Nasal Function and Appearance Post Flap Repair: NAFEQ Study

In this interview, Dr Etzkorn and Dr Golda discussed the findings of their multi-center prospective cohort study on patients undergoing 2-stage interpolated flap repair for nasal defects. They focused on comparing nasal function and appearance before surgery and at 16 weeks after flap takedown using the Nasal Appearance and Function Evaluation Questionnaire (NAFEQ). The study revealed a slight improvement in patients' perceptions of nasal function and appearance post-takedown, providing valuable insights into the outcomes of this surgical approach for nasal reconstruction.

Jeremy Etzkorn, MD, MS-Biostatistics, is an associate professor in dermatology at the University of Pennsylvania in Philadelphia, PA. He is board-certified in both dermatology and micrographic dermatologic surgery and specializes in cutaneous oncology and Mohs micrographic surgery.

Nicholas Golda, MD, FAAD, FACMS, is board-certified in both dermatology and micrographic dermatologic surgery. His specializations include skin cancer and Mohs micrographic surgery, which he practices at the US Dermatology Partners Lee’s Summit in Lees Summit, MO.

The Dermatologist: How does the NAFEQ assess nasal function and appearance in patients undergoing 2-stage interpolated flap repair?

Dr Etzkorn: The NAFEQ is a validated survey instrument used to evaluate both function and appearance after nose reconstruction. There are 2 components; the functional component, which consists of 6 questions scored on the scale of 1 to 5. And the appearance component, which consists of 8 questions. The functional component has different questions such as, do you have trouble breathing? How is your smell ability? How well can you breathe? And do you have nasal crust or a bloody nose? Do you have any change in your speech? And in the appearance component, the first several questions are about different parts of your nose, so the wings of your nose, the tip of your nose, the dorsum of your nose, and then it asks about symmetry of your nostrils and similar other questions.

The Dermatologist: What were the key findings of the study regarding patients' nasal function and appearance before surgery and at 16 weeks after flap takedown? How do these findings contribute to our understanding of the outcomes of 2-stage interpolated flap repair?

Dr Etzkorn: The findings were generally reassuring for patients. Both function and appearance were, on average, improved at 16 weeks after flap takedown compared to before surgery. Importantly, this assessment was based on the patient's own evaluation, rather than the physician's evaluation. That was more than what we had anticipated. I would've anticipated maybe a slight decrement in either appearance or function, given the fact they had a sizable surgery to their nose. But the patients felt like they had an actual improvement in both function and appearance. What sets it apart from prior literature is the use of the NAFEQ, which is rigorously objective. It's validated as opposed to prior studies that have used off the cuff assessment instruments.

We had both pre- and post-assessment. Most studies just take a sample of patients at any time after their surgery and ask them how they felt about their surgery. We asked patients to score their nasal function appearance before surgery and at exactly 16 weeks after flap takedown, so everybody had the exact same timeframe so we could compare across all the different patients. Additionally, it wasn't just 1 surgeon. Pretty much all the other studies that have been done before are based on a single surgeon at a single center, we had multiple surgeons at multiple centers. They were all fellowship trained nose surgeons. But still, it shows that multiple surgeons at multiple sites can do this work and do it well.

Dr Golda: For all the effort and the risk that we as surgeons take on doing that procedure and the risk that patients take on having it done for them, what value are we producing for our patients? Therefore, I think the big take home message from this work is that patients are happier with the appearance of their nose following reconstruction, and it's better than before surgery. There are exceptions. There are people who come in with something that is an insidious skin cancer, and we end up having to remove a lot of their nose.

But by and large patients with a cancer that requires this reconstruction have a cancer of sufficient size and appearance that their nose doesn't look great to begin with, and they know that they've got a cancer there and they're unhappy with that. People will offer commentary on your appearance whether you like it or not. And say, "Hey, you should have that thing looked at. You should do something about your nose." So being able to provide people with both good oncologic care with nose surgery and then being able to follow up with an expert reconstruction that produces results where they end up happier with their nose than before we started, that's a win. And I think the data from this study support that.

The Dermatologist: The study found that overall NAFEQ scores increased slightly by 1.09 points at 16 weeks after flap takedown. Can you elaborate on the significance of this change in patients' perceptions of their nasal function and appearance?

Dr Etzkorn: The magnitude of the change is hard to really put too much emphasis into, in part because it's small. But if I were to be honest, when I first designed the study, I thought we were going to have a decrease in change. So, we were just hoping that we'd have at least less than a 5% decrease in change from baseline. Having an actual improvement in how patients felt about both the appearance and function of their nose was more than I had anticipated. I think, in general, it’s very reassuring for how we can counsel patients both pre- and postoperatively.

Dr Golda: I think basically this is showing that once the reconstruction has an opportunity to mature, people continue to become more and more happy with the outcome. This is a multi-stage reconstruction, and, in some cases, surgeons are having to do at a minimum 2 steps, and occasionally up to 3 or even 4 steps with these reconstructions just because of what is required to get that tissue moved from one place to another, have it stay alive, and then contour it and get it to the appearance that you're looking for. So, giving some time for the wound to mature and for people to settle in on how the wound's going to look as it matures a little bit. And I think even 16 weeks isn't total wound maturity. It shows that at what I would consider to be a somewhat early stage in the maturation of reconstruction, patients are already happy with how things look.

It just substantiates, again, the fact that this reconstruction works is worth the trouble, and most surgeons and dermatologic surgeons do a good job executing this reconstruction and providing good results for our patients.

The Dermatologist: You mentioned that you were expecting a decrease in change. Was there any reason behind it?

Dr Etzkorn: We are looking at it at an early timeframe, compared to other studies. When you look at the surgical literature and how wounds mature over time, a lot of people, including the reviewers who reviewed our study, asked, "Why did you ask people so early after their surgery, just 16 weeks after surgery, to assess their outcome?" For one, we felt, that it was more practical. To get patients to follow up, the longer you wait, the harder it is for them to follow up for a study. And it was the most critical way we could look at the outcome. If we look at things a year after, a lot of times people forget how things looked before, and they're much more forgiving. We wanted to get patients in a timeframe where they would still be quite critical of how they felt about the outcome. And candidly, as I said, I thought we would get maybe a decrease because of that. But we were surprised, frankly, to get an increase in the scores.

These surveys were conducted offsite, so they didn't have to look at us or interact with us when they were completing the surveys. They didn't have any pressure from us to give a higher score. I feel like we got their unbiased and honest assessment of how things turned out.

The Dermatologist: How do the results of this study impact the decision-making process for clinicians and patients considering 2-stage interpolated flap repair for nasal defects caused by skin cancer? Are there any implications for postoperative care or patient counseling based on the study's findings?

Dr Etzkorn: The one word I'd use is probably that we can be really reassured. We can be reassured that we're doing the right thing for the patient when we do these more complex procedures. Patients in the long run feel happy and confident with both, how their nose functions and appears. And a lot of times the competing option, which is radiation therapy, can give early good outcomes, but in the long run may not have as good curative outcomes from the standpoint of the skin cancer, but also cosmetically. It's nice to know that even at just 16 weeks after the surgery, we can get to a point where patients feel like their nose looks and functions just as well as it did before.

Dr Golda: I think the findings of the study support the decisions of people who do these reconstructions frequently. They also support surgeons in knowing that they're doing the right thing for their patients provided the patient is counseled in advance and wants to undergo this procedure, because it is an undertaking for the patient at home. This is straightforward reconstruction once you're well-trained in doing it. I feel like this reconstruction is probably more straightforward than some of the other more contrived single-stage reconstructions I try to execute for patients who don't want a 2-stage reconstruction. I think morbidity-wise, it can be less for them to go through. But then for those surgeons that maybe are doing fewer of these reconstructions because they feel like, “I'm not sure that this is the best thing for the patient, or I'm not sure that they're going to want to go through all of this,” I think it might embolden them to say, "Hey, look, the reconstruction works."

You're properly trained to do it. And once we get patients over that hump of dealing with the awkwardness of being between those 2-stages, they really like how it turns out. Relevant counseling, if I counsel patients properly about what to expect in the short and medium range, I can get them to that 16-week point where we can demonstrably show that not only is it going to look good, but you might like how your nose looks more than before I started, if we do this right.

You should be able to confidently tell patients that we're going to go through an awkward moment here between where we are now with that defect on your nose and where we want to be with you having a normal appearing nose. But if you trust me, I can get you there. And I think that's nice to have that information in our back pocket as we have those conversations with our patients.

Between the first and second stage, there's quite a bit of postoperative care that anybody who's doing this reconstruction knows to offer. The risk of bleeding is at least anecdotally higher. You've got exposed tissue there that isn't sewn together. There's more effort for the patients in all the stages of the reconstruction, and the postoperative care will be more than any other single-stage reconstruction that we do. Our goal is to produce a good result for our patients, but also have the reconstruction be as simple as possible. What's the simplest reconstruction I can do to get my patients to where they want to be? Sometimes it's a more complicated option than this, but ultimately you get to a point where just keeping a thin layer of petroleum jelly over a wound and giving it some time for healing is really it. Yes, the postoperative care is a bit more involved in the short term, but in the long term, really, it's like any other reconstruction that we do.

The Dermatologist: Are there any tips or insights you would like to share with your dermatologist colleagues regarding nasal function and appearance after flap takedown in patients with nasal skin cancer?

Dr Etzkorn: The toughest thing about doing these flaps is how we counsel patients, both before and after. And I learned this from a colleague a long time ago, Dr Shin, who told me the way she preoperatively counseled patients when this is an option to fix their nose. She asked them, "Do you care how your nose looks?" And now we have objective evidence that if patients really care how their nose looks after they must have a complex tumor taken off their nose, then the right way to do it is still the right way to do it. It may take more work, but in the long run, patients are happy with how things look and how things function. And in the end, doing the more complex thing sometimes is still the best thing.

Dr Golda: I tend to agree. Even for our simpler closures, very often when we're done just doing a straight-line closure, folks will look in the mirror and say, "Wow, that's bigger than I thought it would be," even if you counsel people in advance. So, I'm always careful to go over that with them, or at least have my staff do it. We say, "All right, here's what we're doing, here's what we've drawn out, here's what we're planning, this is how big it's going to be. And I can either give you a larger prettier scar, or a smaller uglier scar." It's a little bit of a false dichotomy, but it encapsulates what we’re doing on a small scale with those simpler closures, where sometimes we must do a little bit more or a slightly bigger procedure to get you to the place that you want to be, even if you don't know that's the path we have to take.

And I think that ties in with these advanced nasal reconstructions using these interpolated flaps where it is a real thing to do. It is well outside of the normal layperson’s experiencing in terms of, “You're going to do what, again, to fix my nose?” But just explaining to them that this is the path to getting you to, like Dr Etzkorn said, a place where your nose is going to look more normal. It's a bit of a longer path and it involves some things you may not have been expecting, but this is the right way to get it done for you. I basically want to double down on what Dr Etzkorn was saying and what Dr. Shin had mentioned to him. Find out where their priorities are and try to attend to their priorities first and foremost, but make sure they're informed that big scary thing is the road to the nasal promised land, basically.

Reference
Veerabagu SA, Perz AM, Lukowiak TM, et al. Patient-reported nasal function and appearance after interpolation flap repair following skin cancer resection: a multicenter prospective cohort study. Facial Plast Surg Aesthet Med. 2023;25(2):113-118. doi:10.1089/fpsam.2021.0271