Key Points
Question
What factors are associated with increases in the risk of poor long-term aesthetic-related outcomes after microvascular free tissue transfer for head and neck cancer?
Findings
In this cross-sectional analysis of 124 patients with head and neck cancer at a median of nearly 3 years after microvascular free tissue transfer, osteocutaneous reconstruction and adjuvant chemotherapy or radiotherapy resulted in worse patient-reported aesthetic satisfaction. A history of anxiety or depression, female sex, osteocutaneous flaps, prolonged tube feeding, recurrent disease, and poor aesthetic satisfaction resulted in worse patient-reported appearance-related psychosocial functioning.
Meaning
The findings of this study suggest that aesthetic outcomes should be prioritized during microvascular free tissue transfer for head and neck cancer, particularly among patients with risk factors for worse long-term aesthetic-related outcomes.
Abstract
Importance
Aesthetic outcomes are key determinants of psychosocial functioning among surgically treated patients with head and neck cancer (HNC); however, long-term aesthetic outcomes after microvascular free tissue transfer (MFTT) are not well described.
Objective
To examine risk factors for impaired long-term aesthetic satisfaction and appearance-related psychosocial functioning after HNC ablation with MFTT.
Design, Setting, and Participants
A cross-sectional, web-based survey was conducted at an academic tertiary care center. A total of 228 individuals who underwent MFTT between January 1, 2015, and December 31, 2019, for treatment of HNC were included. The study was conducted from November 1, 2020, through January 15, 2021.
Exposures
Head and neck cancer ablation with MFTT.
Main Outcomes and Measures
Patient-reported outcomes were assessed via Aesthetic FACE-Q scales. The primary objective was aesthetic satisfaction determined by the Satisfaction With Facial Appearance scale. Secondarily, the Appearance-Related Psychosocial Distress, Psychological Function, and Social Function scales were used to assess appearance-related psychosocial functioning. Patients were stratified by demographic, disease, surgical, and postoperative characteristics. Survey scores on a 100-point scale were compared and subjected to univariable and multivariable linear regression.
Results
A total of 124 of 228 patients (54.4%) completed surveys a median of 34.4 months after MFTT (interquartile range, 22.6-48.8). Most responders (79 [63.7%]) were men with advanced cancer of the oral cavity or skin, reconstructed with anterolateral thigh or osteocutaneous fibula free flaps. Nonresponders had no significant differences in baseline characteristics. The Satisfaction With Facial Appearance score was independently lower among patients who received osteocutaneous flaps (regression coefficient, −10.6 points, 95% CI, –20.4 to –0.8 points) and/or adjuvant (chemo)radiotherapy (regression coefficient, –6.9 points; 95% CI, –13.8 to –0.1 points). Impaired appearance-related psychosocial functioning was independently associated with female sex, a history of anxiety or depression, osteocutaneous flaps, prolonged tube feeding requirements, and any recurrent or persistent disease. After adjustment for covariates, each 1-point increase in the Satisfaction With Facial Appearance score independently estimated improved appearance-related psychosocial functioning as determined by the Appearance-Related Psychosocial Distress scale (regression coefficient, –0.5 points; 95% CI, –0.7 to –0.4 points), Psychological Function scale (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.5 points), and Social Function scale (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.6 points).
Conclusions and Relevance
The findings of this cross-sectional, web-based survey study suggest that osteocutaneous reconstruction and adjuvant therapy independently increase the risk of poor patient-reported long-term aesthetic satisfaction, which correlated with impaired appearance-related psychosocial functioning. Aesthetic outcomes appear to be a priority to address in patients with HNC undergoing MFTT.
This cross-sectional study examines patient-reported satisfaction with their appearance after undergoing microvascular free tissue transfer for treatment of head and neck cancer.
Introduction
More than 110 000 individuals across the US are expected to be diagnosed with head and neck cancer (HNC) in 2021.1 Owing to fear of disease recurrence, functional deficits, and aesthetic changes, up to 40% of these patients may develop depression at some point in their treatment course.2,3,4 Ablative surgery is a necessary step in oncologic control but often disturbs nearby structures that are necessary for self-expression and social interaction.5 Patients subsequently undergoing head and neck reconstruction emphasize altered facial appearance as a key contributor to impaired psychosocial functioning.6,7,8
Body image distress involves one’s perceptions and feelings about one’s body and has been associated with depression and psychosocial impairment after surgery for HNC.9,10,11,12 Along with bodily dysfunction, facial aesthetics contribute to body image distress. Even minor alterations in normal facial anatomy and facial expressivity are associated with decrements in perceived attractiveness and social penalties.13,14 This finding is most apparent and substantial in the short-term postoperative period, but aesthetic outcomes beyond 1 year from surgery are not well known. In previous studies, patients undergoing heterogeneous reconstructive approaches, ranging from primary closure to microvascular free tissue transfer (MFTT), have been analyzed together.15,16,17,18 Microvascular free tissue transfer—the most complicated choice in a graduated system of reconstruction designed to meet the complexity of the surgical wound—is usually reserved for the most-advanced cancers and most serious defects.15,16 Microvascular free tissue transfer also has substantial complication rates that may require hospital readmission and/or operating room takebacks.17,18 As a result, patients with HNC undergoing MFTT are likely at the greatest risk for impaired aesthetic outcomes and psychosocial functioning.
A recent questionnaire-based study has reported that osteocutaneous reconstruction and adjuvant radiotherapy are associated with an increase in the risk of poor aesthetic outcomes within 1 year from MFTT,19 but there is a paucity of literature describing long-term outcomes, specifically among patients with malignant disease. As technological advances continue to improve the survival for patients with advanced cancer, it is necessary to understand long-term treatment ramifications on aesthetic outcomes. We hypothesized that osteocutaneous flaps and adjuvant therapy are risk factors for worse long-term aesthetic outcomes. Using aesthetic-related patient-reported outcome instruments, this study was designed to evaluate associations between these variables, among others, and aesthetic outcomes more than 1 year after HNC ablation with MFTT.
Methods
This was a single-center, cross-sectional, web-based survey study of aesthetic-related patient-reported outcomes at least 1 year after HNC ablation with MFTT. Institutional review board approval was obtained from the University of California, San Francisco, Medical Center. All patients provided written informed consent; participants did not receive financial compensation. The study was performed in accordance with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline for cross-sectional studies.
Patient Selection
We queried a prospectively maintained database for consecutive head and neck MFTT surgeries performed between January 1, 2015, and December 31, 2019. Inclusion criteria were (1) ablation of an HNC followed by MFTT, (2) duration of at least 1 year from initial MFTT, (3) at least aged 18 years, and (4) a valid email address. Patients were excluded if they underwent recent treatment (defined as [chemo]radiotherapy, or any additional surgery ≤1 month before the survey). Of 552 unique patients who underwent MFTT, 158 had died; 108 had benign, premalignant, or other noncancerous defects; 53 did not have a valid email address; 4 had undergone recent treatment; and 1 was a pediatric patient; 228 patients were invited to participate. Figure 1 depicts patient selection and exclusion at each phase of the study.
Figure 1. Patient Selection.
Patient inclusion and exclusion at each phase of the study.
Outcomes and Independent Variables
Aesthetic patient-reported outcomes were assessed via 4 FACE-Q scales: Satisfaction With Facial Appearance (SFA), Appearance-Related Psychosocial Distress (ARPD), Psychological Function (PF), and Social Function (SF). Each of these scales has been validated for use in facial plastic and reconstructive surgery.20,21,22,23 Our primary objective was aesthetic satisfaction as determined by the SFA scale, which addresses topics such as facial symmetry and appearance in photographs. Secondarily, we evaluated appearance-related psychosocial function via the ARPD, PF, and SF scales, which investigate how facial appearance is associated with stress, self-confidence, and making friends, among other related topics. Each scale contains 8 to 10 Likert-style questions that are summed, then subject to Rasch transformation for a final survey score of 0 to 100. Higher SFA, PF, and SF scores indicate greater satisfaction or functioning; however, higher ARPD scores indicate greater levels of distress.
We hypothesized that certain characteristics, including osteocutaneous flaps and adjuvant radiotherapy, are associated with worse survey scores. Survey follow-up time, defined as the time from initial MFTT until survey completion, was calculated. We recorded demographics (age, sex, and race/ethnicity), relevant medical history at the time of surgery (tobacco use, history of anxiety or depression, prior head and neck surgery, and prior radiotherapy or chemotherapy), American Society of Anesthesiologist (ASA) class, disease characteristics (subsite, pathologic findings, and American Joint Committee on Cancer 8th edition overall stage), and flap type and composition. Detailed postoperative data were also collected, including prolonged tube feeding requirements as determined by a speech-language pathologist (defined as ≥1 month), hospital readmissions for any disease or reconstruction-related indication, additional head and neck surgery, adjuvant chemotherapy or radiotherapy, and recurrent or persistent disease. We created an “any recurrence” variable to evaluate all patients with recurrent/persistent disease by the time of the survey.
Data Collection and Statistical Analysis
Web-based surveys were collected between November 1, 2020, and January 15, 2021, through our institution’s Research Electronic Data Capture database. We did not conduct telephone or in-person surveys in an attempt to reduce observation bias owing to potentially sensitive topics. Our sample size was feasibility driven. Variables with missing data are indicated and were excluded from relevant analyses.
Categorical variables are presented as frequency (percent) and continuous variables are presented as median (interquartile [IQR] range). Effect size is depicted by the difference in survey scores between stratified baseline characteristics and linear regression coefficients with 95% CIs. To adjust for covariates, multivariable linear regression was performed, using risk factors with the highest clinical relevance and largest score differences. Categorical variables used in the regression were converted to integers, such as male, 0; and female, 1. Adjuvant chemotherapy or radiotherapy was coded as none, 0; radiotherapy, 1; and chemoradiotherapy, 2 for regression analyses. Linear regression coefficients are reported with 95% CIs. We also performed multivariable linear regression to evaluate the correlation between SFA and each of the appearance-related psychosocial function scales (ARPD, PF, and SF) while adjusting for covariates. determined by Mann-Whitney testing, χ2, or Fisher exact, as appropriate. The significance threshold was set at P < .05, it was 2 sided and unpaired. All statistical analyses were performed via Stata, version 15 (StataCorp LLC).
Results
Patient Characteristics
Of 228 patients who satisfied inclusion and exclusion criteria, 124 completed surveys (54.4%) (Figure 1). Median survey follow-up time was 34.4 months after MFTT (IQR, 22.6-48.8 months) (Table 1). Participants included 79 men (63.7%) and 45 women (36.3%) with a median age of 63 years (IQR, 54-72 years). Most participants had stage III (26 [21.0%]) or IV (69 [55.7%]) cancer of the oral cavity (65 [52.4%]) or skin (21 [16.9%]) and underwent reconstruction with anterolateral thigh (51 [41.1%]) or fibula (35 [28.2%]) free tissue flaps. To assess for nonresponse bias, we compared baseline characteristics of the responders with the 104 nonresponders and found no significant differences in follow-up time (had the survey been completed by the end of the study), age, sex, ASA class, disease subsite, disease pathologic characteristics, overall stage, and type of flap (eTable in the Supplement).
Table 1. Characterization of 124 Survey Responders.
| Characteristic | No. (%) |
|---|---|
| Survey follow-up time, median (IQR), mo | 34.4 (22.6-48.8) |
| Age, median (IQR), y | 63 (54-72) |
| Sex, No. (%) | |
| Female | 45 (36.3) |
| Male | 79 (63.7) |
| Race/ethnicity, No. (%) | |
| Asian | 18 (14.5) |
| Black or African American | 4 (3.2) |
| Hispanic or Latino | 8 (6.5) |
| White or Caucasian | 91 (73.4) |
| Unknown | 3 (2.4) |
| Smoking history, No. (%) | |
| Never smoker | 61 (49.2) |
| Former smoker | 53 (42.7) |
| Current smoker | 10 (8.1) |
| Pack-years, median (IQR) | 12.5 (5-30) |
| History of anxiety or depression, No. (%) | 34 (27.4) |
| Receiving antidepressants preoperatively, No. (%) | 13 (10.5) |
| Disease history, No. (%) | |
| Previous head and neck surgery | 44 (35.5) |
| Previous or neoadjuvant radiotherapy | 33 (26.6) |
| Previous chemotherapy | 22 (17.7) |
| Preoperative persistent/recurrent disease | 53 (42.7) |
| ASA classification, No. (%) | |
| ASA 1 | 4 (3.2) |
| ASA 2 | 59 (47.6) |
| ASA 3 | 61 (49.2) |
| Subsite, No. (%) | |
| Hypopharynx | 2 (1.6) |
| Larynx | 5 (4.0) |
| Midface | 8 (6.5) |
| Oral cavity | 65 (52.4) |
| Oropharynx | 10 (8.1) |
| Parotid | 12 (9.7) |
| Skin | 21 (16.9) |
| Thyroid | 1 (0.8) |
| Pathologic diagnosis, No. (%) | |
| Squamous cell carcinoma | 95 (76.6) |
| Adenocarcinoma | 7 (5.7) |
| Mucoepidermoid carcinoma | 5 (4.0) |
| Sarcoma | 4 (3.2) |
| Clear cell carcinoma | 3 (2.4) |
| Basal cell carcinoma | 2 (1.6) |
| Other cancera | 8 (6.5) |
| Overall stage, AJCC 8th ed, median (IQR) | |
| I | 12 (9.7) |
| II | 17 (13.7) |
| III | 26 (21.0) |
| IV | 69 (55.7) |
| Flap type, No. (%) | |
| Anterolateral thigh | 51 (41.1) |
| Fibula | 35 (28.2) |
| Latissimus or serratus | 4 (3.2) |
| Radial forearm | 33 (26.6) |
| Rectus abdominis | 1 (0.8) |
| Osteocutaneous flaps | 40 (32.3) |
| Discharged with parenteral nutrition requirements, No. (%) | 82 (66.1) |
| Prolonged parenteral nutrition requirements, No. (%)b | 43 (34.7) |
| Hospital readmission, No. (%) | 69 (55.7) |
| Additional surgery, No. (%)c | 61 (49.2) |
| Postoperative adjuvant therapy, No. (%) | |
| None | 34 (27.4) |
| Adjuvant radiotherapy | 57 (46.0) |
| Adjuvant chemoradiotherapy | 33 (26.6) |
| Postoperative immunotherapy | 16 (12.9) |
| Postoperative recurrent (or persistent) disease | 31 (25.0) |
Abbreviations: AJCC, American Joint Committee on Cancer, 8th edition; ASA, American Society of Anesthesiologists; IQR, interquartile range.
There was 1 of each of the following cancers: melanoma, papillary thyroid cancer, peripheral malignant nerve sheath tumor, sinonasal undifferentiated carcinoma, adenoid cystic carcinoma, invasive atypical fibroxanthoma, poorly differentiated neuroendocrine carcinoma, and poorly differentiated carcinoma, not otherwise specified.
Determined by speech-language pathologist and defined as 1 month or longer.
Included aesthetic revisions, surgical feeding tube placement, eyelid surgery, debulking and/or vestibuloplasty, would debridement, fistula repair, hardware revision, reanimation procedures, and salvage resection with or without reconstruction.
Postoperatively, 43 patients (34.7%) required prolonged tube feeding, 69 (55.7%) were readmitted, and 61 (49.2%) underwent at least 1, but often multiple, additional surgeries. These surgeries were heterogeneous, including aesthetic revisions, surgical feeding tube placement, eyelid surgery, debulking and/or vestibuloplasty, wound debridement, fistula repair, hardware revision, reanimation procedures, and salvage resection with or without reconstruction. For the 61 patients who underwent additional surgeries, the median time from the most recent surgery to completion of the survey was 16.4 months (IQR, 8.0-33.4 months). Most patients underwent post-MFTT adjuvant radiotherapy (57 [46.0%]) or chemoradiotherapy (33 [26.6%]), completed a median of 28.5 months (IQR, 17.5-44.4 months) before the survey.
Aesthetic Satisfaction
The overall mean (SD) SFA score was 61.8 (26.9). This score was lower with women, osteocutaneous flaps, hospital readmission, and adjuvant (chemotherapy or radiotherapy (Table 2). With multivariable linear regression, impaired SFA was independently associated with osteocutaneous flaps (10.6 points; 95% CI, –20.4 to –0.8 points) and/or adjuvant chemotherapy or radiotherapy (–6.9 points per increase in treatment group from none, to radiotherapy, to chemoradiotherapy; 95% CI, –13.8 to −0.1 points). The SFA score did not appear to be associated with survey follow-up time, ASA class, anxiety or depression, defect location, overall stage, prolonged tube feeding requirements, additional surgery, or recurrent disease.
Table 2. Analysis of Risk Factors for Impaired Patient-Reported Satisfaction With Facial Appearance and Appearance-Related Psychosocial Distress After MFTT.
| Characteristic | Group, No. | Satisfaction with facial appearancea | Appearance-related psychosocial distressa | ||
|---|---|---|---|---|---|
| Univariable score difference (95% CI) | Multivariable regression coefficient (95% CI) | Univariable score difference (95% CI) | Multivariable regression coefficient (95% CI) | ||
| Survey follow-up time, y | |||||
| 1-2 | 37 | 0 [Reference] | 1.1 (–2.2 to 4.5) | 0 [Reference] | 2.8 (–0.4 to 6.0) |
| 2-3 | 30 | 2.0 (–11.5 to 15.6) | 6.3 (–6.7 to 19.4) | ||
| 3-4 | 22 | 2.7 (–13.0 to 18.4) | 7.0 (–7.7 to 21.7) | ||
| 4-5 | 20 | 3.2 (–12.6 to 19.0) | 9.1 (–5.7 to 23.9) | ||
| 5-6 | 15 | 11.4 (–6.5 to 29.3) | 3.5 (–12.3 to 19.4) | ||
| Age, y | |||||
| <65 | 67 | 0 [Reference] | 5.81 (–3.7 to 15.4) | 0 [Reference] | –7.8 (–16.9 to 1.4) |
| ≥65 | 57 | 8.8 (–0.7 to 18.3) | –9.1 (–18.6 to 0.4) | ||
| Sex | |||||
| Male | 79 | 0 [Reference] | –8.9 (–18.7 to 0.9) | 0 [Reference] | 8.6 (–0.8 to 17.9) |
| Female | 45 | –10.7 (–20.5 to –0.9)b | 11.4 (1.6 to 21.2)b | ||
| ASA classification | |||||
| 1-2 | 63 | 0 [Reference] | 0 [Reference] | ||
| 3 | 61 | 2.5 (–7.1 to 12.1) | 5.1 (–4.5 to 14.7) | ||
| Anxiety and/or depression | |||||
| No | 90 | 0 [Reference] | –5.5 (–16.1 to 5.1) | 0 [Reference] | 11.1 (1.0 to 21.2)b |
| Yes | 34 | –7.0 (–17.7 to 3.7) | 11.2 (0.6 to 21.8)b | ||
| Defect location | |||||
| Aerodigestive | 90 | 0 [Reference] | 0 [Reference] | ||
| Superficial | 34 | –2.4 (–13.2 to 8.3) | 1.1 (–11.9 to 9.6) | ||
| Flap composition | |||||
| Soft tissue alone | 84 | 0 [Reference] | –10.6 (–20.4 to –0.8)b | 0 [Reference] | 12.5 (3.1 to 21.9)b |
| Osteocutaneous | 40 | –12.3 (–22.3 to –2.2)b | 13.9 (3.9 to 23.9)b | ||
| Overall stage, AJCC 8th Ed. | |||||
| Early, I or II | 29 | 0 [Reference] | –1.7 (–13.0 to 9.6) | 0 [Reference] | 4.5 (–6.3 to 15.3) |
| Advanced, III or IV | 95 | –9.7 (–21.0 to 1.5) | 12.1 (1.0 to 23.3)b | ||
| Parenteral nutrition (determined by speech-language pathologist) | |||||
| Short-term or no requirement | 81 | 0 [Reference] | –5.4 (–14.9 to 4.1) | 0 [Reference] | 7.5 (–1.6 to 16.6) |
| Prolonged requirement (≥1 mo) | 43 | –6.8 (–16.8 to 3.2) | 10.0 (0.1 to 20.0)b | ||
| Disease or reconstruction-related readmission | |||||
| No | 55 | 0 [Reference] | –8.7 (–18.1 to 0.7) | 0 [Reference] | 6.2 (–2.8 to 15.2) |
| Yes | 69 | –12.4 (–21.8 to –3.0)b | 11.8 (2.3 to 21.3)b | ||
| Additional or revision surgery | |||||
| No | 63 | 0 [Reference] | 0 [Reference] | ||
| Yes | 61 | –9.3 (–18.7 to 0.2) | 8.1 (–1.5 to 17.6) | ||
| Postoperative adjuvant therapy | |||||
| None | 34 | 0 [Reference] | –6.9 (–13.8 to –0.1)b | 0 [Reference] | 6.6 (0 to 13.2) |
| Adjuvant radiotherapy | 57 | –3.1 (–15.0 to 8.7) | –1.9 (–13.0 to 9.2) | ||
| Adjuvant chemoradiotherapy | 33 | –12.9 (–25.3 to –0.6)b | 8.9 (–5.4 to 23.1) | ||
| Preoperative or postoperative recurrent/persistent disease | |||||
| No | 55 | 0 [Reference] | –7.5 (–17.1 to 2.1) | 0 [Reference] | 12.3 (3.1 to 21.4) |
| Yes | 69 | –4.7 (–14.3 to –5.0)b | 8.5 (–1.1 to 18.0) | ||
Abbreviations: AJCC, American Joint Committee on Cancer 8th edition; ASA, American Society of Anesthesiologists; MFTT, microvascular free tissue transfer.
Higher score meanings given in Methods section.
Compared with the reference group.
Appearance-Related Psychosocial Functioning
The mean (SD) ARPD score was 29.5 (26.8) overall. This score was higher with women, a history of anxiety or depression, osteocutaneous flaps, advanced-stage disease, prolonged tube feeding requirements, and hospital readmission (Table 2). Upon multivariable linear regression, ARPD was independently associated with a history of anxiety or depression (11.1 points; 95% CI, 1.0-21.2 points) and osteocutaneous flaps (12.5 points; 95% CI 3.1-21.9 points). The ARPD score was not associated with survey follow-up time, ASA class, defect location, additional surgery, adjuvant therapy, and recurrent disease.
The mean (SD) PF score was 69.6 (24.6) overall. This score was lower with women, a history of anxiety or depression, osteocutaneous flaps, advanced-stage disease, and prolonged tube feeding requirements (Table 3). On multivariable linear regression, the PF score was associated with women (–10.5 points; 95% CI, –18.9 to –2.1 points), a history of anxiety or depression (–13.2 points; 95% CI, –22.3 to –4.1 points), osteocutaneous flaps (–10.4 points; 95% CI, –18.8 to –1.9 points), prolonged tube feeding requirements (–11.2 points; 95% CI, –19.4 to –3.1 points), and any recurrent or persistent disease (–9.8 points; 95% CI, –18.0 to –1.6 points). The PF scores were not associated with survey follow-up time, age, ASA class, defect location, additional surgery, adjuvant therapy, and recurrent disease.
Table 3. Analysis of Risk Factors for Impaired Patient-Reported Aesthetic-Related Psychological and Social Function After MFTT.
| Characteristic | Group, No. | Psychological functiona | Social functiona | ||
|---|---|---|---|---|---|
| Univariable score difference (95% CI) | Multivariable regression coefficient (95% CI) | Univariable score difference (95% CI) | Multivariable regression coefficient (95% CI) | ||
| Survey follow-up time, y | |||||
| 1-2 | 37 | 0 [Reference] | –0.7 (–3.6 to 2.2) | 0 [Reference] | –0.9 (–4.2 to 2.2) |
| 2-3 | 30 | –1.9 (–14.3 to 10.5) | –0.9 (–14.1 to 12.4) | ||
| 3-4 | 22 | 1.8 (–11.9 to 15.4) | –1.6 (–16.3 to 13.2) | ||
| 4-5 | 20 | –6.6 (–21.1 to 7.9) | –7.4 (–21.9 to 7.2) | ||
| 5-6 | 15 | 6.8 (–8.4 to 22.0) | 5.5 (–10.2 to 21.2) | ||
| Age, y | |||||
| <65 | 67 | 0 [Reference] | 0.7 (–7.6 to 8.9) | 0 [Reference] | 7.3 (–1.9 to 16.4) |
| ≥65 | 57 | 2.0 (–6.8 to 10.8) | 8.0 (–1.2 to 17.1) | ||
| Sex | |||||
| Male | 79 | 0 [Reference] | –10.5 (–18.9 to –2.1)b | 0 [Reference] | –3.1 (–12.4 to 6.3) |
| Female | 45 | –13.9 (–22.7 to –5.1) | –7.9 (–17.4 to 1.6) | ||
| ASA classification | |||||
| ASA 1-2 | 63 | 0 [Reference] | 0 [Reference] | ||
| ASA 3 | 61 | –5.6 (–14.3 to 3.2) | 0.1 (–9.3 to 9.1) | ||
| Anxiety and/or depression | |||||
| No | 90 | 0 [Reference] | –13.2 (–22.3 to –4.1)b | 0 [Reference] | –15.9 (–26.0 to –5.7)b |
| Yes | 34 | –15.0 (–24.4 to –5.5) | –16.2 (–26.1 to –6.2)b | ||
| Defect location | |||||
| Aerodigestive | 90 | 0 [Reference] | 0 [Reference] | ||
| Superficial | 34 | –0.4 (–9.4 to 10.3) | 0 (–10.4 to 10.3) | ||
| Flap composition | |||||
| Soft tissue alone | 84 | 0 [Reference] | –10.4 (–18.8 to –1.9)b | 0 [Reference] | –8.8 (–18.2 to 0.6) |
| Osteocutaneous | 40 | –11.8 (–21.0 to –2.7) | –9.3 (–19.1 to 0.4) | ||
| Overall stage, AJCC 8th Ed. | |||||
| Early, I or II | 29 | 0 [Reference] | –4.9 (–14.6 to 4.8) | 0 [Reference] | –4.6 (–15.5 to 6.2) |
| Advanced, III or IV | 95 | –11.2 (–21.4 to –1.1) | –9.4 (–20.2 to 1.3) | ||
| Parenteral nutrition (determined by speech-language pathologist) | |||||
| Short or no requirement | 81 | 0 [Reference] | –11.2 (–19.4 to –3.1)b | 0 [Reference] | –9.1 (–18.2 to 0.1) |
| Prolonged requirement (≥1 mo) | 43 | –13.6 (–22.5 to –4.7) | –11.2 (–20.7 to –1.7)b | ||
| Disease or reconstruction-related readmission | |||||
| No | 55 | 0 [Reference] | –3.6 (–11.7 to 4.5) | 0 [Reference] | –4.2 (–13.3 to 4.8) |
| Yes | 69 | –7.6 (–16.3 to 1.1) | –8.7 (–17.9 to 0.5) | ||
| Additional or revision surgery | |||||
| No | 63 | 0 [Reference] | 0 [Reference] | ||
| Yes | 61 | –3.6 (–12.3 to 5.2) | –6.0 (–15.2 to 3.1) | ||
| Postoperative adjuvant therapy | |||||
| None | 34 | 0 [Reference] | –4.9 (–10.8 to 1.0) | 0 [Reference] | –2.2 (–8.8 to 4.4) |
| Adjuvant radiotherapy | 57 | 3.3 (–6.8 to 13.3) | 5.8 (–5.9 to 17.4) | ||
| Adjuvant chemoradiotherapy | 33 | –4.5 (–17.5 to 8.5) | –2.7 (–15.1 to 9.8) | ||
| Preoperative or postoperative recurrent/persistent disease | |||||
| No | 55 | 0 [Reference] | –9.8 (–18.0 to –1.6)b | 0 [Reference] | –6.0 (–15.2 to 3.2) |
| Yes | 69 | –8.2 (–16.9 to 0.5) | –4.4 (–13.7 to 4.8) | ||
Abbreviations: AJCC, American Joint Committee on Cancer 8th edition; ASA, American Society of Anesthesiologists; HNC, head and neck cancer; MFTT, microvascular free tissue transfer.
Higher score meanings given in Methods section.
Compared with the reference group.
The mean SF score was 57.8 (25.9) overall. This score was lower with a history of anxiety or depression and tube feeding requirements (Table 3). With multivariable linear regression, the SF score was only associated with a history of anxiety or depression (−15.9 points; 95% CI, −26.0 to −5.7 points). The SF scores were not associated with survey follow-up time, age, sex, ASA class, defect location, osteocutaneous flaps, overall stage, disease or reconstruction-related readmission, additional or revision surgery, adjuvant therapy, and recurrent disease.
Figure 2 is a linear prediction plot demonstrating the association between SFA scores and the appearance-related psychosocial function scales: ARPD, PF, and SF. After adjusting for follow-up time, age, sex, anxiety or depression history, disease stage, osteocutaneous flaps, prolonged tube feeding, hospital readmission, adjuvant therapy, and recurrent disease via multivariable linear regression models, each 1-point increase in the SFA score remained predictive of lower ARPD (regression coefficient, –0.5 points; 95% CI, –0.7 to –0.4 points), higher PF score (regression coefficient, 0.4 points, 95% CI, 0.3 to 0.5 points), and higher SF score (regression coefficient, 0.4 points; 95% CI, 0.3 to 0.6 points).
Figure 2. Correlation Between Aesthetic Satisfaction and Appearance-Related Psychosocial Functioning.
Linear prediction plot showing association of Satisfaction With Facial Appearance (SFA) scores with survey scores after adjusting for baseline characteristics. A, Appearance-related psychosocial distress scale; adjusted regression coefficient, −0.5 points; 95% CI, −0.7 to −0.4 points. B, Psychological Function scale; adjusted regression coefficient, 0.4 points; 95% CI, 0.3 to 0.5 points. C, Social Function scale; adjusted regression coefficient, 0.4 points; 95% CI, 0.3 to 0.6 points. ARPD indicates Appearance-Related Psychosocial Distress; PF, psychological function; SF, social function.
Discussion
Psychosocial function after head and neck reconstruction is associated with patient-perceived aesthetic outcomes.4,10,19 This study reports the risk of poor long-term aesthetic outcomes among patients with HNC who undergo MFTT. In comparison, the mean FACE-Q scores approximately 3 years after MFTT in this study were worse than those previously reported only 10 months after local reconstruction of head and neck deficits.24 We highlight the multitude of demographic, disease, treatment, and complication-related risk factors that appear to exacerbate this risk. Osteocutaneous flaps and adjuvant chemotherapy or radiotherapy were independently associated with impaired aesthetic satisfaction several years after MFTT.
Functional measures are often prioritized over aesthetic outcomes in HNC research.7,25,26 Few instruments have been developed that prioritize aesthetic outcomes in HNC.26,27 The new FACE-Q HNC instrument has recently been validated in patients with cancer, but only 2 scales (Face Overall and Appearance Distress) prioritize aesthetic outcomes.28 The IMAGE-HN instrument was also recently published and may serve as an important multidomain instrument for assessing body image distress in surgically treated patients with HNC.29 It is important to recognize that facial appearance is a component of body image distress, which involves perceptions, thoughts, and feelings about the entire body.10 Originally designed for cosmetic surgery, the Aesthetic FACE-Q scales used in our study provide detailed data on aesthetic outcomes, including appearance-related psychosocial functioning. The Aesthetic FACE-Q scales, FACE-Q HNC scales, and the IMAGE-HN instrument may together provide a comprehensive assessment of appearance-related outcomes and body image distress among patients with HNC.
Approximately half of patients with advanced HNC survive beyond 5 years.30 There is an unclear association between follow-up time and aesthetic outcomes. A substantial body of evidence demonstrates aesthetic outcomes are worse in the first year from surgery but improve over time.9,31 However, our findings suggest that patients with HNC remain dissatisfied with the aesthetic outcomes several years after MFTT and is not significantly affected by longer follow-up time. This finding is consistent with studies that have shown body image distress persisting more than 1 year after diagnosis and treatment.10,32 As medical and surgical advances continue to improve the survival for patients with HNC, it is necessary to optimize aesthetic outcomes in the postoperative period.
A history of anxiety or depression and female sex have been identified as risk factors for worse aesthetic outcomes or posttreatment body image distress,4,9,10,11,33 both of which were associated with impaired appearance-related psychosocial functioning in this study. Psychiatric history should be routinely documented in preoperative consultations and may be particularly important among women. Women with significant facial disfiguration are at a greater risk for psychosocial dysfunction, but this distress may be buffered by a strong social support system.34 Recognizing high-risk patients may allow surgeons to place referrals for support before the emergence of substantial psychosocial deficits.
Facial aesthetics are also associated with the extent of surgery.9,32 Along these lines, we found that osteocutaneous flaps were associated with impaired aesthetic outcomes. Composite grafts of bone and soft tissue are among the most complex types of MFTT. The osteocutaneous fibula free flap is commonly performed for oral cavity tumors invading the mandible but may be associated with impaired social and role functioning.15,35 The anatomic structures encompassing the oral cavity have important aesthetic roles and figure prominently in social functions, such as mastication, swallowing, and speaking. Extensive oral cavity resection increases the risk of prolonged tube feeding requirements,17 which correlated with impaired aesthetic-related psychosocial functioning in our study. Oral incompetence when eating or speaking may create embarrassing appearance-related social interactions. Dental implants are a potential solution, improving aesthetics, social eating, and psychosocial quality of life after osteocutaneous fibula free flap reconstruction.36,37
Although most risk factors identified in this study are nonmodifiable, recognizing high-risk patients may allow implementation of risk mitigation strategies. Few patients with psychiatric history had received antidepressant medication preoperatively. Surgeon recognition of this potential oversight by placing referrals with mental health professionals might improve rates of therapeutic intervention. This action is important because most patients report unmet psychological needs, and many would have liked to receive resources for coping with aesthetic deficits before surgery.10,38 Fingeret et al39 described a systematic framework for approaching body image conversations, identifying patient concerns, and referring for psychosocial support. More research is needed because psychosocial interventions, such as cognitive behavioral therapy, psychoeducation, mindfulness, and group therapy, do not appear to consistently provide clinical benefit.40 However, patients with laryngeal cancer recently randomized to participate in an intensive psychoeducational course showed significantly lower depression rates and better quality of life after treatment.41 Implementing well-organized educational courses may help patients prepare and adjust for potential psychosocial impairments. Psychosocial function is needed for overall quality of life and may also have oncologic importance, as studies suggest an association between depression and survival in HNC.42
In addition to psychosocial interventions, surgical procedures may help improve aesthetic outcomes. Approximately 10% of patients undergo elective aesthetic or functional revisions after MFTT.43 These procedures may be used to address facial ptosis and skin asymmetry or redundancy. As reported previously, adjuvant radiotherapy is associated with worse aesthetic outcomes,19 in part due to significant scarring and lymphedema. Submental or cervical liposuction, fat augmentation, and flap refinement are potential methods for counteracting these posttreatment changes.44 Specifically, fat injections and/or vascularized fat transplants may be useful for correcting facial contour after multimodality treatment.45 It may be useful for surgeons to consider each of these procedures when evaluating patients who report poor aesthetic outcomes after MFTT.
Limitations
This study had limitations. Our sample size and response rate may lead to selection bias and limit the generalizability of these results. We were unable to evaluate aesthetic outcomes among patients who died before the study and those without email addresses. Many of the nonresponders have not followed up with our hospital system for several years and some were discharged to receive supportive care alone at their last encounter. Owing to the natural history of HNC, it is likely that many of these nonresponders have died, making our true response rate higher than we are able to confirm. Furthermore, there were no significant differences in baseline characteristics of responders and nonresponders. In light of this, we believe the 124 responses in this study are representative of patients with HNC 1 to 6 years after MFTT; however, we acknowledge the potential for nonresponse bias. Owing to the cross-sectional design of this study, we also did not have baseline questionnaires and could not evaluate meaningful improvements patients may experience over time. The minimal clinically important difference is also not known for the Aesthetic FACE-Q instruments. Although these instruments provide insight into aesthetic outcomes, they were not validated in patients with cancer. In addition, our population was skewed toward those with advanced disease undergoing complex reconstruction, which may be unique from other institutions. Future multicenter, prospective interventional studies with additional instruments and strict follow-up are needed to overcome these limitations.
Conclusions
In addition to functional and oncologic outcomes, facial aesthetics play an important role in psychosocial functioning after MFTT. The findings of this study suggest that patients with HNC undergoing osteocutaneous reconstruction and adjuvant (chemo)radiotherapy are at an increased risk of impaired aesthetic outcomes more than 1 year after MFTT. Women with a history of anxiety or depression, prolonged postoperative tube feeding requirements, and any recurrent disease are most vulnerable to appearance-related psychosocial impairments. It is important to identify these patients and implement risk mitigation strategies, such as psychosocial interventions or aesthetic revision surgeries. Considering aesthetic outcomes as a priority, reconstructive surgeons may help maintain the best psychosocial function among patients with HNC.
eTable. Comparison of Responder and Nonresponder Characteristics
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Associated Data
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Supplementary Materials
eTable. Comparison of Responder and Nonresponder Characteristics
