Rod Franklin

October 03, 2011

October 3, 2011 (Denver, Colorado) — A significant number of plastic surgeons have faith in the ability of tissue engineers to invent products in the next 15 years that will arm them with the tools to effectively rebuild the malformed ears of children with congenital microtia.

However, a descriptive correlative survey, the results of which were presented here at Plastic Surgery 2011: American Society of Plastic Surgeons (ASPS) Annual Meeting, suggests that winning providers over with progressive ear reconstruction technology will be no easy task.

The results of a 20-item Web-based questionnaire, which was sent to 6103 ASPS members in late 2010, quantified a long-held bias in favor of autogenous ear reconstruction methods for microtia patients; 88% of respondents said they prefer native tissue over alloplastic alternatives, such as Medpor, and just 8% favor alloplastics exclusively.

Still, only 29% of practitioners said they believe autogenous ear reconstruction will remain the accepted paradigm, and 56% are convinced that a game-changing product will come to the fore as researchers continue to advance the art of tissue engineering.

Few surgeons, however, are so confident that they believe that any new innovation that emerges in the categories of alloplastics or osseointegrated implants will reach "gold-standard" status.

Great hope exists for the future with regard to tissue engineering, even though survey results indicate that a "lack of evolution" has limited advances in microtia reconstruction methodology, Daniel Im, from the University of Southern California Medical Center in Los Angeles, who was lead investigator of the survey effort, told Medscape Medical News in a written communication.

"Cao et al successfully transplanted bovine chondrocytes grown in vitro onto a synthetic, biodegradable ear scaffold that was implanted under the skin of an immune competent mouse," he noted [Plast Reconstr Surg. 1997;100:297-302]. "Kamil et al constructed ear-shaped cartilage with gold molds in a bovine model [Laryngoscope. 2004;114:867-870], and Neumeister et al successfully generated vascularized ears using a tissue engineering approach [Plast Reconstr Surg. 2006;117:116-122]."

In spite of these advances, Dr. Im is less optimistic than the survey respondents that a breakthrough will occur within the 15-year time frame, as suggested in the questionnaire.

"I estimate that it will be more than 50 years before we will be consistently using tissue engineered frameworks in microtia reconstruction as the favored approach," he said.

Although the survey concluded that a "deficiency" in training has affected the degree to which alternative ear reconstruction techniques are embraced, Boris Paskhover, MD, an otolaryngology resident at Yale New Haven Hospital in Connecticut, who assisted with statistical analysis on the project, doesn't believe an institutionalized bias exists.

"Alloplastic techniques using Medpor and allowing for tissue ingrowth have been around for approximately 20 years, but compared with autogenous reconstruction, are relatively new," he said. "The reason for the preference disparity is most likely that people were trained in the older technique and thus feel comfortable with it. In addition, since alloplastic techniques are relatively new, we are unsure of their long-term outcomes."

In all, 47% of surgeons who offer microtia reconstruction indicated that they completed either craniofacial or pediatric plastic surgery fellowships, and 70% said they had been exposed exclusively to staged autogenous cartilage methods. Only 16% had received exposure to alloplastic reconstruction.

"There is not a lot of research advocating alloplastic reconstruction," acknowledged Dr. Im. "In addition, the relative rare incidence of microtia leads to restricted case availability for young surgeons."

Survey data also illustrated a certain level of variability within the provider community with regard to the timing of ear reconstruction.

More than half said they like to wait until the patient is at least 7 years of age, and 72% of surgeons agreed that aesthetic outcomes are improved in older microtia patients. Yet 56% acknowledged that a potential for greater psychosocial morbidity exists when reconstruction is delayed, with 34% indicating that they like to rebuild the ear earlier, when the child is 4 to 6 years of age.

According to Dr. Im, the timing issue is "difficult for the microtia surgeon to reconcile."

"Jiamei et al looked at mood disorders in children," he said (Plast Reconstr Aesthet Surg. 2008;61[Suppl 1]:S37-S43). "They found a tendency for the prevalence of mood disorders, including depression, interpersonal sensitivity and social difficulties, and hostility or aggression to increase with age in patients who have not had reconstructive surgery."

"Our finding that most surgeons rank the creation of an aesthetically pleasing ear for the child as the most important outcome supports the preference to wait until the child is older before performing surgery. Yet one must balance the aesthetic benefits of delayed repair with the potential negative psychological issue."

Dr. Im and Dr. Paskhover have disclosed no relevant financial relationships.

Plastic Surgery 2011: American Society of Plastic Surgeons (ASPS) Annual Meeting. Presented in electronic format September 23-27, 2011.

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