the standard procedure for ear reconstruction; however, side effects such as pneumothorax, loss of thoracic cage shape, and respiratory complications have been documented. Three-dimensional (3D) printing allows the generation of biocompatible scaffolds that mimic the shape, mechanical strength, and architecture of the native extracellular matrix necessary to promote new elastic cartilage formation. We report the potential use of a 3D-bioprinted poly-ε-caprolactone (3D-PCL) auricle-shaped framework seeded with remaining human microtia chondrocytes for the development of elastic cartilage for autologous microtia ear reconstruction. An in vivo assay of the neo-tissue formed revealed the generation of a 3D pinna-shaped neo-tissue, and confirmed the formation of elastic cartilage by the presence of type II collagen and elastin with histological features and a protein composition consistent with normal elastic cartilage. According to our results, a combination of 3D-PCL auricle frameworks and autologous microtia remnant tissue generates a suitable pinna structure for autologous ear reconstruction.

Extracellular Vesicles Derived from Auricular Chondrocytes Facilitate Cartilage Differentiation of Adipose-Derived Mesenchymal Stem Cells

PURPOSE

Adipose-derived mesenchymal stem cell (ADSC)-based therapies have been utilized for cartilage regeneration because of their multi-lineage differentiation ability. However, commonly used cartilage inducers such as the transforming growth factor beta-3 (TGF-β3) may be prone to cartilage dedifferentiation and hypertrophy. The directional differentiation of elastic cartilage is limited nowadays. Extracellular vesicles (EVs) have been reported to influence the specific differentiation of mesenchymal stem cells (MSCs) by reflecting the composition of the parental cells. However, the role of auricular chondrogenic-derived EVs (AC-EVs) in elastic chondrogenic differentiation of ADSCs has not yet been reported.

RESULTS

AC-EVs isolated from the external ears of swine exhibited a positive effect on cell proliferation and migration. Furthermore, AC-EVs efficiently promoted chondrogenic differentiation of ADSCs in pellet culture, as shown by the elevated levels of COL2A1, ACAN, and SOX-9 expression. Moreover, there was a significantly higher expression of elastin and a lower expression of the fibrotic marker COL1A1 in comparison with that achieved with TGF-β3. The staining results demonstrated that AC-EVs promoted the deposition of cartilage-specific matrix, which is in good concordance with the real-time polymerase chain reaction (RT-PCR) results.

CONCLUSIONS

Auricular chondrogenic-derived EVs are a crucial component in elastic chondrogenic differentiation and other biological behaviors of ADSCs, which may be a useful ingredient for cartilage tissue engineering and external ear reconstruction.

NO LEVEL ASSIGNED

This journal requires that authors 42 assign a level of evidence to each submission to which 43 Evidence-Based Medicine rankings are applicable. This 44 excludes Review Articles, Book Reviews, and manuscripts 45 that concern Basic Science, Animal Studies, Cadaver 46 Studies, and Experimental Studies. For a full description of 47 these Evidence-Based Medicine ratings, please refer to the 48 Table oôf Contents or the online Instructions to Authors 49 www.springer.com/00266 .

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.

Use of Convolutional Neural Networks to Evaluate Auricular Reconstruction Outcomes for Microtia

OBJECTIVES

The objective of this study is to determine whether machine learning may be used for objective assessment of aesthetic outcomes of auricular reconstructive surgery.

METHODS

Images of normal and reconstructed auricles were obtained from internet image search engines. Convolutional neural networks were constructed to identify auricles in 2D images in an auto-segmentation task and to evaluate whether an ear was normal versus reconstructed in a binary classification task. Images were then assigned a percent score for "normal" ear appearance based on confidence of the classification.

RESULTS

Images of 1115 ears (600 normal and 515 reconstructed) were obtained. The auto-segmentation task identified auricles with 95.30% accuracy compared to manually segmented auricles. The binary classification task achieved 89.22% accuracy in identifying reconstructed ears. When the confidence of the classification was used to assign percent scores to "normal" appearance, the reconstructed ears were classified to a range of 2% (least like normal ears) to 98% (most like normal ears).

CONCLUSION

Image-based analysis using machine learning can offer objective assessment without the bias of the patient or the surgeon. This methodology could be adapted to be used by surgeons to assess quality of operative outcome in clinical and research settings.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2413-2416, 2023.

Experience of the 'Ear Glove' in children with microtia

INTRODUCTION

Microtia is a congenital condition which can be found in isolation or as part of a syndrome. The key factors to consider when treating a child with microtia are hearing, speech and language development, cosmesis, and the psychological impact on the patient as well as the family. As children age and become more self-aware, the anxiety about transition from primary to secondary school can often be a trigger for carers and child to want a cosmetic solution at a younger age. Any form of cosmetic surgery ideally requires a child with an understanding of what is involved, as well as sufficient growth and anatomy to provide soft tissue resources for surgery. An additional issue for some children with microtia is the concern about adding to their already 'different' appearance by using a bone conduction solution/hearing implant. We present the outcomes of a novel non-surgical prosthesis 'Ear Glove' offered to pediatric patients with microtia.

METHODS

Children with microtia are seen in the multidisciplinary outpatient clinic and reviewed by the team which includes an Otolaryngologist, Audiologist, Plastic surgeon and Maxillofacial prosthetist. When discussing cosmesis, all reconstruction options are explored. These include a 'no treatment' option, both adhesive and implant-retained prosthetic ears, and autologous and/or MedporⓇ ear reconstruction (age appropriate). All children who chose to undergo the adhesive non-surgical prosthetic option 'Ear Glove' for microtia were identified by our prosthetic department (n = 9), and their outcomes reviewed.

RESULTS

Nine children have been fitted with the 'Ear Glove', with all 9 achieving excellent symmetry and aesthetics. Seven patients continue to successfully use their prostheses either daily or for special occasions. Two of these patients also decided to undergo bone anchored hearing implant surgery. One patient opted to change his treatment plans and chose 'no treatment' after feeling he preferred his 'little' ears. Finally, one patient reported the daily use of adhesive to be a deterrent. No skin reactions to the adhesive were reported in any patient.

CONCLUSIONS

The 'Ear Glove' is increasingly being used by microtia patients in our department to good effect. This non-surgical alternative allows young patients to appreciate the cosmetic results of the surgical options before committing to an invasive procedure.

Epidemiological Study of Neonatal Congenital Microtia in Shandong Province, China, 2011-2020

OBJECTIVE

Congenital microtia is a common congenital disease in newborns. The specific cause of congenital microtia is currently unknown. The main objective of this study is to elucidate the epidemiological characteristics of congenital microtia and explore the possible etiology of congenital microtia.

METHODS

Part of the newborn data from 2011 to 2020 in Shandong Province Birth Defects Monitoring Hospitals were randomly selected. The software GraphPad Prism 9 was used to analyze the data and draw figures.

RESULTS

A total of 4247 infants were diagnosed with congenital malformation among 149,525 newborns randomly selected from the Shandong Province Birth Defects Monitoring Hospitals. Among them, a total of 115 infants were diagnosed with congenital microtia. The mean incidence of microtia during 10 years was 76.14±21.93 per 100,000 infants. The mean incidence of microtia in infants with congenital malformation was 2.67±0.75%. The average incidence of male and female infants with microtia during 10 years were 86.93±23.22 and 64.18±32.71 per 100,000 infants, respectively. In terms of maternal age, the older the mother, the higher the incidence of microtia. In terms of the place of residence, rural infants have a higher incidence of microtia than urban infants.

CONCLUSIONS

The average incidence of microtia was 76.14±21.93 per 100,000 infants in Shandong Province, China, 2011-2020. The female-to-male incidence ratio was 1.45:1. The authors recommend that women choose to give birth at the age of 25 to 29. They hope that the government will take measures to improve the medical and health conditions in rural areas and improve parenting knowledge in rural areas. This can effectively reduce the prevalence of microtia in infants.

Social Perceptions of Pediatric Hearing Aids

OBJECTIVES

To determine whether hearing aid (HA) use affects social perceptions of general public adults and age-matched peers and if so, determine if effects are modulated by lack of societal representation of pediatric HAs.

METHODS

A 10-year-old boy was presented in six photographic conditions with and without HAs and eyeglasses (a worn sensory aid with wider societal representation). HAs were presented in neutral skin tone and bright blue colors. Photographic conditions were embedded into web-based surveys with visual analog scales to capture social perceptions data and sourced to 206 adults (age 18-65) and 202 peers (age 10) with demographic characteristics representative of the general US population. Mean differences in scores for each condition compared to control images were computed using two-tailed t-tests.

RESULTS

In both adult and child respondents, HAs were associated with decreased athleticism, confidence, health, leadership, and popularity. Glasses were associated with decreased athleticism and popularity but increased intelligence, overall success, and in the child respondents, friendliness. When worn in combination, the beneficial effects of glasses were mitigated by brightly colored but not neutrally colored HAs.

CONCLUSION

Negative effects of pediatric HAs on social perceptions may be influenced by poor societal representation of HAs. These results suggest that greater representation of pediatric HAs is necessary to make society more inclusive for children with hearing loss.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E2387-E2392, 2021.