Measuring Outcomes of Facial Skin Cancer Surgery Using the FACE-Q Skin Cancer Module

Abstract

Background:

Facial skin cancer and surgical removal can alter appearance, contributing to patient morbidity through effects on self-perception and psychosocial well-being. This study aimed to assess the impact of surgical intervention on appearance and health-related quality of life before and after surgery.

Methods:

A single-center, prospective cohort study of 108 participants undergoing facial skin cancer surgery was conducted between November 2021 and December 2023. Participants completed the FACE-Q Skin Cancer questionnaire preoperatively up to 12 months postoperatively. Statistical significance was defined as P < 0.05.

Results:

A total of 105 participants completed the preoperative questionnaires, with 101, 96, 93, and 76 completing questionnaires at 1, 3, 6, and 12 months postoperatively. Postoperatively, participants were more satisfied with their facial appearance and reported improvements in appearance-related distress. Significant improvements (P < 0.001) were shown in cancer worry, appraisal of scars, sun protection behaviors, and adverse effects. Younger age (<65 y) was a significant predictor of worse outcomes across all domains. Participants with melanoma and those managed with reconstructive repair were associated with lower satisfaction and greater appearance-related distress. Women were more satisfied with their facial appearance, although they rated their scars less favorably. Nonmelanoma skin cancers were predictive of increased cancer worry.

Conclusions:

Facial skin cancer surgery improves health-related quality of life, appearance factors, and sun protection behaviors. Younger participants, and those with melanoma or managed with a component of reconstructive repair, may benefit from targeted perioperative support alongside interdisciplinary care. Further clinical integration of the FACE-Q Skin Cancer module will assist in providing individualized patient care.

Takeaways

Question: How does facial skin cancer and its procedural treatment impact patients?

Findings: This single-center prospective cohort study showed improvements in FACE-Q scores over time with significance (P < 0.001) in cancer worry, appraisal of scars, sun protection behaviors, and adverse effects. Younger age (<65 y) was a significant predictor of worse outcomes in all domains. Participants with melanoma and those managed with reconstructive repair were less satisfied and reported more distress.

Meaning: Younger participants, and those with melanoma or managed with a component of reconstructive repair, experience a greater impact from skin cancer procedures. This could inform perioperative care.

INTRODUCTION

Skin cancers are the most common malignancies globally¹ and are broadly categorized into melanomas and nonmelanoma skin cancers (NMSCs).² NMSCs mainly consist of basal cell carcinomas and squamous cell carcinomas.^2,3 These carcinomas are principally diagnosed in skin areas exposed to high levels of ultraviolet radiation and influenced by occupational exposure.^2–4 They have a high prevalence of lesions found on the face, head, and neck.^5–8 The incidence of both melanoma and NMSCs is increasing, with approximately 1.23 million NMSCs, excluding basal cell carcinomas, and more than 331,000 melanomas diagnosed in 2022 globally.¹ Although mortality rates for skin cancers are relatively low,² facial skin cancers have significantly higher morbidity than lesions in other locations due to their anatomical position and impact on facial cosmesis.^9–12

Complete surgical resection is the primary management for most skin cancers through excisional removal with histologically clear margins. Both facial tumors and excisional surgery can result in prominent scarring, impacting aesthetic appearance.^13,14 This alteration to facial cosmesis can affect self-perception, cancer worry, and psychosocial well-being.^15–21 The tailoring of information for patients regarding surgical outcomes occurs during the preoperative consultation. The approach used at this point influences patients’ expectations of surgical outcomes, decisions, and the treatment plan. Pusic et al²² showed that capturing patient-reported outcomes in plastic surgery is fundamental to accurately understanding patient morbidity and helps refine management to improve surgical outcomes. This study explored appearance, health-related quality of life (QoL) factors, and psychosocial well-being in patients with facial skin cancer and the impact of surgical intervention over time, using the FACE-Q Skin Cancer patient-reported outcome measure (PROM). Furthermore, this study investigated the impact of patient age, sex, cancer type, and surgical repair on outcomes to provide future directions for individualized patient-centered perioperative support, particularly in patients at higher risk of worse outcomes.

METHODS

This prospective single-center cohort study recruited participants aged 18 years or older who received exclusively surgical management for confirmed skin cancers of the face, head, and neck. Participants managed by the Southern Adelaide Local Health Network Plastic and Reconstructive Surgery Unit in Adelaide, South Australia, Australia, between November 2021 and June 2023 were invited. Participants were asked to complete the FACE-Q Facial Skin Cancer module (copyright 2016, Memorial Sloan Kettering Cancer Center) questionnaire preoperatively and at 1, 3, 6, and 12 months postoperatively. Those aged younger than 18 years, unable to speak sufficient English, diagnosed with cognitive impairments, who had lesions not on the head or were neck, or were receiving adjuvant treatments were excluded to minimize confounding factors.

Participant demographic and surgical characteristics, including sex, age, cancer type, location of cancer, and type of surgical repair, as well as previous facial skin cancer history, were collected from medical records and through a study-specific questionnaire. Participants were followed up by a maximum of 2 phone calls at each timepoint. Missing data were handled according to FACE-Q regulations before analysis.

Patient-reported Outcome Measure

The FACE-Q Skin Cancer module is a psychometrically validated PROM that consists of 5 scales and 2 checklists.^23–26 The 5 scales cover 3 domains: appearance, health-related QoL, and experience of care.^23–26 The 2 checklists measure sun protection behaviors and adverse effects following skin cancer treatment. Mean Rasch-transformed scores (0–100) were calculated for all scales, whereas cumulative total scores were reported for the 2 checklists. For example, the adverse effects checklist provides a total score for the number of adverse symptoms experienced following surgery: pain, discomfort, sensitivity, numbness, tingling, tightness, itchiness, swelling, bruising, and difficulty with certain facial movements.

Statistical Analysis

A power calculation was performed a priori to ascertain the number of participants. The distribution of participant demographics and surgical factors was assessed using descriptive statistics and graphical measures in IBM SPSS statistical software v29.0.1.0 (IBM, Armonk, NY). Statistical significance was defined as a P value of less than 0.05. Linear mixed models were used to calculate the significance of changes in FACE-Q scores between preoperative and postoperative timepoints, where the dependent variable was the FACE-Q score and time was the fixed effect. In all FACE-Q domains, a change score was calculated, with a higher score representing a larger improvement from baseline. A 1-way analysis of variance was used to compare mean FACE-Q scores between participant demographic and surgical factors: age, sex, cancer type, and surgical type. Multiple linear regression was used to assess whether any collected variables were predictive of the change in FACE-Q scores from baseline to 12 months after surgery.

RESULTS

Of 326 people identified, 161 met inclusion criteria and were invited to participate, 108 consented, and 105 (97.2%) successfully completed questionnaires at baseline (see Fig. 1). Of this cohort, 101 (93.5%) returned completed questionnaires at 1 month, 96 (88.9%) at 3 months, 93 (86.1%) at 6 months, and 76 (70.4%) at 12 months postoperatively. The attrition rate at 12 months was 27.6%.

Fig. 1.

Scope flow diagram outlining participant cohort.

Participant and surgical characteristics are presented in Table 1. Most participants had lesions located centrally on the face (55.6%), 28 participants had peripheral locations, and the remaining had a combination of both. Out of the 142 lesions, the nose (50, 35.2%) was the most common location, with double the number of lesions compared with any other region; reconstructive closure consisting of a full-thickness skin graft or a local flap was the most common repair type (61.1%) (see Table 1).

Table 1.

Participant Demographic and Surgical Characteristics (n = 108)

Variable	Value (%)
Total consented participant cohort	108
Sex
Male	72 (66.7)
Female	36 (33.3)
Age preoperatively, y
Mean ± SD	68.5 ± 11.7
Median (range)	70 (40 to 94)
Age group, y
≤49	8 (7.4)
50–59	17 (15.7)
60–69	28 (25.9)
70–79	33 (30.6)
80–89	20 (18.5)
90–99	2 (1.9)
Age groups
<65	39 (36)
≥65	69 (64)
Previous skin cancer
Yes	49 (45.4)
No	40 (37.0)
Unknown	19 (17.6)
Cancer type per participant
BCC	74 (68.5)
SCC	20 (18.5)
Melanoma	7 (6.5)
Combination of NMSC	6 (5.6)
Combination of SCC and melanoma	1 (0.9)
Cancer location
Scalp	8 (5.6)
Forehead	11 (7.8)
Eyelid and canthal	12 (8.5)
Ear	12 (8.5)
Nose	50 (35.2)
Cheek	19 (13.4)
Lip	7 (4.9)
Mandible	1 (0.7)
Neck	2 (1.4)
Preauricular	8 (5.6)
Postauricular	3 (2.1)
Temple	5 (3.5)
Eyebrow	4 (2.8)
Cancer location condensed
Central	60 (55.6)
Peripheral	28 (25.9)
Combination	20 (18.5)
Surgical repair type
Primary closure	33 (30.6)
Reconstructive closure	66 (61.1)
Combination	9 (8.3)
No. lesions
Total	142
Mean ± SD	1.5 ± 0.9
Lesions per patient
1	85 (78.7)
2	18 (16.7)
3	4 (3.7)
10	1 (0.9)
Withdrawn participants	5 (4.6)
Sex
Male	4 (80.0)
Female	1 (20.0)
Age preoperatively, y
Mean ± SD	79.6 ± 6.5
Median (range)	83 (68 to 86)

Values are numbers (percentages) unless stated otherwise.

BCCs, basal cell carcinomas; SCCs, squamous cell carcinomas.

The mean domain scores and their change scores for each FACE-Q domain are shown in Tables 2 and 3, respectively. Figures 2–5 depict the trends and changes in FACE-Q scores over time. Participants were generally more satisfied with their appearance after surgery and experienced a gradual improvement in appearance-related distress. They also reported significant improvement in worrying about cancer and concern about scars in the months following procedures. (See figure, Supplemental Digital Content 1, which displays mean FACE-Q scores for cancer worry and appearance-related distress by age group preoperatively and 12 months postoperatively, https://links.lww.com/PRSGO/E565.)

Table 2.

Summary of Mean (SD) FACE-Q Skin Cancer Scores in All Participants Over Time

FACE-Q Domain	Preoperative	Postoperative
		1 mo	3 mo	6 mo	12 mo
	(n = 105)	(n = 100)	(n = 96)	(n = 93)	(n = 76)
Appearance
Satisfaction with facial appearance	68.8 (23.1)	70.5 (23.6)	74.2 (23.7)	77.6 (25.1)	75.6 (23.8)
Appraisal of scars*	—	78.2 (23.8)	86.1 (18.9)	87.5 (18.5)	87.9 (17.0)
Health-related QoL
Appearance-related distress	34.7 (20.7)	31.1 (22.1)	25.6 (22.9)	21.5 (24.4)	28.2 (24.7)
Cancer worry	46.9 (19.8)	38.9 (21.1)	36.5 (23.7)	33.8 (21.9)	34.5 (23.4)
Experience of care
Satisfaction with information*	—	76.2 (24.1)	77.1 (25.4)	79.9 (23.0)	80.1 (25.6)
Checklists
Sun protection behaviors	14.2 (3.0)	15.1 (3.0)	15.2 (2.8)	15.6 (2.8)	15.5 (2.8)
Adverse effects*	—	16.1 (5.1)	14.2 (4.3)	13.4 (4.2)	12.5 (3.9)

^*Scale/checklist only included in postoperative questionnaires.

Table 3.

Mean Change Scores (95% Confidence Interval) of All FACE-Q Skin Cancer Module Domains Over Time

FACE-Q Domain	Baseline to 1-mo Postoperative	Baseline to 3-mo Postoperative	Baseline to 6-mo Postoperative	Baseline to 12-mo Postoperative
Appearance
Satisfaction with facial appearance	1.7 (−4.8 to 8.2)	5.4 (−1.3 to 12.0)	8.8 (2.1 to 15.5)*	6.8 (−0.2 to 13.9)
Appraisal of scars†	—	7.9 (2.3–13.5)‡	9.3 (3.6–14.9)‡	9.6 (3.7–15.6)‡
Health-related QoL
Appearance-related distress	−3.6 (−9.9 to 2.7)	−9.1 (−15.4 to −2.7)‡	−13.3 (−19.7 to −6.8)‡	−6.6 (−13.3 to 0.2)
Cancer worry	−8.0 (−14.0 to −2.0)‡	−10.4 (−16.5 to –4.4)‡	−13.1 (−19.2 to −7.0)‡	−12.4 (−18.9 to -5.9)‡
Experience of care
Satisfaction with information†	—	1.0 (−6.0 to 7.8)	3.7 (−3.2 to 10.6)	4.0 (−3.4 to 11.3)
Checklists
Sun protection behaviors	0.9 (0.1–1.7)*	1.0 (0.2–1.8)*	1.4 (0.5–2.2)‡	1.3 (0.4–2.1)‡
Adverse effects†	—	−1.9 (−3.1 to −0.7)*	−2.6 (−3.8 to −1.4)‡	−3.5 (−4.7 to −2.2)‡

^*Differences between baseline and postoperative scores were significant at the P < 0.05 level.

^†Scale/checklist only collected postoperatively (1-month data used as comparison instead of baseline).

^‡Differences between baseline and postoperative scores were significant at the P < 0.001 level.

Fig. 2.

Mean FACE-Q scores for satisfaction with facial appearance, appearance-related distress, and cancer worry. For cancer worry and appearance-related distress scales, a lower score indicates a better outcome. ** Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.001. * Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.05.

Fig. 5.

Mean FACE-Q scores for the adverse effects checklist. The adverse effects checklist was scored on a 4-point Likert scale for 10 adverse effects experienced in the week leading up to the completion of the questionnaire, resulting in a score range of 10–40. This included pain, discomfort, sensitivity when touching the area, numbness, tingling, tightness, itchiness, swelling, bruising, and difficulty with facial movements. ** Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.001. * Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.05.

Fig. 3.

Mean FACE-Q scores for appraisal of scars and satisfaction with information. ** Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.001.

Fig. 4.

Mean FACE-Q scores for the sun protection behaviors checklist. The sun protection behaviors checklist consisted of 5 questions and was scored on a 4-point Likert scale, resulting in a score of 5–20. These questions included whether one was careful not to get too much sun, wore sunscreen when outside, stayed in shady areas outdoors, wore a hat in sunny weather, and wore clothing to cover skin in sunny weather. ** Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.001. * Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.05.

Participants improved their sun protection behaviors, using 71% at baseline to 78% at 12 months postoperatively. A statistically significant reduction in symptoms related to skin cancer surgery (adverse effects checklist) was seen over time between 1 month postoperatively and all other timepoints (see Fig. 5).

Participant Characteristics and Surgical Factors

Participant sex and age, cancer and surgical repair type, and their influence on 12-month postoperative FACE-Q scores are shown in Figures 6–9 and Supplemental Digital Contents 2–6. (See table, Supplemental Digital Content 2, which displays comparison between FACE-Q Skin Cancer scores by demographic and surgical factors preoperatively and at 12 months postoperatively, https://links.lww.com/PRSGO/E566.) (See table, Supplemental Digital Content 3, which displays comparison between FACE-Q Skin Cancer scores by demographic and surgical factors 1 month postoperatively and at 12 months postoperatively, https://links.lww.com/PRSGO/E567.) (See table, Supplemental Digital Content 4, which displays descriptive statistics of each surgical repair type, https://links.lww.com/PRSGO/E568.) (See table, Supplemental Digital Content 5, which displays participant demographic and surgical characteristics for patients who responded at 12 months postoperatively [n = 76], https://links.lww.com/PRSGO/E569.) (See table, Supplemental Digital Content 6, which displays participant demographics of nonresponders following Q1 [preoperative questionnaire, n = 29], https://links.lww.com/PRSGO/E570.)

Fig. 6.

Mean FACE-Q score in comparison to sex at 12 months postoperatively. The orange line represents the mean FACE-Q score within the respective scale and checklist for all participants. Error bars indicate 95% confidence intervals. For cancer worry and appearance-related distress scales, a lower score indicates a better outcome.

Fig. 9.

Mean FACE-Q score in comparison to the type of surgical repair at 12 months postoperatively. The orange line represents the mean FACE-Q score within the respective scale and checklist for all participants. Error bars indicate 95% confidence intervals. For cancer worry and appearance-related distress scales, a lower score indicates a better outcome. "Both" means that participants underwent a combination of primary and reconstructive repair. * Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.05.

In comparison to men, women had a strong association with reporting fewer postoperative symptoms. Women were generally more satisfied with their facial appearance and reported a larger improvement in appearance-related distress from preoperative to postoperative than men. They were more critical of their surgical scars and less satisfied with preoperative information than men (Fig. 6). Furthermore, women tended to be better at sun protection over the course of the study (Supplemental Digital Content 2, https://links.lww.com/PRSGO/E566). In comparison to older participants (≥65 y), younger participants tended to worry significantly more about cancer and reported more symptoms; they also reported a higher level of appearance-related distress and were more critical of their scars (see Fig. 7).

Fig. 7.

Mean FACE-Q score in comparison to age at 12 months postoperatively. The orange line represents the mean FACE-Q score within the respective scale and checklist for all participants. Error bars indicate 95% confidence intervals. For cancer worry and appearance-related distress scales, a lower score indicates a better outcome. * Denotes that differences between baseline and postoperative scores were significant at a P value less than 0.05.

Participants with melanoma experienced less satisfaction with facial appearance, rated their scars lower, and reported more appearance-related distress than those with NMSCs (see Fig. 8). Levels of worry about cancer varied widely, but overall, those with melanoma demonstrated a higher level of worry preoperatively and a lower level of worry postoperatively than those with NMSCs (Supplemental Digital Content 2, https://links.lww.com/PRSGO/E566). A combination of primary and reconstructive repair for participants with more than 1 facial cancer lesion was associated with the lowest satisfaction and the greatest distress related to facial appearance at 12 months (see Fig. 9).

Fig. 8.

Mean FACE-Q score in comparison to cancer type at 12 months postoperatively. The orange line represents the mean FACE-Q score within the respective scale and checklist for all participants. Error bars indicate 95% confidence intervals. For cancer worry and appearance-related distress scales, a lower score indicates a better outcome.

Predictors of FACE-Q Scores

Predictive factors for FACE-Q scores are shown in Table 4. Age was found to be a significant predictor for all scales and checklists. The type of surgical repair was a significant predictor of how satisfied the patient was about appearance and the level of distress, whereas the number of cancers and the cancer type were strong predictors of cancer worry and symptoms. Sun protection behaviors were more likely to be adopted by women and by those who underwent complex surgical repairs.

Table 4.

Multiple Linear Regression Models for FACE-Q Scales

Variable	Coefficient (β)	Standard Error	95% Confidence Interval	P
Cancer worry
Intercept	68.413	16.034	36.905 to 99.922	<0.001
Age	−0.600	0.087	−0.763 to −0.175	0.002
Sex	2.202	2.122	−1.566 to 6.939	0.215
Previous skin cancer	1.717	1.068	−0.546 to 3.745	0.144
No. cancers	3.727	1.189	0.972 to 5.789	0.006
Cancer type	−7.981	1.226	−15.064 to –0.898	0.027
Surgical repair type	−0.329	1.692	−3.654 to 2.996	0.846
Appearance-related distress
Intercept	46.764	16.895	13.563 to 79.966	0.006
Age	−0.334	3.717	−0.645 to –0.022	0.036
Sex	−3.277	2.280	−7.758 to 1.204	0.151
Previous skin cancer	−0.163	1.152	−2.426 to 2.101	0.888
No. cancers	2.804	1.289	0.271 to 5.338	0.030
Cancer type	−7.175	3.832	−14.706 to 0.355	0.062
Surgical repair type	4.045	1.780	0.547 to 7.543	0.024
Satisfaction with facial appearance
Intercept	51.256	18.039	15.807 to 86.705	0.005
Age	0.471	0.168	0.140 to 0.802	0.005
Sex	−1.655	2.432	−6.435 to 3.125	0.497
Previous skin cancer	0.035	1.229	−2.379 to 2.449	0.977
No. cancers	−1.987	1.380	−4.698 to 0.724	0.150
Cancer type	2.111	4.059	−5.866 to 10.088	0.603
Surgical repair type	−4.424	1.903	−8.164 to –0.684	0.021
Sun protection behaviors checklist
Intercept	21.748	2.209	17.408 to 26.088	<0.001
Age	−0.043	0.021	−0.083 to –0.002	0.039
Sex	−0.751	0.296	−1.332 to –0.169	0.012
Previous skin cancer	−0.044	0.150	−0.338 to 0.250	0.770
No. cancers	0.147	0.167	−0.182 to 0.476	0.379
Cancer type	−0.121	0.504	−1.112 to 0.870	0.810
Surgical repair type	−0.566	0.231	−1.021 to –0.112	0.015
Appraisal of scars
Intercept	39.300	16.684	6.489 to 72.112	0.019
Age	0.598	0.156	0.292 to 0.904	<0.001
Sex	2.677	2.245	−1.738 to 7.091	0.234
Previous skin cancer	0.342	1.132	−1.885 to 2.569	0.763
No. cancers	0.747	1.749	−1.745 to 3.239	0.472
Cancer type	0.129	3.712	−7.170 to 7.429	0.972
Surgical repair type	−1.258	1.749	−4.698 to 2.181	0.472
Satisfaction with information: appearance
Intercept	51.995	21.022	10.653 to 93.337	0.014
Age	0.577	0.195	0.194 to 0.960	0.003
Sex	−2.788	2.802	−8.298 to 2.722	0.320
Previous skin cancer	−1.165	1.419	−3.956 to 1.626	0.412
No. cancers	1.243	1.584	−1.872 to 4.359	0.433
Cancer type	−3.255	4.721	−12.540 to 6.029	0.491
Surgical repair type	−1.599	2.186	−5.897 to 2.699	0.465
Adverse effects checklist
Intercept	21.299	3.793	13.840 to 28.757	<0.001
Age	−0.121	0.035	−0.190 to –0.052	<0.001
Sex	0.949	0.505	−0.045 to 1.943	0.061
Previous skin cancer	−0.103	0.256	−0.606 to 0.399	0.687
No. cancers	0.642	0.286	0.080 to 1.204	0.025
Cancer type	−0.293	0.850	−1.965 to 1.378	0.730
Surgical repair type	−0.421	0.395	−1.197 to 0.355	0.287

DISCUSSION

This prospective cohort study reports the first medium-term postoperative outcome data relating to QoL, appearance satisfaction, and experience of care in the Australian health care setting using the FACE-Q Skin Cancer module for patients undergoing surgery for facial skin cancer. Overall, all FACE-Q scales and checklists were found to improve between baseline and the postoperative timepoints. This indicated that, collectively, all patients receiving surgical treatment for facial skin cancers were more satisfied with their facial appearance, experienced decreased psychosocial distress associated with both their cancer and appearance, and were more engaged in sun protection behaviors. Postoperatively, this study showed that over time, the number of surgery-related symptoms experienced by patients decreased, and there was a high level of overall satisfaction with the information provided by the treating surgical team about the patient’s expected appearance changes. Additionally, from the time of treatment, patients were less bothered by their scars throughout the 12-month postoperative period.

Our findings have demonstrated that facial skin cancer patients experience less worry after their cancer treatment, consistent with existing findings described by Van Hensbergen et al.¹⁹ However, participants still reported some level of cancer worry 12 months after surgery. This is consistent with long-term outcomes reported by Nierich et al,²⁷ who demonstrated that cancer worry and psychosocial distress remain higher compared with short-term reports.²⁷ In contrast to the findings of both Van Hensbergen et al¹⁹ and Nierich et al,^19,27 this study showed that younger patients reported significantly more cancer worry than older patients. The study by van Hensbergen et al¹⁹ proposed that a baseline level of cancer worry, even postoperatively, may be beneficial to patients for improving preventative measures.¹⁹ In contrast, our data showed no significant change in sun protection behaviors between younger and older patients, indicating that although the younger cohort of patients reported more oncological concern, they were not significantly more proactive in performing preventative measures.

It is expected that increased levels of worry about cancer would be present in patients with melanoma, due to its natural history and association with poorer prognosis.²⁸ This was observed in our study with high preoperative worry and a large variance in persistent cancer worry at 12 months postoperatively. Additionally, with NMSC and the number of cancers being strong predictors of cancer worry, this highlights that although prognosis and disease progression are significantly better in NMSC, a high burden of worry around cancer still persists in this cohort. A contributing factor may include the presentation of lesions in multiples, as evidenced in this study, with a mean of 1.5 lesions per patient and 94% being NMSCs. Furthermore, there is an increased risk of developing subsequent NMSCs following an initial lesion, potentially inducing cancer recurrence worry. This further supports the proposed use of the FACE-Q outlined by Denadai and Araujo,²⁹ with appropriate perioperative oncological outcome counseling by the treating surgeon and engagement in interdisciplinary communication between plastic surgeons and oncological psychologists. Using FACE-Q score facilitates shared decision-making and support, particularly for patients who fall into high-risk subgroups for poorer outcomes.

Patient distress is influenced by both oncological worry and appearance-related changes.^24,30 Lee et al²⁴ found that facial skin cancer patients most commonly reported worry about having a noticeable scar that would impact their self-perception and confidence to engage in social events and attend professional commitments.⁴ This is supported by the study by Veldhuizen et al³¹ with a notable increase in appearance-related distress reported at 1 month postresection. Other studies in patients with facial skin malignancies have shown an association between female sex and decreased appearance-related QoL, with subsequently higher levels of psychosocial distress with facial skin cancer compared with men.^11,16,27,32 In contrast, in our study, distress levels were higher in women preoperatively but were equivalent to those of men at 12 months postoperatively. All participants in our study still exhibited a level of distress at 12 months, which was higher than that reported at 6 months (P < 0.001). Although our study demonstrates significant improvement in patients’ appraisal of scars at 12 months, this delayed rise in distress levels is attributed to the persistence of noticeable scars and adverse symptoms, in addition to operations for incomplete excisions. As Vaidya et al¹⁶ found, younger individuals experienced increased psychosocial distress following surgery.¹⁸ This may be attributed to increased criticisms or pressures within social and professional environments, resulting in higher expectations of their appearance. In addition, social media, artificial intelligence, and Photoshop platforms further add to the societal constructs of facial aesthetics, particularly with the development of conditions such as “Snapchat dysmorphia,” which is becoming prevalent in society, as seen in a study of people aged 18–55 years by Chen et al.^33–35

For patients who are referred for reconstructive or combination repair with either a skin graft or local flap for their lesion(s), these procedures routinely result in larger defects, prolonged postoperative healing, and poorer cosmetic outcomes due to greater tissue movement.¹⁶ The findings by Helmy Ali et al³⁶ support this with a 6% complication rate with reconstructive repairs compared with 3.7% with direct closure. Reconstructive repair is a significant predictor of postoperative distress, as we have demonstrated. The findings by Vaidya et al¹⁶ and Rhee³⁰ show larger defects,¹⁶ paramedian forehead flaps,¹⁶ and patients who required extensive reconstructions reported worse outcomes.³²

It is well documented with meta-analysis–level evidence,³⁷ that there is an increased risk of developing subsequent NMSCs following an initial lesion.³⁷ This significant recurrence risk supports the importance of counseling about preventative measures to aid in minimizing the physical, psychosocial, and health system impacts of facial skin cancers. Primarily, this involves reducing exposure to ultraviolet radiation through sun protection behaviors, which additionally aids in reducing wound healing complications and hyperpigmentation of scars.³⁷ We observed a significant improvement in the number of sun protection behaviors following resection with 7% more preventative measures used regularly. Multiple studies^38–41 have shown similar, elevated sun protection actions in patients post–skin cancer treatment to support these findings, with Veldhuizen et al³⁸ reporting a similar 5% increase in behaviors at 3 months. Although improvements were observed, the consideration of Australia’s skin cancer age-standardized rates,¹ the elevated recurrence risk,³⁷ and the fact that 22% of potential behaviors were still not being used highlights a key aspect of perioperative care that needs to be improved through patient education.

Physical appearance plays a significant role in a patient’s perioperative experience of facial skin cancer resection. The disfigurement and scarring, which can be associated with both facial skin cancers and surgical management, impact physical appearance and can significantly influence a patient’s perspective on the level of care they have received.¹⁴ However, we have shown that surgical removal does significantly improve satisfaction with facial appearance. Previous studies by Blank et al¹⁵ and Vaidya et al¹⁶ have shown that younger patients¹⁶ and women^15,16 are more likely to have lower postoperative satisfaction with appearance and appraisal of scars. However, in our study, only younger participants were significantly more bothered by their scars following surgery, compared with older participants. Furthermore, age was found to be a significant predictor of negative outcomes across all FACE-Q scales and checklists. It has been suggested that the older population has more prominent, relaxed skin tension lines, amenable to primary closure, resulting in better cosmetic outcomes that may contribute to the difference in scar bother observed in our study.^16,19,30 Although scarring may improve over time, Nierich et al²⁷ demonstrated that long-term patient satisfaction with scars is comparable to short-term reports. The disparity in satisfaction of younger participants, combined with significantly lower reported satisfaction with information scores in this demographic, highlights the need for more targeted perioperative practices regarding postoperative expectations.

The outcomes of this study provide plastic surgeons and other specialists treating facial skin cancers with an understanding of the factors contributing to patient outcomes. These results may help to refine perioperative treatment approaches to improve health-related QoL, appearance, and experience of care outcomes. Through incorporating the FACE-Q Skin Cancer module into clinical practice, clinicians are able to capture patient-reported information from specific demographic populations and tailor their patient-centered care and education accordingly. With the addition of recent, large-scale evidence by Veldhuizen et al⁴² providing valuable minimal important difference values for FACE-Q scales, accurate application into clinical care is only going to increase. This would be especially beneficial for younger patients with demographic and surgical characteristics at a higher risk of negative outcomes. Adjusting individual patient expectations through addressing psychosocial and appearance-related concerns preoperatively will enable a refinement in patient choices with regard to treatment timing, repair type, and engagement with ongoing postoperative services. The goal is to improve the informed consent process, efficiency, and quality of care in facial skin cancer treatment collectively. Widespread, routine clinical integration of this PROM may be possible with the development of a refined FACE-Q Skin Cancer module that maintains precision yet significantly reduces the assessment length, as proposed by Ottenhof et al.⁴³ This would allow in-depth patient outcomes to be obtained and considered by the treating team without compromising valuable, limited clinical time practitioners experience in the healthcare setting.

The strengths of this study include having a high response rate in a large prospective participant cohort. Additionally, this study incorporates all FACE-Q Skin Cancer module scales and checklists. Potential limitations are that all participants were treated at a single hospital network, postoperative data were limited to 12 months, and there were significantly more male nonresponders at 12 months. We acknowledge a 27.6% attrition rate; however, existing literature by Asch et al⁴⁴ demonstrates this as the above appropriate mean response rates. The results of this study may therefore reflect the protocols, treating surgeons, and quality of care delivered. Therefore, the findings may not represent treatment undertaken outside of the public hospital setting by dermatologists, private plastic surgeons, or general practitioners who were not included. Additionally, the small sample of participants with melanomas led to wider data variability and may therefore limit the generalizability of these findings to the wider population with melanomas.

CONCLUSIONS

Facial skin cancer resection can significantly improve patient-reported health-related QoL and appearance perception. Characteristics including age, type of cancer, and surgical repair were shown to impact distress pertaining to a patient’s cancer diagnosis and changes in appearance. Younger patients, those presenting with melanoma, or those requiring a reconstructive component in the management of their skin cancer reported the poorest outcomes. These subgroups may benefit from more tailored preoperative counseling and postoperative support by treating surgeons with consideration of interdisciplinary inputs to increase patient education, set expectations, reduce psychosocial distress, and enhance the patient experience. Furthermore, increased education on preventative sun protection measures is recommended in both the preoperative and postoperative period.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ETHICAL APPROVAL

All procedures were performed in compliance with relevant laws and institutional guidelines and have been approved by the Southern Adelaide Clinical Human Research Ethics Committee (approval number 173.21).

Supplementary Material

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