Autologous reconstruction was the predominant approach [76.2% of cases (n = 355)] in this cohort, followed by local tissue rearrangement [23.0% (n = 107)] and alloplastic reconstruction [0.9% (n = 4)]. Of note, local tissue rearrangement likely represents a later stage of microtia reconstruction. There were 54 (11.6%) cases of simultaneous external ear reconstruction and atresia/middle ear repair, of which 68.5% (n = 37) were performed by ENT physicians and 31.5% (n = 17) by plastic surgeons (P< 0.001). ENT physicians also performed a greater proportion of cases in the outpatient setting [64.8% (n = 114) versus 53.4% (n = 155), P= 0.016]. Operative time was significantly longer in the PS cohort (235.2 ± 142.9 minutes versus 205.8 ± 129.2 minutes, P= 0.026).
The rate of all-cause complications was 4.0% (n = 7) in the ENT cohort and 5.9% (n = 17) in the PS cohort (P= 0.372). No significant differences were noted for any of the postoperative complication variables (P> 0.05 for all comparisons; Table 6). Rates of reoperation were also similar between the 2 groups [2.8% (n = 8) in the PS cohort versus 2.3% (n = 4) in the ENT cohort, P= 0.241].
To identify independent risk factors, a multivariate binary regression analysis was performed for all-cause complications (Table 7) and included the following variables: age, sex, surgical specialty, diagnosis of 1 or more additional congenital anomalies, and concurrent repair of auditory defect. The regression analysis did not identify any statistically significant predictors for all-cause complications.
Congenital auricular deformities are associated with significant psychosocial, functional, aesthetic, and financial burdens.9–15,44–48 The treatment of microtia and the concomitant health issues is costly, with reconstruction alone estimated at $17,000 per ear.33,44 Further, there is substantial psychological morbidity in both children and adults with microtia, including low self-esteem, difficulty with social integration, and high rates of depression and anxiety.11,12,15,17 Improvement in psychological functioning following successful ear reconstruction is well documented,14,49–52 thus highlighting the importance of continued investigation into the safety, efficacy, and epidemiology of this procedure.
Prior epidemiologic research into microtia has been predominantly focused on the condition itself,1,45–47 with little published regarding the demographics of reconstruction specifically. Furthermore, the majority of outcomes research in this arena pertains to aesthetics,2,23,35–40,53,54 thus creating a dearth of information on the overall safety of this operation. This study employed the ACS NSQIP-P database to provide an assessment of nationally reported demographic characteristics and postoperative complication rates of auricular reconstruction for microtia and anotia.
Overall, our study demonstrates that microtia repair is a safe procedure, with low rates of 30-day postoperative complications, readmissions, and reoperations. Plastic surgeons and ENT surgeons had comparable postoperative complication profiles. Rates of postoperative complications reported in the literature are highly variable, ranging from 0% to 72%,55 a finding that likely reflects differences in experience with the procedure. Wound infections were the most common complications encountered in our analysis, a finding consistent with prior studies.55,56
Importantly, the presence of 1 or more co-occurring congenital anomalies was not associated with an increased risk of postoperative complications. Numerous authors have reported on the difficulty of reconstructing the auricle in patients with concomitant facial asymmetry, as in most syndromic presentations.34,57–59 However, such cases typically involve more extensive preoperative planning and are often postponed until optimal treatment of the skeletal malformations is complete,60 which may explain the absence of adverse events in this cohort.
There was a preponderance of male subjects in this cohort, with a male-to-female ratio of 1.51:1. This finding is consistent with the literature, which notes a 20%–40% increased risk of microtia in males compared with females.1 Similarly, Hispanic ethnicity has been identified as an independent risk factor for the development of microtia.1,61 The proportion of Hispanic individuals in our cohort was 2.5 times greater than that of the United States general population,62 thus reflecting prior studies.
Autologous reconstruction using costal cartilage was the predominant approach to microtia repair in our study. This technique, pioneered by Radford Tanzer in 195954,63–65 and subsequently refined by Brent,66,67 Nagata,38,68–71 Firmin,72 and Park,73,74 has remained the preferred method since its inception. After harvesting the rib cartilage, the surgeon carves the auricular framework out of the graft, often using the contralateral (if normal) ear as a reference. The majority of surgeons elect to perform this procedure in 3 stages, although anywhere from 1 to 3 has been reported.21 Importantly, autologous reconstruction necessitates that patients have an adequate bulk of costochondral cartilage. This anatomical requirement ultimately limits the age at which this operation can be performed, with the majority of surgeons opting to wait until the patient is at least 8 years old.20 Our analysis is consistent with the literature, as the mean age of subjects was 9.4 years. ENT surgeons, however, operated on a significantly younger patient population. The discrepancy in age between the 2 surgical specialties is possibly explained by the high rate of coexisting auditory abnormalities,8–10,13 and the improved outcomes seen with earlier atresiaplasty.75 This is also consistent with our analysis, as ENT surgeons performed the majority of the cases involving concurrent atresia or middle ear repair.
Families of patients affected by microtia often request that reconstruction be completed as early as possible, preferably before school begins.4 The psychosocial impact of auricular deformity has been well documented12,15 and, importantly, it has been suggested that this may worsen with age.76,77 Further, as Rutter78 proposes, psychological morbidity becomes less amenable to external influences as children age, thus increasing the likelihood that certain maladaptive behaviors will become fixed.
Driven in part by the dynamic psychosocial impact of microtia and the steep learning curve associated with autologous reconstruction, there has been a rise in the frequency of alloplastic repair.20,21 As described by Romo,79–81 Reinisch,82,83 Berghaus,84 Yang,85 and others, this technique involves a porous polyethylene framework along with a temporoparietal fascial flap. Implant-based reconstruction requires, on average, less stages and shorter operating times than its autologous counterpart and is generally considered to have a gentler learning curve.21 Additionally, this approach obviates the need for costal cartilage, thereby reducing donor-site morbidity, and, importantly, permitting reconstruction at as early as 3 years of age. Horlock et al.15 reported improvements in psychosocial outcomes in children following ear reconstruction, with no difference between autologous and alloplastic techniques.
However, alloplastic techniques were initially plagued by high rates of implant exposure and poor long-term outcomes.86 Although the use of a temporoparietal fascial flap significantly reduced these complications,2,83 it is likely that the early failures have prevented a major paradigm shift in auricular reconstruction. This is apparent in our analysis with alloplastic techniques accounting for only 0.9% of all reconstructions. As technical refinements continue to yield improved outcomes, rates of alloplastic reconstruction are expected to rise.
Another important consideration in this population is the timing of microtia reconstruction relative to the restoration of auditory function, if needed. Some surgeons, like Tanzer,65 believed that early efforts to improve hearing would complicate auricular reconstruction at a later point, whereas other surgeons believed just the opposite.87 Recently, there has been a growing interest in simultaneous repair of the external ear along with atresiaplasty88,89 or placement of bone-anchored hearing aids.25 Of the 54 patients in our study, who underwent simultaneous auricular reconstruction and either atresiaplasty, middle ear reconstruction, or placement of bone-anchored hearing aids, there were no postoperative complications.
Limitations to this study are inherent to all analyses using large databases. First, postoperative outcomes are limited to 30 days and, thus, fail to capture potential long-term complications. With respect to auricular reconstruction, outcomes such as graft failure or prosthesis extrusion may arise outside of this 30-day window. Second, the data recorded in the ACS NSQIP-P preclude an assessment of the functional, aesthetic, or patient-reported outcomes of auricular reconstruction, all of which are important aspects of this procedure. Finally, case selection within the ACS NSQIP-P relies on ICD and/or Current Procedural Terminology codes, which may explain the low number of alloplastic reconstructions within our patient population. Thus, the ability to identify and analyze a subset of this database depends on the precision with which these codes are defined. For example, atresia repair on the contralateral side could not be extrapolated. For this reason, we were unable to assess differences in outcomes between first and later stage ear reconstructions. Furthermore, the decision to undergo reconstruction is partially based on confounders that are not accounted for in NSQIP. This bias could be due to referral patterns, surgeon experience, or case complexity and could impact the number of cases included in this study. Additionally, the rigor with which ICD codes are defined inherently limits an assessment of preoperative illness severity, such as the specific type or classification of the ear deformity. Similarly, the accuracy of data entry and interinstitutional variability in reporting are also important limitations to consider. Although the ACS NSQIP offers a robust dataset from over 400 institutions, all studies utilizing this database are subject to sampling bias; thus, results should not be extrapolated onto a population level.
Nonetheless, this is the first study to use a national database to conduct an analysis of the epidemiologic characteristics and postoperative complication rates for auricular reconstruction. Important future directions of this study include assessment of the socioeconomic characteristics of this patient population and a further cost analysis for microtia reconstruction.
Auricular reconstruction is a critical component in the management of microtia. Our findings suggest that this is a safe procedure exemplified by low rates of postoperative complications. Autologous reconstruction remains the preferred modality for repair of the external ear. A nationwide epidemiologic analysis informs the demographic composition of this patient population. Overall, these results have implications in the context of resource utilization and patient selection.
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