Otoplasty in Adults: Psychological Impacts on Quality of Life

Abstract

Psychological distress, emotional trauma, and behavioral problems related to prominent ears can cause complicated situations in children and adults. This study aimed to investigate the changes in the psychological impact on quality of life after Otoplasty. The study used several measures, including the Glasgow Benefit Inventory, Social Appearance Anxiety Scale (SAAS), Body Image Scale (BIS), Rosenberg Self-Esteem Scale (RSES), and Visual Analogue Score (VAS), which were completed before and six months after the surgery. The GBI questionnaire was used to detect the health-related quality of life changes after Otoplasty, as it is a reliable, valid, and responsive measure. Six months after the surgery, BIS total scores, VAS scores, and SAAS scores decreased significantly, while RSES scores were not significantly different. These results suggest that Otoplasty can significantly impact adult patients’ psychological well-being and quality of life and that the surgery should be considered regardless of age.

Introduction

The most common congenital abnormality of the external ear is prominent ear deformity which is very important in diary social life as in childhood and adulthood [1–3]. Psychological distress, emotional trauma, and behavioral problems resulting from prominent ears can cause more complicated issues [4, 5]. The most important part of otoplasty surgery for the prominent ear is to increase the patient's satisfaction rate after the operation and thus to improve self-confidence, social relations, and other psychological factors [5–7]. There are few studies on the effect of functional results of ear reconstruction on patient satisfaction and its impact on the quality of life (QOL)in adults [8–11]. In this study, we aimed to evaluate the effect of Otoplasty on Health-Related Quality Of Life( HQOL) in adult patients using The Glasgow Benefit Inventory (GBI), Social Appearance Anxiety Scale (SAAS), Body Image Scale (BIS), Rosenberg Self-Esteem scale (RSES), and VAS score before and after surgery [11–25].

Methods

Study Design

The study was performed prospectively at our hospital, including 22 adult patients (8 men, 14 women). We searched the procedural database of who had undergone “Otoplasty” between September 1, 2019, and February 28, 2022. All patients were evaluated with photo recording, bilateral ear measurement (Fig. 1), and sociodemographic dates. The Glasgow Benefit Inventory (GBI), Social Appearance Body Image Scale (BIS), Anxiety Scale (SAAS), Rosenberg Self-Esteem scale (RSES), and Visual Analogue Score (VAS) were completed preoperatively and six months postoperatively.

Fig. 1.

Intraoperatively photos

Patients

Our exclusion criteria were: revision otoplasty, patient with physiatric disorders, and age under 18 years. The hospital's committee evaluated the study ethically, and all patients were informed about the study, surgery, and data usage before the surgery. The ethics committee approved this study and conducted it in accordance with the Declaration of Helsinki.

Surgical Treatment

We used Mustarde and Stenströn combined technique with posterior incision and anterior auricular suturing for prominent ear reconstruction in all patients under general anesthesia [7]. Cartilage resection and excision were made with a posterior auricular incision, and the auricle approached the mastoid. Antihelix and helix were formed with 3 "hidden" sutures in the anterior auricular. The patients were routinely checked on the second day after Otoplasty. The dressing was tight, and the full dressing was removed in the 1st week. Mid-tight dressing night was continued in the second week, and the full dressing was removed in the second week. Between the 2nd week and the 1st month, the patients used ear protection bandages at night. Photographs of the patients were taken before the surgery, one month later, and also during the surgery by taking 3-point measurements (Figs. 1 and 2).

Fig. 2.

Postoperative view

The Questionnaires

The main questionnaire after otoplasty surgery for HRQOL is The Glasgow Benefit Inventory (GBI), which has been proven to be valid, reproducible, and responsive. And this questionary is divided into three subscales: a social support subscale, a general health subscale, and a physical health subscale. The scores on the GBI were standardized from 0 to 100, with higher scores indicating an improvement in QOL following Otoplasty. Our questionnaire also included questions about sociodemographic data such as gender, concomitant chronic diseases, and satisfaction with the surgical outcome. In addition to this questionary to measure the patient's general feelings related to their ear disfigurement, a Visual Analog Scale (VAS) was used before and after surgery [11, 15, 16, 18].

The Body Image Scale consists of 40 items, developed by Secord and Jourand and adapted to Turkish by Hovardaoğlu and Secord and Jourard [23, 24]. Each item on the scale is related to a part of the body or a function. The total score varies by about 40; a higher score indicates a positive body image [12].

Social Appearance Anxiety Scale (SAAS)-is a self-report scale of one’s body shape with a 16-item questionnaire. Rosenberg Self‑Esteem Scale (RSES) self-esteem evaluation for self-administered with ten items [25]. Scale, which is commonly used to evaluate self-esteem. Contrary to previous studies that identified separate Self-Confidence and Self-Depreciation factors, factor analysis identified a single common factor. The data were fitted to a unidimensional model for graded item responses, where a model that constrained the 10 items to equal discrimination was compared with a model that allowed the discriminations to be estimated freely. The test results indicated that the unconstrained model better fits the data, revealing that the 10 items of the Rosenberg Self-Esteem Scale are differentially related to self-esteem and not equally discriminating. Furthermore, the content of the items was examined to understand their functioning, and the study provides implications for developing and validating future personality instruments. Items 2, 5, 6, 8, and 9 are reverse-scored. Give “Strongly Disagree” 1 point, “Disagree” 2 points, “Agree” 3 points, and “Strongly Agree” 4 points. Total scores for all ten items. Keep scores on a continuous scale. Higher scores indicate higher self-esteem [12, 14, 20, 22].

In this study, all questionary were completed before and six months after surgery. Questionnaires are shown in Appendix 1(A–B).

Mann–Whitney U, Wilcoxon signed-rank, and Spearman’s correlation tests were used to compare the data of the baseline BIS, SAAS, and RSES scores. Mann–Whitney U-tests were used to compare two groups for HRQOL Glasgow Benefit Inventory (GBI). The data were presented as mean and standard deviation (SD), median, 25th and 75th percentiles, and range. Statistical significance was set at P < 0.05. The data were presented as a range if the sample size was small. All analyses were performed using SPSS for Windows 11.5 software (SPSS, Chicago, IL, US).

Results

A total of 22 (8 males, 14 females) patients who had Otoplasty between September 1, 2019, and February 28 completed all five questionaries. The mean follow-up was 1.8 years (SD T 0.7; range, two years); the mean age was 28.5 ± 6.2 years (median 24 years: range 18–37). Sixteen of the patient underwent bilaterally, and six were unilaterally operated on.

The Glasgow Benefit Inventory (GBI) questionnaire consisted of several subgroups, including the general health subscale, physical health subscale, social support subscale, and GBI total score.

The median values for the different GBI scores were as follows: GBI total score was 36 (with 25th and 75th percentiles of 27.32 and 65.21, and a range of 82.21–52.87); general health subscale was 52,1 (with 25th and 75th percentiles of 49.3 and 47.8, and a range of 82.21–83.82); social support subscale was 0.00 (with 25th and 75th percentiles of 0.00 and 0.00, and a range of 82.21–68.05); and physical health subscale was 0.000 (with 25th and 75th percentiles of 0.00 and 0.00, and a range of 82.21–13.34) (Table 1).

Table 1.

GBI scores

GBI Score	Median	25th percentile	75th percentile	Range
GBI total score	36	27.32	65.21	82.21–52.87
General health subscale	52,1	49.3	47.8	82.21–83.82
Social support subscale	0.00	0.00	0.00	82.21–68.05
Physical health subscale	0.0009	0.008	0.008	82.21–13.34

Moreover, no significant difference between males and females was found in GBI total score and GBI subscores.

Table 2 compares the GBI scores between men and women and the p-values obtained from a t-test. The GBI scores are divided into four subscales: total score, general health subscale score, social support subscale score, and physical health subscale score. For each subscale, the table shows the median score for men and women, as well as the 25th and 75th percentiles and the range of scores. The study found no significant difference between males and females in the GBI total score and subscale scores. The median GBI total score for men was 29.86, while for women, it was 38.89, and the difference was not statistically significant (p > 0.05). Similarly, no significant difference was found in the general health subscale score between males and females, with a median score of 53.03 for men and 59.18 for women (p > 0.05). The same was true for the social support subscale, with a median score of 0.03 for men and 0.04 for women (p > 0.05). Regarding the physical health subscale, the median score was 0.05 for men and 0.06 for women; the difference was not statistically significant (p > 0.05).

Table 2.

GBI scores by gender and subscales

	Men	Women	P-value
GBI total score	Median: 29.86	Median: 38.89	p > 0.05
	(25th Percentile: 28.81, 75th Percentile: 55.61)	(25th Percentile: 36.93, 75th Percentile: 65.1)
	Range: 82.21–56.62	Range: 15.73–56.62
GBI general health subscale score	Median: 53.03	Median: 59.18	p > 0.05
	(25th Percentile: 21.32, 75th Percentile: 73.42)	(25th Percentile: 33.56, 75th Percentile: 74.23)
	Range: 82.21–82.21	Range: 24.0–82.21
GBI social support subscale score	Median: 0.03	Median: 0.04	p > 0.05
	(25th Percentile: 24.0, 75th Percentile: 0.0)	(25th Percentile: 23.0, 75th Percentile: 0.0)
	Range: 82.21–0.0	Range: 31.22–68.77
GBI physical health subscale score	Median: 0.05	Median: 0.06	p > 0.05
	(25th Percentile: 49.90, 75th Percentile: 0.0)	(25th Percentile: 25.09, 75th percentile: 0.0)
	Range: 82.21–82.21	Range: 24.0–82.21

Table 3 presents GBI scores and chronic disease status among the study participants, median, 25th percentile, 75th percentile, range, and p-values for each GBI subscale.

Table 3.

GBI scores by chronic disease status

GBI score	Chronic disease	Median	25th percentile	75th percentile	Range	p-value
GBI total score	Yes	44.25	32.83	52.45	33.54 to 59.43	p > 0.05
	No	33.89	15.56	52.87	81.21 to 53.65
General health subscale	Yes	71.98	54.35	80.63	49.87 to 81.21	p > 0.05
	No	55.56	24.96	68.88	81.21 to 81.21
Social support subscale	Yes	0.05	13.1	0.06	− 15.96 to 0.06	p > 0.05
	No	0.08	− 9.21	0.06	81.21 to 72.43
Physical health subscale	Yes	0.03	− 16.07	11.89	− 15.03 to 15.04	p > 0.05
	No	0.05	− 5.09	0.06	81.21 to 0.09

The results indicate no significant difference in GBI scores between patients with chronic disease and those without. The median GBI total score for the chronic disease group was 44.25, with a range of 33.54–59.43, while the median for the group without chronic disease was 33.89, with a range of 81.21–53.65. However, the p-value was greater than 0.05, indicating that this difference was not statistically significant.

Similarly, the two groups had no significant difference in scores on the general health subscale. The median score for the chronic disease group was 71.98, with a range of 49.87–81.21, while the median for the group without chronic disease was 55.56, with a range of 81.21–81.21. Again, the p-value was greater than 0.05.

There was also no significant difference in scores on the social support subscale between the two groups. The chronic disease group had a median score of 0.05, with a range of − 15.96 to 0.06, while the group without the chronic disease had a median score of 0.08, with a range of 81.21–72.43. The p-value was greater than 0.05.

Finally, the two groups had no significant difference in scores on the physical health subscale. The median score for the chronic disease group was 0.03, with a range of − 15.03 to 15.04, while the median for the group without chronic disease was 0.05, with a range of 81.21–0.09. The p-value was greater than 0.05. Therefore, the study did not find any significant correlation between GBI scores and the presence of chronic disease or critical life events.

GBI, a reproducible, valid questionnaire, was the base of the used inquiry for detecting the changes in HRQOL after Otoplasty. Six months postoperatively, BIS total scores (p = 0.004), VAS scores(p = 0.004), and SAAS scores (p = 0.002) decreased significantly relative to that of the baseline values, and RSES score (p = 0.008) was not substantially different from the baseline value. There were no significant between women's and men's baseline and postoperative GBI, BIS, SAAS, RSES, and VAS scores.

Discussion

Prominent ear deformity is the most common congenital abnormality of the external ear, and it can cause significant psychological distress, emotional trauma, and behavioral problems in both childhood and adulthood. Patients with prominent ears often experience low self-esteem, social isolation, and anxiety due to their ear disfigurement [1–5]. Otoplasty surgery is an effective treatment for prominent ears, aiming to increase patient satisfaction, improve self-confidence, and enhance other psychological factors [5–7]. Although many studies have evaluated the functional results of ear reconstruction surgery, few studies have investigated the impact of Otoplasty on the patient's HQOL in adults [8–11]. The present study aimed to evaluate the effect of Otoplasty on Health-Related Quality Of Life (HQOL) in adult patients using The Glasgow Benefit Inventory (GBI), Social Appearance Anxiety Scale (SAAS), Body Image Scale (BIS), Rosenberg Self-Esteem scale (RSES), and VAS score before and after surgery [11–22]. Our results demonstrated a significant improvement in patients' HQOL after Otoplasty, as evidenced by decreased scores on the BIS, SAAS, and VAS scales and a non-significant difference in the RSES score. This study provides valuable insight into the impact of Otoplasty on adult patients' psychological and social well-being.

For years, other medical and surgical fields have utilized quantitative tools to evaluate subjective QOL outcomes. However, in facial plastic and reconstructive surgery, especially in cosmetic procedures, outcomes are often assessed qualitatively by either patient or physician satisfaction [26–31]. Therefore, there is a need to apply outcomes research methodology in facial plastic surgery to improve the study of these results and provide a more rigorous and objective evaluation of surgical outcomes. This is especially important as outcome research becomes increasingly critical in clinical investigations, particularly in socioeconomic aspects, and the search for objective measurement necessary for evidence-based medicine [4, 32, 33].

Several recent studies have investigated gender dominance in patients undergoing Otoplasty. A literature review suggests a predominance of females seeking Otoplasty, consistent with the PubMed manuscript's findings. This aligns with previous studies that have reported that up to 80% of otoplasty patients are female. However, it is important to note that studies have reported no significant gender difference in the frequency of otoplasty procedures [34–37]. The reasons behind the gender predominance in Otoplasty are not fully understood, but it has been suggested that this may be due to societal pressures and expectations regarding appearance, particularly for women. In addition, it has been suggested that women may be more likely to seek out cosmetic procedures than men, although this is not well-established [35, 38, 39].

Regarding the specific findings of the manuscripts, our study reports that 14 out of the 22 patients who underwent Otoplasty were female, which is consistent with the overall trend of gender predominance in otoplasty patients. The study also reports that 16 patients underwent bilateral Otoplasty, while 6 underwent unilateral Otoplasty. This finding also aligns with previous studies that reported bilateral Otoplasty is more common than unilateral Otoplasty.

Overall, while the reasons for the gender predominance in otoplasty patients are not fully understood, healthcare professionals need to be aware of these trends when considering patient demographics for otoplasty procedures. It is also important for future research to continue investigating the underlying factors contributing to gender differences in Otoplasty.

Mustarde and Stenströn, combined technique with posterior incision and anterior auricular suturing for prominent ear reconstruction is a common approach in otoplasty procedures [40–43]. This technique allows for effective ear reshaping while minimizing scarring and maintaining a natural appearance. The use of general anesthesia in this procedure is also a common practice to ensure patient comfort and safety. In the past five years, several studies have investigated the efficacy and safety of various otoplasty techniques, including the Mustarde and Stenströn combined techniques. For example, a study by Agha and colleagues compared the outcomes of Otoplasty using the Mustarde technique with and without conchal alteration [41]. The study found that the addition of conchal alteration resulted in better ear symmetry and improved patient satisfaction. Another study by Pek and colleagues investigated the use of a modified Mustarde technique for correcting lop ear deformity [42]. The modified technique involved using a 2-layered conchal cartilage framework, resulting in better ear shape correction and improved postoperative outcomes. Regarding postoperative care, a study by Lim and colleagues investigated using ear splints in otoplasty procedures [43]. The study found that using ear splints resulted in faster recovery times and improved cosmetic outcomes compared to traditional dressing methods. Overall, these studies highlight the importance of selecting the appropriate otoplasty technique for each patient's unique needs and considering using postoperative care methods, such as ear splints, to improve outcomes. Healthcare professionals must stay current on the latest research in this field to provide the best possible care for their patients. We also used the same technique the getting better results.

Research has shown that adults who cope with disfigurement over a longer period tend to develop more severe problems than children. This is why auricular deformity, even though not life-threatening, can still cause significant psychological distress in adults and is a strong argument for surgical intervention such as Otoplasty [12–20]. To assess the impact of Otoplasty on individual health-related quality of life (HRQOL), it is necessary to use a standardized questionnaire such as the Glasgow Benefit Inventory (GBI). The GBI is specifically designed to measure patients' subjective perception of QOL after otolaryngological interventions and is a validated and well-studied instrument. It is highly sensitive in detecting changes in patients' QOL after surgical interventions, especially otolaryngological procedures [3, 31].

We observed a significant improvement in both the GBI total score and the general health subscale score after Otoplasty, suggesting that this surgical procedure positively affects the self-perception of adult patients with prominent ears and supports the hypothesis that Otoplasty has a substantial impact on the health of patients with this condition. Interestingly, we found no difference in GBI scores with respect to follow-up time, indicating that Otoplasty has a long-lasting effect on patients' disease-specific quality of life, highlighting the enduring impact of this intervention. Furthermore, we found no significant difference in GBI subscores between men and women, contrary to previous research suggesting that HRQOL tends to be worse for females as they age. This finding supports the notion that the psychological impact of prominent ears is so profound that postoperative improvement leads to better mental health status, independent of gender.

The study found no significant difference in GBI subscores among patients with concomitant chronic diseases, indicating that individual circumstances do not affect the outcome of Otoplasty. This strengthens the idea that Otoplasty strongly impacts the health-related quality of life (HRQOL) of patients with prominent ears, independent of external factors. The Visual Analog Scale and patient satisfaction survey also positively influenced overall well-being. The improvement in QOL also has a socioeconomic impact as the number of missed workdays decreases. However, the study's limitation could be the recall bias associated with retrospective evaluation.

Nevertheless, such measures are more sensitive to change and may correlate more with patient satisfaction. The World Health Organization defines health as complete physical, mental, and social well-being, with facial form and its consequences contributing significantly to overall health. Measuring facial plastic surgery outcomes comprehensively follows the clinical focus on overall well-being and individual satisfaction. Otoplasty is an appropriate therapy for selected adult patients with prominent ears, supported by the long-lasting advancement of HRQOL. Future studies with a larger cohort will further strengthen the benefit of surgical intervention, and GBI is appropriate to measure changes in HRQOL.

We think our study will contribute to the literature showing that Otoplasty surgery positively affects adults and increases their quality of life. One of the positive aspects of the study is that the researchers used a validated questionnaire, the GBI, to assess the changes in HRQOL after Otoplasty. This questionnaire has been widely used in previous studies and is reliable and valid. Additionally, the study had a relatively long follow-up period of 1.8 years, which allowed the researchers to assess the long-term effects of Otoplasty on HRQOL.

However, our research is still in its early stages, and some limitations to the study should be considered. First, the sample size was small, limiting the findings' generalizability. The reason for this is that our research coincided with the COVID-19 pandemic period. As a result of the necessity of isolation of people and the postponement of operations due to aesthetic reasons during the Covid-19 Pandemic period, a small number of patients participated in our study. The study had limitations, including a small sample size and reliance on self-reported data. Future studies with larger sample sizes, multiple institutions, and control groups are needed to confirm these findings and better understand the impact of Otoplasty on HRQOL.

Conclusions

In adult patients, Otoplasty can provide significant psychological impacts on quality of life, and this surgery should be performed in adults. Our aim in publishing this article is to contribute to science.

Appendix 1

The glasgow benefit ınventory (GBI) for quality of life measures
(A)
1. Has the result of the operation affected the things you do? 2. Have the results of your operation made your overall life better or worse? 3. Since your operation, have you felt more or less optimistic about the future? 4. Since your operation, do you feel more or less embarrassed when you are with a group of people? 5. Since your operation, do you have more or less self-confidence? 6. Since your operation, have you found it easier or harder to deal with a company? 7. Since your operation, do you feel that you have more or less support from your friends? 8. Have you been to your family doctor for any more or less frequent reasons since your operation? 9. Since your operation, do you have more or less confidence about your job opportunities? 10. Since your operation, are you more or less self-conscious? 11. Since your operation, are there more or fewer people who really care about you? 12. Since you had the operation, do you catch colds or infections more or less often? 13. Have you had to take more or less medicine for any reason, since your operation? 14. Since your operation, do you feel better or worse about yourself? 15. Since your operation, do you feel that you have had more or less support from your family? 16. Since your operation, are you more or less inconvenienced by your health problems? 17. Since your operation, have you been able to participate in more or fewer social activities? 18. Since your operation, have you been more or less to withdraw from social situations? 19. Are you satisfied with the result of your operation? 20. How old are you? 21. What is your gender? 22. In which year did you undergo surgery? 23. Do you suffer from any chronic illness?

Rosenberg self‑esteem scale (RSES)
Below is a list of statements dealing with your general feelings about yourself Please indicate how strongly you agree or disagree with each statement	Strongly agree	Agree	Disagree	Strongly disagree
(B)
1. On the whole, I am satisfied with myself:
2. At times I think I am no good at all
3. I feel that I have a number of good qualities
4. I am able to do things as well as most other people
5. I feel I do not have much to be proud of
6. I certainly feel useless at times
7. I feel that I’m a person of worth, at least on an equal plane with others
8. I wish I could have more respect for myself
9. All in all, I am inclined to feel that I am a failure
10. I take a positive attitude toward myself

Author Contributions

AA, conception, and design, data acquisition, statistical analysis, manuscript drafting, data analysis, and interpretation, critical revision of the manuscripts, approval of final manuscripts; OY, conception, and design, data acquisition, statistical analysis, manuscript drafting, data analysis, and interpretation, critical revision of the manuscripts, approval of final manuscripts; MEC, manuscript drafting, critical revision of the manuscripts.

Funding

The authors have no funding or financial relationship to declare.

Declarations

Conflict of interest

The authors declare that they have no competing interests.

Consent for Publication

The patients consented to the publication of this research.

Ethical Approval

The study was approved by the Ethics Committee, and written informed consent was obtained from all patients in this study.