an investigation of psychological profiles and risk factors in congenital microtia patients

Journal of Plastic, Reconstructive & Aesthetic Surgery (2008) 61, S37eS43

An investigation of psychological profiles and riskfactors in congenital microtia patients

Du Jiamei a, Chai Jiake a,*, Zhuang Hongxing b, Guo Wanhou b,Wang Yan c, Liu Gaifen d

a First Hospital Affiliated to General Hospital of People’s Liberation Army (formerly 304th Hospital), Beijing, Chinab Plastic Surgery Hospital, Chinese Academy of Medical Science, Beijing, Chinac Department of Psychology, Capital Normal University, Beijing, Chinad Department of Epidemiology, Capital Medical University, Beijing, China

Received 6 August 2006; accepted 10 September 2007

KEYWORDSCongenital microtia;Risk factor;Cross-sectional study;Mood disorders

* Corresponding author. Division of(formerly 304th Hospital), No.51# Fuc

E-mail address: [email protected] (

1748-6815/$-seefrontmatterª2007Britdoi:10.1016/j.bjps.2007.09.002

Summary Objectives: Among congenital deformities, microtia is often said to be one of themost difficult for the reconstructive surgeon. However, few reports have investigated patients’and their families’ psychological profiles. This study sought to determine the prevalence ofmood disorders among patients with microtia and to explore clinical features associated withmood disorders.Methods: Congenital microtia patients were interviewed about Symptom Checklist-90 (SCL-90)and the Achenbach Child Behavior Checklist (CBCL), gender and age of patients, severity ofmalformation, first perceived age and approach to deformity, being teased by peers, educationlevel of parents, family harmony or not, emotional impact of un-repaired microtia on parentsand attitudes of family to patients.Results: The prevalence of mood disorders among microtia patients: ‘depression’ 20.2%, ‘in-terpersonal sensitivity/social difficulties’ 36.6% and ‘hostility/aggression’ 26.3%. Multivariateanalyses suggested that age of patients, severity of microtia, low levels of maternal education,being teased by peers, family disharmony, psychological impact on parents and overprotectionfrom parents are significantly associated with mood disorders of patients.Conclusion: Our findings suggest that microtia patients exhibit three significant mood disordersincluding depression, interpersonal sensitivity/social difficulties and hostility/aggression.Some risk factors should be actively prevented and controlled, such as being teased by peers,family disharmony, psychological impact on parents and overprotection from family.ª 2007 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published byElsevier Ltd. All rights reserved.

Burn and Plastic Surgery, First Hospital Affiliated to General Hospital of People’s Liberation Armyheng Road, Haidian district, Beijing100037, China. Tel.: þ86 01 66867972; fax: þ86 01 68989225.C. Jiake).

ishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.

mailto:[email protected]

S38 D. Jiamei et al.

Microtia is an incompletely formed ear. At times there isa bump of skin where the ear would normally be found.Other times, the lower part of the ear is formed but theupper part of the ear is missing. In the most serious cases,the whole ear is missing. Because of the prominent locationof the ears, any deformity is visible. For the patients andtheir families, the physical deformity of microtia hasa significant and emotional impact. Parents often reportavoidance behaviour. Their children may seek to avoidplaying outside, exercising and even going to school. Whenthe children asked ‘why is my ear so little?’ or ‘why am Idifferent from others?’ many parents do not know how toexplain the deformity to the child.

Despite the well documented1e4 importance of surgeryto improve psychological distress and self-esteem inpatients with auricular deformities, questions remain re-garding prevalence of mood disorders among patients whoare not currently undergoing reconstructive procedures.The prevalence of microtia is estimated at 2.35 per 10 000births. Therefore a lack of evidence regarding the preva-lence of mood disorders among microtia patients may beattributed to the difficulty in recruiting significant numbersof subjects.5

The aim of our study was to assess the prevalence ofmood disorders associated with microtia and the associatedrisk factors. We thought that determination of the preva-lence of mood disorders among patients with congenitalmicrotia may provide insight into differential risk foremotional impact. Moreover, a better understanding ofthe features associated with greater mood disorders mightimprove assessment of emotional risk and assist in thedevelopment of intervention and prevention strategies. Tothe best of our knowledge, this study is the first toinvestigate patients with microtia in terms of the preva-lence of mood disorders and the clinical characteristicsassociated with mood disorders.

Methods

Subjects

A total of 410 subjects with congenital microtia wereincluded in the study. The subjects were recruited frompatients presenting at the Auricle Centre at the PlasticSurgery Hospital of the Chinese Academy of MedicalScience, for the evaluation and treatment of microtia.The subjects included all patients presenting betweenJanuary 2003 and December 2004 except those who de-clined to take part (n Z 17, 4.0%). The mean age was 12.2years (standard deviation 6.73). Ninety-six females (23.4%)and 314 males (76.6%) were included. All subjects wereChinese, namely Mongoloid. Written informed consentwas obtained from all subjects as required by the Institu-tional Review Board.

Clinical assessment tools

The profiles of the patients and their families wereassembled during a clinical interview. Information gatheredfrom patients and their families included: patients’ gender,age, severity of malformation, age at which patients first

perceived their deformity and level of maternal andpaternal education. They were also questioned as towhether or not they had been teased by peers, whetheror not the family regarded themselves as harmonious, whatemotional impact the deformity had prior to reconstructivesurgery, and what attitudes the wider family had to thepatient. The interviews were conducted by surgeons witha master-level degree qualification. The surgeons had beentrained in interviewing and administering questionnaires.Answers were recorded and collated after a consensusconference.

The psychological outcomes of the patients were as-sessed in detail by two different scales according to the ageof the patient. The Symptom Checklist-906 (SCL-90) was usedto assess mood disorders of the patients who were 13 yearsold and above. It is a well-established, self-report, clinicalrating scale that assesses patient symptomatic psychologicaldisturbance developed by Derogatis.1e3 The scale assessesthree main psychological problems: ‘depression’, ‘interper-sonal sensitivity’ and ‘hostility’.

Mood disorders of the children with microtia under 13years of age were measured by the Child Behavior Checklist(CBCL).7 CBCL is one of the most widely-used measures inchild psychology and records the psychological problemsof children, as reported by their parents or other individualswho know the child. The checklist is composed of 113 itemsthat are all scored on a three-step scale, 0 Z not true,1 Z somewhat true, and 2 Z very true. The three mainsymptoms which were evaluated were ‘depression’, ‘socialwithdrawal’ and ‘aggression’.

Statistical analysis

Statistical analysis was undertaken using SPSS Version 12.0for Windows (2003) (SPSS Inc., Chicago, IL, USA). Frequen-cies for the responses of psychological prevalence accordingto scales were evaluated. A Chi-square (c2) statistic wasused to evaluate the correlation between three main psy-chological symptoms and independent variables. Relativerisk (odds ratio (OR)) and 95% confidence interval (95% confi-dence interval (CI)) were calculated. Further analyses wereperformed using a multivariable logistic regression analysisto determine the correlation between the main psychologi-cal symptoms and other variables when there was a signifi-cant difference among the independent groups. For rankeddata about risk factors, we employed a trend test using theChi square (c2) statistic. A value of P� 0.05 was consideredstatistically significant. All tests were two-tailed.

Results

Demographics of patients with microtia and theirparents

In our study 96 subjects (23.4%) were female and 314subjects (76.6%) were male. The age ranged from 5 to 37years with a mean age of 12.2 years. All subjects wereChinese, namely Mongoloid. A total of 66.3% of the fathershad completed education of high school or above and 60.0%of the mothers had an education level of high school orabove.

Psychological profiles and risk factors in congenital microtia patients S39

Clinical features of patients with microtia

A total of 249 patients (60.7%) had right-side microtia, 141patients (34.4%) had left-side microtia, and 20 patients(4.9%) had bilateral microtia. Referring to Marx’s classifi-cation,8 the severity of deformity is classed grade 1 to 4.Ninety-six patients (23.4%) had grade 1 microtia; 260patients (63.5%) had grade 2 microtia; 53 patients(12.9%) had grade 3 microtia and only one patient (0.2%)had grade 4. The majority of patients with microtia(Figure 1) first perceived their deformity when they were3 or 4 years old. According to parental or patient recall,176 patients (46.8%) found their deformation by comparingsides in front of the mirror or touching themselves, and200 patients (53.2%) were told about their ear deformationby others. Two hundred and forty-five patients (61.1%)admitted that they had been teased by peers about themicrotia when they were a child.

Emotional impact on the family

When the baby with congenital microtia was born, someparents felt shocked and some felt depressed. Othersdescribed themselves as being sorry but in control oftheir emotions. From the parents reporting the experi-ence, we analysed the description of the personal effectsand graded the emotional impact as minimal, moderateor severe. The emotional impact was severe in 139families, moderate in 138 families and minimal in 79.Forty-three families (10.6%) blamed family disharmony onthe deformity.

Prevalence of mood disorders among patientswith microtia

We calculated the total scores of related items with CBCLor SCL-90 scales according to patients’ ages respectively,and assessed prevalence of three mood disorders amongpatients with microtia. Prevalence of ‘depression’ inpatients with microtia was 20.2% (83 patients); prevalenceof ‘interpersonal sensitivity or social withdrawal’ was 36.6%(150 patients) and prevalence of ‘hostility or aggression’was 26.3% (108 patients).

160

140

120

100

80

60

40

20

0

Num

ber o

f Pat

ient

s

1 2 3 4Age

5 6 7

54

148

75

50

2316

32

Figure 1 Frequence distribution of patients’ perceived age.

Risk factors of three mood disorders

Tables 1e3 summarise the univariate analyses examiningrelationships between patients’ characteristics (gender,age, severity of malformation, first perceived age andapproach to deformity, teasing by peers, parental educa-tional level, family disharmony, emotional impact on par-ents and attitudes of family to patients) and prevalenceof mood disorders. These analyses highlight the apparentlysignificant impact of patient characteristics on mood disor-ders of microtia patients.

The trend test with chi-square (c2) statistic has sug-gested that the older patients were significantly morelikely than young patients to have mood disorders suchas depression(c2

trend Z 5.24, P< 0.01) and interpersonalsensitivity/social withdrawal (c2

trend Z 5.19, P< 0.01); thepatients with severe deformity (grade 3 or 4) were signifi-cantly more likely than the patients with mild deformity tohave depression(c2

trend Z 2.72, P< 0.01); patients whoseparents’ emotional impact was severe were significantlymore likely to have psychological symptoms such asdepression(c2

trend Z 3.85, P< 0.01), interpersonal sen-sitivity/social withdrawal (c2

trend Z 3.83, P< 0.01) andhostility/aggression (c2

trend Z 3.45, P< 0.01).Based on the statistically significant differences un-

covered in univariate analyses, we conducted a logisticregression analysis with depression as the dependentvariable. The model (Table 4) showed that age (OR: 1.7;95%CI: 1.3e2.2), severity of malformation (OR: 2.8; 95%CI: 0.2e0.6), level of maternal education (OR: 2.5; 95%CI: 0.2e0.7), being teased (OR: 2.6; 95% CI: 0.2e0.8), fam-ily disharmony (OR: 2.6; 95% CI: 0.2e0.9), severe emo-tional impact on parents (OR: 1.9; 95% CI: 0.3e0.8) andoverprotection of children with microtia (OR: 2.5; 95%CI: 1.3e4.5) all had significant effects on depression.Gender and the perceived approach to the patient didnot appear to affect the prevalence of mood disorders.In other words, being older, having a higher grade ofmicrotia, a lower level of maternal education, beingteased, coming from an inharmonious, overprotective orseverely affected family all increased the risk of depres-sion. The similar analysis with interpersonal sensitivity orsocial withdrawal as the dependent variable (Table 5)showed that age of patients (OR: 1.6; 95% CI: 1.3e2.0),being teased by peers (OR: 3.3; 95% CI: 0.2e0.5) and theemotional impact on parents (OR: 1.9; 95% CI: 0.4e0.7)had significant effects on this mood disorder. Howeverfactors such as gender, severity of microtia and perceivedapproach to the deformation did not reach statisticalsignificance as risk factors of interpersonal sensitivity orsocial withdrawal. The analysis with hostility or aggressionas the dependent variable (Table 6) suggested that beingteased by peers (OR: 2.5; 95% CI: 0.2e0.7) and higher emo-tional impact on parents (OR: 1.8; 95% CI: 0.4e0.8) weresignificantly associated with greater hostility or aggression.

Discussion

In addition to holding up our eyeglasses and funnellingsounds towards our ear drums to improve hearing, earsmake us look better and feel much better about ourselves

Table 1 Univariate analysis of variables associated with depression

Variable Level Depression c2 P Oddsratio

95%Confidenceinterval

Yes No

n % n %

Gender Male 63 20.72 241 79.28 0.03 0.87 1.05 0.59e1.86Female 19 20.00 76 80.00 1.00

Age 0e10 years 23 11.92 170 88.08 1.0010e15 years 17 18.68 74 81.32 2.29 0.13 1.69 0.85e3.3415e20 years 17 33.33 34 66.67 13.36 <0.01 3.67 1.77e7.60�20 years 26 39.39 40 60.61 23.99 <0.01 4.77 2.47e9.22

Severity I Degree 28 29.47 67 70.53 6.08 0.01 0.31 0.12e0.81II Degree 48 19.20 202 80.80 1.72 0.19 0.54 0.22e1.35III Degree 6 11.54 46 88.46 1.00

Father’s education <High School 35 27.56 92 72.44 4.60 0.03 1.72 1.04e2.85�High School 46 17.97 210 82.03 1.00

Mother’s education <High School 49 32.24 103 67.76 18.48 <0.01 2.92 1.77e4.83�High School 33 13.92 204 86.08 1.00

Perceived age �4 54 17.53 254 82.47 7.19 <0.01 0.48 0.28e0.83�5 27 30.68 61 69.32 1.00

Perceived approach Positive 34 19.43 141 80.57 0.37 0.54 0.85 0.52e1.41Passive 44 22.11 155 77.89 1.00

Being teased Yes 65 26.75 178 73.25 15.31 <0.01 3.12 1.73e5.64No 16 10.39 138 89.61 1.00

Impact of family Severe 44 31.88 94 68.12 11.42 <0.01 3.64 1.66e7.95Moderate 30 16.67 150 83.33 1.23 0.27 1.57 0.70e3.47Mild 9 11.39 70 88.61 1.00

Family’s attitudes Dislike 2 33.33 4 66.67 1.84 0.18 3.17 0.54e18.24Normal 24 13.64 152 86.36 1.00Special care 56 25.81 161 74.19 9.02 <0.01 2.22 1.31e3.75

Family harmony No 16 38.10 26 61.90 8.85 <0.01 2.71 1.38e5.34Yes 66 18.44 292 81.56 1.00

Note: Some patients did not answer all questions, resulting in different totals.


as a whole person. Microtia patients and their families paymore attention to the obvious aesthetic deformity. Thisconsistently rekindles their anxiety. Naturally, patientswant the deformity corrected as soon as possible. Thefindings from previous studies showed that auricular re-construction has significant psychosocial benefit in themajority of children and adults despite donor-site morbid-ity and a range of technical results.1e3 However, it is nottechnically feasible before the child reaches school age.Meanwhile, the patients and their families continuouslyseek guidance and support form the plastic surgeon. Under-standing the psychological profile and risk factors in micro-tia patients will provide professionals with the necessaryinformation to counsel and direct them.

Age effect on mood disorders

Our findings showed a tendency for the prevalence of mooddisorders to increase with age in patients who have not hadreconstructive surgery. This would seem to reflect the

increasing burden of psychosocial trials which individualsface as they grow older. The slings and arrows of school,adolescence, work and relationships must all be overcome.Brent1,2 has suggested that the first trial manifests in aboutthe first year in school, when children are continually ex-posed to a large group of their peers for the first time. Itis at this time that their self-awareness is heightened asthey begin to compare, contrast and form real conceptsof body image. This is when name-calling and teasing be-gins, and the microtia patient learns what it means to bedifferent. From the psychological point of view, the earlysurgery is ideal. This presumes, however, that the qualityof the result is as good in 5e6 year old children. Some arguethat the volume of cartilage in such children is very limitedbefore the age of 10 and therefore the aesthetic resultswhich can be achieved before that age are often limited.Many surgeons therefore delay surgery until the age of10. Moreover, presumably the potential psychological ben-efits of surgery are only likely to be achieved in response toa good aesthetic reconstruction. A poor result may have an

Table 2 Univariate analysis of variables associated with interpersonal sensitivity/social withdrawal

Variable Level Interpersonal sensitivity/social withdrawal c2 P Oddsratio


Yes No

n % n %


Age 0e10 years 50 25.91 143 74.09 1.0010e15 years 34 37.36 57 62.64 3.79 0.05 1.69 0.99e2.8815e20 years 28 52.83 25 47.17 13.73 <0.01 3.18 1.69e5.96�20 years 38 57.58 28 42.42 21.73 <0.01 3.85 2.14e6.91

Severity I Degree 41 42.71 55 57.29 0.76 0.38 0.73 0.36e1.47II Degree 89 35.32 163 64.68 <0.01 0.99 0.99 0.53e1.87III Degree 18 35.29 33 64.71 1.00

Father’s education <High School 60 47.24 67 52.76 6.85 <0.01 1.78 1.15e2.74�High School 86 33.33 172 66.67 1.00

Mother’s education <High School 75 48.70 79 51.30 12.49 <0.01 2.11 1.39e3.22�High School 73 30.80 164 69.20 1.00

Perceived age �4 103 33.55 204 66.45 6.35 0.01 0.54 0.33e0.87�5 43 48.31 46 51.69 1.00




Family’s attitudes Dislike 1 16.67 5 83.33 0.79 0.37 0.38 0.04e3.38Normal 60 34.09 116 65.91 1.00Special Care 88 40.18 131 59.82 1.64 0.20 1.30 0.86e1.97

Family harmony No 23 54.76 19 45.24 6.23 0.01 2.23 1.17e4.26Yes 126 35.00 234 65.00 1.00



adverse psychological effect. If the ear goes uncorrected ora poor result is achieved by an inexperienced surgeon, thepatient tends to feel flawed, ‘less than’ others, and con-tinues to be plagued by low self-esteem that may lasta lifetime.

Correlation between severity of malformation andpsychological morbidity

Interestingly, contrary to prior research, in the univariateanalysis, the degree of disfigurement was significant asso-ciated with depression in our analysis. Multivariable logisticregression analysis also identified it as a risk factor fordepression. While some prior research has suggested thedegree of facial disfigurement is not directly correlatedwith the number of psychological disorders.9,10 We pre-sumed that contradictory results may be attributed to pa-tients’ perception to mild ear deformity. Many childrenwith a mild deformity may think they were born with onebig ear and one little one, and that when they are older,the little one can be made larger to match the other. This

is related to the reduction in psychological morbidity ofthe patients with mild microtia.

Initial perception of deformity

Our results suggested that the child will discover that he/she is different at around the age of three to four (Figure 1),which is consistent with Brent’s findings.1,2 The manner inwhich patients came to perceive their microtia was ratedas passive or active. Usually, the parents found their childactively comparing sides in front of a mirror. Others werepassively told of their ear deformation. Our study suggeststhat the earlier the patient is aware of his/her ear defor-mation, the lower prevalence of psychological disorders.Interestingly, the manner of discovery and assimilation ofthe microtic ear(s), be it active or passive, did not appearto impact significantly on future psychological wellbeing.Therefore, we would encourage parents to be honest withtheir child, to give him or her reasonable explanation early.They should reassure the child that the ear can be repairedand made to look more normal in the future. Persistent

Table 3 Univariate analysis of variables associated with hostility/aggression

Variable Level Hostility/aggression c2 P Oddsratio


Yes No

n % n %


Age 0e10 years 52 26.94 141 73.06 1.0010e15 years 18 19.78 73 80.22 1.77 0.19 0.66 0.36e1.2215e20 years 20 39.22 31 60.78 2.84 0.09 1.73 0.91e3.31�20 years 18 27.27 48 72.73 <0.01 0.98 1.01 0.53e1.89

Severity I Degree 28 29.17 68 70.83 0.99 0.32 0.66 0.30e1.48II Degree 69 27.60 181 72.40 0.79 0.37 0.72 0.35e1.48III Degree 11 21.57 40 78.43 1.00

Father’s education <High School 35 27.13 94 72.87 <0.01 0.92 1.02 0.63e1.65�High School 68 26.56 188 73.44 1.00

Mother’s education <High School 48 30.97 107 69.03 2.07 0.15 1.39 0.88e2.19�High School 57 24.26 178 75.74 1.00

Perceived age �4 82 26.80 224 73.20 0.05 0.82 0.94 0.55e1.59�5 25 28.09 64 71.91 1.00




Family’s attitudes Dislike 1 16.67 5 83.33 0.46 0.50 0.48 0.05e4.21Normal 52 29.38 125 70.62 1.00Special care 54 25.00 162 75.00 0.89 0.34 0.81 0.51e1.26

Family harmony No 18 43.90 23 56.10 6.80 <0.01 2.37 1.22e4.58Yes 89 24.79 270 75.21 1.00


Table 4 Logistic regression analysis of variables related to depression of microtia patients

Variables b SE c2 P Oddsratio

95% Confidenceinterval

Age of patient 0.54 0.134 16.24 <0.01 1.72 1.32e2.23Degree of microtia �1.02 0.27 14.73 <0.01 0.36 0.22e0.61Mother’s education �0.91 0.32 8.32 <0.01 0.40 0.22e0.75Being teased �0.95 0.37 6.71 <0.01 0.39 0.19e0.79Impact of family �0.68 0.23 8.45 <0.01 0.51 0.32e0.80Family’s attitudes 0.90 0.31 8.38 <0.01 2.45 1.34e4.51Family harmony �0.94 0.45 4.37 0.04 0.39 0.16e0.94

Table 5 Logistic regression analysis of variables related to interpersonal sensitivity/social withdrawal of microtia patients

Variables b SE c2 P Odds ratio 95% Confidence interval

Age of patient 0.48 0.11 19.36 <0.01 1.62 1.31e2.02Being teased �1.21 0.27 19.78 <0.01 0.30 0.18e0.51Impact of family �0.64 0.17 13.59 <0.01 0.53 0.38e0.74


Table 6 Logistic regression analysis of variables related to hostility/aggression of microtia patients

Variables b SE c2 P Odds ratio 95% Confidence interval

Being teased �0.91 0.28 10.28 <0.01 0.40 0.23e0.70Impact of family �0.59 0.18 10.68 <0.01 0.56 0.39e0.79


hiding or avoidance of the truth, results in a more severeemotional impact on both parents and children.

Teasing and mood disorders

Our results demonstrate a correlation between teasing andpsychological morbidity. Teasing resulted in significantlyhigher levels of all three mood disorders uncovered in bothunivariate and multivariate analyses. Two hundred andforty-five patients (61.1%) admitted that they had beenteased about their microtia by peers as a child. Otherstudies3 have shown that teasing was a prominent problemin both children (88%) and adults (85%) with auricular defor-mity. Thus, we believe childhood teasing to have a signifi-cantly detrimental effect on the patients’ wellbeing.

The family situation

Both univariate analysis and multivariable logistic regres-sion analysis all identified the following parental parame-ters to be significant risk factors: low level of maternaleducation, emotional impact, family disharmony and illconceived attitudes towards the patient. Because the eardeformity consistently rekindles parents’ guilt, the parentsare also faced with many emotional tribulations. Theemotional impact upon parents was classified as severe in34.7%, moderate in 45.6% and mild in 19.7% of cases. Brent2

believes that the major determinant of microtia-relateddisturbance before the age of six or seven is transmissionof parental anxiety. When parents make a fuss about thedeformity, the child feels upset and self esteem drops. Ifname-calling and teasing by his peer groups are added tothe situation, the afflicted child is likely to be plagued byself perpetuating feelings of low self-esteem. Thus, thefamily should play a major role in building and bolsteringself-image, creating a normal life, and encouraging normal,productive engagement with society. The child with micro-tia should be treated normally. Time should be given to dis-cussing the situation in an objective manner withoutmaking a fuss. This study demonstrates that in 54.7% ofcases parents had overprotected and compensated withspecial care. This may lead to loss of opportunities forlearning and social interaction. If the family gives the childchances to try, he will develop enough self confidence.

Limitations

The groups studied were self selected by virtue of theirrequest for surgery. Any generalisations of these findings tothe entire population of congenital microtia patients shouldbe made with caution. Another limitation concerning oursample size is that our microtia group contained a higherproportion of males (n Z 314) than females (n Z 96). But ep-idemiological studies11 report that females and males are

equally affected by microtia. The findings reported in ourstudy should be considered preliminary because no controlpopulation is studied. We have no idea what the relevantlevels of depression, etc. are in the control population.This will be clarified in a future prospective study.

In conclusion, an apparently high prevalence of mooddisorders amongst patients with microtia was identified.These included depression, interpersonal sensitivity/socialdifficulties and hostility/aggression. Moreover, we identi-fied the risk factors to be associated with mood disorders.Being subjected to teasing by peers, or growing up ina disharmonious or overprotective family are all riskfactors, which may be amenable to early intervention byhealthcare or education professionals. Certainly if a teamapproach can be adopted with a view to reducing thepsychological impact of the deformity upon the parentsthen the patient may suffer less in the long term.

Acknowledgement

The authors thank Kenneth Stewart, M.D., for his editorialassistance with the manuscript.

References

1. Brent B. Auricular repair with autogenous rib cartilage grafts:two decades of experience with 600 cases. Plast ReconstrSurg 1992;90:355e74.

2. Brent B. The pediatrician’s role in caring for patients with con-genital microtia and atresia. Pediatr Ann 1999;28:374e83.

3. Horlock N, Vogelin E, Bradbury ET, et al. Psychosocial outcomeof patients after ear reconstruction: a retrospective study of62 patients. Ann Plast Surg 2005;54:517e24.

4. Bradbury ET, Hewison J, Timmons MJ. Psychological and socialoutcome of prominent ear correction in children. Br J PlastSurg 1992;45:97e100.

5. ICBDMS. Congenital malformations worldwide. A report fromthe International Clearinghouse for Birth Defects MonitoringSystems. Amsterdam: Elsevier; 1991.

6. Derogatis LR, Lopman RS, Covi L. SCL-90: an outpatient psychi-atric rating scale preliminary report. Psychopharmacology1973;9:13e28.

7. Taoyuan Xu. Achenbach child behavior checklist. Chin MentHealth J 1993;7(Suppl.):54e61.

8. Marx H. Die missbildungen des ohres. In: Henke F, Lubarsch O,editors. Handbuch der spez path aanat hist. Berlin, Germany:Springer; 1926. p. 620e5.

9. Sarwer DB, Wadden TA, Pertschuk MJ, et al. The psychology ofcosmetic surgery: a review and reconceptualization. Clin Psy-chol Rev 1998;18:1e22.

10. Lansdown R, Lloyd J, Hunter J. Facial deformity in childhood:severity and psychological adjustment. Child Care Health Dev1991;17:165e71.

11. Zhu J, Wang Y, Liang J, et al. An epidemiological investigationof anotia and microtia in China during 1988e1992. Zhonghua ErBi Yan Hou Ke Za Zhi 2000;35:62e5.

an investigation of psychological profiles and risk factors in congenital microtia patients

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