A million dollar smile. Face value. Save face.
Based on the number of expressions that pop up in cultures all around the world that link our faces to our sense of worth and our standing in our communities, you’d think we’d have a full understanding of the profound effect a healthy face can have on our psychological and emotional well-being. While Americans spend $12 billion on cosmetic procedures such as Botox each year in an attempt to enhance appearance, there’s a group of patients for whom the intentions may be different, but the psychological impact is the same. Three million Americans receive surgeries to remove skin cancer each year. And for many, the scars that are left behind carry a substantial psychological burden.
With many in society placing such a high value on physical appearance, researchers at Penn wondered what would happen to patients’ lives when their facial appearance was altered. In both cases – necessary surgery to remove cancer as well as elective injectable procedures – the link between outcomes and quality of life is relatively under-researched. A pair of new studies on these two groups of patients provides innovative answers as to whether beauty truly is only skin deep.
“Often times the research that attempts to evaluate outcomes in these cases is focused on objective measures of the cosmetic aspects. We can show we removed a wrinkle or left a smaller scar, but we need to better understand how these procedures are really impacting patients’ lives,” said Joseph F. Sobanko, MD, an assistant professor of Dermatology and director of Dermatologic Surgery Education at Penn who was a leader of both research projects.
The first study, published in the Journal of the American Academy of Dermatology, evaluated the relationship between Mohs surgery, reconstruction, and the patient’s perception of their quality of life measured before surgery, 1-2 weeks after, and again three months down the line.
Mohs micrographic surgery is the gold standard for the removal of skin cancer in cosmetically important areas such as the face. One of the most appealing features of Mohs is that doctors can microscopically examine the tissue they remove during the surgery rather than after. In other words, they don’t need to estimate how far the skin cancer’s roots extend. They know right away. This means Mohs surgeons can remove cancer cells while sparing as much normal tissue as possible. After the cancer is removed, the Mohs surgeon reconstructs the face to restore a normal appearance and minimize any scarring.
The team found that 1-2 weeks after surgery, the postoperative change in physical appearance had a major impact on how patients felt, but it manifested in a very different way than it had pre-surgery.
“Right after surgery, patients had less anxiety about their cancer since it had been removed, but that was replaced with heightened anxiety about social interactions and physical appearance,” said Sobanko, the senior author on the study.
Researchers found it wasn’t until the three-month evaluation that patients said they felt their quality of life had improved.
“In most cases, these patients got to a point that was better than where they started, but that was only after a rough period early on in their recovery,” said lead author Junqian Zhang, MD, who will begin a dermatology residency with Penn this summer.
The second study, published in Dermatologic Surgery, was focused on injectable cosmetic procedures and found they also left patients more satisfied with their body image. Much like the Mohs study, the rise in satisfaction happened after an initial delay. For this study, patients were evaluated six weeks after the procedure.
Sobanko, lead author of the study, says the findings of both studies are linked and provide greater understanding of how patients react to the changes in physical appearance these procedures entail.
“Understanding how these procedures affect our patients in the long-term helps us better counsel our patients and set realistic expectations,” Sobanko said. “They know ahead of time that Botox won’t bring them the changes they’re looking for in a day, but after a week or two, they’ll see the changes they’re expecting. We can also now confidently tell patients receiving Botox and fillers that these injectable procedures can have positive effects about how they feel about themselves.”
Sobanko said the studies also identified risk factors that may lead to worse outcomes, which further helps doctors counsel their patients. In skin cancer patients, for example, researchers showed those who smoked were reported lower quality of life scores, as did patients who used tanning beds. Patients with basal cell and squamous cell carcinomas had reduced quality of life on par with patients with melanoma.
“It’s important for doctors to realize that these procedures are also about improving people’s psychosocial health as well as their appearance, and now we have evidence to show the degree to which that emotional and psychological improvement is happening and the timeline patients follow in their recovery,” said the study’s senior author Ivona Percec, MD, PhD, an assistant professor of Plastic Surgery and associate director of Cosmetic Surgery at Penn.
The authors credited the Penn Dermatology Oncology Center, Penn Center for Human Appearance, and Dermatology Foundation for their help with the research.