Cross‐cultural adaptation and psychometric validation of the Patient Scar Assessment Questionnaire to the Spanish language in head and neck surgery

Abstract

External appearance is the main aesthetic outcome in patients who undergo surgical procedures. Scars located in exposed areas, such as the neck and face, are important for patients. There are at least eight instruments that are used to evaluate postoperative scars, but few fulfil standard methodological conditions. The Patient Scar Assessment Questionnaire (PSAQ) was designed and validated using psychometric methodology. However, this scale has not been translated or validated in the Spanish language. The aim of this study was to undergo a cross‐cultural adaptation and psychometric validation of the PSAQ scale to the Spanish language in patients who underwent head and neck surgery. We followed The Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for the translation and validation of health‐related scales. Forward and back translations were made by independent translators. We included adult patients who underwent thyroidectomy, parathyroidectomy, parotidectomy, and neck dissection. For the psychometric validation, we used a principal axis exploratory factor analysis with oblimin rotation. A reliability test involving Cronbachs alpha and the item‐total correlation was performed and for the convergent/concurrent validity, we selected the Spanish version of the Vancouver Scar Scale. A total of 180 patients were recruited. Factor analysis showed a five‐factor solution. Cronbachs alpha for the subscales was >0.7. The comparison between the PSAQ appearance subscale and the VSS demonstrated a high correlation (rho = − 0.89). In a sample of 62 patients, the test‐retest evaluation showed high correlation (0.74‐0.99). Our study supports the Spanish version of the PSAQ as a valid, reliable, and reproducible tool to assess the perception and impact of neck scars in Spanish‐speaking patients who undergo head and neck surgery.

1. INTRODUCTION

A scar is one of the sequelae of all surgical procedures and represents the process of tissue damage and repair that occurs when a surgeon performs any procedure on an organ. External appearance is the main aesthetic outcome in patients who undergo surgical procedures, and it is one of the main factors in considering whether a surgery is successful. Depending on the anatomical site of the scar, the scar can affect quality of life (QOL). It is clear that scars located in exposed areas, such as the neck and face, are more important for patients than scars located in occult sites.1, 2, 3

Some research has demonstrated that the results of physician evaluations of patient scars are very subjective and are not correlated with patient perception or the impact of scar appearance on QOL.4 Not only do scars have aesthetic consequences but they can also produce unexpected symptoms and functional impairments and can affect social activities and self‐confidence.5, 6 These findings have forced the development of specific instruments to assess postoperative scar impacts from the viewpoint of the patient.7 To date, there are at least eight instruments that are used to objectively evaluate postoperative scars, but few of these instruments fulfil standard methodological conditions.3, 8

In 2009, Durani et al7 developed the Patient Scar Assessment Questionnaire (PSAQ) using validated psychometric methodology. The PSAQ has five subscales (appearance, symptoms, consciousness, satisfaction with appearance, and satisfaction with symptoms) and 39 questions with four answer choices that range from very favourable to very unfavourable. The PSAQ has demonstrated high internal consistency and stability. However, this scale has not been translated or validated in the Spanish language.

In the field of head and neck surgery, scars have always been of particular interest, and this interest has increased in recent decades, represented by the development of distant approaches for thyroidectomy,9 neck dissection,10 and salivary gland surgery11 that attempt to reduce the size and visibility of scars. Some previous studies have specifically evaluated the impact of scars in patients after thyroidectomy, examining the effective impact of these new and different approaches on patients' perceptions.4, 12, 13 As scar evaluation is becoming more important in order to justify surgical decisions, with consequences in terms of operative times, resources, and complications, a validated instrument is necessary in order to assess the effect of scars on patient QOL.

The aim of this study was to undergo a translation and cultural adaptation of the PSAQ scale to the Spanish language and to validate its psychometric properties in a cohort of patients who underwent head and neck surgery.

2. MATERIALS AND METHODS

This study utilised a descriptive and prospective cross‐sectional design to validate the PSAQ instrument in patients undergoing head and neck surgery. This study was approved by the Ethics in Research Committee of the Fundacion Colombiana de Cancerologia‐ Clinica Vida. Informed consent was obtained for the inclusion of the patients in the study.

The author was contacted to receive authorisation for use of the instrument, and the original version of the PSAQ was obtained from Durani et al.7 This instrument has 39 questions and five subscales (appearance, symptoms, consciousness, satisfaction with appearance, and satisfaction with symptoms) that score patient perceptions on a scale of 1 to 4 points (with 1 point assigned to the most favourable category and 4 points assigned to the least favourable category). Each subscale also contains a single global assessment item used to provide a clinically meaningful descriptor for the summary score generated. Higher scores indicate a worse cosmetic outcome. In their analysis, Durani et al7 decided to exclude symptom subscales because of low reliability, so we followed the same directive. We also excluded the single global assessment item of each subscale. Finally, 4 subscales and 28 items were evaluated. The final score of each subscale was calculated by summing the scores for each question.

We followed The Professional Society for Health Economics and Outcomes Research (ISPOR) guidelines for the translation and validation of health‐related scales.14, 15, 16 Translation was performed by two native English translators. A consensus document was back‐translated by two native Spanish translators. The final document was compared with the original instrument and was evaluated by two native Spanish head and neck surgeons to detect differences from the original scale. A pilot test was performed with 10 patients to assess readability and the understanding of words and sentences.

In a second phase, we asked candidates to complete the Spanish‐validated versions of the PSAQ and the Vancouver Scar Scale (VSS).17 The interviewer presented the instrument personally to each patient. The inclusion criteria were as follows: adult patients who underwent elective head and neck surgery (thyroidectomy, parathyroidectomy, parotidectomy, and neck dissection) and where Spanish was the native language. Patients with physical impairments that prevented reading, hearing, or understanding the scale, those with adjuvant treatment with radiotherapy, and those who did not consent to participate were excluded. All patients were treated by the same surgical group. We also obtained demographic, comorbidity, ASA classification, surgical procedure, and wound complication data from the clinical charts. For the test‐retest analysis, randomly selected patients completed the PSAQ instrument for a second time 2 weeks after the first evaluation. The VSS assesses four characteristics: vascularity, height (thickness), pliability, and pigmentation with the use of a numerical score. The maximum score is 14, and a high score indicates a poor aesthetic scar result.

A sample size of 180 patients was calculated using the Bonnet formula18 with the following parameters: a type I error of 0.05, power of 80%, Cronbachs alpha estimate of 0.8, and a scale of 39 items. A test‐retest analysis was planned in a random subsample of 43 patients.

The categorical variables are presented as percentages and ranges, and the continuous variables are shown as the mean and SD. For the analysis, some continuous variables were categorised. For these analyses, we set the significance level to P < .05. We used Stata statistical software (StataCorp, Texas, Version 9.1) for the psychometric validation, and we used a principal axis exploratory factor analysis with oblimin rotation to identify the underlying dimensions as measures of construct validity and to provide evidence regarding whether the instrument reproduced the same factor‐loading pattern observed for the original English PSAQ.19 The assumptions of the determinant of the correlation matrix, Bartletts test of sphericity for intercorrelation, and the Kaiser‐Meyer‐Olkin measure of sampling adequacy for factor analysis were used. A reliability test involving Cronbachs alpha and the item‐total correlation was performed. Values higher than 0.70 were considered acceptable. For the convergent/concurrent validity, we selected the Spanish version of the Vancouver Scar Scale, and for the known‐group validity, we used the type of surgical procedure. The scores were compared using Spearmans correlation coefficients. For the test‐retest reliability, we used the Lin coefficient.

3. RESULTS

3.1. Population

A total of 180 patients were recruited. Demographic and clinical data are shown in Table 1. The mean age was 49 ± 15 years (range 20‐86 years). Most patients were female, 22.8% of the patients had undergone university studies, and 55% of the patients were classified as the low socioeconomic level. Furthermore, 86% of the patients reported at least one comorbidity, and 7.8% were classified as ASA 3. A total of 36.1% had scars for >3 months. The most frequent type of surgery was thyroidectomy (68.9%), and only 5.6% and 9.4% of the patients required reintervention or had a complication, respectively.

Table 1.

Demographic data of a cohort for validation of the Patient Scar Assessment Questionnaire (PSAQ) questionnaire

Characteristics	Number	%
Age	49 ± 15*	20‐86**
Sex (female)	144	80
Marital status
Married	79	43.9
Single	42	23.2
Divorced	10	5.6
Widow	18	10
Other	31	17.2
Education level
None	3	1.7
Primary school	52	28.9
High school	84	46.7
University	37	20.6
Postgraduate	4	2.2
Socioeconomic level
Low	100	55.6
Medium	71	39.4
High	9	5.1
Comorbidity (yes)	94	52.2
ASA score
1	105	58.3
2	61	33.9
3	14	7.8
Type of surgery
Thyroidectomy	124	68.89
Parathyroidectomy	3	1.67
Parotidectomy	7	3.89
Neck dissection	11	6.11
Thyroidectomy + lateral neck dissection	35	19.44
Drain use	80	44.4
Reoperation	10	5.56
Time from surgery (months)	31.7 ± 61*	0.4–459**
Wound complications
None	163	90.56
Seroma	9	5.00
Haematoma	2	1.11
Dehiscence	3	1.67
Other	3	1.67

Note: * mean ± standard deviation ** range.

3.2. Cross‐cultural adaptation

There was good agreement between the translated and the original English versions. The review required only minimal word changes. The pretest performed in 10 patients demonstrated good readability. The final version of the PSAQ questionnaire can be found in Appendix 1.

3.3. Item description

The mean scores for each subscale were as follows: appearance 14.8 ± 3.9 (median 14, range 9‐30), consciousness 11.2 ± 4.7 (10, 6‐24), satisfaction with symptoms 7.1 ± 2.95, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18 and satisfaction with appearance 12.8 ± 4.1 (13, 8‐29), Figure 1. The items with the worst qualifications3, 4 were width, length, noticeability, and looking at the scar. The best qualifications were in shininess, hiding the scar, and redness.

Figure 1.

Distribution of scores of the Patient Scar Assessment Questionnaire (PSAQ) per item

3.4. Construct validity

Factorial analysis was performed by replicating the methods of the original study. Principal components factor analysis showed a five‐factor solution using the Kaiser criterion (eigenvalue > 1). The five factors explained 67% of the variability, Table 2. The diagnostic test results were good (Kaiser‐Meyer‐Olkin value was 0.91, and Bartlett sphericity test yielded P < .001).

Table 2.

Factor analysis of items included in the Patient Scar Assessment Questionnaire (PSAQ) questionnaire

	Item	Factor 1	Factor 2	Factor 3	Factor 4	Factor 5
Appearance	1. Colour	0.6823	−0.0485	0.2664	0.1127	−0.1263
	2. Darkness	0.5520	−0.0799	0.3707	0.2395	−0.0994
	3. Redness	0.5885	0.2587	−0.0605	0.4885	0.2766
	4. Length	0.4673	0.1229	0.0357	−0.5986	0.2305
	5. Width	0.7103	−0.1076	−0.0283	−0.1166	−0.0930
	6. Flatness	0.6849	0.0815	0.0566	0.1897	0.1915
	7. Shininess	0.1856	−0.0177	−0.0051	−0.0250	0.8431
	8. Lumpiness	0.7110	0.0536	0.0654	0.1491	0.2745
	9. Texture	0.6344	0.0284	−0.0978	−0.2856	−0.1929
Scar consciousness	18. Noticeable for you	0.7056	−0.0272	0.4811	0.1305	−0.0225
	19. Noticeable for other	0.7193	0.0055	0.4729	0.2067	−0.0134
	20. Stare at your scar	0.6891	0.1026	0.4120	0.1567	0.1712
	21. Hide your scar	0.5978	0.2088	0.2570	−0.1305	0.1251
	22. Think about your scar	0.5084	0.2318	0.6177	−0.1476	−0.0293
	23. Look at your scar	0.5015	0.2110	0.6505	−0.1235	0.0142
Satisfaction with appearance	25. Satisfied with colour	0.8164	−0.0313	0.0881	0.0744	−0.1207
	26. Satisfied with redness	0.6186	0.2783	−0.1214	0.4261	0.2183
	27. Satisfied with length	0.7438	0.0169	−0.0414	−0.3682	0.1049
	28. Satisfied with width	0.8329	0.0346	−0.1677	−0.1611	0.0053
	29. Satisfied with height	0.8528	−0.0004	−0.1444	−0.0945	0.0148
	30. Satisfied with texture	0.8309	0.1811	−0.0818	−0.1521	−0.0874
	31. Satisfied with lumpiness	0.8704	0.0573	−0.1766	0.0091	−0.0936
	32. Satisfied with shininess	0.5645	0.3604	−0.2850	0.1956	0.2553

3.5. Internal consistency reliability

Cronbachs alpha for the subscales was >0.7. The results for individual item and multi‐item subscales to assess convergent and divergent validity are shown in Table 3. All values of Cronbachs alpha were > 0.7. All item correlations were > 0.40, except for shininess.

Table 3.

Reliability, item‐scale, and item‐rest correlation for items and subscales of the Patient Scar Assessment Questionnaire (PSAQ) questionnaire

Subscale	Item	Cronbachs alpha item	Cronbachs alpha subscale	Item‐test correlation	Item‐rest correlation
Appearance	1. Colour	0.9501	0.81	0.6684	0.6361
	2. Darkness	0.9513		0.5589	0.5190
	3. Redness	0.9504		0.6435	0.6093
	4. Length	0.9518		0.5055	0.4624
	5. Width	0.9505		0.6298	0.5946
	6. Flatness	0.9499		0.6928	0.6621
	7. Shininess	0.9542		0.2642	0.2110
	8. Lumpiness	0.9497		0.7130	0.6840
	9. Texture	0.9511		0.5802	0.5417
Scar consciousness	18. Noticeable for you	0.9495	0.90	0.7286	0.7009
	19. Noticeable for other	0.9493		0.7493	0.7234
	20. Stare at your scar	0.9492		0.7562	0.7307
	21. Hide your scar	0.9501		0.6744	0.6425
	22. Think about your scar	0.9504		0.6431	0.6088
	23. Look at your scar	0.9505		0.6369	0.6021
Satisfaction with appearance	25. Satisfied with colour	0.9491	0.92	0.7654	0.7408
	26. Satisfied with redness	0.9502		0.6610	0.6279
	27. Satisfied with length	0.9497		0.7096	0.6803
	28. Satisfied with width	0.9491		0.7639	0.7393
	29. Satisfied with height	0.9490		0.7774	0.7539
	30. Satisfied with texture	0.9486		0.8064	0.7857
	31. Satisfied with lumpiness	0.9488		0.7949	0.7729
	32. Satisfied with shininess	0.9507		0.6133	0.5766
Satisfaction with symptoms	34. Satisfied with itchiness	0.9505	0.88	0.5629	0.5274
	35. Satisfied with pain	0.9521		0.4739	0.4289
	36. Satisfied with discomfort	0.9499		0.6872	0.6561
	37. Satisfied with numbness	0.9500		0.6813	0.6497
	38. Satisfied with odd sensations	0.9502		0.6637	0.6308
Test scale		0.9519

Note: Bold represents coefficients lower than 0.4.

3.6. Concurrent validity

The comparison between the PSAQ appearance subscale and the VSS demonstrated a high correlation (rho = − 0.89). For the known group validity, patients in the lateral neck dissection group with longer scars showed a higher score in terms of the appearance and satisfaction with appearance subscales compared with those with shorter scars (18.1 vs 14.5, P < .04 and 14.4 vs 12.6, and P = .007, respectively). However, there were no statistically significant differences in consciousness (11.0 vs 13.4, P = .5) or satisfaction with symptoms (8.9 vs 6.9, P = .36).

3.7. Test‐retest reliability

In a sample of 62 patients, the Lins correlation concordance coefficient showed high correlation (appearance subscale 0.99 [95% confidence interval 0.98‐0.99]), consciousness subscale (0.74 [0.61‐0.84]), satisfaction with appearance (0.94 [0.90‐0.96]), and satisfaction with symptoms (0.99 [0.98‐0.99]).

4. DISCUSSION

The appearance of surgical scars is more important to patients than what is perceived in the medical community, and surgeons and patients usually have different perceptions of scar impact. Habitually, evaluations of scars are made by surgeons, including particular characteristics such as length, without acknowledging patient perception.20, 21 However, modern instruments that assess quality of life (QOL) usually include patient‐reported outcomes, such as satisfaction with appearance.

The assessment of aesthetic results of neck scars is a very important issue because of the visibility of the area and the effect on self‐image and QOL. Choi et al2 found an association between abnormal scars (hypertrophic and adherent) and lower QOL measured with the Dermatology Life Quality Index but not with the VSS. Kurumety et al22 found a weak association between domains of anxiety, depression, social function, and fatigue with worse perception of neck scars.

Recently, the evolution of distant endoscopic surgical techniques that offer an improvement in the outcomes related to neck scars has resulted in the development and validation of instruments that surpass subjective evaluations and provide reliable and replicable measurements of these outcomes.20

In this study, we made the first cultural adaptation of a validated instrument (PSAQ) to the Spanish language to obtain an objective tool to assess the impact of scars in patients undergoing head and neck surgery. Spanish is spoken by almost 400 million people worldwide, being the fourth most spoken language. Moreover, in the Uinted States, there are more than 50 million people who speak Spanish for whom this instrument can be used.

The results of our study showed that psychometric properties were similar to those reported originally by Durani et al7 and were accomplished with reliable methodological criteria.23 Construct validity and total scale and subscale internal consistency offered promising results. A concurrent validation with the VSS showed good correlation, specifically in the appearance subscale. The instrument was stable during the test‐retest evaluation, but we also demonstrated a difference in relation to the type of surgery (patients with or without neck dissection), which supports the discriminative ability of the instrument.

Few studies have validated PSAQ performance in the field of head and neck surgery. Economopoulos et al24 assessed 667 patients after thyroidectomy and parathyroidectomy and found good scores of reliability and internal consistency. However, he included a small number of neck dissections and excluded parotidectomy. Linos et al12 evaluated 691 patients with the PSAQ and found that the questionnaire was useful for defining the effect of neck scars on the appearance subscale.

Our study included a wide range of characteristics including age, sex, sociocultural conditions, and the most common types of surgical neck procedures, which offers high applicability of the results.12 We included only head and neck major surgical procedures with a long scar, which differs from the original study of Durani et al,7 where minimal procedures, such as nevus resection were included; thus, this is a strength of our study. Similar to the methods of Durani et al7 and Economopoulos et al,24 we excluded the symptom subscale from our evaluation. Although previous studies have suggested that symptom evaluation is more informative and sensible to change,25 their measurements in this condition are homogenous and invariable and do not offer a greater impact in terms of the global assessment.

We identified some weaknesses in our study. As the design was cross‐sectional, we could not evaluate the temporal change in symptoms and the association between the scores and the scar modifications during the normal process of scarring. An important number of patients had their scars for less than 6 months. As healing can last up to 2 years, some patients may have demonstrated overestimated values on the appearance subscale during this early period of time.

5. CONCLUSION

Our study supports the Spanish version of the PSAQ as a valid, reliable, and reproducible tool to assess the perception and impact of neck scars in Spanish‐speaking patients who undergo head and neck surgery.

CONFLICT OF INTEREST

None.

APPENDIX 1 1. Spanish version of the PASQ questionnaire

Escala PSAQ en español

Favor responder uno a uno cada interrogante, y señale el cuadrado en blanco con lapicero o marcador, según la respuesta escogida.

1. ¿Qué tan parecido es el color de su cicatriz con el color de la piel que la rodea?

Muy parecida	Parecida	Diferente	Muy diferente
□	□	□	□

2. ¿Es su cicatriz más clara o más oscura que la piel que la rodea?

No	□
Sí, es más oscura □	Un poco □	Moderado □	Mucho □
Sí, es más clara □

3. ¿Cree usted que su cicatriz tiene enrojecimiento?

No	□
Sí, tiene enrojecimiento □	Muy poco □	Moderado □	Mucho □

4. ¿Qué tan larga es la cicatriz?

Muy corta	Corta	Larga	Muy Larga
□	□	□	□

5. ¿Qué tan ancha es la cicatriz?

Muy delgada	Delgada	Ancha	Muy ancha
□	□	□	□

6. ¿Qué tan lisa está la cicatriz respecto con la piel cercana?

Es lisa y uniforme □	□
Está levantada □	Muy poco □	Moderado □	Mucho □
Está hundida □

7. Para usted, ¿la cicatriz tiene una apariencia brillante?

No	□
Sí, es brillante □	Muy poco □	Moderado □	Mucho □

8. ¿Su cicatriz se siente gruesa?

No	□
Sí, es más gruesa □	Muy poco □	Moderado □	Mucho □

9. La textura de su cicatriz es

Muy suave	Suave	Áspera	Muy áspera
□	□	□	□

10. En general, ¿qué piensa de la apariencia de la cicatriz?

Excelente	Buena	Aceptable	Mala	Muy mala
□	□	□	□	□

11. ¿Siente rasquiña en su cicatriz?

No	□
Sí, me genera rasquiña	A veces □	Frecuentemente □	Siempre □
	¿Qué tanta rasquiña le genera?:
	Muy poca □	Moderada □	Mucha □

12. ¿La cicatriz le causa algún dolor?

No	□
Sí, me duele	A veces □	Frecuentemente □	Siempre □
	¿Qué tanto dolor le genera?:
	Muy poco □	Moderado □	Mucho □

13. ¿Es su cicatriz incómoda?

No	□
Sí, me incomoda	A veces □	Frecuentemente □	Siempre □
	¿Qué tanta incomodidad le genera?:
	Muy poca □	Moderada □	Mucha □

14. ¿Siente entumecimiento en su cicatriz?

No	□
Sí, se entumece	A veces □	Frecuentemente □	Siempre □
	Y cuando siente entumecimiento, es:
	Muy poco □	Moderado □	Mucho □

15. ¿Alguna vez tiene sensaciones raras en su cicatriz?, como punzadas, hormigueo o tracción

No	□
Sí, siento sensaciones extrañas en la cicatriz	A veces □	Frecuentemente □	Siempre □

16. ¿Alguna vez su cicatriz se enreda en algo? Por ejemplo, joyas o ropa

No	□
Sí, se enreda en objetos	A veces □	Frecuentemente □	Siempre □

17. En general, ¿qué tan molestos son los síntomas de su cicatriz?

No me molesta nada	Muy poco molestos	Son molestos	Son muy molestos	Son Insoportables
□	□	□	□	□

18. ¿Qué tan notoria es su cicatriz para usted?

No la noto nada	Muy poco notoria	Es notoria	Es muy notoria
□	□	□	□

19. ¿Qué tan notoria cree usted que su cicatriz es para otras personas?

Nadie la nota	Muy poco notoria	Es notoria	Es muy notoria
□	□	□	□

20. ¿Cree usted que otras personas se quedan mirando su cicatriz?

Nunca la miran	Muy pocas veces la miran	Frecuentemente la miran	Siempre la miran
□	□	□	□

21. ¿Hace algún esfuerzo para ocultar su cicatriz?

Nunca la oculto	Muy pocas veces la oculto	Frecuentemente la oculto	Siempre la oculto
□	□	□	□

22. ¿Qué tan frecuentemente se acuerda de su cicatriz?

Nunca la recuerdo	Muy pocas veces la recuerdo	Frecuentemente la recuerdo	Siempre la recuerdo
□	□	□	□

23. ¿Con que frecuencia mira usted su cicatriz?

Nunca la miro	Muy pocas veces la miro	Frecuentemente la miro	Siempre la miro
□	□	□	□

24. En general, ¿qué tan avergonzado se siente de su cicatriz?

No siento vergüenza	Me avergüenza muy poco	Sí, me avergüenza	Muy avergonzado
□	□	□	□

25. ¿Qué tan satisfecho está con el color de su cicatriz y el parecido con el resto de su piel?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

26. ¿Qué tan satisfecho está con el color rojizo de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

27. ¿Qué tan satisfecho está con la longitud de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

28. ¿Qué tan satisfecho está con el ancho de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

29. ¿Qué tan satisfecho está usted con la altura de su cicatriz respecto al resto de su piel?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

30. ¿Qué tan satisfecho está con la sensación de su cicatriz cuando usted la toca?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

31. ¿Qué tan satisfecho se siente con el grosor de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

32. ¿Qué tan satisfecho está con el brillo de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

33. En General, ¿qué tan satisfecho se encuentra con la apariencia de su cicatriz

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

34. ¿Qué tan satisfecho está con la “rasquiña” de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

35. ¿Qué tan satisfecho está con el dolor que le causa su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

36. ¿Qué tan satisfecho está con la incomodidad que le causa su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

37. ¿Qué tan satisfecho está con el “entumecimiento” de su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

38. ¿Qué tan satisfecho está con las sensaciones extrañas que le causa su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

39. En general, considerando todos los problemas que le pueda causar, ¿qué tan satisfecho esta con su cicatriz?

Muy satisfecho	Satisfecho	Insatisfecho	Muy insatisfecho
□	□	□	□

Restrepo S, Rojas S, Sanabria A. Cross‐cultural adaptation and psychometric validation of the Patient Scar Assessment Questionnaire to the Spanish language in head and neck surgery. Int Wound J. 2020;17:21–31. 10.1111/iwj.13218