There was no change in tumor-related quality-of-life domains following ED&C. For Mohs surgery, the mean-adjusted quality-of-life score for symptoms, emotions, and functioning improved by 10.2 points (95% CI: 7.4, 12.9), 21.7 points (95% CI: 18.1, 25.3), and 5.0 points (95% CI: 2.4, 7.6), respectively. There were also no differences in the amount of improvement on any of the quality-of-life domains between surgical excision and Mohs surgery [1].

The study by Maser et al. [2] attempted to determine changes in patient perception and behavior postMohs surgery. A mailed questionnaire was sent to 260 patients treated with Mohs surgery. Patients were asked questions regarding sun-protection behavior (i.e., sunscreen use, self-exam for abnormal moles, and exams performed by physicians). The study showed that patients treated with Mohs surgery appear to take preventative measure to avoid skin cancer. Of the patients who reported no sunscreen use before Mohs surgery, 70.1% of these patients began using sunscreen post Mohs surgery. Of the patients who reported using sunscreen before Mohs surgery, 40.7% of these patients increased the SPF by an average of 14.9 post-Mohs surgery. About half of the patients (53.3%) started to perform more self-exam for abnormal moles, and over a quarter of patients (28%) had a physician examine their moles more frequently [2].

Summary: The Potential Detrimental

Impact of Mohs Surgery

¥While Mohs surgery can offer many psychological and perhaps behavioral beneÞts, it can also result in adverse psychological consequences for a signiÞcant number of the patients. Mohs surgery is often reserved for excision of large, histologically aggressive tumors, with poorly delineated clinical borders that are likely to recur or even metastasize [4, 9]. Consequently, excision of these tumors can result in large surgical defects and complex reconstructive procedures, usually in highly visible anatomic locations (i.e., the face) [11]. Thus, disÞgurement, particularly facial disÞgurement, can result following Mohs surgery. DisÞgurement of any type can have serious psychological consequences.

But, facial disÞgurement is especially concerning. In the subsequent sections, a discussion is given on the signiÞcance of surgical disÞgurement, particularly facial disÞgurement, and how disÞgurement can lead to a negative selfimage, difÞculties in social interactions, and serious psychological distress [12].

47.3The Potential Detrimental Impact of Mohs Surgery

47.3.1 Acquired Surgical Disfigurement

Mohs surgery can result in serious acquired surgical disÞgurement. Studies have illustrated that surgical defects following Mohs surgery can be extensive in size and require complex reconstructive procedures. For instance, the study by Kimyai-Asadi et al. [11] examined 3,937 patients undergoing Mohs surgery. Of these patients, 86% had tumors located on the head and neck regions. The study found that the average tumor measured 1.1 cm × 1.0 cm, and resulted in an average surgical defect of 2.4 cm × 1.8 cm. Linear closures, skin ßaps, skin grafts, and secondary-intention healing were employed in 69%, 14%, 6%, and 11% of defects, respectively [11].

Any of the above-mentioned reconstructive procedures have the potential consequence of signiÞcant disÞgurement [7, 13, 14]. For example, primary closure of oval defects can frequently result in Òdog earÓ deformities, or redundant skin folds from closure of unfavorably shaped defects. Further correction of Òdog earÓ deformities may require additional incisions with necessary increases in wound length. Split-thickness skin grafts (e.g., grafts harvested from the preor retroauricular areas and grafted to repair nasal tip defects) can often differ in coloration and texture from the surrounding skin [7]. In addition, skin retraction following graft placement can commonly occur [13].

Composite grafts (i.e., grafts consisting of both skin and cartilage) are also frequently used to correct fullthickness defects following tumor excision. For example, composite auricular grafts can be used to repair small nasal alar rim defects. However, composite grafts pose the added concern for inadequate replacement of nasal lining and supporting structures, as well as poor

restoration of nasal contour. Finally, delayed reconstruction of the surgical defect is another real possibility following tumor excision. Patients having tumors with questionable bone invasion, or with a high likelihood of recurrence, often have delayed reconstruction 1Ð2 years later. In such cases, immediate reconstruction is not possible because it would hinder early detection of tumor recurrence or mask tumor invasion. Consequently, these patients may have to wear obvious external prostheses, either temporarily or permanently [7].

47.3.2 Significance of the Face

Having extensive facial disÞgurement can have profound emotional impact on the patientÕs psyche because of the tremendous signiÞcance of the face itself. The face is the most visible and, arguably, the most important part of the body. The face functions as the organ of communication with the outside world. We use our facial gestures to express symbolic messages of our internal feelings and motivations. The face is the window by which others can peer into our innermost self. It is how others come to know who we are. The face provides information regarding gender, age, ethnicity, and identity. As social beings, the face is crucial to successful interpersonal relationships and is, therefore, vital to our overall health and wellbeing [12, 15Ð17].

47.3.3“View from Inside” vs. “View from Outside”

The psychological impact of facial disÞgurement is very much dependent upon both intrapsychic (internal) and external factors. This two-sided perspective is often termed the Òview from insideÓ, vs. the Òview from outside,Ó respectively. The Òview from insideÓ is how appearance affects oneÕs self-perception (i.e., body image). The Òview from outsideÓ is how appearance affects social interactions with other people. Consequently, a change in appearance can alter not only an individualÕs self-image, but also social relationships with family, friends, and the outside world. These alterations in self-image and social relationships ultimately inßuence the extent to which patients with disÞgurement experience psychological difÞculties [18]. Thus, it is not the disÞgurement itself that has the profound impact on those affected. Instead, it is how the patients and others respond to the disÞgurement [19].

47.3.4 Negative Self-Image

To understand how disÞgurement can alter body image, one must Þrst have a good understanding of what body image is. The classic deÞnition of body image, written by Paul Schilder in his 1935 book, is Òthe picture of our body which we form in our mind, that is to say the way in which our body appears to ourselvesÓ [20]. Body image is dynamic, continually changing over time. It can change gradually over a lifetime, or it can change suddenly in response to short-term alterations (such as, changes in mood, clothing, or acute trauma). Bob Price [21] developed one of the most comprehensive descriptions of body image. Price created a three-component model of body image, consisting of body reality, body ideal, and body presentation. Body reality is the way our body really is. Body ideal is how we want our body to look. Body presentation is the manner in which we dress and act toward those around us. Based on this model, these three related components are continually being weighed against one another. When these components are held in state of balance, an individual is able to maintain a healthy body image [19].

However, changes in body reality (e.g., from acquired surgical disÞgurement) can disrupt the delicate balance between body reality and body ideal. The individual may attempt to cope with such deÞciencies in body reality, with compensatory changes in both body presentation and body ideal. In instances of acquired surgical disÞgurement, the individual may change body presentation by wearing make-up or clothing that can conceal this disÞgurement. The individual may also invoke good coping strategies and adequate social support to help develop a revised concept of what constitutes their body ideal [19, 22Ð24].

Most patients make reasonable psychological adjustment to disÞgurement, regardless of the cause or severity. West et al. [25] studied 152 patients with facial disÞgurement following treatment of extensive head and neck cancer. An astonishing 82.6% of these patients adapted well to their disÞgurement [25].

For many patients, however, disÞgurement can have serious negative effects on self-esteem, self-conÞ- dence, and self-image. These patients are regrettably unable to compensate for the changes in body reality as a result of surgical disÞgurement. This is understandable in light of the fact that people, especially those in Western societies, tend to hold very narrow standards of physical beauty. Faces that are round, symmetrical, and without blemishes are considered

more attractive [26]. So, despite a patientÕs best efforts, attempting to Þt a cosmetic defect within the rigid framework of oneÕs body ideal may not be possible.

47.3.5Psychological Distress As a Result of Difficulties in Social Interactions

Surgical disÞgurement has been demonstrated to be related to high levels of psychological distress [27]. In general, psychological distress secondary to surgical disÞgurement can be grouped into two broad categories: (1) those that are distressing to the patient, but not severe enough to meet the Diagnostic and Statistical Manual of Mental Disorders, 4th edition text revision (DSM-IV-TR) [28] criteria for mental illness, and (2) those that are distressing enough to meet psychiatric diagnostic criteria. In this section, difÞculties from social interactions that are not severe enough to be diagnosed as a psychiatric condition will be discussed.

One of the predominant concerns for patients with disÞgurement, especially facial disÞgurement, is learning how to cope with the stigma of the disÞgurement. Stigma is a mark of disgrace that devalues persons who are seen as different. Here disÞgurement becomes the focus of a personÕs social identity. It discredits all other attributes that the person possesses and labels the person to be different from the norm [12, 29].

Frances Macgregor [30], in her extensive work on facial disÞgurement, explains that people with visible disÞgurement are victims of much social inequities, including blatant stares and hurtful comments.

In their efforts to go about their daily affairs they are subjected to visual and verbal assaults and a level of familiarity from strangers (not) otherwise dared: naked stares, startle reactions, Òdouble-takes,Ó whispering remarks, furtive looks, curiosity, personal questions, advice, manifestations of pity or aversion, laughter, ridicule, and outright avoidance. Whatever form the behaviors may take, they generate feeling of shame, impotence, anger, and humiliation in their victims [30].

Individuals with disÞgurement report signiÞcant difÞculties in social interactions (e.g., meeting new people, forming long-term friendships, etc.) [18, 31Ð 33]. As brießy mentioned in MacgregorÕs quote, people go out of their way, either consciously or subconsciously, to avoid those with disÞgurement [30]. Studies have shown that people generally sit further away [34] and offer less help to those with facial disÞgurement [35]. It is also well established that people hold stereotypes against those with disÞgurement.

Studies have found that individuals with abnormal facial appearances are presumed to be less honest, less employable, less capable, and less intelligent than individuals with normal facial appearances [36].

For many patients with disÞgurement, these continual negative encounters in social situations may eventually result in social withdrawal. Many will limit their social contacts to only immediate family members or close friends. In the extreme circumstances, social withdrawal can result in complete social isolation, or as Macgregor termed Òsocial deathÓ [23, 37]. The severity of social difÞculties may not just present itself as social isolation, but also as coexisting feelings of anxiety in any social setting.

Thus, the social difÞculties experienced by those with facial disÞgurements might be secondary to phobic anxiety in social situations. The study by Moolenburgh et al. [38] compared 30 patients with partial or total nasal amputation following radical tumor resection, majority of which were being treated for BCC or SCC, against 99 control participants. Based on the Social Avoidance and Distress Scale, the study found that patients reported signiÞcantly higher levels of social anxiety and avoidance [38]. For most patients, the psychological distress from social interactions is not severe enough to be considered a psychiatric disorder. However, for some, this may develop into genuine social phobia (discussed in detail in Sect. 47.4.1).

47.3.6Location, Age, Gender, and Severity as They Relate to the Psychological Distress of Disfigurement

Studies suggest that location of disÞgurement, and possibly even age or gender, are correlated with extent of psychological impairment. DisÞgurement on visible locations, especially the face, is intuitively and clinically related to greater difÞculties [27]. The study by Gardiner et al. [39] found cosmetic defects on the young and female to be associated with greater impact than those on the old and male. Defects of the central face may also hold greater relevance than those found more peripherally [39].

Recent studies have attempted to examine this relationship between objective severity of disÞgurement and degree of distress. It may seem logical to expect that more severe disÞgurement would be correlated to greater levels of psychological distress. For example, a person with a scar over 25% of their face may have

signiÞcantly more difÞculties than a similar person with a scar covering only 5% of their face [40].

The study by Tebble et al. [19] found that objective measures of disÞgurement severity are related to psychosocial adjustment. SpeciÞcally, the study recruited 63 patients with minor, yet visible, facial lacerations over 1.5 cm in size. The study found that those with larger scar size (4 cm or above) reported signiÞcantly higher levels of self-consciousness and anxiety [19].

However, the study by Moss [41] suggested that subjective measures of disÞgurement severity (or, patient-rated measures of disÞgurement severity) are better correlated with levels of psychological distress, than objective measures of disÞgurement severity. SpeciÞcally, the study analyzed 400 patients with a wide array of physical differences in appearance. Patients rated subjective severity of disÞgurement, whereas physicians rated objective severity of disÞgurement. The study determined subjective severity to be linearly correlated to psychological adjustment, with increased subjective ratings of severity to be associated with worse adjustment. Objective severity demonstrated a complex, rather than linear, relationship to adjustment for visible anatomic locations, but not for non-visible anatomic locations. Objective severity rated as ÒmildÓ or ÒsevereÓ was associated with better adjustment than ÒmoderateÓ severity. In other words, the data indicated that patients with objective severity rated as ÒmoderateÓ disÞgurement actually faired worse than those with objective severity rated as ÒsevereÓ disÞgurement [41]. This illustrates how severity of disÞgurement does not necessarily predict level of distress.

From a scientiÞc, evidence-based perspective, it may seem rational to assume that objective measures of disÞgurement severity hold greater signiÞcance. However, in regards to assessment of the disÞgurement severity, it is generally the case that subjective measures, not objective measures, are correlated with psychosocial adjustment and quality-of-life impact. In fact, even minor disÞgurement can be profoundly disturbing [40]. Body image is clearly subjective. If a patient with minor disÞgurement places signiÞcant weight on physical appearance, that patient may have as great, if not greater, psychological distress as someone with major disÞgurement who is less focused on physical appearance [23].

Furthermore, Frances Macgregor [37] made the counterintuitive argument that people with more extensive disÞgurement often fair better overall than people

with lesser disÞgurement. Based on this argument, those with obvious disÞgurement have an easier time adapting to social interactions because they can reliably predict the social response to their facial appearance. But, those with less noticeable disÞgurement struggle with a constant sense of uncertainty in social settings. They are in, what can be described as, a state of Òlimbo,Ó which may inevitably lead to greater levels of anxiety and social distress [23].

Summary: Psychiatric Disorders Secondary to Disfigurement

¥It is important to realize that patient with disÞgurement, regardless of the location, age, gender, or severity, may experience psychological distress following Mohs surgery. Depending on the severity of distress, patients may meet DSM-IV-TR criteria for psychiatric illness. In the following sections, the most common psychiatric conditions resulting from disÞgurement (i.e., social phobia, generalized anxiety, and depression) are discussed, along with a description of the diagnostic criteria and appropriate management of these conditions.

47.4Psychiatric Disorders Secondary to Disfigurement

47.4.1 Social Phobia

Patients with disÞgurement are at risk of developing social anxiety that is distressing enough to meet DSM-IV-TR diagnostic criteria of social phobia. The study by Newell et al. [42] compared 112 facially disÞgured patients with 66 patients with social phobia and 68 patients with agoraphobia. The study suggested that facially disÞgured patients resembled patients with social phobia, as they had similar scores on the anxiety and depression subscales of the Fear Questionnaire [42].

According to the DSM-IV-TR [28], social phobia refers to a condition in which the patient develops a persistent fear of social situations where he or she is likely to be scrutinized by others. If the patient is under the age of 18 years, the duration must be at least