Cosmetic outcomes following head and neck melanoma reconstruction: The patient's perspective

Head and neck melanoma poses challenges from both an oncological and a reconstructive perspective. First and foremost, these melanomas exhibit a higher rate of recurrence and poorer prognosis than melanomas in other locations (1). Furthermore, the proximity of head and neck melanomas to vital structures such as the eyes, nose and mouth requires that surgeons achieve a balance between adequate margins of excision and the functional and aesthetic needs of patients. With the increase in patient survival associated with better diagnostic and treatment protocols, attention to achieving these reconstructive goals has become increasingly important (2). There are three main goals when surgically treating head and neck melanomas. First, and foremost, is the prevention of recurrence. This is best achieved by following the American Joint Commission on Cancer (AJCC) and National Comprehensive Cancer Network guidelines for margins of wide local excision, which vary from 0.5 cm to 2 cm depending on the thickness of nonmetastatic melanomas (3). The second goal is adequate coverage of soft tissue defects that are created by wide local excision. Several reconstructive techniques including primary closure, skin grafting, local tissue transfer and free flaps may be used in this setting without impacting recurrence rates (4). The third goal is selecting a method of soft tissue reconstruction that enables adequate restoration of function and optimizes aesthetic outcomes. A few articles have reported on the preferred method of reconstruction to optimize aesthetic outcomes following wide local excision of head and neck melanomas. Primary closure is often sufficient for lesions <3 cm in diameter (5). Full thickness skin grafts were once the standard for larger defects, but they often left patients with disfiguring surface deformities and were replaced with more advanced reconstructive procedures (5,6). Currently, local tissue transfer is a common method of soft tissue reconstruction following excision of head and neck melanomas (4). Although only two articles have reported the outcomes of using local and free flaps in head and neck melanoma reconstruction, both described better functional and aesthetic outcomes than skin grafting in larger defects in which primary closure was not possible (4,6). Anecdotal evidence largely supports the observation that plastic and reconstructive surgeons prefer local flap reconstruction over skin grafting whenever possible. The patient’s perspective on this matter, however, remains unknown. The intense psychosocial sequelae of extirpation and reconstruction of head and neck melanomas experienced by patients is important to evaluate from their perspective. Traditionally, subjective appearance evaluations are rarely solicited from patients due to the assumption that only expert evaluations provide a valid assessment of outcomes (7–9). It has been found, however, that the surgeon-based method of evaluation suffers from poor test-retest reliability and poor interobserver agreement (10). Interestingly, patient-based methods of evaluation are less affected by these factors (9–11). Appearance scales using subjective ratings are often used in measuring breast reconstruction outcomes, and are accepted as a relevant and meaningful tool in evaluating aesthetic results (12,13). The visual analogue scale (VAS), specifically, is useful for measuring cosmetic outcomes of wounds and evaluating the patient’s satisfaction and emotions (14–16). Similarly, ordinal scales are useful for evaluating certain subcriteria of wounds. These scales can be used to rate the pain, itching, colour, scarring, thickness and irregularity of wounds and, thus, provide more detailed information about the wound itself than the unimodal VAS (17). In the present study, patients undergoing head and neck melanoma excisions followed by soft tissue reconstruction were asked to evaluate their reconstructive outcomes. A VAS was used to evaluate the patient’s perception of appearance alteration, satisfaction with their result and emotional impairment. An ordinal scale was used to evaluate several criteria of the wound. These results were compared with information gathered from a retrospective medical record review, which included the patient’s demographics, melanoma characteristics, treatment and prognosis.