The Psychosocial Consequences of Reconstruction of Severe Ear Defects or Third-Degree Microtia With Rib Cartilage

Abstract

Background: There are few data focusing on the improvement of psychosocial functioning and self-esteem in patients with congenital or acquired severe auricular defects.

Objective: We investigated the satisfaction of patients following auricular reconstruction with rib cartilage.

Methods: One hundred patients treated for reconstruction with rib cartilage for congenital or traumatic auricular defects have been evaluated retrospectively for changes in self-esteem, performance ability, and psychosocial attitude using a clinically established questionnaire, Frankfurter Selbstkonzeptskalen (FSKN). In addition, patients were asked to judge the new auricle and the thoracic scar using a new questionnaire.

Results: Of 68 patients who took part in this study, almost 90% could integrate the new ear into their body concept. If faced with the same decision for surgery again, 75% would again choose a reconstruction with rib cartilage. More than three-quarters rated the thoracic scar as acceptable in relation to the benefits of the new ear, although one-third felt uncomfortable with the pain and cosmetic appearance of the thoracic scar. According to the results of the FSKN questionnaire, values in psychosocial abilities improved postoperatively. There was no clear change in either self-esteem or performance ability.

Conclusions: Ear reconstruction with rib cartilage remains, under most circumstances, the procedure of choice for repairing auricular defects. There is a high acceptance of this method among patients, although the impact of the thoracic scar needs to be discussed extensively before surgery. The importance of the surgeon's experience cannot be underestimated, because it determines the aesthetic results and the patient's satisfaction in this challenging area of plastic surgery.

Ear reconstruction with autologous rib cartilage appears to be the most acceptable method for the repair of auricular defects (Figure 1) because its long-term reliability has been demonstrated in large series.^1–9 Equivalent alternative materials do not exist. Several surgeons^10–14 have reported early results with porous polyethylene (MEDPOR; Porex Technologies, Fairburn, GA); although long-term results are now available, the lack of an individually shaped structure has proven to be disappointing, and the risk of extrusion and infection is problematic.¹⁵ Despite many efforts in the field, tissue engineering remains an option of the future, not a currently available treatment.^16,17 It is universally agreed, however, that ear prostheses are the solution of choice for defects caused by malignancy or with heavy scarring with a presumably nonviable, axial pattern temporoparietal fascia flap.^18–21 Future scarring and aesthetic results must be kept in mind when deciding on a method of ear reattachment in trauma.²² Therefore, ear reconstruction with rib cartilage using the 2-stage technique described by Nagata^23,24 remains the method of choice, leading to aesthetically and functionally impressive results when performed by experienced surgeons.^7,8,21,25

Figure 1

A, B, Preoperative views of classic lobule-type microtia on the left side in a 12-year-old boy. C, D, Appearance after framework implantation. E, F, Postoperative view 3 months after framework release. G, Cartilage framework with integrated tragus-antitragus-complex.

While the techniques and physical results of ear reconstruction have been extensively reported, few studies have focussed on the psychosocial ramifications to patients with congenital or traumatic ear defects.^26–28 Psychological interviews²⁷ and the interpretation of pictures created by the patients²⁹ are strongly influenced by the observer and are difficult to relate to the clinical setting. Therefore, we examined patients with reconstructed auricles using a clinically well established questionnaire that concentrates on self-rated psychosocial attributes and provides standard values. We sought to discover whether ear reconstruction led to improved values in self-esteem, psychosocial status, and performance abilities. Furthermore, the influence of potential factors such as age, gender, and cause of defect were evaluated. In addition, we investigated the varying degrees of effectiveness among patients in integrating the new auricle into their body concept and the role of the thoracic scar in daily life. These results could yield helpful information for counselling patients before surgery and discussing their expectations.

Methods

Patients were offered treatment options of reconstruction with autologous rib cartilage, osseo-integrated ear prosthesis, or no treatment at all, although reasonable emphasis was placed on the cartilage technique according to our previously reported protocol and the technical approach described previously by Katzbach^20,21 and Weerda.^7,8

Our study population consisted of patients aged 12 years or older who had undergone ear surgery by two of the authors (SK and RK) for major congenital or trauma defects, excluding procedures after tumor ablation, between 1999 and 2004. They were asked to fill in the psychological questionnaire Frankfurter Selbstkonzeptskalen (FSKN) by Deusinger³⁰ twice: one version concerned their actual situation (postoperative) and the other concerned their presumable responses if they were completing the questionnaire before the ear reconstruction (preoperative). This test consists of 78 items to be answered on a 6-point ordinal scale. The items form 3 complexes, addressing the self-assessment of performance ability, general self-esteem, and psychosocial attitude. The questionnaire was extensively evaluated for its reliability, objectivity, and reproducibility in repeated tests for persons more than 12 years of age.³⁰ Results obtained from a normal population served as standard values. Higher scores imply a more positive judgment of his or her self-esteem, performance abilities, and possibilities to stay or get in contact with others. Because of copyright reasons, it is not possible to provide example items here.

Also administered was a newly designed semistructured questionnaire with a 5-point ordinal scale to evaluate satisfaction, daily life experience with the reconstructed ear, and the patient's opinion on the thoracic scar (Figure 2). Checkmarks on the 2 left- or right-most boxes on each question indicate agreement or disagreement, respectively.

Figure 2

Questionnaire for evaluation of the reconstructed ear and the thoracic scar.

Descriptive statistics for continuous and ordinally scaled variables included median and range. The Mann–Whitney U test for unpaired data and the Fisher exact test for the χ² test were used as exploratory tests for median differences in potential influence factors. Bivariant correlations of ordinal data were explored using Spearman rank correlation coefficients. Approval was obtained from the ethics committees of the University of Lübeck (AZ 05-012 v. 22.02.2005), and informed consent was obtained from all subjects completing the questionnaire.

Questionnaires were sent to 100 patients meeting the age requirements; in 13 cases, the addresses were incorrect and no contact could be established. Among the remaining 87 patients, 68 (78.2%) completed the questionnaire, 7 persons (8.0%) refused, and 12 patients (13.8%) did not respond. Among the nonparticipants, there was a balanced gender ratio and a tendency towards more patients with traumatic deformities, a higher number of previous surgical attempts, and with a partially higher number of surgical revisions during the reconstructive process. Time between the final step of reconstruction and survey was longer for nonparticipants, but not significantly.

Sixty subjects with congenital and 8 with traumatic ear defects returned the questionnaire. In congenital cases, the patient population was young, with a median age of 20.0 years at study time (range, 12 to 58 years); males outnumbered females at a ratio of almost 2:1. The mean time since reconstruction was 2.4 years (range, 1 to 6 years). Right-sided microtia dominated in unilateral cases. Patients with traumatic ear defects were older (median age, 31.5 years; range, 16 to 52 years) and predominantly men (7:1). These epidemiologic data are consistent with previous results.³¹

Results

After ear reconstruction, 64 patients (94.1%) in our study population experienced positive support from family, friends, and other important persons. Fifty-two (86.7%) patients with congenital defects and all eight (100%) trauma patients reported to have integrated well or very well the reconstructed auricle into their body concept and saw the new ear as part of their body (Figure 3). Support from family and friends correlated positively with successful integration of the new ear (r = 0.296; exploratory 2-sided P = .014).

Figure 3

Integration of the reconstructed auricle.

The thoracic scar was judged to be absolutely acceptable in relation to the reconstructed ear by more than three-quarters of patients (52/68; Figure 4). About one-third of all patients were disturbed by the thoracic scar and tried to hide it with clothing; this rate was slightly higher in female patients (39.1%; Figure 5). The thoracic scar caused 17.6% of all patients to feel inhibited in public; for example, at the swimming pool (Figure 6). Again, female patients were more likely to find this bothersome (30.4%). The data showed differences for age, gender, or the origin of the ear defect. Good integration of the new ear correlated positively with acceptance of the thoracic scar (r = 0.263; exploratory 2-sided P = .030), but not with complaints about the scar (Figure 2; question 4.2: r = −0.101, exploratory 2-sided P = .411; question 4.3: r = −0.105, exploratory 2-sided P = .395). As expected, complaints about the chest scar correlated positively with each other (r = 0.874; exploratory 2-sided P < .001) and negatively with the acceptance of the scar in relation to the new ear (question 4.2: r = −0.411, exploratory 2-sided P < .001; question 4.3: r = −0.387, exploratory 2-sided P = .001).

Figure 4

Evaluation of the thoracic scar I: acceptability of the scar in relation to new ear.

Figure 5

Evaluation of the thoracic scar II: discomfort.

Figure 6

Evaluation of the thoracic scar III: embarrassment.

Patients were asked about their judgment of reconstruction methods (Figure 2). Three-quarters (51/68) would again undergo the rib cartilage method; 7% (5/68) of patients would have preferred an ear prosthesis or would have done nothing at all (Figure 7). No differences were found for age or gender. Among trauma patients, there was no one who would have preferred to keep his or her preoperative appearance.

Figure 7

Evaluation of reconstruction options.

With respect to perireconstructive stress factors, about half of the patients were especially worried about the cosmetic result of the new ear (58.8%) and feared complications during surgery (44.1%). The knowledge of having a scar on the chest afterward (27.9%) and the length or the number of hospital stays (22.1%) was less stressful (Figure 8). In patients with acquired ear deformities, concern about possible complications (87.5%) and the future cosmetic result (87.5%) played a greater role than in congenital cases (38.3% and 55.0%). Women tended to be more concerned with the chest scar (30.4%, compared with 26.7% in men), but the data showed no relevant differences according to age or the origin of the ear defect.

Figure 8

Treatment concerns.

The analysis of the FSKN psychological questionnaire demonstrated no relevant change in any subscore of the test. The results in self-rated performance abilities and in self-esteem were not influenced by age, gender, or defect origin. Among patients who underwent reconstructive surgery for trauma, as compared to those with congenital defects, the measures of psychosocial attitude showed slightly higher improvement without reaching statistical significance with respect to different group sizes (Figure 9). Higher values in postoperative psychosocial attitude correlated positively with good integration of the new ear (r = −0.324; exploratory 2-sided P = .007). No correlation was found between self-esteem and ear integration or between self-esteem or psychosocial abilities and thoracic scar rating.

Figure 9

Comparison of pre- and postoperative results of the psychological questionnaire (self-concept: 36 to 108—negative, 108 to 144—neutral, and 144 to 216—positive).

Discussion

The reconstruction of severe acquired or congenital ear deformities with rib cartilage can lead to superior, natural-appearing results in experienced hands. In the past, psychological interviews, self-designed questionnaires, and especially anecdotal reports were used to explore the psychosocial and emotional impact of the ear defect. Our aim was to evaluate the pre- and postreconstructive change of self-esteem, performance abilities, and psychosocial attitude by using a standardized psychological questionnaire. To the best of our knowledge, this was the first time such an evaluation has been attempted in an adult and adolescent group in which ear reconstruction with autologous rib cartilage was the only reconstruction method used. Additionally, aspects of the integration of the new ear, the thoracic scar, perireconstructive stress factors, and the evaluation of the reconstruction method were analyzed.

There was a high return rate of the questionnaires (∼80%). The analysis of nonparticipants has to be kept in mind, as it might imply a higher rate of cosmetically unsatisfied patients. After reconstruction with rib cartilage, almost 90% of the patients could integrate the new auricle into their body concept. Three-quarters would prefer this method again to repair the ear defect. This very high acceptance confirms the results of other surgeons. Depending on the age group, in Brent's work³² about 90% of patients responded as “pleased with the result.” He described some association between emotional relief and deformity impact rated by the family, especially in the group of patients operated on in the 10- to 14-year age range. These patients benefit emotionally and are more willing to socialize and to participate in sports after surgical repair. Additionally, more than 85% of Brent's patients responded that they “carry on normal life without giving the ear a thought,” which should be the main goal for surgery—to forget about any difference with other people. In a survey by Siegert et al,²⁷ 92% rated the result as “better” or “much better” after surgery; 82% were more satisfied with their appearance.

The disadvantage of the rib cartilage method is the rib cartilage harvesting, which leaves a scar at the chest. Although more than three-quarters of our respondents considered the thoracic scar acceptable in relation to the new ear, about one-third were disturbed and tried to hide it with clothing, and nearly one-fifth felt inhibited by the scar in public. These were more likely to be issues for female patients. Horlock et al²⁶ reported comparable data; 67% of their patients scored their thoracic scars as excellent or good, and one-fifth reported some pain. Our results show that the expectation of having a chest scar after surgery is apparently less stressful during the reconstructive process than other issues, such as the future cosmetic result of the ear or complications during surgery. Future studies are needed to examine body image distress and patients' characterization of thoracic scarring.

Motivational factors for ear reconstruction were not evaluated in our study. As Siegert et al²⁷ reported, parents of microtic children wished to prevent later problems, whereas in adolescents and adults, unhappiness with their appearance and the desire to overcome psychological difficulties were major factors; up to half of their patients reported teasing and were ashamed of their ear deformity. This is in agreement with Horlock et al's²⁶ findings, in which teasing as an evident symptom had been experienced by almost 90% of their retrospectively examined 62 patients who had their ear deformity reconstructed by a cartilage reconstruction or prosthesis. Before intervention, 73% were not happy with their appearance, and about one-third responded that they wanted a normal ear and wished to be like everyone else.

Parents of children with ear defects often ask whether a higher rate of psychosocial abnormalities is to be expected. They fear that the emotional stress of a defective appearance may require greater coping skills than children may possess, leading to more difficult social relations at school, work, and in society at large than those experienced by children with normal ears. In an early report from the pioneer of ear reconstruction, Tanzer³³ found in a long-term study of 43 patients that 88% showed no or only minor emotional effects of deformity on daily social contacts. On the other hand, Siegert et al²⁷ found an obvious difference of personality characteristics such as anxiety, aggressiveness, and withdrawn life in their 65 patients before ear reconstruction compared with data from a retrospective questionnaire of 39 patients who underwent ear reconstruction previously. In their analysis, about one-third gained more self-confidence after ear reconstruction with rib cartilage. Siegert's results agree with the work of Horlock et al,²⁶ who described a prevalence of anxiety and depression in half of their 62 patients before having their auricular deformity repaired by cartilage reconstruction or prosthesis. After ear intervention, 74% of adults and 91% of children reported improved social life and leisure activities. Astonishingly, the obvious improvement of lifestyle and self-consciousness revealed no difference with respect to autologous or prosthetic ear reconstructions. Du et al²⁸ recently found severe psychosocial problems (such as lacking self-confidence) among a quarter of their 102 microtic patients that were strongly influenced by age, education, and parents. The importance of these findings is difficult to judge because of language problems with the original article and the fact that a self-designed questionnaire was used. The authors concluded from their data that patients should have surgery as early as possible.

The optimal age for patients to have surgery to prevent severe psychological damage is controversial. Kobus et al⁶ recommend an age of 12 or 14 years rather than earlier because of the scarcity of required rib cartilage, whereas Brent³² and Aguilar^34,35 argue with the impressive clinical results that it is possible even at the age of 7 or 8 years. Using the more detailed technique requiring more framework material described by Weerda^7,8 and Nagata²³ and at our institution a reconstruction with rib cartilage can be performed beginning at age 10, but preferably is performed at age 12.

Our results using the standardized, psychological questionnaire (FSKN) showed a moderate but not relevant improvement of psychosocial abilities after reconstruction with rib cartilage; there was no change in self-esteem or self-rated performance abilities. These findings are in contrast to our clinical impression and to what patients communicated in addition to the questionnaires. The test results might be explained by the retrospective approach—it could have been difficult to remember correctly his or her feelings and attitude in the time before ear reconstruction. It should be kept in mind that the full test consists of 78 items that had to be checked twice for our study purpose, which implies some kind of tedium. The retrospective design is the main and clear difficulty of this study, but it was chosen in order to gain a better group size and to preserve information about these patients. Currently, we are undertaking this study again in a prospective manner to eliminate this methodologic shortcoming. In addition, the results of the questionnaire might include bias stemming from patients who report a positive assessment to please the investigator. Faced with the fact that there is no ear reconstruction–specific questionnaire, we designed one, although reliability and validity statistics are missing in this approach. We look forward to gaining more experience with this questionnaire in future studies. Furthermore, the cosmetic result and the reconstructive process itself have a potential impact on the evaluation of the preoperative status. Despite these exceptions, patient test results were within normal limits for self-esteem and psychosocial abilities after reconstruction. Higher values in psychosocial abilities correlated positively with good integration of the new ear, which might imply a kind of reciprocal amplification.

Conclusion

Our study points out the very high acceptance and satisfaction of ear reconstruction with autologous rib cartilage. Special attention should be paid to the thoracic scar while advising female patients with ear defects. The use of MEDPOR as an alternative to cartilage in very experienced hands has to be considered, especially for those patients who cannot accept a rib cartilage harvest. There should be a frank discussion with these patients about the material used for ear reconstruction.

For the most part, patients showed normal psychological test results, even when auricular reconstruction was postponed because surgical conditions would improve by the age of 10, or be even better at age 12. Future studies should overcome the retrospective aspects of our work. It would be of great interest to establish a reliable presurgery test in order to select patients who are suitable for reconstruction.

Acknowledgments

We wish to express our gratitude to Kimberly Wood at the Department of Psychiatry at Dartmouth-Hitchcock Medical Center for her very helpful comments in the preparation of this manuscript. We thank Professor Hilko Weerda for his intensive discussion and advice in this article.

Disclosures

The authors have no disclosures with respect to the content of this article.

Author notes

Presented at the 6th Meeting of the North German Society for Otorhinolaryngology and Cervicofacial Surgery, Hamburg, Germany, April 21–23, 2006.