Impact of Preoperative Hair Removal on Self-Esteem after Brain Tumor Surgery

Abstract

Background

While surgical outcomes for brain tumors have traditionally focused on neurological and functional recovery, cosmetic and psychosocial factors such as hair shaving are increasingly recognized for their impact on patient well-being. This study aimed to evaluate the association between the extent of preoperative hair shaving and postoperative self-esteem, and to identify factors associated with low self-esteem following brain tumor surgery.

Materials and Methods

A retrospective cohort study was conducted among 179 patients who underwent brain tumor surgery. Patients were categorized into three groups based on shaving extent: no shaving, partial shaving, and total shaving. Postoperative self-esteem was assessed using the Rosenberg Self-Esteem Scale (RSES). Functional outcomes (Karnofsky Performance Status, Barthel Index, and Glasgow Coma Scale) and quality of life were routinely recorded. Analysis of variance (ANOVA) and logistic regression were used to assess associations between clinical variables and self-esteem.

Results

The median RSES score was highest in the no shaving group (22.5, interquartile range [IQR] 6.0) and lowest in the total shaving group (19.0, IQR 4.5). One-way ANOVA revealed a significant difference in self-esteem scores among the shaving groups (p < 0.001). Multivariable logistic regression identified total shaving as an independent predictor of low self-esteem (adjusted odds ratio = 9.54; 95% confidence interval: 1.12–80.78; p = 0.04). Functional and neurological scores were not significantly associated with self-esteem outcomes.

Conclusion

Total head shaving is significantly associated with lower postoperative self-esteem in brain tumor patients. Minimizing shaving when clinically feasible may enhance psychological outcomes and support holistic recovery.

 

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Keywords

brain tumor surgery - self-esteem - hair shaving - psychosocial outcomes - patient-centered care

Introduction

Brain tumor surgery is one of the most complex operations in neurosurgery.[1] [2] While the major goal of neurosurgical treatments has typically been survival and functional recovery, recent years have seen an increase in interest in the psychosocial outcomes that have an important effect on patients' quality of life.[3] [4] Self-esteem is one of these that is crucial to psychological health following surgery.

Preoperative hair shaving is one aspect that can affect self-esteem but is frequently disregarded in neurosurgical practice.[5] While total scalp shaving has been associated with improved operative visibility and a tendency to lower infection risk,[6] [7] a previous systematic review and meta-analysis reported no significant difference in surgical site infection between no hair removal and hair removal with clippers.[8] Therefore, hair shaving has been questioned in the context of evolving surgical techniques, antiseptic protocols, and patient-centered care models.

Previous research has examined self-esteem in diverse surgical patients, including those undergoing breast surgery and facial reconstruction.[9] [10] [11] A limited number of studies investigated the relationship between scalp shaving and self-esteem.[12] Diccini et al studied self-esteem and scalp shaving in neurosurgical patients who underwent craniotomy and found that hair removal was not associated with self-esteem.[13] Recently, an alternative way of hair removal has been studied for surgical site infection. Arfaie et al compared the infection rate between the traditional hair clipping and hair-sparing approach. Nevertheless, there is a lack of evidence regarding alternative approaches in the context of self-esteem.[14]

Therefore, the purpose of this work was to close this information gap. The primary objective was to evaluate the association between the extent of hair shaving (none, selective shaving, or total shaving) and postoperative self-esteem in patients undergoing brain tumor surgery. The secondary objective was to determine clinical factors associated with low self-esteem postoperatively.

 

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Materials and Methods

Study Design and Participants

We conducted a retrospective cohort study of patients who underwent brain tumor surgery between October 2023 and June 2025. Inclusion criteria were patients aged ≥ 15 years with pathologically confirmed brain tumors who had completed the postoperative self-esteem assessment. Exclusion criteria included incomplete medical records or missing self-esteem scores.

 

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Data Collection

Demographic and clinical data were gathered from medical records, including age, gender, tumor type, surgical procedure, Glasgow Coma Scale (GCS), Karnofsky Performance Status (KPS), Barthel Index, and quality of life (QOL) scores, and Rosenberg Self-Esteem Scale (RSES) before and after surgery. In our neurosurgical ward, these measures (KPS, Barthel Index, QOL scores, and RSES) are part of routine clinical documentation conducted at both preoperative and postoperative time points as part of the standard patient care protocol.

Some variables were operationally defined. Hair shaving was classified into three groups: no shaving, selective shaving (limited to the surgical field), and total shaving (complete head shaving), as shown in [Fig. 1A-C]. The extent of hair shaving was determined by the surgeon's preferences. In addition, self-esteem was assessed postoperatively using the RSES.[15] [16] A score threshold of 14 was used for classifying patients into low and normal self-esteem groups.[15]

Fig. 1 Type of shaving. (A) No shaving. (B) Selective shaving with clipping. (C) Total shaving.

 

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Ethical Considerations

This study was approved by the Institutional Review Board of the Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand (REC 68-322-10-1). Because the present study was a retrospective review, patient's informed consent was not required. However, patient identification numbers were encoded before analysis.

 

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Statistical Analysis

Continuous variables were summarized as means with standard deviations and medians with interquartile ranges (IQRs), where appropriate, to account for potential skewness. Categorical variables were presented as frequencies and percentages. The independent t-test was used to compare the means of two independent groups, and one-way analysis of variance (ANOVA) was employed to compare the mean RSES scores after surgery across the three hair shaving groups. In addition, a violin plot was performed to compare postoperative RSES scores by shaving type.

Univariate logistic regression was used to identify the potential predictors of low self-esteem. Variables with p < 0.10 were entered into multivariable logistic regression models to determine independent predictors. In detail, backward stepwise selection was performed, and the final prediction model was selected by the lowest Akaike information criterion (AIC). Odds ratios (ORs) with 95% confidence intervals (CIs) were presented. A p-value of < 0.05 was considered statistically significant. The analyses were performed with R version 4.3.3.

 

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Results

Patient Characteristics

A total of 179 patients were included: 71 (39.7%) male and 108 (60.3%) female, as shown in [Table 1]. The distribution of shaving types was no shaving (20.1%), selective shaving (43.6%), and total shaving (36.3%). Regarding preoperative functional status, the mean KPS was 73.4 ± 20.5, with 63.7% of patients scoring 80 and higher. Postoperatively, the mean KPS was 73.3 ± 18.2. Most patients underwent craniotomy (82.7%), while smaller proportions had suboccipital craniotomy/craniectomy (8.9%), burr hole with biopsy (4.5%), or craniectomy (3.9%). In terms of tumor type, the majority of patients were diagnosed with meningioma (87.2%), followed by glioma (6.7%) and other tumor types (6.1%). In addition, the distribution of hair shaving patterns was as follows: no shaving (20.1%), partial shaving (43.6%), and total shaving (36.3%).

Table 1 Clinical characteristics of patients

Factor	N (%)
Gender
Male	71 (39.7)
Female	108 (60.3)
Mean preoperative Karnofsky Performance Status (SD)	73.4 (20.5)
Preoperative Karnofsky Performance Status
≥ 80	114 (63.7)
< 80	65 (36.3)
Mean postoperative Karnofsky Performance Status (SD)	73.3 (18.2)
Postoperative Karnofsky Performance Status
≥ 80	101 (56.4)
< 80	78 (43.6)
Mean preoperative Barthel Index (SD)	79.1 (20.4)
Preoperative Barthel Index
≤ 40	24 (13.4)
41–60	15 (8.4)
61–100	140 (78.2)
Postoperative Barthel Index
≤ 40	20 (11.2)
41–60	12 (6.7)
61–100	147 (82.1)
Mean postoperative Barthel Index (SD)	80.6 (25.4)
Preoperative Glasgow Coma Scale score
15	156 (87.2)
14	14 (7.8)
13	9 (5.0)
Preoperative Glasgow Coma Scale score
15	155 (86.6)
14	19 (10.6)
13	5 (2.8)
Mean preoperative quality of life score (SD)	70.24 (18.5)
Mean postoperative quality of life score (SD)	78.2 (16.3)
Type of brain tumor
Meningioma	156 (87.2)
Glioma	12 (6.7)
Other	11 (6.1)
Type of operation
Craniotomy	148 (82.7)
Suboccipital craniotomy/craniectomy	16 (8.9)
Burr hole with biopsy	8 (4.5)
Craniectomy	7 (3.9)
Type of shaving
No shaving	36 (20.1)
Selective shaving	78 (43.6)
Total shaving	65 (36.3)
Postoperative self-esteem
Low	24 (13.4)
Normal	155 (86.6)

Abbreviation: SD, standard deviation.

 

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Factors Associated with Low Self-Esteem

Regarding postoperative psychosocial status, low self-esteem was reported in 13.4% of patients, while 86.6% reported normal self-esteem. For postoperative RSES scores based on the three shaving groups, patients who did not undergo hair shaving had the highest median self-esteem score of 22.5, with an IQR of 6.0, indicating generally high and stable self-esteem. The partial shaving group showed a slightly lower median of 21.5, but exhibited a wider IQR of 8.0, suggesting greater variability in self-esteem levels within this group. In contrast, patients in the total shaving group had the lowest median postoperative RSES score, at 19.0, and the narrowest IQR of 4.5, reflecting consistently lower self-esteem levels postoperatively.

A one-way ANOVA was performed to compare the mean postoperative RSES score across the three shaving groups. The result was statistically significant (p < 0.001), indicating that mean self-esteem scores differ significantly among the groups. Post hoc comparisons showed that patients in the total shaving group had significantly lower postoperative RSES scores compared to both the no-shaving and selective shaving groups. The difference between the no-shaving and selective shaving groups was not statistically significant (p = 0.14), as shown in [Fig. 2].

Fig. 2 Violin plot of postoperative Rosenberg Self-Esteem Scale scores by shaving type.

Univariate analysis showed that total shaving (OR = 9.60, 95% CI: 1.20–76.43; p = 0.03) was significantly associated with low self-esteem, as shown in [Table 2]. No other demographic or clinical variables reached statistical significance. In multivariable analysis, the final prediction model that had the lowest AIC value comprised type of shaving, postoperative GCS scores, and postoperative QOL scores. In detail, total shaving remained an independent predictor of low self-esteem (OR = 9.54, 95% CI: 1.12–80.78; p = 0.04), while partial shaving did not show a significant association (p = 0.14), as shown in [Table 3].

Table 2 Factors associated with low self-esteem after surgery using univariate analysis

Factor	Odds ratio (95% CI)	p-Value
Gender
Male	Ref
Female	1.34 (0.56–3.18)	0.50
Age-year	0.97 (0.95–1.00)	0.13
Preoperative Karnofsky Performance Status
≥ 80	Ref
< 80	0.63 (0.26–1.50)	0.30
Postoperative Karnofsky Performance Status
≥ 80	Ref
< 80	0.61 (0.25–1.45)	0.26
Preoperative Barthel Index
≤ 40	Ref
41–60	1.25 (0.23–6.56)	0.79
61–100	0.69 (0.21–2.26)	0.54
Postoperative Barthel Index
≤ 40	Ref
41–60	0.80 (0.12–5.20)	0.81
61–100	0.55 (0.16–1.85)	0.34
Preoperative Glasgow Coma Scale score
13	Ref
14	0.58 (0.06–5.11)	0.62
15	0.51 (0.10–2.65)	0.42
Postoperative Glasgow Coma Scale score
13	Ref
14	0.40 (0.04–3.27)	0.39
15	0.19 (0.03–1.26)	0.08
Mean preoperative quality of life score (SD)	0.98 (0.96–1.04)	0.11
Mean postoperative quality of life score (SD)	0.97 (0.95–1.02)	0.06
Type of brain tumor
Meningioma	Ref
Glioma	0.58 (0.07–4.76)	0.61
Other	1.42 (0.28–7.07)	0.66
Type of operation
Craniotomy	Ref
Suboccipital craniotomy/craniectomy	0.97 (0.20–4.60)	0.96
Craniectomy	1.13 (0.12–9.92)	0.91
Burr hole with biopsy	2.26 (0.42–12.03)	0.33
Type of shaving
No shaving	Ref
Selective shaving	4.56 (0.55–37.49)	0.15
Total shaving	9.60 (1.20–76.43)	0.03

Abbreviations: CI, confidence interval; SD, standard deviation.

Table 3 Factors associated with low self-esteem after surgery using multivariable analysis

Factor	Odds ratio (95% CI)	p-Value
Postoperative Glasgow Coma Scale score
13	Ref
14	0.42 (0.04–3.62)	0.43
15	0.43 (0.06–3.10)	0.40
Mean postoperative quality of life score (SD)	0.97 (0.95–1.00)	0.09
Type of shaving
No shaving	Ref
Selective shaving	4.96 (0.59–41.68)	0.14
Total shaving	9.54 (1.12–80.78)	0.04

Abbreviations: CI, confidence interval; SD, standard deviation.

 

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Discussion

The present study examined the association between the extent of preoperative hair shaving and postoperative self-esteem in patients undergoing brain tumor surgery. Our findings revealed a statistically significant relationship between total head shaving and low postoperative self-esteem, even after adjusting for other clinical variables. Although there is limited literature directly assessing hair shaving and self-esteem in neurosurgical patients, analogous evidence exists in other surgical contexts. Downing et al studied factors related to self-esteem levels in patients suffering traumatic brain injury and found that high Glasgow Outcome Scale-Extended scores were associated with high self-esteem levels.[17] Body deformities after cancer surgery, such as patients with breast cancer or oral cancer, associated with low self-esteem.[18] After cancer treatment, the patients' global QOL score and self-esteem deteriorated after surgery. In addition, Álvarez-Pardo et al studied factors influencing self-esteem and body image in breast cancer patients who had undergone surgery. As a result, a sense of humor, family history, and reconstruction were significantly associated with self-esteem.[9] While physical discomfort has been reported to predict low self-esteem in patients in other surgical fields, loss of hair, particularly total hair shaving in neurosurgical patients, can contribute to feelings of vulnerability, stigma, and altered self-image.

While total hair shaving significantly affects patients' self-esteem, the selective shaving did not reach statistical significance. These findings raise important considerations for surgical decision-making and patient-centered care.[19] [20] Total head shaving may not be necessary in all cases. A more selective or minimally invasive shaving approach, which is guided by the location and extent of the craniotomy, may help keep the dignity and body image of patients without compromising operative sterility. Iwami et al proposed a hair-sparing approach in cranial operation and reported no significant difference in the rate of wound complications between traditional hair clipping and the hair-sparing approach.[12]

Several limitations must be acknowledged. First, the retrospective nature of this study introduces inherent biases, including missing data and unmeasured confounders (e.g., baseline mental health status, socioeconomic support).[21] Second, the sample was drawn from a single center, which may limit generalizability. Therefore, prospective, multicenter studies are needed to validate these findings and explore the longitudinal effects of shaving on body image, depression, and social reintegration.[22] [23] [24] Additionally, qualitative research may provide deeper insight into patient perspectives and coping mechanisms. Ultimately, integrating cosmetic and psychosocial considerations into neurosurgical protocols may enhance recovery more holistically.[25] [26]

 

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Conflict of Interest

None declared.

Authors' Contributions

T.T. and N.P. conceived the study and designed the method. T.T. supervised the completion of the data collection. N.P. undertook the recruitment of participating centers and patients and managed the data, including quality control. T.T. provided statistical advice on the study design and analyzed the data, while N.P. drafted the manuscript, and all authors contributed substantially to its revision. T.T. and N.P. take responsibility for the paper as a whole.

Ethical Approval

A human research ethics committee of the Faculty of Medicine, Prince of Songkla University, approved the present study (REC 68-322-10-1) on September 5, 2025.

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Publication History

Article published online:
17 September 2025