Beyond Aesthetics: The Impact of Facial Non-Melanoma Skin Cancer (NMSC) Surgery on Patient Quality of Life

1. Introduction

Non-melanoma skin cancers (NMSC), primarily squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), represent the most common types of skin malignancy globally [1,2], with around 80% affecting the head and neck region [3]. Although early diagnosis generally leads to good oncological outcomes, lesions on the face pose additional challenges, extending beyond cosmetic concerns to impact physical function, mental health, and overall quality of life. Although dermatologists frequently manage minor excisions and local flaps, more complex cases require surgical excision and reconstruction by plastic surgeons. While achieving clear oncological margins remains the primary goal, successful reconstruction demands a comprehensive, patient-centered approach that also addresses functional restoration, psychological resilience, and sustained quality of life [4].

Reconstructive options following excision include direct suturing (DS), skin grafts, flap surgery (FS), or free flaps. In reconstructive plastic surgery, FS are often preferred for defect closure—when primary closure are inadequate—due to their reliable vascular supply and robust tissue viability. However, they may also present challenges such as excessive bulk, color mismatch, and noticeable scarring [5]. While surgical success has traditionally been measured through complication rates and aesthetic outcomes, an increasing pa-tient-oriented movement highlights the need to consider how reconstructive choices impact patients—encompassing physical comfort, emotional adaptation, and social integration [6].

Scar assessment are key in post-reconstructive evaluation, but discrepancies between clinical assessments and patient-reported outcomes persist. While surgeons may focus on objective measures such as scar texture and symmetry, patients prioritize factors such as discomfort, tightness, and self-consciousness in social settings [7].

This study investigates the patient reported outcomes one year after removal of NMSC of the face and closure with DS or FS. We wish to investigate the impact on quality of life after facial surgery, as there are limited literature available in this field.

2. Materials and Methods

The study investigates patient-reported satisfaction with facial appearance and quality of life one year after facial non-melanoma skin cancer (NMSC) surgery, assessed with FACE-Q Skin Cancer questionnaire, a validated com-prehensive patient-reported outcome instrument specifically designed to measure outcomes in patients undergoing facial aesthetic and reconstructive procedures and evaluating quality of life and satisfaction of patients that have undergone treatment for skin cancer on the face [8]. The questionnaire consists of seven different components: cancer worry, appearance, appearance-related distress, appraisal of scars, satisfaction, information and sun protection behavior. Each module can be used independently, and scores are calculated based on patient responses through conversion tables to transform raw scores into standardized 0-100 scales, facilitating comparison and interpretation. Higher scores generally indicate greater levels of worry, distress or adverse effects or higher satisfaction and better outcomes de-pending on the module. By incorporating the FACE-Q questionnaire into this study, we can systematically evaluate and compare the subjective experiences of patients [9,10].

The study are conducted as a single-center prospective cohort study at the Department of Plastic and Breast Surgery, Zealand University Hospital, Roskilde, Denmark. The study was conducted in accordance with the Declaration of Helsinki and approved by the Research Registry of Region Zealand, Denmark (protocol code 098-2020; approval date 22 October 2020). The department are a high-volume center specializing in skin cancer treatment and reconstructive surgery. The study included patients undergoing facial NMSC excision and reconstruction between June 1, 2021, and June 20, 2023. Informed consent was obtained from all subjects involved in the study. Written informed consent has been obtained from the patient(s) to publish this paper.

Inclusion criteria required patients to have a histopathological confirmed BCC or SCC in the facial regions; temple, forehead, periorbital area, cheeks, nose, lips/perioral area, and chin, provided that the lesion was not recurrent. The follow-up period was one year +/- one month. Patients underwent either NMSC removal closed with DS or reconstructed with FS.

Before NMSC removal of the face, informed consent was obtained. Demographic data and surgical details were recorded for all participants. Data on postoperative complications occurring within 30 days were extracted from the medical records, either as patient-reported outcomes or as findings documented during ambulatory follow-up—whether as part of routine postoperative care or upon patient request for additional clinical evaluation. At one-year follow-up, all patients were contacted by phone to evaluate long-term outcomes through the FACE-Q Skin Cancer module assessing patient-reported satisfaction and quality of life.

Patient data, including demographics, surgical details, and complications, were recorded in Sundhedsplatformen (Epic) and subsequently transferred to a prefabricated REDCap (Research Electronic Data Capture) database. Standardized definitions and measurement parameters were used to ensure data consistency. Data from the FACE-Q questionnaire was entered into REDCap completing data collection for analysis in one database. The data presented in this study are available on request from the corresponding author. The data are not publicly available due to patient privacy.

Statistical analysis was conducted using R-Studio. Logistic regression was used to evaluate associations between cat-egorical and numerical predictors with categorical outcomes. Chi-square tests were applied to analyze categorical variables. A p-value ≤ 0.05 was considered statistically significant.

3. Results

Patient Demographics

This prospective study evaluated 225 Danish patients, who were categorized according to surgical treatment: DS, n = 141 and FS, n = 40 and other, n=44. The 181 patients that underwent DS and FS were included in the study. At one year follow-up 38 patients from the DS group and 14 from the FS group completed the FACE-Q questionnaire and were included in the final study population, reasons for non-participation at follow-up were documented (Appendix 1).

Patient age was 72.72 [IQR: 67.2-79.1] for DS and 73.17 [IQR: 64.7-80.7] for FS. A table of patient demographics are shown in table 1a. Patient comorbidities are shown in table 1b.

Table 1. a: Patient demographics.

Group	Mean Age, years (SD), [IQR]	Mean BMI	Sex, male	Sex, female
Flap Surgery	73.17 (SD=8.89) [67.2-79.1]	25.98 (SD=4.02)	50.0%	50.0%
Simple Excision	72.72 (SD=11.89) [64.7-80.7]	29.61 (SD=5.34)	46.8%	53.2%

Table 1. a: Patient demographics.

Group	Mean Age, years (SD), [IQR]	Mean BMI	Sex, male	Sex, female
Flap Surgery	73.17 (SD=8.89) [67.2-79.1]	25.98 (SD=4.02)	50.0%	50.0%
Simple Excision	72.72 (SD=11.89) [64.7-80.7]	29.61 (SD=5.34)	46.8%	53.2%

Table 1. b: Patient comorbidities.

Table 1. b: Patient comorbidities.

Group	Flap Surgery	Direct suture	P-value
Medical conditions1	10 (71.4%)	25 (65.8%)	0.707
Smoking Status			0.474
Never smoked	4 (28.6%)	13 (34.2%)
Former smoker	2 (14.3%)	8 (21.1%)
Current smoker	1 (7.1%)	2 (5.3%)
Unknown	7 (50.0%)	14 (36.8%)
Comorbidities
Hypertension	7 (50.0%)	17 (44.7%)	0.477
Heart Disease	4 (28.6%)	5 (13.2%)	0.241
Diabetes	1 (7.1%)	5 (13.2%)	0.576
Melanoma	3 (21.4%)	7 (18.4%)	1.000
Other Cancers	4 (28.6%)	7 (18.4%)	0.506
NMSC Type			0.051
BCC	14 (100%)	34 (89.5%)
SCC	0 (0.0%)	4 (10.5%)
Both BCC and SCC	0 (0.0%)	0 (0.0%)

Medical conditions contain those requiring the use of blood thinners, glucocorticoids, NSAIDs, and/or antihypertensives.

Tumor Size

Tumor sizes were a median of 9.5 mm [IQR:5.00-12.00] in the DS group and a median of 9.0 mm [IQR:5.00-12.00] in the FS group (p = 0.945).

Complications

Postoperative complications were more frequently observed among patients treated with flap surgery compared to those treated with direct suture, although none of the differences reached statistical significance. Postoperative complications are shown in Table 2 below.

Facial Distribution of Surgery

Flap surgeries were primarily performed on the nose, accounting for most FS cases; n=11 (78.6%), whereas DS procedures were more evenly distributed across facial regions; n=14(36.8%) in the cheek region; n=6 (15.8%) in the forehead and perioral area and n=7 (18.4%) in the temporal region.

The distribution of surgical sites by procedure type are presented in Table 3.

Table 4. FACE-Q scores.

FACE-Q aspect	FS raw score	FS conversion	DS raw score	DS conversion	P-value
SATISFACTION WITH FACIAL APPEARANCE	30.14	71	32.13	78	0.358
APPRAISAL OF SCARS	27.86	71	30.68	91	0.011*
APPEARANCE-RELATED DISTRESS	12.14	23	10.18	14	0.058
CANCER WORRY	21.14	42	15.68	25	0.005**
SUN PROTECTION BEHAVIOR	15.79	x	13.37	x	0.069

Table 4. FACE-Q scores.

FACE-Q aspect	FS raw score	FS conversion	DS raw score	DS conversion	P-value
SATISFACTION WITH FACIAL APPEARANCE	30.14	71	32.13	78	0.358
APPRAISAL OF SCARS	27.86	71	30.68	91	0.011*
APPEARANCE-RELATED DISTRESS	12.14	23	10.18	14	0.058
CANCER WORRY	21.14	42	15.68	25	0.005**
SUN PROTECTION BEHAVIOR	15.79	x	13.37	x	0.069

Association Between Cancer Worry and Scar Satisfaction

Using FACE-Q Skin Cancer modules, the study investigates the relationship between cancer-related worry and scar satisfaction among patients surgically treated for NMSC. A subtle negative correlation was found (Pearson’s r = –0.34, p < 0.01), indicating that lower cancer worry was associated with higher satisfaction with the surgical scar, the regression are plotted in figure 1. Cancer worry explained approximately 11.2% of the variance in scar satisfaction (R² = 0.112). When stratified by surgical technique, the correlation was stronger among patients treated with flap reconstruction (r = –0.56, R² = 0.517, p = 0.107) than those treated with direct closure (r = –0.35, R² = 0.085, p = 0.038).

Figure 1. Association between cancer worry and scar satisfaction.

Figure 1. Association between cancer worry and scar satisfaction.

Figure 2. Association between cancer worry and scar satisfaction stratified by surgery type.

Figure 2. Association between cancer worry and scar satisfaction stratified by surgery type.

Stratified Patient Satisfaction by Anatomical Location and Treatment Type

Scar satisfaction was assessed using the FACE-Q across different facial regions and surgical techniques.

Flap surgeries were primarily performed on the nose (n =11), while direct suture (DS) was most commonly used on the cheeks (n = 14), forehead (n = 6), and temporal region (n = 7).

In the nasal region, the median scar satisfaction scores were 8.5 (IQR: 8.0–9.0) for flap surgery (FS) and 8.5 (IQR: 8.0–8.5) for DS (based on three patients in the DS group).

For the cheek region, the DS group reported a median of 10.0 (IQR: 9.0–10.0), and the single FS case reported a score of 9.0 (IQR: 9.0–9.0).

In the forehead region, FS (n = 2) reported a satisfaction score of 10.0 (IQR: 10.0–10.0), while DS showed a median of 9.0 (IQR: 8.5–9.5).

No subgroup statistical analyses were performed due to limited sample sizes.

Detailed localizations are presented in Table 5.

4. Discussion

This study highlights scar perception, psychological well-being, and cancer-related anxiety in patient-reported outcomes following NMSC removal of the face and defect closure using DS or reconstruction utilizing FS. These findings underscore how different surgical treatments impact patients' subjective experiences.

Scar Perception and Satisfaction

One of the statistically significant findings were that patients who underwent DS were significantly more satisfied with their scars compared to those who had FS despite no statistically significant tumor size difference between the two groups. This suggests that the additional scars needed for FS, in cases where DS are not a viable surgical option, leaves the patients with lower scar satisfaction.

The study was unable to stratify satisfaction across all anatomical regions, as some locations were treated with only one surgical method. DS was the only procedure performed in following locations: perioral, periorbital, temporal and chin.

Although flap surgery is often required for nasal reconstruction due to anatomical complexity, the slightly lower satisfaction scores in this region suggest that anatomical location itself may have a stronger influence on patient-perceived outcomes than the technique applied. Satisfaction across the cheek region and forehead remained high regardless of method, though the small number of FS cases in these regions limits the generalizability of the findings.

Another aspect of scar perception involves preoperative expectations and psychological adaptation. For instance, studies in other reconstructive settings—such as breast flap reconstruction—have shown that patients who expected a more complex surgical process tended to report greater acceptance of visible scarring afterward [11]. Conversely, DS patients may have had lower aesthetic ex-pectations, yet still reported better scar outcomes, likely due to less invasive procedures and shorter healing times. Prior research suggests that age-related differences in body image perception could also contribute to this, as older patients tend to exhibit greater psychological resilience and lower aesthetic dissatisfaction [12].

Psychological Impact and Cancer-Related Anxiety

A significant difference was observed in cancer worry, with DS patients reporting lower levels of postoperative anxiety regarding cancer recurrence. This finding supports the notion that FS patients may experience greater psychological distress, possibly due to more extensive follow-up, longer healing times, more extensive scarring, or an implicit perception of their condition as being more severe. Cancer-related anxiety has previously been associated with increased surgical intervention for breast cancer [13]. Previous studies have indicated that cancer-related anxiety are not solely determined by oncological outcomes but also by the patient’s perception of their treatment and recovery process [14].

While the appearance-related distress scores were not statistically different between groups, a clear trend emerged, suggesting higher distress levels among FS patients. This could be linked to the greater physical changes and prolonged recovery associated with flap procedures, reinforcing the need for enhanced psychological support and counseling for these [15]

In our cohort, we observed a subtle negative correlation between cancer worry and satisfaction with the surgical scar (r = –0.34, p < 0.01), suggesting that patients who are less worried about cancer tend to report greater aesthetic satisfaction postoperatively. This relationship was particularly evident, but not significant, in the subgroup of patients undergoing flap reconstruction (r = –0.56), where the procedures are typically more complex and cosmetically impactful. These findings imply that psychological factors such as cancer-related anxiety may influence how patients appraise their surgical outcomes, potentially overshadowing the objective extent of reconstruction.

Clinical Implications

FS patients may benefit from additional counseling and expectation management to mitigate distress related to appearance changes and cancer-related anxiety. However, it should be acknowledged that extensive preoperative information may in some cases increase worry, as patients may focus more on potential risks and complications. Balancing adequate information with reassurance are therefore essential, and future studies should explore how communication strategies influence psychological outcomes in this patient group.

Psychosocial interventions, including preoperative discussions on expected outcomes and psychological follow-ups, may be valuable in reducing cancer worry and improving overall postoperative well-being.

By recognizing that surgical success are not solely defined by clinical outcomes but also by psychological and social well-being, healthcare providers can develop more comprehensive, patient-centered strategies that improve long-term quality of life.

Limitations and Future Directions

A major limitation of this study is the high attrition rate: only 52 out of 181 enrolled patients completed the FACE-Q questionnaire at the one-year follow-up. This substantial loss to follow-up reduces statistical power and may introduce response bias, as responders may not fully represent the overall study population—for example, individuals with higher resources or greater satisfaction with their surgical outcome may be more likely to complete follow-up []. Patients who did not respond may differ systematically from those who did, potentially skewing the results toward those with more positive or more negative experiences. The reasons for non-participation were heterogeneous (see Appendix 1), but the overall dropout rate limits the generalizability and robustness of the findings. Future studies should prioritize strategies to enhance follow-up compliance, including reminder systems or integration with routine outpatient visits.

Although this study provides valuable insights into patient-reported outcomes following facial skin cancer reconstruction, certain limitations must be acknowledged. The relatively small sample size of FS patients may limit the generalizability of findings, and future research with larger, multi-center cohorts are warranted. Additionally, while FACE-Q provides a comprehensive assessment of patient satisfaction, a longer follow-up period could better capture long-term psychological adaptation and aesthetic perception changes.

Future studies should also explore the role of demographic factors, including sex, age, and baseline psychological status, in shaping patient perceptions of surgical outcomes. Furthermore, objective clinical evaluations of scar healing could complement pa-tient-reported measures to provide a more holistic understanding of surgical success.

5. Conclusions

This study investigated patient reported outcomes after NMSC removal of the face and DS or reconstruction with FS. Flap surgery following NMSC excision are associated with lower patient-reported satisfaction compared to DS. Our findings indicate that the need to go up the reconstructive ladder does influence patient-reported outcomes: FS was associated with significantly lower scar satisfaction and higher levels of cancer-related worry. However, when stratified by anatomical location, satisfaction appeared more closely linked to the surgical site—particularly the nasal re-gion—than to the reconstructive method itself.

Furthermore, a moderate negative correlation between scar satisfaction and cancer worry suggests that aesthetic outcomes are not merely cosmetic concerns, but closely intertwined with patients’ psychological well-being and quality of life. These results underline the importance of adopting a holistic, patient-centered approach—one that integrates technical outcomes with emotional recovery, expectation management, and long-term psychosocial support..