INTRODUCTION
In addition to having a significant impact on morbidity, benign and malignant
skin lesions can decrease productivity, cause social exclusion, and affect an
individual’s quality of life (QoL)1,2. Among skin
lesions, skin cancer has shown an increasing incidence in the past three
decades, with it being the most frequently observed neoplasm and affecting
approximately 0.06% of the population in 20153.
The most common sites of skin neoplasms are the head and neck regions, accounting
for up to 80% of non-melanoma skin cancer cases4. The consequences of treatment, especially in this region, may
include physical and psychological disorders5,6 because
sequelae and scars resulting from surgical treatment can cause different types
of facial deformities and physical changes7.
The burn sequela is another type of skin injury that triggers serious physical,
psychological, and financial problems for patient, families, and society8. Even when the causes of psychological
discomfort are minor deformities or minor aesthetic failures, they may cause
inferiority feeling or emotional conflict9,10.
These patients are often referenced for surgery services in order to correct
anatomical and functional defects. In this condition, the concept of healing
should not only be based on biological recovery, but should also include
well-being, psychic survival, self-esteem and QoL11,12.
According to the World Health Organization, “quality of life is the perception of
the individual, of his position in life, in the context of the culture and value
system in which he lives and in relation to his goals, expectations, standards,
and interests”9, which is related to
health promotion and disease prevention, treatment, and rehabilitation to
improve patients’ well-being10-12.
Self-esteem, in turn, consists of the positive feelings of the individual about
oneself. This is subjective because it determines how the individual thinks and
behaves, and their measures are based on individual and social experiences13.
Several studies have evaluated the impact of cosmetic surgery on QoL or
self-esteem after procedures such as blepharoplasty, rhinoplasty, and
rhytidectomy13-15, and further studies may examine the
impact of restorative surgery on patients described here.
OBJECTIVE
The present study investigated the effect of reconstructive plastic surgery on
QoL and self-esteem in patients with benign or malignant skin lesions who were
referred to the Plastic Surgery Service of a university hospital in the South
of
Brazil for surgical procedures.
METHODS
This non-randomized, open-label clinical trial examined patients with indications
for repair surgery and evaluated the changes in QoL and self-esteem between the
pre- and postoperative periods.
Patients aged ≥18 years with benign or malignant skin lesions classified
by the International Statistical Classification of Diseases and Related Health
Problems 10 with or without deeper planes and indications for surgical repair
procedures were included in the study. These patients were referred from other
services to the outpatient surgery clinic. The exclusion criterion was the lack
of intellectual capacity to respond to the questionnaire.
The patients underwent procedures in the surgical center in the presence of a
team consisting of the surgeon, surgical assistant, medical resident or medical
student, and anesthesiologist. After the procedure, patients were contacted by
telephone to remind them to return for follow-up appointments to reduce the risk
of losses. The indication for the surgical procedure was identified by two
surgeons independently; in cases of disagreement, the decision was made by
consensus. To diagnose the patients’ lesions, clinical examinations,
transoperatory examinations, and histopathological studies were used.
The outcomes of the study were patient QoL and self-esteem. For the QoL
evaluation, the 36-Item Short Form Health Survey (SF-36) questionnaire was used.
The SF-36 is easy to use, validated in Brazil, and frequently used to assess
this topic16,17.
The SF-36 is a multidimensional questionnaire consisting of 36 items grouped into
8 components or domains: functional capacity, limitation by physical aspects,
pain, general health, vitality, social aspects, limitation by emotional aspects,
and mental health. The domains are calculated according to formulas already
established by the questionnaire itself, and the results are transformed into
a
scale of 0-100, where zero is considered the worst state and 100 is the
best18,19.
The Rosenberg Self-Esteem Scale (RAS), a quick and easy-to-use research
instrument20, was used to assess
patient self-esteem. In the present study, the Brazilian version of the EAR was
used, as it has been validated and adapted to the needs and characteristics of
the country’s population20.
The EAR is a 10-item questionnaire with contents related to the feelings of
respect and acceptance of the individual in relation to oneself, and each
question is answered on a scale of totally agree, agree, disagree, and totally
disagree (4, 3, 2, and 1 point(s), respectively). The higher the score, the
higher the self-esteem level21.
QoL and self-esteem were assessed, and patients’ baseline characteristics were
recorded at the preoperative visit. The surgical procedure was performed a mean
4 weeks later, at which time information was collected about the technique used
and the lesion’s characteristics. At the postoperative visit a mean 8 weeks
after the first visit, the QoL and self-esteem questionnaire were applied for
the second time and data on the lesion’s histopathological diagnosis were
collected.
The sample was calculated using the expected difference between the different
domains of the QoL questionnaire and the differences in the self-esteem scores.
The estimated values were obtained from an earlier study22. A 95% confidence level and 95% statistical power were
used in all calculations. For each of the QoL domains, the required sample size
calculation was performed considering the mean and standard deviation (SD) in
the preoperative and postoperative periods.
The mental health domain required a larger sample size. Pre- and postoperative
scores for this domain were 55 (DP 8) and 65 (DP 13), respectively. The
calculated sample size was 52 patients, considering 10% for losses and 50% for
confounding factors. Calculation of the sample for RAS considered a mean and
DP
before and after 20 (DP 5) and 28 (DP 6), respectively. The n necessary for this
outcome was 26 individuals. Thus, the sample size required for the two outcomes
was 52 patients.
The independent variables studied included:
a) Sociodemographic: age, skin color reported by the patient (white, black,
or yellow), sex, marital status, literacy, education level, per capita
family income classified in quartiles, activity performed in the month
prior to the interview;
b) Lesion or disease characteristics: area size, clinical and
histopathological diagnosis, presence or absence of systemic neoplastic
disease, and lesion topography defined as the face (nose, ear, lip,
periorbital, frontal malar), cranial, cervical, trunk, upper limbs,
lower limbs, or genital;
c) Classification of surgical treatment: type, resection with primary
closure, graft preparation, resection followed by local flap, and use of
tissue expanders;
d) Stress-producing life events defined as changes in the environment
occurring up to 12 months prior to the evaluation, the magnitude of
which required a degree of social or psychological adaptation by the
patient: severe illness, death of close relatives, hospitalization,
separation/divorce, forced housing change, severe financial problems,
robbery, or robbery with violence23.
A database was built in the Epidata 3.1 program. The data were typed in duplicate
by two independent typists. Subsequently, the bank was cleaned by the
identification of errors of amplitude or consistency. For the data analysis,
the
bank was translated into a statistical program (Stata 13.1). A descriptive
analysis was performed of the studied sample.
SF-36 scores by domain and RAS scores were calculated for the first and second
queries. The difference in scores was statistically analyzed using Student’s
t-test for paired samples. Subsequently, the differences in
the proportion of individuals in whom their self-esteem and QoL scores in each
category were improved were analyzed using the chi-square test. In all analyses,
a p value of <0.05 was used for a two-tailed test.
The project followed the guidelines of Resolution No. 466 (December 12, 2012) and
was approved by the Research Ethics Committee in the Health Area of the Federal
University of Rio Grande. All patients signed an informed consent form to
confirm that they were willing to voluntarily participate in the study.
RESULTS
A total of 52 patients were selected for and participated in the study; there
were no losses. The mean time between the first and second application of the
questionnaire was 63.08 days (SD, 2.51; minimum, 58; maximum, 67). The data
collection period was from June to October 2016.
The mean patient age was 51.69 (SD, 24.12; range, 19-90) years, with the highest
number of patients being aged ≥60 years, female, white, unmarried, and
literate with a low education level (40% with less than 3 years of study). The
first and last quartiles of monthly income were 458 and 1,300 reals,
respectively. Four of the 10 patients were employed.
The mean skin lesion size was 6.8 cm2; 46.15% of lesions were
malignant neoplasms, whereas 53.85% of lesions were benign. They were
characterized as trauma or burns, pathological or unsightly scars, or benign
neoplasms. Among the neoplasia types, 75% were basal cell carcinoma, 20.83% were
squamous cell carcinoma, and 4.17% were melanoma. In 69.23% of the patients,
defect closure techniques included the use of surgical flaps or skin grafting.
Most lesions were found on the face or scalp (67.31%) (Table 1).
Table 1 - Characteristics of patients who underwent reconstructive plastic
surgery at a university hospital in South Brazil, Rio Grande, RS, 2016
(n = 52).
Characteristics |
n |
(%) |
Age (years) |
|
|
0-19 |
5 |
(9.62) |
20-39 |
13 |
(25) |
40-49 |
11 |
(21.15) |
≥60 |
23 |
(44.23) |
Skin color |
|
|
White |
46 |
(88.46) |
Black or brown |
6 |
(11.54) |
Sex |
|
|
Female |
30 |
(57.69) |
Male |
22 |
(42.31) |
Marital status |
|
|
Unmarried |
33 |
(63.43) |
Married |
19 |
(36.54) |
Literacy |
|
|
Literate |
51 |
(98.08) |
Illiterate |
1 |
(1.92) |
Education |
|
|
Up to 3rd grade
|
21 |
(40.38) |
4th to 7th grade
|
19 |
(36.54) |
8th grade or more
|
12 |
(23.08) |
Family income |
|
|
1st quartile
|
458.00 |
(90.6) |
2nd quartile
|
644.00 |
(62.5) |
3rd quartile
|
900.00 |
(81.7) |
4th quartile
|
1,300.00 |
(293) |
Employment status |
|
|
Unemployed |
30 |
(57.69) |
Employed |
22 |
(42.31) |
Lesion area (cm2)
|
6.86 |
(5.62) |
Lesion type |
|
|
Malignant neoplasm |
24 |
(46.15) |
Other |
28 |
(53.85) |
Neoplasm type |
|
|
Basal cell carcinoma |
18 |
(75.00) |
Squamous cell carcinoma |
5 |
(20.83) |
Melanoma |
1 |
(4.17) |
Location |
|
|
Face/scalp |
35 |
(67.31) |
Trunk/limbs/other |
17 |
(32.69) |
Type of surgical treatment |
|
|
Primary closure |
16 |
(30.77) |
Surgical graft or flap |
36 |
(69.23) |
Stress event |
|
|
None |
44 |
(84.62) |
At least 1 |
8 |
(15.38) |
Table 1 - Characteristics of patients who underwent reconstructive plastic
surgery at a university hospital in South Brazil, Rio Grande, RS, 2016
(n = 52).
As for SF-36 results (Table 2), the
initial scores of the domains were mostly >70 points, and social aspect was
the domain with the best score. After the surgical intervention, significant
improvement was noted in the QoL life score for emotional aspects, limitation
for physical aspects, social aspects, pain, general health, and mental health.
The greatest increase was observed in the emotional aspects domain, followed
by
physical aspects and social aspects. The differences between the scores and the
means are shown in Table 2.
Table 2 - Quality of life and self-esteem scores before and after
reconstructive plastic surgery in Rio Grande, RS, Brazil, 2016 (n =
52).
Function |
1st measure
|
2nd measure
|
Difference |
P |
Mean |
SD |
Mean |
SD |
36-Item Short Form Health Survey item |
|
|
|
|
|
|
Functional capacity |
75.67 |
25.65 |
76.35 |
27.79 |
0.68 |
0.6 |
Limitations due to physical aspects |
74.51 |
36.85 |
91.8 |
19.62 |
17.29 |
0.0004 |
Bodily pain |
74.03 |
15.9 |
76.35 |
15.21 |
2.32 |
0.004 |
General health status |
73.75 |
17.25 |
85.2 |
14.41 |
11.45 |
0.0001 |
Vitality |
66.15 |
8.02 |
67.95 |
8.85 |
1.8 |
0.2 |
Social aspects |
77.64 |
19.7 |
92.75 |
13.17 |
15.11 |
0.0001 |
Emotional aspects |
67.3 |
40.95 |
91.02 |
23.90 |
23.72 |
0.0001 |
Mental health |
76.53 |
9.98 |
82.38 |
9.57 |
5.85 |
0.0004 |
Rosenberg Self-Esteem Scale score |
22.13 |
3.61 |
28.92 |
1.45 |
6.79 |
0.001 |
Table 2 - Quality of life and self-esteem scores before and after
reconstructive plastic surgery in Rio Grande, RS, Brazil, 2016 (n =
52).
In terms of RAS (Table 2), there was a
significant difference of 6.79 points between the post- and preoperative
periods.
The proportions of individuals with increased QoL and self-esteem after surgery
differed among categories (Table 3). A
higher education level significantly affected the physical, social, and
emotional aspects. The proportion of patients aged ≥ 60 years for whom
QoL increased was significantly higher than that that of subjects aged < 60
years in the emotional aspects domain.
Table 3 - Proportion of patients in whom QoL and self-esteem scores increased
after reconstructive plastic surgery according to sociodemographic
variables, neoplasm type, and stress event in Rio Grande, RS, Brazil,
2016 (n = 52).
|
Quality of life, % (n) |
Self-esteem, % (n) |
Variable |
Functional capacity |
Physical aspect |
Bodily pain |
Health |
Vitality |
Social aspects |
Emotional aspects |
Mental health |
Sex |
|
|
|
|
|
|
|
|
|
Male |
13.6 (3) |
31.82 (7) |
22.73 (5) |
68.18 (15) |
40.91 (9) |
63.64 (14) |
31.82 (7) |
36.36 (8) |
90.00 (27) |
Female |
6.7 (2) |
26.67 (8) |
13.33 (4) |
60.00 (18) |
33.33 (10) |
56.67 (17) |
43.33 (13) |
46.67 (14) |
90.91 (20) |
Age ≥60 years |
|
|
|
|
|
|
|
|
|
Yes |
17.4 (4) |
34.78 (8) |
21.74 (5) |
73.91 (17) |
34.78 (8) |
73.91 (17) |
56.52 (13)a |
39.13 (9) |
86.96 (20) |
No |
3.4 (1) |
24.14 (7) |
13.79 (4) |
55.17 (16) |
37.93 (11) |
48.28 (14) |
24.14 (7) |
44.83 (13) |
93.10 (27) |
Color |
|
|
|
|
|
|
|
|
|
Black or yellow |
0.0 (0) |
0.00 (0) |
16.67 (1) |
50.00 (3) |
16.67 (1) |
33.33 (2) |
16.67 (1) |
0.00 (0)a |
100.00 (6) |
White |
10.87 (5) |
32.61 (15) |
17.39 (8) |
65.22 (30) |
39.13 (18) |
63.04 (29) |
41.30 (19) |
47.83 (22) |
89.13 (41) |
Education |
|
|
|
|
|
|
|
|
|
<3 years |
4.76 (1) |
9.52 (2)a |
9.52 (2) |
52.38 (11) |
38.10 (8) |
42.86 (9)a |
14.29 (3)b |
42.86 (9) |
95.24 (20) |
≥3 years |
12.90 (4) |
41.94 (13) |
22.58 (7) |
70.97 (22) |
35.48 (11) |
70.97 (22) |
54.84 (17) |
41.94 (13) |
87.10 (27) |
Married |
|
|
|
|
|
|
|
|
|
Yes |
12.12 (4) |
21.21 (7) |
21.21 (7) |
60.61 (13) |
39.39 (13) |
51.52 (17) |
33.33 (11) |
42.11 (8) |
89.47 (17) |
No |
5.26 (1) |
42.11 (8) |
10.53 (2) |
68.42 (20) |
31.58 (6) |
73.68 (14) |
47.37 (9) |
42.42 (14) |
90.91 (30) |
Malignant neoplasm |
|
|
|
|
|
|
|
Yes |
16.67 (4) |
37.50 (9) |
29.17 (7)a |
70.83 (17) |
45.83 (11) |
66.67 (16) |
50.00 (12) |
46.43 (13) |
87.50 (27) |
No |
3.57 (1) |
21.43 (6) |
7.14 (2) |
57.14 (16) |
28.57 (8) |
53.57 (15 |
28.57 (8) |
37.50 (9) |
92.86 (26) |
Stress event |
|
|
|
|
|
|
|
|
|
Yes |
0.00 (0) |
50.00 (15) |
25.00 (2) |
50.00 (4) |
50.00 (4) |
75.00 (6) |
37.50 (3) |
75.00 (6)a |
87.50 (7) |
No |
11.36 (5) |
25.00 (11) |
15.91 (7) |
65.91 (29) |
34.09 (15) |
56.82 (25) |
38.64 (17) |
36.36 (16) |
90.91 (40) |
Table 3 - Proportion of patients in whom QoL and self-esteem scores increased
after reconstructive plastic surgery according to sociodemographic
variables, neoplasm type, and stress event in Rio Grande, RS, Brazil,
2016 (n = 52).
In the mental health field, a significantly higher proportion of white patients
than black or yellow patients displayed an increased QoL. A significantly higher
proportion of patients with malignant neoplasms than those with benign neoplasms
presented an improved QoL in the pain domain.
A higher proportion of patients who had at least one stressful event than those
who did not have a stressful event demonstrated statistically significant
improvement in the mental health domain. There was no significant difference
in
self-esteem, and the proportions of increases in all categories were
>86%.
DISCUSSION
The present study found a statistically significant difference in patients’ QoL
and self-esteem after reconstructive surgery.
With regard to QoL, improvement was seen in all domains, particularly in
emotional aspects (improvement of 23.72), limitations in physical aspects
(improvement of 17.29 points), and social aspects (improvement of 15.11 points),
as well as changes in areas such as mental health (improvement of 5.85 points).
Some studies have analyzed the effect of restorative surgery on QoL, and most
studies show a significant association affecting several domains.
The change in the emotional aspect domain could be justified mainly by the
psychic effect caused by the surgical correction of localized lesions,
especially in areas of exposure, such as the face, that cause constant concern,
especially neoplasias, which generate fear, anxiety, and distress6.
This result is consistent with those of other studies that have evaluated this
aspect. An article on the effect of QoL in repairing surgery performed
specifically to correct venous ulcers through skin grafting also observed a
positive impact on QoL similar to that obtained here, with improvement seen
especially in the domains related to limitation by physical and emotional
aspects22.
Another study comparing QoL between patients who did or did not undergo breast
reconstruction after mastectomy observed that women who did not undergo breast
reconstruction had greater emotional fragility and more greatly affected
emotional domain of QoL24. Another study
detailing the effect of reductive mammoplasty on QoL identified that the
surgical correction of breast hypertrophy improved QoL and the emotional
aspect25.
Finally, a subsequent German study of 72 patients with non-melanoma skin cancer
who completed a QoL questionnaire found a moderate-to-strong impact on QoL,
emotional aspects, functional capacity, and disease-related symptoms after
surgery26.
The increase in the physical aspect domain observed in our study could be
explained by an improvement in function and impact on the psychological aspect
of the patient, repercussion with improved disposition, decreased fatigue, and
fatigue altering rest and sleep, leading to an improved capacity to perform
personal and professional activities27.
The improvement observed in the present study in terms of social aspects could
also be justified by the physical improvement, appearance, and psychic questions
of the individual, especially considering that he feels accepted by his group
in
social activities, the professional environment, and relationships with family
and friends28.
We identified an important improvement in the mental health domain, demonstrating
the role of reconstruction. These data are consistent with those of another
study of patients with head and neck neoplasia in which the impact on QoL was
assessed after surgical treatment and where postoperative improvement was
observed, especially in the mental health domain29.
The important increase observed in the RAS scores after the interventions (6.79
points) demonstrates the relevant role of restorative surgery in the recovery
function of the individual’s self-esteem. The psychological impact due to
improved function, as in the case of correction of cicatricial retractions
caused by burns or the treatment of skin cancer, is also capable of improving
self-esteem, i.e., this is not an exclusive benefit of cosmetic surgery22.
Other articles refer to the positive impact of purely esthetic plastic surgery on
self-esteem and present results similar to those observed in the present
study13-15,30,31. A
study to evaluate the effect of surgery for body contouring, including
abdominoplasty and liposuction, demonstrated an important response in
self-esteem with patients reporting feeling happier after surgery30.
These patients undergoing cosmetic surgery have different psychological
characteristics and perceptions of their own body than those who underwent
restorative surgery, with higher stress levels in relation to appearance and
different motivations for seeking treatment. Cases with a subjective indication
of surgical intervention32.
The outlook for the future and type of recovery the individual may be subjected
to may influence the patient’s expectations of their disease and treatment33. Although cosmetic surgery has a more
specific objective of treating complaints of psychological origin and focuses
on
self-esteem, the restorative process has no such expectation regarding the
aesthetic result; rather, it aims to improve function and treat the disease.
This different psychological characteristic inherent to the patient’s profile
can generate the important QoL self-esteem scores in cases of repair component
surgery34.
Regarding the association between factors studied and QoL and self-esteem before
and after the intervention, among the patients with increased scores after
treatment, a significantly higher proportion of score increases was found in
patients aged ≥ 60 years, who were white, with a higher education level,
who suffered a stressful event, and who had malignant neoplasms.
The best QoL in older individuals was reported by Engel et al.35; in a study of 990 patients, the younger
the patient, the greater their concern about their health, financial situation,
and future, negatively reflecting QoL. In another study, the QoL of women with
breast cancer was evaluated for a period of 6 years after diagnosis, with 577
women aged between 30 and 61.6 years being interviewed. In older patients, QoL
was higher in terms of social and emotional aspects36, these results agree with those of the present study.
However, in the physical aspects, younger women had better QOL results, which
could be associated with a lower occurrence of comorbidities in this group.
We observed no sex-based differences in QoL or self-esteem improvement. Another
study that analyzed the impact of cosmetic surgery on QoL and self-esteem found
that women had a greater impact on QoL and self-esteem15. In another study conducted in patients with cutaneous
melanoma, sex was not associated with changes in QoL score37. These differences between studies may be due to
methodological differences, particularly a lack of statistical power.
A greater proportion of individuals with higher education levels displayed
improvements in QoL in the physical, social, and emotional aspects. This finding
can be explained by the fact that a higher education level is more closely
associated with better job opportunities, salaries, and treatment adherence,
leading to improved QoL38. Other studies
evaluated patients who underwent surgery for skin cancer and found no
differences in QoL related to sociodemographic factors.26,29
The presence of a malignant lesion was significantly associated with improvement
in QoL in the pain domain after the surgical intervention. This may be explained
by the greater susceptibility to pain perception among neoplastic patients39, which would change with surgical
intervention. It is known that cancer pain intensity varies and worsens
according to tumor location and neoplasia stage40.
Although the lesions found in our study patients were in the early stages, pain
is subjective and each individual develops the symptom from their traumatic
experiences and their perception influenced by various components, such as
physical incapacity, social and family isolation, financial difficulties, and
especially the fear of mutilation and death in cases of neoplasia41.
Stressful events affect QoL23,42-44; in the
present study, this was also observed in the mental health field. The fact that
individuals with a stressful event present greater gain in this domain than
individuals without the stressful event may be due to the fact that the
correction of the health problem in this group would generate greater comfort
and compensation. The absence of a control group not subjected to the
intervention was this study’s primary limitation.
However, its open non-randomized before-after design was the most adequate
considering the difficulty obtaining a control group in the evaluation of
surgical procedures. Another limitation was the lack of statistical power for
some differences in the proportions of patients with QoL improvements. Studies
with this design type and larger samples are required to adequately analyze some
associations that were not significant.
CONCLUSION
Restorative surgery improves patients’ QoL and self-esteem; in particular, it
improves emotional, physical, and social aspects. This change facilitates the
rehabilitation, and the improvement in patients’ well-being contributes to their
reintegration into family and society. Certain factors may contribute to the
effect of surgery on QoL, particularly sociodemographic aspects. The practice
of
determining QoL and self-esteem in patients who will undergo repair surgery can
serve as an evaluation tool as part of a more integrated approach to managing
surgical patients.
COLLABORATIONS
VFST
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; conception and design of the study;
completion of surgeries and/or experiments; writing the manuscript
or critical review of its contents.
|
RAMS
|
Analysis and/or interpretation of data; statistical analyses; final
approval of the manuscript; conception and design of the study;
writing the manuscript or critical review of its contents.
|
LZD
|
Final approval of the manuscript; completion of surgeries and/or
experiments.
|
SHLM
|
Writing the manuscript or critical review of its contents.
|
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1. Universidade Federal do Rio Grande, Rio Grande,
RS, Brazil.
2. Harvard University, Cambridge, MA,
USA.
3. Universidade Federal de São Paulo, São Paulo,
SP, Brazil.
Corresponding author: Victor Felipe dos
Santos Tejada
Rua Santos Dumont, sala 405, Cond. Santa Casa Doctors -
Centro
Pelotas, RS, Brazil Zip Code 96020-380
E-mail: victorfelipetejada@gmail.com
Article received: July 29, 2017.
Article accepted: May 17, 2018.
Conflicts of interest: none.