Introduction

The reconstruction of defects resulting from facial skin tumor excision requires a careful prior assessment of the patient and the defect itself. The ideal outcome is the best potential form and function with the lowest morbidity.

The loss of facial structure affects self-perception, and the subject’s identity often requires restoration. Psychological well-being and social function in everyday life are the most significant parameters in the quality of life (QoL) of each person.¹

As such, facial reconstruction surgeries play fundamental functional and social roles in the patient’s life. However, the surgeon’s perception of beauty standards may not be consistent with the patients’ due to geographical and social contexts. Therefore, it is fundamental to assess the degree of postoperative satisfaction, including its demographic, physical, and psychological determinants. According to Alanko et al., a harmonious face is commonly associated with intelligence, better interpersonal relationships, and a higher social status.²

Several factors, both intrinsic and extrinsic to the patient, influence the reconstruction procedure. This study aimed to comprehensively evaluate this impact, considering the QoL and changes in facial physiognomy for a more complete analysis.

The standardized 36-item Short Form Health Survey (SF36) is a critical tool for QoL assessment. The volume of references available in bibliographic databases and the growing number of validation studies in different countries and cultural contexts demonstrate its scope in population surveys and studies evaluating public policies and the health status of patients.³

This tool aims to detect clinically and socially relevant differences in the health status of the general population and people affected by some diseases. It also identifies health changes over time as a reduced number of statistically efficient dimensions.

Objective

The current study aimed to evaluate the impact of treatment on the QoL of patients undergoing surgical skin tumor resection and facial reconstruction using the SF-36. This tool enables an objective outcome analysis, eliminating potential biases from the surgeon’s perception.

Materials and Methods

This research study applied the SF-36 to patients who underwent facial defect reconstruction after skin tumor resection from January 2022 to December 2022 at the Integrated Plastic Surgery Services of Hospital Ipiranga (Serviços Integrados de Cirurgia Plástica do Hospital Ipiranga, SICPHI, in Portuguese). We conducted in-person interviews with 50 volunteer patients aged 28 to 100 (mean: ¼ 70.13 13.68) years. Among them, 14 were female (28%) and 36 were male (72%) subjects. All patients signed the informed consent form (ICF) and received information on the objectives, the significance of the study, and the potential results. The Ethics in Research Committee of Hospital Ipiranga approved this study.

The inclusion criteria consisted of patients from both sexes, with no age limit, in the American Society of Anesthesiologists (ASA) II classification undergoing elective facial defect reconstruction surgeries with confirmed tumor-free margins at paraffin embedding slides. All surgeries occurred with a standardized local anesthetic solution (lidocaine 2% without vasoconstrictor, 20 mL þ saline solution 0.9%, 60 mL þ 1 epinephrine vial) at SICPHI. Postoperative outpatient follow-up occurred in 48 hours, 7 Table 1 Demographic characteristics and 15 days, 1, 3, and 6 months, as well as 1 year after surgery.

Table 1 - Demographic characteristics

We excluded subjects with cognitive impairment or who did not understand how to read and interpret the SF-36.

The SF-36 is a multidimensional QOL instrument developed in 1992 by Ware and Sherbourne and validated in Brazil by Ciconelli.³ It consists of 36 items divided into 8 sections: functional capacity (10 items), physical aspects (4 items), pain (2 items), general health status (5 items), vitality (4 items), social aspects (2 items), emotional aspects (3 items), mental health (5 items), and 1 question for comparative assessment between current health conditions and those from 1 year ago. It assesses negative (illness or disease) and positive health aspects (well-being).

Each SF-36 question receives a score from 0 to 100, in which zero is the worst and 100 is the best health status. The analysis of each dimension occurs separately. Purposefully, no single value summarizes the entire assessment, translating into a better or worse general state of health. As such, the average score avoids the error of not identifying or underestimating the patient’s health issues.

The statistical analysis was performed using the IBM SPSS Statistics for Windows (IBM Corp.) software, version 20.0. The descriptive analysis was presented as mean and SD values. The Kolmogorov-Smirnov test indicated a normal data distribution except for the general health perceptions and vitality variables, which presented a distribution similar to a Gaussian curve, allowing the use of parametric tests.

Multivariate analysis of variance (MANOVA) compared mean and standard deviation (SD) values between sexes and SF-36 domains. Pearson correlation coefficient was perfect (r ¼ 1), strong (r > 0.75), moderate (r > 0.5), weak (r < 0.5), or nonexistent (r ¼ 0). The significance level for the test was 5% (p< 0.05).

Results

►Table 1 presents demographic characteristics. Of the 50 volunteer patients interviewed, 14 (28%) were females, and 36 (72%) were males. The mean age of the sample was of 70.13 13.68 years. All volunteers could answer the questionnaire completely, and there were no withdrawals.

►Table 2 shows the mean and SD values for each domain of the SF-36 questionnaire. Each domain has a final score from 0 to 100, in which zero corresponds to the worst and 100 to the best general health status.

Table 2 - Mean score on each 36-Item Short Form Survey (SF-36) domain

►Table 3 compares the mean values between sexes and comorbidities considering the SF-36 questionnaire domains. This comparison showed differences between subjects with and without type-2 diabetes mellitus (T2DM). However, statistical tests indicate that males and females presented similar QoL.

Table 3 - Sex comparison regarding the 36-Item Short Form Survey (SF-36) domains

However, since the number of participants did not reach the minimum required for MANOVA, we investigated paired comparisons using the Bonferroni correction, as shown in ►Table 4. People with T2DM presented a higher level of limitations due to emotional aspects and lower mental health when compared to those without. Therefore, we can infer that the presence of T2DM correlated with higher health impairment, regarding emotional aspects and mental health.

Table 4 - Univariate model results (ANOVA)

Additionally, ►Table 4 shows that men presented higher levels of vitality and mental health than women, indicating that they have more privilege in general health. Finally, womenwith T2DM presented lower levels of general health and mental health than healthy women and men, indicating that this group was the most affected among those studied here.

►Table 5 presents the correlation among the SF-36 domains. The comparison between the functional capacity domain had statistical significance when correlated with physical aspects, pain, general health status, social aspects, and mental health, with a weak positive linear Pearson correlation. The same occurred for the physical aspects domain and functional capacity, vitality, emotional aspects, and mental health; pain and functional capacity, vitality, social aspects, and mental health; general health status and functional capacity, vitality, social aspects, and mental health; vitality and physical aspects, pain, general health status, social aspects, and emotional aspects; social aspects and functional capacity, pain, general health status, vitality, and mental health; emotional aspects and physical aspects; and mental health domain and functional capacity, physical aspects, pain, general health status, vitality, and social aspects.

Table 5 - Correlation among the 36-Item Short Form Survey (SF-36) domains

The pain and emotional domains and the social and emotional domains presented statistically significant differences and weak negative or inverse linear Pearson correlation.

Discussion

Patient satisfaction with their facial appearance is a critical outcome criterion for assessing the effectiveness of the reconstructive procedure. Although previously considered a “soft indicator,” patient satisfaction evaluation has become an integral part of healthcare quality management. Patients’ self-perception of satisfaction with their postoperative facial appearance must be a fundamental criterion for success.^4,5

For instance, QoL can relate to the idea of health, professional achievement, happiness, self-esteem, and self-acceptance. In search of a better definition, medicine no longer considers disease as symptom control or reduced mortality, but as psychology and aesthetics, often aiming at acceptance of one’s image.⁶

In plastic surgery, an unexpected outcome frequently results in irrevocable regrets. Therefore, surgeons must assess expectations and know how to distinguish the reasons leading a patient to their office since erroneous interpretations can lead to distress on both sides and even legal disputes.⁷

This study revealed that, on average, participants who underwent surgical skin tumor resection and facial reconstruction scored higher than 50 in all SF-36 quality-of-life questionnaire domains. These results indicate that their postoperative QoL is not below the expected average. Furthermore, male participants demonstrated slightly higher performance than females in functional capacity, pain, social, and emotional aspects, but without statistically significant differences (p> 0.05).

This study has some limitations. As a retrospective crosssectional study, it could not establish causal relationships, only associations between variables. Another limitation is the small sample size (n ¼ 50), potentially compromising the generalization of the results to larger populations. In addition, the difference in the proportion of male and female participants may have influenced the comparative analysis.

Therefore, future studies with more robust designs, larger samples, and greater variable control are required to corroborate the findings presented here and explore details of the identified associations. Additional investigations can also contribute to deepening knowledge about the factors impacting the QoL of patients undergoing surgical resections and facial reconstructions, expanding the scope of clinical and scientific implications.

Conclusion

Our findings showed no statistically significant differences in SF-36 questionnaire domains comparing men and women undergoing surgical skin tumor resection and facial reconstruction. Additionally, subjects with T2DM presented higher health impairment, particularly regarding limitations in emotional aspects and mental health, than people without the disease. These findings highlight the significance of considering the emotional and mental health of patients with T2DM in the perioperative context, indicating the need for specific interventions to improve their QoL after surgery.