Health-Related Quality-of-Life Instruments for Pediatric Patients with Diverse Facial Deformities: A Systematic Literature Review

Reconstruction of extensive lower lip defects using vascularized mucosal flap with external skin complex tissue

BACKGROUND

The complexity of lip anatomy and the roles played by the lip make the reconstruction of lip defects more challenging. Adequate reconstruction of lip defects requires adaptation of mucosa, vermilion, and skin features in lip as well as its specific function.

METHODS

A 59-year-old male with left lower lip cancer underwent en-bloc resection and left selective neck dissection (SND), followed by immediate reconstruction using Facial Artery Myomucosal Island Flap (FAMMIF) with external Skin Complex Tissue.

RESULTS

The use of chimeric flap based on FAMMIF and its external skin tissue allowed minimizing the postoperative problem of combination of both aesthetic and functional impairments. The FAMMIF is suitable for the reconstruction of lip mucosa and lip vermilion, while the external skin tissue can be use to replace the external lip skin defect. The patient was satisfied with the treatment outcomes. He is undergoing follow-up without any evidence of recurrence.

CONCLUSION

FAMMIF with external skin complex tissue, as a reconstructive approach selected in our case of lip defect secondary to lip cancer resection, combined the reconstruction of both aesthetics and functions of the lower lip. The technique was found feasible and provided satisfactory postoperative outcomes.

Disability Caused by Cleft Lip and Palate: A Systematic Review and Critical Valuation Appraisal

OBJECTIVE

Measuring disability as a concept of impaired global function enables beneficiaries of treatment, the impact of treatment, and targets of health system investment to be rigorously assessed. Measures of disability are not well established for cleft lip and palate. This study aims to systematically review disability weight (DW) studies pertaining to orofacial clefts (OFCs) and identify methodological strengths and shortcomings of each approach.

DESIGN

Systematic literature review of studies that met the following criteria: (1) peer-reviewed publication, (2) focus on disability valuation, (3) mention orofacial clefts, and (4) publication January 2001-December 2021.

SETTING

None.

PATIENTS/PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE(S)

Disability weight method of valuation and the value itself.

RESULTS

The final search strategy yielded 1,067 studies. Seven manuscripts were ultimately included for data extraction. The disability weights used in our studies, including those newly generated or taken from the Global Burden of Disease Studies (GBD), ranged widely for isolated cleft lip (0.0-0.100) and cleft palate with or without cleft lip (0.0-0.269). The GBD studies limited their consideration of cleft sequelae informing disability weights to impact on appearance and speech-related concerns, while other studies accounted for comorbidities such as pain and social stigma.

CONCLUSIONS

Current measures of cleft disability are sparse, inadequately reflect the comprehensive impact of an OFC on function and socialization, and are limited in detail or supporting evidence. Use of a comprehensive health state description in evaluating disability weights offers a realistic means of accurately representing the diverse sequelae of an OFC.

Establishing Reliability and Validity of the FACE-Q Craniofacial Module for Pediatric Head and Neck Cancer

Purpose: We aimed to establish content validity and assess the psychometric properties of the FACE-Q Craniofacial Module, a patient-reported outcome measure, for use in pediatric and adolescent patients with head and neck cancer (HNC). Methods: To establish content validity (Part 1), between June 2017 and August 2019, cognitive interviews were conducted with survivors of pediatric HNC (n = 15), and input was obtained from clinical experts (n = 21). To examine item and scale performance (Part 2), Rasch Measurement Theory (RMT) analysis was performed using data from two international studies (n = 121). Results: Part 1: Qualitative data from 15 survivors and input from 21 experts provided evidence to support the use of the FACE-Q Craniofacial Module in pediatric HNC. Part 2: The field-test study sample included 121 survivors of pediatric HNC. RMT analysis provided evidence of reliability and validity for 10 FACE-Q scales. Data for each scale fit the RMT model. Scale reliability was high, with Person Separation Index and Cronbach's alpha values ≥0.82 for 9 scales. Mean scores on the Appearance, Psychological, and Social scales were higher for those who liked aspects of their face more. For participants with (vs. without) a facial difference, mean scores were lower for the Face, Jaws, Psychological, and Social scales. Conclusion: The FACE-Q Craniofacial Module evidenced reliability and validity for HNC survivors aged 8-29 years and can be used in research and clinical care to measure quality of life of pediatric survivors with HNC.

The appropriateness and quality of patient-reported outcome measures (PROMs) in plastic surgery randomized controlled trials: A systematic review

BACKGROUND

Patient-reported outcome measures (PROMs) quantify patient perspectives to measure outcomes that matter to patients. The aim of this study was to assess the reporting of appropriateness and quality of PROM selection in plastic surgery randomized controlled trials (RCTs).

METHODS

MEDLINE, Embase, and CENTRAL were searched from January 1, 2000, to June 5, 2022, to identify published RCTs within the plastic surgery literature. Included studies were categorized as follows: 1) a clearly defined patient-reported primary outcome; 2) a primary outcome could be inferred; or 3) no clear or implied primary outcome. The Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) database was consulted to assess the available literature on the PROMs.

RESULTS

There were 130 plastic surgery RCTs identified. Of the 43 studies with a clear or inferred primary outcome, the percentage of studies that commented with supporting references on the PROM's appropriateness for the population, disease/condition, and outcome were 20.9% (n = 9/43), 18.6% (n = 8/43), and 27.9% (n = 12/43), respectively. The percentage of studies that commented on the PROM's validity, reliability, and responsiveness with supporting references were 34.9% (n = 15/43), 14.0% (n = 6/43), and 11.7% (n = 5/43), respectively. There were 21 unique PROMs identified; 28.6% (n = 6/21) were available in the COSMIN database.

CONCLUSION

The majority of plastic surgery RCTs assessing patient-reported primary outcomes lack transparency surrounding PROM selection and quality. We recommend investigators conducting plastic surgery clinical research report explicitly why they used a particular PROM and support its appropriateness and psychometric properties with supporting references. Finally, they should familiarize themselves with the COSMIN initiative.

Psychosocial and Health-Related Experiences of Individuals With Microtia and Craniofacial Microsomia and Their Families: Narrative Review Over 2 Decades

This paper describes 20 years of microtia and craniofacial microsomia (CFM) psychosocial and healthcare studies and suggests directions for clinical care and research.

A narrative review of papers January 2000 to July 2021 related to psychosocial and healthcare experiences of individuals with microtia and CFM and their families.

Studies (N = 64) were mainly cross-sectional (69%), included a range of standardized measures (64%), and were with European (31%), American (27%), or multinational (23%) samples. Data were generally collected from both patients and caregivers (38%) or patient self-report (35%). Sample sizes were 11 to 25 (21%), 26 to 50 (19%), 51 to 100 (22%), or over 100 (38%). Studies addressed 5 primary topics: (1) Healthcare Experiences, including Medical Care, Hearing Loss/Amplification, Diagnostic Experiences, and Information Preferences; (2) Psychosocial Experiences, including Teasing, Behavioral Adjustment, Psychosocial Support, and Public Perception; (3) Neurocognitive Functioning and Academic Assistance; (4) Pre- and Post-Operative Psychosocial Outcomes of Ear Reconstruction/Canaloplasty; and (5) Quality of Life and Patient Satisfaction.

Care involved multiple specialties and was often experienced as stressful starting at diagnosis. Psychosocial and neurocognitive functioning were generally in the average range, with possible risk for social and language concerns. Coping and resiliency were described into adulthood. Satisfaction and positive benefit of ear reconstruction/canaloplasty were high. Care recommendations include increasing: hearing amplification use, microtia and CFM knowledge among providers, efficient treatment coordination, psychosocial support, academic assistance, and advances to minimize surgical scarring. This broad literature overview informs clinical practice and research to improve psychosocial outcomes.

Psychosocial status of patients with unilateral and bilateral microtia before auricular reconstruction surgery

OBJECTIVE

Microtia can profoundly influence health-related quality of life. The aim of this study was to investigate the psychosocial status of children and adolescents with unilateral and bilateral microtia before reconstruction surgery.

METHODS

Eighty-six patients with microtia from Peking Union Medical College Hospital (54 with unilateral microtia and 32 with bilateral microtia) responded to structured interviews before reconstruction surgery. The 3 clinically validated questionnaires were the Piers-Harris Children's Self-concept Scale (PHCSS), the Social Anxiety Scale for Children (SASC), and the Children's Loneliness Scale (CLS). Scores from the PHCSS and SASC were compared with Chinese norms. The total scores of the unilateral and bilateral groups were compared for all three questionnaires.

RESULTS

Males with unilateral and bilateral microtia had significantly different PHSCC scores than norms (both P < 0.05), and male patients overall had a total score that was 10.61 ± 2.20 points lower than female patients overall. Patients who were 7-9 years-old in the unilateral group and 10 to 13 years-old in the bilateral group had lower total PHSCC scores than norms of the same age (both P < 0.05). There was no significant difference between patients and norms in the 14-16 years-old group. The SASC scores of patients were significantly higher than the norms (P < 0.05). The CLS score was significantly lower in the unilateral group than in the bilateral group (50.17 ± 14.63 vs. 61.38 ± 13.24, P < 0.05), but these two groups did not significantly differ in PHCSS and SASC scores.

CONCLUSION

Compared to Chinese norms, children with unilateral and bilateral microtia had lower self-concept, especially males and those who were 7-13 years-old. Patients with microtia also had increased social anxiety and loneliness. Patients with bilateral microtia were more likely to report loneliness than those with unilateral microtia.

Good Outcome for an Individual with Severe Facial Anomalies and Hypogonadotropic Hypogonadism: A Consequence of His Cognitive Function, Pragmatic Approach, and Temperament

The multiple factors that determine outcomes for individuals with visible developmental errors and/or atypical development of the reproductive system are not fully understood. This case report of an individual with Bosma arhinia microphthalmia syndrome causing severe facial anomalies and hypogonadotropic hypogonadism is used to highlight factors that impacted his adjustment from childhood through adulthood. Key factors include his temperament, intact cognitive ability, and pragmatic approach for controlling his physical and social environment. His successful adjustment even in the face of significant early life challenges demonstrates that positive outcomes are attainable for individuals with significant developmental errors. His story and experiences with the health-care system offer insight into some factors that may be pertinent to resilience and lifelong adjustment for patients with similar conditions and the importance of continually seeking the patient's perspective to tailor treatment across the lifespan.

FACE-Q Craniofacial Module: Part 1 validation of CLEFT-Q scales for use in children and young adults with facial conditions

BACKGROUND

The CLEFT-Q includes 12 independently functioning scales that measure appearance (face, nose, nostrils, teeth, lips, jaws), health-related quality of life (psychological, social, school, speech distress), and speech function, and an eating/drinking checklist. Previous qualitative research revealed that the CLEFT-Q has content validity in noncleft craniofacial conditions. This study aimed to examine the psychometric performance of the CLEFT-Q in an international sample of patients with a broad range of facial conditions.

METHODS

Data were collected between October 2016 and December 2019 from 2132 patients aged 8 to 29 years with noncleft facial conditions. Rasch measurement theory (RMT) analysis was used to examine Differential Item Function (DIF) by comparing the original CLEFT-Q sample and the new FACE-Q craniofacial sample. Reliability and validity of the scales in a combined cleft and craniofacial sample (n=4743) were examined.

RESULTS

DIF was found for 23 CLEFT-Q items when the datasets for the two samples were compared. When items with DIF were split by sample, correlations between the original and split person locations showed that DIF had negligible impact on scale scoring (correlations ≥0.995). In the combined sample, RMT analysis led to the retention of original content for ten CLEFT-Q scales, modification of the Teeth scale, and the addition of an Eating/Drinking scale. Data obtained fit with the Rasch model for 11 scales (exception School, p=0.04). Person Separation Index and Cronbach alpha values met the criteria.

CONCLUSION

The scales described in this study can be used to measure outcomes in children and young adults with cleft and noncleft craniofacial conditions.

FACE-Q craniofacial module: Part 2 Psychometric properties of newly developed scales for children and young adults with facial conditions

BACKGROUND

The FACE-Q Craniofacial Module is a patient-reported outcome measure designed for patients aged 8 to 29 years with conditions associated with a facial difference. In part 1, we describe the psychometric findings for the original CLEFT-Q scales tested in patients with cleft and noncleft facial conditions. The aim of this study was to examine psychometric performance of new FACE-Q Craniofacial Module scales.

METHODS

Data were collected between December 2016 and December 2019 from patients aged 8 to 29 years with conditions associated with a visible or functional facial difference. Rasch measurement theory (RMT) analysis was used to examine psychometric properties of each scale. Scores were transformed from 0 (worst) to 100 (best) for tests of construct validity.

RESULTS

1495 participants were recruited with a broad range of conditions (e.g., birthmarks, facial paralysis, craniosynostosis, craniofacial microsomia, etc.) RMT analysis resulted in the refinement of 7 appearance scales (Birthmark, Cheeks, Chin, Eyes, Forehead, Head Shape, Smile), two function scales (Breathing, Facial), and an Appearance Distress scale. Person separation index and Cronbach alpha values met criteria. Three checklists were also formed (Eye Function, and Eye and Face Adverse Effects). Significantly lower scores on eight of nine scales were reported by participants whose appearance or functional difference was rated as a major rather than minor or no difference. Higher appearance distress correlated with lower appearance scale scores.

CONCLUSION

The FACE-Q Craniofacial Module scales can be used to collect and compare patient reported outcomes data in children and young adults with a facial condition.

Concepts Important to Patients With Facial Differences: A Qualitative Study Informing a New Module of the FACE-Q for Children and Young Adults

Objective:

The concepts important to children and young adults who undergo treatments for facial differences are not well-defined. Measurement of treatment outcomes from the patient’s perspective is necessary to ensure goals of treatment are met. We aimed to identify concepts important to children and young adults with facial differences through a qualitative study.

Design:

An interpretive description qualitative approach was followed. Semistructured interviews were conducted, transcribed verbatim, and coded using a line-by-line approach. Qualitative analysis led to the development of a conceptual framework of outcomes important to patients.

Setting:

Interviews were conducted in Canada and the United Kingdom at home, by telephone, or in the hospital.

Participants:

Participants (N = 72) were recruited between May and June 2014 from craniofacial clinics at the Hospital for Sick Children (Toronto) and Great Ormond Street Hospital (London). Participants included anyone with a visible and/or functional facial difference aged 8 to 29 years and fluent in English, excluding patients with a cleft. The sample included 38 females and 34 males, with a mean age of 13.9 years, and included 28 facial conditions (11 facial paralysis, 18 ear anomalies, 26 skeletal conditions, and 17 soft tissue conditions).

Results:

Analysis led to identification of important concepts within 4 overarching domains: facial appearance, facial function, adverse effects of treatment, and health-related quality of life (psychological, social, and school function).

Conclusions:

Our study provides an understanding of concepts important to children and young adults with facial differences.

Quality of Life Using General Population Validated Questionnaires in Children With Cleft Lip and/or Palate in New Zealand

Objective:

To determine the level of quality of life (QoL) in children with cleft lip and/or palate (CL/P) and whether this differs by cleft phenotype.

Design:

A cohort of children with CL/P born in New Zealand.

Setting:

A nationwide study of children born with CL/P and having primary surgery in New Zealand.

Participants:

Children with CL/P and their families (n = 397) who attended a cleft clinic between October 1, 2014, and September 30, 2017, and agreed to complete questionnaires on QoL.

Main Outcomes:

Primary outcomes were QoL from the PedsQL 4.0 core generic questionnaires and the PedsQL 2.0 Family impact scale.

Results:

Children with CL/P in New Zealand generally have a high QoL as assessed by the PedsQL. The impact of cleft phenotype had limited effects on the child, however there were significant impacts on parents and families. We found that the family impact scale differed by cleft phenotype with those with CL having the highest QoL and those with cleft palate the lowest, and this was consistent across QoL subscales. Quality of life improved as a whole by age, particularly in physical and cognitive functioning, as well as in the ability to undertake family activities.

Conclusions:

Children with CL/P have generally good levels of QoL in New Zealand, however cleft phenotype impacts on the level, with the lowest levels in those with cleft palate. Psychological support of children with cleft and their families should be an integral part of cleft care.

Outcome Measures Reported in Published Clinical Research Studies in Craniosynostosis: A Systematic Review

CONTEXT

The fair comparison of treatment interventions for craniosynostosis across different studies is expected to be impaired by incomplete reporting and the use of inconsistent outcomes.

OBJECTIVE

This review assessed the outcomes currently reported in studies of craniosynostosis, and whether these outcomes are formally defined and prespecified in the study methods.

DATA SOURCES, SEARCH TERMS, AND STUDY SELECTION

Studies were sourced via an electronic, multi-database literature search for "craniosynostosis." All primary, interventional research studies published from 2011 to 2015 were reviewed.

DATA EXTRACTION

Two independent researchers assessed each study for inclusion and performed the data extraction. For each study, data were extracted on the individual outcomes reported, and whether these outcomes were defined and prespecified in the methods.

DATA SYNTHESIS AND RESULTS

Of 1027 studies screened, 240 were included and proceeded to data extraction. These studies included 18,365 patients.2192 separate outcomes were reported. Of these, 851 outcomes (38.8%) were clearly defined, 1394 (63.6%) were prespecified in the study methods."Clinical and functional" was the most commonly reported outcome theme (900 outcomes, 41.1%), and "patient-reported" outcomes the least (7 outcomes, 0.3%)."Duration of surgery" was the most commonly reported single outcome (reported 80 times). "Cranial index" was the most variably defined outcome (18 different definitions used).

CONCLUSION

The outcomes reported following treatment interventions for craniosynostosis are incompletely and variably defined. Improving definitions for these outcomes may aid comparison of different management strategies and improve craniosynostosis care. Suboptimal prespecification of these outcomes in the study methods implied that outcome reporting bias cannot be excluded.

Evaluation of Long-term Outcomes of Facial Sensation following Cranial Vault Reconstruction for Craniosynostosis

Supplemental Digital Content is available in the text.

Background:

Cranial vault reshaping to correct craniosynostosis in infants may injure terminal branches of the trigeminal nerve, namely the supraorbital, supratrochlear, zygomaticofacial, and zygomaticotemporal nerves, especially if a fronto-orbital advancement is performed. Despite numerous studies demonstrating successful esthetic outcome after FOA, there are no long-term studies assessing facial sensation after possible damage to these nerves as the result of surgery.

Methods:

A cross-sectional case-control research design was used to evaluate facial sensory threshold in the trigeminal branches after cranial vault reconstruction in children with isolated, nonsyndromic metopic, and unicoronal craniosynostosis, compared with those with sagittal craniosynostosis and age-matched nonaffected controls. Study participants were recruited from the Hospital for Sick Children between the ages of 6 and 18 years. Sensory outcome was determined using the Weinstein Enhanced Sensory Test, the Ten Test, and self-reported facial sensibility function questionnaire.

Results:

The sensory outcomes of 28 patients and 16 controls were examined at an average age of 9.6 years and 10.3 years, respectively. No subjective or objective sensory deficit was noted in supraorbital, supratrochlear, zygomaticofacial, or zygomaticotemporal nerve distributions between groups. Qualitative reports of facial sensibility function indicated no difference in subjective sensation, protective sensation, or motor behavior between groups.

Conclusions:

These results suggest that while sensory nerve injury during routine FOA may occur, it does not result in a quantifiable nor clinically significant long-term sensory deficit threshold. Patients do not develop long-term neuropathic pain following surgical intervention.