Satisfaction With Head and Neck Scar Appearance in Latin American Patients: A Cross-Sectional Study

The incidence of head and neck tumors is increasing, and most require a surgical procedure for treatment; however, although well tolerated, surgical treatment leaves patients with a visible scar. Surgical scars are important for patients and have been related to poor quality of life.^1,2 This is particularly important for visible scars, as occurs in the head and neck area. Usually, the evaluation of scar appearance is performed by a surgeon with subjective instruments and focusing on specific characteristics, such as length, but without considering the patient’s point of view.^3-5 Some studies have demonstrated that other characteristics, such as hypertrophic aspect and adherence to subcutaneous tissue, are equally important for defining patient satisfaction with scars.^{1, 5} 

Most studies on head and neck scar appearance and satisfaction have been conducted in Asian countries, where scars located in this anatomic area have a specific social and cultural impact.^6-8  Only recently have patients from Western countries been included in trials assessing the effect of scars on appearance and quality of life.^1,9 For Latin American patients, the number of studies is scarce. Moreover, an evaluation of the available literature has shown that most studies that evaluated thyroidectomy scars used  nonvalidated instruments, which makes results difficult to reproduce. Other instruments for measuring scar characteristics, such as the PRISM and SCAR-Q, which have been designed with psychometric standards, have not been validated in Spanish.^10,11 For this reason, we previously validated the Patient Scar Assessment Questionnaire (PSAQ) instrument in the Spanish language in order to use it in Latin America.¹²

The main objective of this study was to describe the self-assessment of patient scars using the PSAQ in a cohort of Latin American patients who underwent head and neck surgery. The secondary objectives were to determine differences between clinical and therapeutic characteristics and to define the most relevant characteristics that affects scar appearance.

This is a descriptive cross-sectional study that utilized data from a previously published study of PSAQ validation.¹² The original study was approved by the Ethics in Research Committee of the Fundacion Colombiana de Cancerologia- Clinica Vida and written informed consent was obtained. The Spanish version of the PSAQ has 39 questions and 5 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 favorable category and 4 points assigned to the least favorable category). The appearance subscale consists of 9 questions (range 9-36), the scar consciousness subscale consists of 6 questions (range 6-24) and the satisfaction with appearance subscale consists of 8 questions (range 8-32). Higher scores indicate a worse cosmetic outcome. Each subscale also has a final global question evaluation of the domain. As suggested by Durani et al,¹³ we excluded the symptom subscales, leaving 23 questions.

Adult patients who underwent elective head and neck surgery were included. The following patients were excluded: those with reading, hearing, or cognitive difficulties; those with previous radiotherapy neck treatment; and those who did not consent to participate. Demographic, comorbidity, ASA classification, surgical procedure, and wound complication data were obtained from clinical charts.

For each procedure, a standardized surgical incision was used (transverse incision using a cervical crease for thyroidectomy, parathyroidectomy, and neck dissection and modified Blair incision for parotidectomy). Drainage was used at the discretion of the surgeon.

Statistical Analysis

The continuous variables are shown as the mean and standard deviation, and the categorical variables are presented as percentages and ranges. A descriptive analysis was performed for each individual item and for subscale scores after recategorizing the values as excellent/good and regular/bad; not at all/slightly noticeable and fairly/very noticeable; never/sometimes and often/always; and very satisfied/satisfied and dissatisfied/very dissatisfied. Comparisons of subscale scores for age, sex, type of procedure, time from surgery to scar assessment, and presence of postoperative complications were performed using Chi-squared, ANOVA, or Student’s t test. Multivariate analysis using a forward logistic regression was planned to assess the weight of specific subscale items on the overall subscale score for appearance and satisfaction with appearance, adjusting for age, sex, type of surgical procedure, and time from surgery. The effect was reported as an odds ratio with a 95% confidence interval. We used Stata statistical software (StataCorp, Texas, version 9.1) and set the significance level to P < .05.

Population

A total of 180 patients were enrolled in the study. The demographic and clinical data are shown in Table 1. The mean age was 49 ± 15.1 (20-86) years, with 43 patients (23.8%) being over the age of 59. A total of 144 patients (80%) were female, with 94 (52.3%) reporting at least one comorbidity. Thyroidectomy was the most common type of surgery, followed by thyroidectomy plus lateral neck dissection.

PSAQ Item Description

Figure 1 shows the results of each categorized individual item of the appearance subscale. The items with the less favorable results were length (regular/bad 38.3%) followed by color (19.4%). The global appearance was classified as excellent/good in 72.2% of patients.

Figures 2 and 3 show the results of each categorized individual item of the scar consciousness and scar appearance satisfaction subscale, respectively. The items with the least favorable results in terms of scar consciousness were noticeable for you and for others (27.8%). Global scar consciousness was classified as excellent/good in 93.9% of patients. The items with the least favorable results in terms of scar appearance satisfaction were satisfaction with length (13.9%) followed by satisfaction with color (10.6%). Global scar appearance satisfaction was classified as excellent/good in 87.8% of patients.

Comparisons of Subscale Scores

The total scores for the appearance, scar consciousness, and satisfaction with scar appearance were 14.8 + -3.9 (3-30), 11.1 + -4.6 (6-24), and 12.8 + -4.1 (8-29), respectively. The total scores were low. Table 2 shows the results of the comparisons of subscale scores by demographic and clinical variables. Appearance subscale scores were significantly different for age, type of procedure, and drain use; scar consciousness subscale scores were significantly different for age, type of procedure, and time from surgery; and satisfaction with scar appearance was significantly different for type of procedure and use of drain.

Multivariate Analysis

The adjusted logistic regression showed that color (OR 5.9, 95% CI 1.7-20.8), width (OR 58.9 [4.3-807.6]), and flatness (OR 5.7 [1.3-23.6]) were the items statistically associated with a regular/bad result in the appearance subscale. The model excluded the shininess item.

Surgical procedures performed in the head and neck area are perceived to be a source of aesthetic complaints due to visibility.³ Usually, surgeons mention their worries and suggest that factors such as length and location are the most relevant characteristics affecting cosmesis. This has helped the development of remote access surgery, which is a surgical strategy that avoids the cervical scar and uses accesses that are located in less visible areas such as the axilla or through natural orifices (transoral surgery) and is usually supported in the concept that the appearance and satisfaction with the cervical surgical wound is poor.¹⁴ However, it is known that assessments of neck and face scars made by physicians and patients are different and that physicians can under- or overestimate the impact of surgical scars.^1,15 On the other hand, most evaluations of surgical scars after thyroidectomy are performed with nonvalidated instruments, the results of which are prone to mismeasurements and bias.^3,4

This study tried to surpass these difficulties. We used a validated instrument with good psychometric properties and asked for patients’ perceptions about their scars. The findings confirm that most patients qualify their scars as excellent and good and that the satisfaction level is high. Although a significant percentage of patients (27%) considered the appearance of their scar to be moderate or poor, dissatisfaction with the scar was low (12%). These findings were similar to those reported by Best et al,¹⁶ who retrospectively evaluated 69 American patients who underwent total thyroidectomy and had more than a year of follow-up. They found an overall satisfaction of 91.3% and satisfaction with the appearance of the scar of 97.1%. On the contrary, Felix et al¹⁷ found much lower satisfaction in a group of 48 patients from Trinidad and Tobago, which may be due to a higher percentage of patients of African descent who have a higher risk of alterations in the surgical scar. Finally, Linos et al¹⁸ discovered a frequency of satisfaction greater than 98% in a retrospective design with 691 Greek patients; 44% of the patients included underwent endoscopic-assisted techniques, with about 13% undergoing selective. These differences can be explained by the inclusion of other more extensive surgical procedures such as neck dissection in our study and by the cultural differences in populations. Unexpectedly, only 6% of patients reported being frequently conscious of their scars. It is clear that the notion of satisfaction is complex, subjective, and influenced by many other factors, such as preoperative information, cosmetic expectations, concern with disease symptoms, fear of tumor recurrence, and culture, which are usually not considered in clinical situations.^19,20 As most patients had malignant disease, this could affect the global perception of scars in the disease context.

A univariate comparison of the subscale scores showed statistically significant differences by age, type of procedure, time from surgery, and drain use. However, in the multivariate analysis, these differences disappeared.

The most relevant characteristics for appearance dissatisfaction were the color, width, and flatness of the scar but not the length of the scar. These findings have been confirmed by some studies^8,21,22  but not others.¹⁶  Otherwise, a common assumption of an association between age and scar aesthetic appearance could not be found. However, Arora et al¹ found an association after multivariate analysis. Knowledge of these scar conditions and the interventions to modify them improves the quality of the scar. Ma et al⁸ designed a protocol named “Aesthetic principles access thyroidectomy” and demonstrated an improvement in scar rating and satisfaction, and Consorti et al²³ demonstrated that the type of suture influenced scar appearance. In a RCT Chung et al²⁴ evaluated the use of subcuticular suture or tissue adhesive combined with local postoperative measures of no-ablative laser and steroid infiltration in patients undergoing thyroidectomy and found a decrease in pigmentation scores and wound thickness. Guo et al,¹⁸ in a meta-analysis that evaluated the infiltration of the wound with botulinum toxin type A, found that its routine use had a significant effect in reducing the thickness of the scar, which suggests that these alternatives may improve scar quality. In addition, the intense search for shortening the length of scars should be critically reassessed, and other interventions directed to preserve the skin color, decrease the width, and increase the flatness of scars must be introduced in clinical practice to improve the cosmetic results.

Some weaknesses of this study must be mentioned. The small sample size and the cross-sectional design could have biased the results. In addition, the time from surgery to scar assessment was short, which could have influenced the appearance evaluation due to the lack of scar maturation.

In conclusion, this is one of the few studies to assess scar appearance, consciousness, and satisfaction in the Latin American population after head and neck surgery with a validated instrument. There is a high level of satisfaction with head and neck scar appearance, and these data should be used to assess the impact of surgical interventions on cosmesis. The intrinsic characteristics of scars such as color, width, and flatness are the most relevant for defining scar satisfaction, and interventions to modify these conditions must be encouraged in order to improve the esthetic aspect of scars.