Satisfaction and Quality of Life Scores
Mean scores for the 6 scales ranged from 59 for Recovery-Early Life Impact to 94 for the Satisfaction with Medical Team surveys (Table 3).
Reliability of the Instrument and Dataset
Internal consistency was good (Cronbach’s alpha: 0.824) for the Recovery-Early Life Impact scale and excellent (Cronbach’s alpha > 0.900) for all of the other scales (Table 3).
Predictors of Satisfaction and Quality of Life
Predictor variables identified by the full regression models are shown in Table 4 for each of the 6 scales. Smoking status, MMF, race, and duration from surgery to survey emerged as predictors for at least 2 of the 6 scales. Injury mechanism, orbit fractures, upper face fractures, and Lefort pattern fractures emerged as predictors for 1 of the 6 scales. No single variable was predictive of outcome across all 6 scales. Age, sex, BMI were not identified as significant predictors on any of the 6 scales. Of note, “Other” race or “Other” injury mechanism were identified as significant predictors on 3 of the scales and merit further description: The 11 patients classified as “Other” race included 3 patients of Asian descent, 3 patients of Middle Eastern descent, and 5 Hispanic patients that do not identify as White. The 7 patients with injury mechanism of “Other” included 3 mechanical work-related injuries (eg, struck by forklift), 2 self-inflicted gunshots, and 2 dog bites.
The key findings from this study are as follows: (1) Following repair of traumatic facial fractures, patient satisfaction/ HRQOL varies across domains: Satisfaction with the medical team is high, whereas Recovery-Early Life Impact is relatively poor; (2) Factors predictive of low satisfaction and/or HRQOL include: current smoking habit, MMF, and Le Fort fractures. (3) FACE-Q scales demonstrate good to excellent reliability in this population.
Although there are no published normative values for FACE-Q, subgroup differences that are greater than one-half the SD are considered clinically meaningful.6,14 Furthermore, scores from published studies may provide clinical context for interpreting our scores. In the following paragraphs, we compare the scores (obtained postoperatively) on the 6 scales, with scores from published studies.
For the Recovery-Early Life Impact scale, mean scores of 80 to 93 were observed in 2 studies 1 month after aesthetic facial surgery/rejuvenation.10,15 Our lower mean score of 59 is not surprising. Given that facial fracture repair is generally more invasive than most aesthetic facial procedures, it should be expected to more severely impact daily activities in the early recovery period. Furthermore, many of our study participants sustained polytrauma and may have been experiencing the sequelae of nonfacial trauma.
For the Satisfaction with Facial Appearance scale, our mean score of 66 compares with mean preprocedure scores of 45 to 53, and postprocedure scores of 64 to 87 for patients undergoing a variety of aesthetic procedures.16,17 Of note, the patient population in these aesthetic studies is older and predominantly female.8,18 Nonetheless, it is noteworthy that facial trauma patients, many of whom have significant facial disfigurement, report higher satisfaction with facial appearance when compared with patients seeking facial aesthetic surgery.19 The composition of the “Other” injury mechanism group (gunshots, dogbites, forklift trauma) likely explains their lower scores. It is unclear why longer duration from surgery is associated with lower scores on this scale. A possible explanation is that unsatisfied patients are more likely to return for postoperative visits, whereas satisfied patients may be lost to follow-up.
Our Social Function scores are similar to published scores from the aesthetic surgery population.15,20–22 The association of cigarette smoking habit with lower social function is consistent with known associations of smoking and social isolation.23 However, to our knowledge, this relationship has not been previously demonstrated in the context of facial aesthetic or reconstructive surgery.
Published averages for the Psychological Well-being scale range from 69, 1 month after aesthetic facial surgery/nonsurgical rejuvenation to 93, after facelifts.15,20–22 Our scores (mean = 77, Q1 = 61) are high, given elevated rates of post-traumatic stress disorder (PTSD) and mental disorders following facial trauma.24,25 Our findings of worse psychological well-being among cigarette smokers and better psychological well-being among patients of black race are consistent with known associations of smoking habit26–28 and race29 with psychological health.
We found no published scores for the Satisfaction with Medical team scale. It is unclear why patients with Le Fort fractures would score lower on this scale. Nevertheless, facial trauma teams should be attentive to the potential for dissatisfaction with the process of care among these patients.
Our internal consistency results compare favorably with published scores from the aesthetic surgery population. The relatively low value Cronbach’s α for the Recovery-Early Life Impact scale was also observed in the aesthetic surgery population.10
The strengths of our study are as follows: This is the first study that seeks to validate FACE-Q scales in the facial trauma population. Utilizing FACE-Q scales may obviate the need to develop separate patient-reported outcome instruments for facial trauma. Second, the number of participants and the response rate for this study are high, affording high reliability and statistical power. Third, the prospective study design should minimize errors due to recall bias, or bias in scoring due to temporal variations in satisfaction or quality of life.
This study has several limitations: First, scientific soundness of the scales in the facial trauma population has not been fully established. In addition to reliability which we have shown, validity and responsiveness need to be demonstrated in the target population. Second, we do not have presurveys that would permit us to adjust for preinjury or preoperative factors. Obviously, it is impractical to collect preinjury data. For most of the patients at our center, surgery is performed within hours to days of injury, during which patients may be under distress that may diminish responsiveness and reliability of the data. Third, the location, severity, soft tissue involvement and surgical procedure that participants underwent are variable. Finally, our regression models did not account for factors like psychological history, employment, family support, litigation, incarceration, which have been shown to affect quality of life following facial trauma.24
Face-Q scales can be utilized for measuring satisfaction and patient perception following repair of traumatic facial fractures. Excellent response rates can be achieved. The scales demonstrate good to excellent reliability in this population. Participants report high satisfaction with the medical team, but poor health-related quality of life in the early postoperative period. Predictors of low satisfaction and/or poor HRQOL include current smoking habit, MMF, and Le Fort fractures.
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Copyright © 2018 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.
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