FACE-Q for Measuring Patient-reported Outcomes after Facial Skin Cancer Surgery: Cross-cultural Validation

Background

Facial skin cancer and its surgical treatment can affect health-related quality of life. The FACE-Q Skin Cancer Module is a patient-reported outcome measure that measures different aspects of health-related quality of life and has recently been translated into Dutch. This study aimed to evaluate the performance of the translated version in a Dutch cohort using modern psychometric measurement theory (Rasch).

Methods

Dutch participants with facial skin cancer were prospectively recruited and asked to complete the translated FACE-Q Skin Cancer Module. The following assumptions of the Rasch model were tested: unidimensionality, local independence, and monotonicity. Response thresholds, fit statistics, internal consistency, floor and ceiling effects, and targeting were assessed for all scales and items within the scales. Responsiveness was tested for the "cancer worry" scale.

Results

In total, 259 patients completed the preoperative questionnaire and were included in the analysis. All five scales assessed showed a good or sufficient fit to the Rasch model. Unidimensionality and monotonicity were present for all scales. Some items showed a local dependency. Most of the scales demonstrate ordered item thresholds and appropriate fit statistics.

Conclusions

The FACE-Q Skin Cancer Module is a well-designed patient-reported outcome measure that shows psychometric validity for the translated version in a Dutch cohort, using classical and modern test theory.

The Use of the FACE-Q Aesthetic: A Narrative Review

INTRODUCTION

In the past decade there has been an increasing interest in the field of patient-reported outcome measures (PROMs) which are now commonly used alongside traditional outcome measures, such as morbidity and mortality. Since the FACE-Q Aesthetic development in 2010, it has been widely used in clinical practice and research, measuring the quality of life and patient satisfaction. It quantifies the impact and change across different aspects of cosmetic facial surgery and minimally invasive treatments. We review how researchers have utilized the FACE-Q Aesthetic module to date, and aim to understand better whether and how it has enhanced our understanding and practice of aesthetic facial procedures.

METHODS

We performed a systematic search of the literature. Publications that used the FACE-Q Aesthetic module to evaluate patient outcomes were included. Publications about the development of PROMs or modifications of the FACE-Q Aesthetic, translation or validation studies of the FACE-Q Aesthetic scales, papers not published in English, reviews, comments/discussions, or letters to the editor were excluded.

RESULTS

Our search produced 1189 different articles; 70 remained after applying in- and exclusion criteria. Significant findings and associations were further explored. The need for evidence-based patient-reported outcome caused a growing uptake of the FACE-Q Aesthetic in cosmetic surgery and dermatology an increasing amount of evidence concerning facelift surgery, botulinum toxin, rhinoplasty, soft tissue fillers, scar treatments, and experimental areas.

DISCUSSION

The FACE-Q Aesthetic has been used to contribute substantial evidence about the outcome from the patient perspective in cosmetic facial surgery and minimally invasive treatments. The FACE-Q Aesthetic holds great potential to improve quality of care and may fundamentally change the way we measure success in plastic surgery and dermatology.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Systematic Review and Overview of Flap Reconstructive Techniques for Nasal Skin Defects

Background: Reconstruction of nasal skin defects can be challenging due to limited skin laxity and underlying cartilage and, therefore, often require a complex repair. The aim of this review is to systematically analyze the literature on nasal skin reconstructions with specific detail to flap reconstructions. Methods: A systematic literature review of nasal skin reconstruction was performed and focused on flap reconstructions. Flap reconstructions were stratified based on defect size, nasal subunit, and reconstruction type. Complication rates (CRs) and patient outcomes were also assessed. Results: A total of 176 articles (11,370 patients) met the inclusion criteria. Of these, 59 articles showed various flap techniques. For defects ≤1.5 cm, every subunit had four to six options except the alar rim, which showed one option. Rotation-advancement flaps were mostly used for the nasal tip and sidewall, whereas bilobed flaps were used more for the ala and dorsum. Defects >1.5 cm were most commonly reconstructed with the forehead flap. The mean CR of flap reconstructions was 13.8%. Only 8 of the 176 articles (4.5%) reported patient satisfaction using a standardized questionnaire. Conclusion: This review shows various flap reconstruction options with their corresponding CR that will help guide the surgeon in choosing reconstructive options for different nasal skin defects.

Construct validity of the anglicised FACE-Q skin cancer module

OBJECTIVES

The FACE-Q Skin Cancer module is a patient-reported outcome measure (PROM) for facial skin cancer. It has been anglicised for the UK population and undergone psychometric testing using classical test theory. In this study, further evaluation of construct validity using Rasch measurement theory and hypothesis testing was performed.

METHODS

Patients were prospectively recruited to the Patient-Reported Outcome Measures In Skin Cancer Reconstruction (PROMISCR) study and asked to complete the anglicised FACE-Q Skin Cancer module. The scalability and unidimensionality of the data were assessed with a Mokken analysis prior to Rasch analysis. Response thresholds, targeting, fit statistics, local dependency, and internal consistency were examined for all items and subscales. Four a priori hypotheses were tested to evaluate the convergent and divergent validity. We additionally hypothesised that the median 'cancer worry' score would be lower in post-operative than pre-operative patients.

RESULTS

239 patients self-completed the questionnaire between August 2017 and May 2019. Of the ten subscales assessed, five showed relative fit to the Rasch model. Unidimensionality was present for all five subscales, with most demonstrating ordered item thresholds and appropriate fit statistics. Two items in the 'cancer worry' subscale had either disordered or very close response thresholds. Subscales of the FACE-Q Skin Cancer module demonstrated convergent and divergent validity with relevant Skin Cancer Index comparators (p < 0.001). Median 'cancer worry' was lower in post-operative patients (44 vs 39, p < 0.001).

CONCLUSION

The anglicised FACE-Q Skin Cancer module shows psychometric validity through hypothesis testing, and both classical and modern test theory.

To see or not to see: Impact of viewing facial skin cancer defects prior to reconstruction

Patient expectations of the scar after Mohs micrographic surgery (MMS) are often not realistic, leading to subsequent psychosocial sequelae such as anxiety, depression, and avoidance of social situations. When patient expectations are not met, this may also contribute to a decrease in patient satisfaction after surgery. Therefore, altering expectation levels may change patient satisfaction and psychosocial distress levels after surgery. To assess whether patient satisfaction improves in patients after MMS when patients view the surgical defect prior to reconstruction. Patients undergoing facial MMS between December 2017 and September 2019 were included. Patients received or did not receive a mirror after MMS to view the surgical defect before closing the defect. Patients were asked to complete the Dutch FACE-Q Skin Cancer before, one-week, three-months, and one-year after MMS. A total of 113 patients where included. One-hundred-eight (95.6%), 113 (100%), and 93 (82.3%) questionnaires were completed, one-week, three-months, and one-year follow-up, respectively. Satisfaction with facial appearance and appraisal of scars significantly improved over time for all patients, no such improvement was seen for appearance-related distress. Female patients who looked in the mirror had higher satisfaction with facial appearance than female patients who did not look in the mirror. Also, lower appearance-related distress scores were seen in patients who looked in the mirror prior to a flap reconstruction. Showing the defect in the mirror prior to the reconstruction may result in higher patient satisfaction in female patients and patients before undergoing a flap reconstruction.

Effect of preventive supplementation with zinc and other micronutrients on non-malarial morbidity in Tanzanian pre-school children: a randomized trial

BACKGROUND

The efficacy of preventive zinc supplementation against diarrhea and respiratory illness may depend on simultaneous supplementation with other micronutrients. We aimed to assess the effect of supplementation with zinc and multiple micronutrients on diarrhea and other causes of non-malarial morbidity.

METHODS AND FINDINGS

Rural Tanzanian children (n = 612) aged 6-60 months and with height-for-age z-score < -1.5 SD were randomized to daily supplementation with zinc (10 mg) alone, multi-nutrients without zinc, multi-nutrients with zinc, or placebo. Children were followed for an average of 45 weeks. During follow-up, we recorded morbidity episodes. We found no evidence that concurrent supplementation with multi-nutrients influenced the magnitude of the effect of zinc on rates of diarrhea, respiratory illness, fever without localizing signs, or other illness (guardian-reported illness with symptoms involving skin, ears, eyes and abscesses, but excluding trauma or burns). Zinc supplementation reduced the hazard rate of diarrhea by 24% (4%-40%). By contrast, multi-nutrients seemed to increase this rate (HR; 95% CI: 1.19; 0.94-1.50), particularly in children with asymptomatic Giardia infection at baseline (2.03; 1.24-3.32). Zinc also protected against episodes of fever without localizing signs (0.75; 0.57-0.96), but we found no evidence that it reduced the overall number of clinic visits.

CONCLUSIONS

We found no evidence that the efficacy of zinc supplements in reducing diarrhea rates is enhanced by concurrent supplementation with other micronutrients. By reducing rates of fever without localizing signs, supplementation with zinc may reduce inappropriate drug use with anti-malarial medications and antibiotics.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00623857.

Effect of preventive supplementation with zinc and other micronutrients on non-malarial morbidity in Tanzanian pre-school children: a randomized trial

Background

The efficacy of preventive zinc supplementation against diarrhea and respiratory illness may depend on simultaneous supplementation with other micronutrients. We aimed to assess the effect of supplementation with zinc and multiple micronutrients on diarrhea and other causes of non-malarial morbidity.

Methods and Findings

Rural Tanzanian children (n = 612) aged 6–60 months and with height-for-age z-score < –1.5 SD were randomized to daily supplementation with zinc (10 mg) alone, multi-nutrients without zinc, multi-nutrients with zinc, or placebo. Children were followed for an average of 45 weeks. During follow-up, we recorded morbidity episodes. We found no evidence that concurrent supplementation with multi-nutrients influenced the magnitude of the effect of zinc on rates of diarrhea, respiratory illness, fever without localizing signs, or other illness (guardian-reported illness with symptoms involving skin, ears, eyes and abscesses, but excluding trauma or burns). Zinc supplementation reduced the hazard rate of diarrhea by 24% (4%–40%). By contrast, multi-nutrients seemed to increase this rate (HR; 95% CI: 1.19; 0.94–1.50), particularly in children with asymptomatic Giardia infection at baseline (2.03; 1.24–3.32). Zinc also protected against episodes of fever without localizing signs (0.75; 0.57–0.96), but we found no evidence that it reduced the overall number of clinic visits.

Conclusions

We found no evidence that the efficacy of zinc supplements in reducing diarrhea rates is enhanced by concurrent supplementation with other micronutrients. By reducing rates of fever without localizing signs, supplementation with zinc may reduce inappropriate drug use with anti-malarial medications and antibiotics.

Trial Registration

ClinicalTrials.gov NCT00623857

[Treatment of haemangiomas of infancy with propranolol; good results, few side effects]

Infantile haemangiomas (IH) are the most commonly occurring benign tumours of infancy, which may lead to considerable morbidity, such as amblyopia, ulceration and airway obstruction, depending on localization. Until recently, treatment was difficult: high-dose systemic glucocorticoids had limited effect and serious side effects. In 2008, the effectiveness of the beta-blocker propranolol for infantile haemangiomas was discovered; by now there is extensive worldwide experience. Data from the literature and from our own patient cohort (n = 132) confirm the remarkable efficacy of propranolol in complicated IH, without significant adverse effects. Propranolol is most effective in the proliferation phase of IH in children under 6 months of age. Timely referral of patients with potentially function-threatening or life-changing IH to a specialised multidisciplinary centre is therefore essential. Pending controlled studies, propranolol appears to have become the first choice treatment in complicated IH.