Cosmetic outcomes following head and neck melanoma reconstruction: The patient's perspective

Abstract

Background: While studies have compared aesthetic outcomes following wide local excision of head and neck melanoma, none have evaluated this important outcome from the patient's perspective. Indeed, one could argue that the psychosocial impact of head and neck melanoma excision and reconstruction is more accurately assessed by deriving patient-based as opposed to surgeon-based outcome measures.

Objective: To evaluate aesthetic outcomes following wide local excision of head and neck melanoma from the patient's perspective.

Methods: Fifty-one patients who underwent excision of 57 head and neck melanomas followed by immediate closure by primary repair, skin grafting, local flap coverage or free tissue transfer were asked to complete a written survey at least six months after their surgery. A visual analogue scale (VAS) was used to assess the patient's perception of appearance alteration, satisfaction with his or her appearance, and emotional impairment. An ordinal scale was used to evaluate several criteria of the reconstructive outcome (pain, itching, colour, scarring, stiffness, thickness and irregularity).

Results: Forty-two patients (82.4%) completed the survey. There were significant correlations between VAS scores reported for appearance alteration, satisfaction with outcome and emotional impairment (P=0.001). Patients who received skin grafts reported significantly unfavourable VAS scores compared with other methods of reconstruction (P=0.046). Moreover, skin grafts received significantly worse ordinal scale ratings for itching (P=0.043), colour (P=0.047), scarring (P=0.003) and stiffness (P=0.041) compared with other methods of reconstruction. Both skin grafts and free flaps were reported to have significantly less favourable thickness (P=0.012) and irregularity (P=0.036) than primary closure or local tissue transfer. There was no significant difference between patients undergoing primary closure with local tissue transfer (P>0.413). Other factors related to the patient's VAS scores included location of the melanoma (P=0.033), size of defect (P=0.037) and recurrence of melanoma (P=0.042).

Conclusion: The degree of emotional impairment following reconstruction of head and neck melanoma excision defects was correlated with the patient's perception of appearance alteration. From the patient's perspective, primary closure and local tissue transfer appeared to result in the highest aesthetic satisfaction.

Keywords: Head and neck reconstruction; Local flap; Melanoma; Outcomes; Patient satisfaction.

Figure 1)

Patient survey. A copy of the survey completed by patients at least six months following their melanoma excision and soft tissue reconstruction. Visual analogue scales were used to evaluate the patient’s perception of appearance alteration, satisfaction with the outcome and emotional impact of their procedures. These scales were measured in millimetre increments from the left end of the scale. Ordinal scales were used to evaluate several subcategories of the reconstructive outcome including sensations of pain and itching, and perceived severity of scarring, stiffness, thickness and irregularity. An overall ordinal score was generated by averaging all scores from the subcategories. In total, 82.4% of patients completed and returned the survey

Figure 2)

Correlation between alteration of appearance, satisfaction with outcomes, emotional impairment, and the overall nominal subcategory scale. There is a significant correlation between the way a patient perceives their alteration of appearance and satisfaction with their outcome (inverse correlation, Pearson coefficient −0.702, P<0.01) (A); emotional impairment (direct correlation, Pearson coefficient 0.542, P<0.05) (B); and overall ratings from the ordinal subcategory scale (direct correlation, Pearson coefficient 0.789, P<0.001) (C). VAS Visual analogue scale

Figure 3)

Factors affecting a patient’s perception of appearance alteration. Visual analogue scale (VAS) scores for alteration of appearance were significantly different depending on location of melanoma, method of reconstruction and size of defect. A Melanomas located on the eyelid and nose received less favourable scores than those located on other parts of the head and neck (P<0.05 versus forehead or scalp). B Reconstruction with full thickness skin grafts received significantly worse scores than primary closure or local tissue transfer (P<0.05). There was no significant difference between primary closure and local flaps. C There was a significant correlation between the defect size created by excision of cheek melanomas and the VAS alteration of appearance score (Spearman rho coefficient 0.525, P<0.05). Bar graphs are presented with a thick bar representing the mean, two solid purple bars representing the two interquartiles, and extension bars representing 95% CIs

Figure 4)

Subcategorical evaluation of reconstructive outcomes. Outcomes from the various methods of reconstruction were evaluated using ordinal scales. A Full thickness skin grafts were reported to be significantly “itchier” than the other reconstructive methods (P<0.05). B Scarring from skin grafts was also reported to be greater than scarring from primary closure and local tissue transfer (P<0.05), but not more than scarring resulting from free tissue transfer. C Skin grafts were reported to be stiffer than local tissue transfers (P<0.05), but not stiffer than primary closure or free flaps. Skin grafts and free flaps were reported to be (D) thicker and (E) have more irregular contours than primary closure and local flaps. All other comparisons among reconstructive techniques were not statistically significant. Bar graphs are presented with a thick bar representing the mean, two solid purple bars representing the two interquartiles, two extension bars representing 95% CIs, and numbered dots representing outliers that were included in the statistical analysis

Figure 5)

Emotional impact of recurrence. (Yes: recurrent diagnosis of melanoma; No: no recurrent diagnosis) Recurrent diagnosis with melanoma significantly affected patients’ visual analogue scale (VAS) scores for emotional impairment (P<0.05), but did not affect VAS scores for alteration of appearance and satisfaction with appearance (data not shown). Bar graphs are presented with a thick bar representing the mean, two solid purple bars representing the two interquartiles, two extension bars representing 95% confidence intervals, and numbered dots representing outliers that were included in the statistical analysis