Importance of physical appearance in patients with skin cancer

Force Modulating Tissue Bridges for Reduction of Tension and Scar: Finite Element and Image Analysis of Preclinical Incisional and Nonincisional Models

Background

Force modulating tissue bridges (FMTB) represent a new class of combined wound closure and scar reduction device designed to optimize the tension milieu of the healing wound.

Objectives

Engineering analysis and testing in both intact skin and incisional models was undertaken to assess changes in tissue tension associated with device placement and compare to standard suture closure.

Methods

Nonlinear, large deformation finite element analyses (FEA) were performed to compare the strains applied to tissues with sutures and FMTB. In the incisional model, a freshly euthanized Yorkshire pig received full thickness cutaneous incisions followed by alternating closure with sutures and FMTBs. FMTBs were also applied to intact adult human skin after pattern application. In each of the experiments, photographs were taken preapplication and postapplication and the resultant dot grid pattern changes were analyzed by image recognition algorithms to calculate applied strains.

Results

FEA indicate compressive stresses at the tissue:suture interface on the order of 4000 mmHg and 20 mmHg at the tissue:FMTB interface. Strain analysis of the sutures and FMTBs applied in the incisional lab testing indicated imposed strains on the tissues of around 40%, with FMTBs providing 10% more compression than sutures and 25% more compression between the applied devices (P = 0.000057). In the longitudinal study, tension reduction of the order of 30% was maintained over the treatment period of 10 days to verify device efficacy.

Conclusions

FMTBs provide wounds while simultaneously modulating skin tension and thus have the potential to improve scar appearance.

Patients' Body Image Improves After Mohs Micrographic Surgery for Nonmelanoma Head and Neck Skin Cancer

BACKGROUND

Most skin cancers occur on the head and neck, areas of the body that are significant to an individual's body image (BI) perception. Poor BI is a robust risk factor for depression and decreased quality of life. Thus, patients with nonmelanoma head and neck skin cancer (NMHNSC) may be more vulnerable to BI disturbance and the negative sequelae of poor BI.

OBJECTIVE

Describe the nature of BI concerns in patients diagnosed with NMHNSC and assess how BI changes with treatment.

METHODS AND MATERIALS

Patients undergoing Mohs micrographic surgery (MMS) for NMHNSC completed assessments of BI and well-being before (N = 239) and 6 months after (N = 80) treatment with MMS. Demographic and tumor data were gathered through retrospective chart review.

RESULTS

Body image improved significantly 6 months after MMS, and the magnitude of this change was large (η = 0.18). Repair length (length of final scar irrespective of repair type) >4 cm predicted poorer BI at 6-month follow-up.

CONCLUSION

Patients' BI improves after treatment with MMS for NMHNSC.

FACE-Q Skin Cancer Module for measuring patient-reported outcomes following facial skin cancer surgery

BACKGROUND

The patient's perspective of their facial scar after skin cancer surgery influences perception of care and quality of life (QoL). Appearance satisfaction after surgery is also an important but often overlooked treatment outcome.

OBJECTIVES

To report the psychometric validation of the FACE-Q Skin Cancer Module consisting of five scales, measuring appearance satisfaction (Satisfaction with Facial Appearance, Appraisal of Scars), QoL (Cancer Worry, Appearance-related Psychosocial Distress) and the patient experience (Satisfaction with Information: Appearance).

METHODS

Participants underwent Mohs surgery for facial basal or squamous cell carcinoma or excision of early facial melanoma. Cohort 1 received a set of scales before and after surgery. Cohort 2 received the scales on two occasions in the postoperative period for test-retest reliability. Rasch measurement theory was used to select (item-reduce) the most clinically meaningful items for the scales. Reliability, validity, floor and ceiling effects and responsiveness were also analysed.

RESULTS

Of 334 patients, 209 (response rate 62·6%) were included. Rasch analysis reduced the total scale items from 77 to 41. All items had ordered thresholds and good psychometric fit. Reliability was high (Person separation index and Cronbach's α ≥ 0·90) and scales measuring similar constructs were correlated. High floor and ceiling effects were seen for the scales. The Cancer Worry scale demonstrated responsiveness (P = 0·004).

CONCLUSIONS

The FACE-Q Skin Cancer Module meet the requirements of the Rasch model providing linearized measurement. Discriminating between patients with minimal appearance or worry impairment may be a limitation. The scales can be used for larger validation studies, clinical practice and research.

Patient quality of life fluctuates before and after Mohs micrographic surgery: A longitudinal assessment of the patient experience

BACKGROUND

Changes in patient perceptions of quality of life (QOL) after Mohs micrographic surgery (MMS) may benefit from different counseling or treatment.

OBJECTIVE

To measure QOL before and after MMS and to identify risk factors associated with impaired QOL.

METHODS

Prospective observational study of 727 patients with skin cancer who self-reported QOL via the Skin Cancer Index immediately before and at 1 to 2 weeks and 3 months after MMS.

RESULTS

QOL fluctuated after MMS. At 1 to 2 weeks after surgery, overall QOL remained unchanged compared with before MMS. Patients reported reduced anxiety about skin cancer but had increased distress about social interactions and physical appearance. At 3 months after surgery, patients reported an overall improvement in QOL compared with before MMS (P = .0007). Age younger than 65 years (P = .0001), female sex (P = .0001), and tobacco use (P = .03) were associated with lower QOL scores at all assessment points.

LIMITATIONS

Single-site observational study. Significant loss to follow-up at both time points after MMS.

CONCLUSION

Patients with skin cancer had persistent concerns about social interactions and physical appearance 1 to 2 weeks after MMS, but all aspects of their QOL improved by 3 months after surgery. Patients who underwent MMS that were younger than 65 years, were female, or smoked were at increased risk for longitudinally impaired QOL.

Optimizing Postsurgical Scars: A Systematic Review on Best Practices in Preventative Scar Management

BACKGROUND

Scar management is critical for every plastic surgeon's practice and, ultimately, the patient's satisfaction with his or her aesthetic result. Despite the critical nature of this component of routine postoperative care, there has yet to be a comprehensive analysis of the available literature over the past decade to assess the best algorithmic approach to scar care. To this end, a systematic review of best practices in preventative scar management was conducted to elucidate the highest level of evidence available on this subject to date.

METHODS

A computerized MEDLINE search was performed for clinical studies addressing scar management. The resulting publications were screened randomized clinical trials that met the authors' specified inclusion/exclusion criteria.

RESULTS

This systematic review was performed in May of 2016. The initial search for the Medical Subject Headings term "cicatrix" and modifiers "therapy, radiotherapy, surgery, drug therapy, prevention, and control" yielded 13,101 initial articles. Applying the authors' inclusion/exclusion criteria resulted in 12 relevant articles. All included articles are randomized, controlled, clinical trials.

CONCLUSIONS

Optimal scar care requires taking into account factors such as incisional tension, anatomical location, and Fitzpatrick skin type. The authors present a streamlined algorithm for scar prophylaxis based on contemporary level I and II evidence to guide clinical practice.

Use of Skin Biopsies Among Dermatologists

BACKGROUND

Skin biopsies are essential to establish a diagnosis in many skin diseases. Utilization has been increasing rapidly and represents a significant health care cost. There are no benchmarks or baselines to guide the practice of skin biopsies.

OBJECTIVE

To create a reference data set of biopsy behavior among dermatologists.

METHODS

Five hundred eighty-eight dermatologists belonging to the American Dermatological Association (ADA) were surveyed. Two hundred eighty-seven responded with 128 of those providing biopsy data.

RESULTS

The mean percentage of biopsies that were malignant was 44.5%. This varied by subspecialty with a mean of 41.7%, 57.4%, and 4.1% of biopsies performed by general dermatologists, Mohs micrographic surgeons, and pediatric dermatologists, respectively. By category or diagnosis, the biopsies were 22.7% basal cell carcinoma, 12.0% SCC, 10.2% benign neoplasms, 10.0% nevi, 8.0% actinic keratosis, 7.6% seborrheic keratosis, 7.5% inflammatory disorders, 6.1% SCC in situ, 5.3% dysplastic nevus, 5.1% benign skin, 1.5% melanoma in situ, 1.4% melanoma, 0.9% lentigines, 0.8% other malignancies, 0.6% infectious, 0.2% not otherwise specified, and 0.1% atypical lesions. There was a statistically significant difference in biopsy results between different dermatological subspecialties.

CONCLUSION

These results should help elucidate dermatologic practice patterns and thus create opportunities to improve dermatologic care and reduce health care costs.

A Novel, Disease-Specific Self-Report Instrument to Measure Body Image Concerns in Patients With Head and Neck Skin Cancer

BACKGROUND

Skin cancer commonly occurs on areas that are salient to body image perception (i.e., head and neck). Patients with head and neck skin cancer (HNSC) may experience negative body image perceptions related to their disease, which is concerning, given the numerous negative sequelae of poor body image. However, there are no existing disease-specific measures of body image concerns in HNSC.

OBJECTIVE

To develop and examine the psychometric properties of a brief self-report, disease-specific measure of body image concerns in patients with HNSC-the Body Image Questionnaire (BIQ).

MATERIALS AND METHODS

Patients with HNSC completed the BIQ before (n = 239) and 6 months after (n = 80) treatment with Mohs micrographic surgery. Analyses examined the internal consistency, convergent validity, and factor structure of the BIQ.

RESULTS

Internal consistency reliability was acceptable, and the measure demonstrated convergent validity with well-being. Four dimensions underlie the BIQ: appearance satisfaction, appearance avoidance, head/neck/skin-specific dissatisfaction, and perceived change.

CONCLUSION

The BIQ is a valid and internally reliable disease-specific instrument that measures body image concerns in patients with HNSC.

Dermatography (Medical Tattooing) for Scars and Skin Grafts in Head and Neck Patients to Improve Appearance and Quality of Life

Importance

Dermatography (medical tattooing) is often overlooked as an adjuvant procedure to improve color mismatch in the head and neck area, and its effect on patient satisfaction and quality of life has not been evaluated, to our knowledge.

Objective

To analyze the effect of dermatography on the subjective perception of the appearance of scars and skin grafts and the quality of life in head and neck patients.

Design, Setting, and Participants

Case series of patients undergoing dermatography at the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, between July 1, 2007, and April 1, 2015. Participants were invited to respond to 2 questionnaires measuring their scar or graft appearance and their quality of life before and after dermatography as an adjuvant treatment for benign or malignant head and neck tumors.

Intervention

Use of dermatography.

Main Outcomes and Measures

Two questionnaires evaluating a visual analog scale score (range, 0-10) and multiple questions on a 5-point scale focusing on satisfaction with the appearance and the quality of life.

Results

Among 76 patients, 56 (74%) were included in the study. The mean (SD) age of the study cohort was 56.5 (16.0) years, and 42 (75%) were female. The mean improvement in scar or skin graft perception on the visual analog scale of the modified Utrecht Questionnaire for Outcome Assessment in Aesthetic Rhinoplasty before and after dermatography was 4 points. On the modified Patient Scar Assessment Questionnaire, uniform improvement of approximately 1 point across 9 questions was observed. The answers to all patient satisfaction and quality-of-life questions on both questionnaires improved significantly after dermatography.

Conclusions and Relevance

Dermatography is an effectual adjuvant procedure to improve the subjective perception of scar and skin graft appearance and the quality of life in head and neck patients.

Level of Evidence

4.

Values of a Patient and Observer Scar Assessment Scale to Evaluate the Facial Skin Graft Scar

Background

The patient and observer scar assessment scale (POSAS) recently emerged as a promising method, reflecting both observer's and patient's opinions in evaluating scar. This tool was shown to be consistent and reliable in burn scar assessment, but it has not been tested in the setting of skin graft scar in skin cancer patients.

Objective

To evaluate facial skin graft scar applied to POSAS and to compare with objective scar assessment tools.

Methods

Twenty three patients, who diagnosed with facial cutaneous malignancy and transplanted skin after Mohs micrographic surgery, were recruited. Observer assessment was performed by three independent rates using the observer component of the POSAS and Vancouver scar scale (VSS). Patient self-assessment was performed using the patient component of the POSAS. To quantify scar color and scar thickness more objectively, spectrophotometer and ultrasonography was applied.

Results

Inter-observer reliability was substantial with both VSS and the observer component of the POSAS (average measure intraclass coefficient correlation, 0.76 and 0.80, respectively). The observer component consistently showed significant correlations with patients' ratings for the parameters of the POSAS (all p-values<0.05). The correlation between subjective assessment using POSAS and objective assessment using spectrophotometer and ultrasonography showed low relationship.

Conclusion

In facial skin graft scar assessment in skin cancer patients, the POSAS showed acceptable inter-observer reliability. This tool was more comprehensive and had higher correlation with patient's opinion.

Correlation Between Appropriate Use Criteria and the Frequency of Subclinical Spread or Reconstruction With a Flap or Graft for Melanomas Treated With Mohs Surgery With Melanoma Antigen Recognized by T Cells 1 Immunostaining

BACKGROUND

Published appropriate use criteria (AUC) for Mohs micrographic surgery (MMS) for melanoma are based on consensus opinion.

OBJECTIVE

To evaluate whether published AUC identify melanomas for which MMS may benefit patients by detecting subclinical spread or confirming clear microscopic margins before flap or graft reconstruction.

MATERIALS AND METHODS

Retrospective cohort study of 591 melanomas in 556 patients evaluating the correlation between current AUC (anatomic location, recurrent status, and tumor stage) and subclinical spread or reconstruction with a flap or graft.

RESULTS

Anatomic location on the head, neck, genitalia, hands, feet, or pretibial leg was associated with a significantly higher frequency of subclinical spread (odds ratio (OR) 1.89, p = .0280) and flap or graft reconstruction (OR 10.3, p = .0001). Compared with primary lesions, recurrent melanomas had a higher frequency of subclinical spread (OR 1.78, p = .0104) and reconstruction with a flap or graft (OR 1.67, p = .0217). The frequencies of subclinical spread and flap or graft reconstruction did not differ between in situ and invasive melanomas.

CONCLUSION

Anatomic location and recurrent status are useful criteria to identify melanomas that may benefit from MMS. Tumor stage is not a useful criterion, as MMS has similar benefits for subsets of both invasive and in situ melanomas.

Optimizing Design and Execution of Linear Reconstructions on the Face

BACKGROUND

Linear closure (LC) is the most common reconstructive design for cutaneous defects. Successful performance of a LC is dependent on both appropriate surgical planning and technical execution.

OBJECTIVE

To review the design and execution of LCs on the face.

MATERIALS AND METHODS

A systematic evaluation of LCs is provided to guide a logical approach for the repair of cutaneous facial defects.

RESULTS

Reproducibly excellent aesthetic and functional results may be achieved with strategies that reduce incisional tension, preserve free margin position, and restore skin contour. Cosmetic unit borders and relaxed skin tension lines may be used to further camouflage facial scars. A comprehensive knowledge of facial anatomy, biomechanical properties of the skin, and incisional tension vectors facilitates correct preoperative planning and intraoperative technique.

CONCLUSION

Proper design and execution of LCs allow for enhanced cosmesis and permit the cutaneous surgeon to progress to more technically advanced surgical procedures such as cutaneous flaps.