Facial Trauma and Facial Cancer

Thomas Pruzinsky PhD

Elie Levine MD

John A. Persing MD

Jeffrey T. Barth PhD

Robert Obrecht PhD, LCDR/MSC/USN

Learning to live with a change in the appearance of one’s face as a result of injury or disease is profoundly challenging. The range of variables (medical, psychological, and social) influencing the process of adaptation is far from fully understood (1). However, the plastic surgery treatment team—including the surgeon, nurses, and professionals from other disciplines—can be certain that the ultimate goal of their work, improving patient quality of life, will be determined not only by their surgical skills, which clearly have a profound positive effect on patient well-being, but also by a range of social and psychological factors. The primary goal of this chapter is to encourage development of higher standards of care for patients with acquired facial disfigurement, which includes giving routine attention to psychosocial rehabilitation (2).

Currently, the psychological and social suffering of patients with acquired facial disfigurement often goes unaddressed by the plastic surgery treatment team. There are many reasons for this, including the obvious fact that the plastic surgery team’s primary goal is to provide patients with the highest standards of surgical care. Most members of the team have not been given adequate training to address patients’ psychosocial concerns. Furthermore, compared to other areas of plastic surgery (e.g., in burn injury [Chapters 6 and 7]) or congenital facial disfigurement (Chapter 5) there has not been a great deal of research elucidating psychosocial responses to the forms of acquired disfigurement addressed in this chapter (1).

This chapter addresses two separate and distinct forms of facial disfigurement acquired during adulthood: disfigurement acquired from trauma (though we will not discuss disfigurement caused by burn injuries as this topic is addressed in Chapter 7) and facial disfigurement acquired through disease—primarily cancer occurring on the face (e.g., skin cancers and other forms of head and neck cancer). There is reason to believe that psychological responses to acquired disfigurement are, at least to some degree, different and perhaps even more pronounced than the psychological responses to congenital disfigurement (1). Furthermore, while patients with disfigurement acquired through trauma and those who acquire facial disfigurement from cancer share many commonalities, they also are likely to have some unique psychological characteristics. We review what is currently known about the psychological adaptation specific to facial trauma and facial cancers. This is followed by a discussion of the psychosocial aspects of adaptation shared by individuals with acquired facial disfigurement, including challenges in social functioning, body image adaptation, experience of depression, and possible substance abuse. The goal of the chapter is to provide the plastic surgery treatment team with enough information so they can more readily identify those patients having difficulties in psychosocial adjustment that can be addressed with proper referrals to mental health professionals who can help them with the process of psychosocial rehabilitation.

PSYCHOLOGICAL CHARACTERISTICS OF INDIVIDUALS SUSTAINING FACIAL TRAUMA

The psychological characteristics of facial trauma patients have received only limited empirical attention (3). The extant data clearly suggest that these individuals can experience a wide range of psychosocial concerns. For example, Shetty et al. (3) found that patients with orofacial injuries were much more likely to report symptoms of depression, anxiety, and hostility when compared to a matched control group. Many patients continued to report significant psychological problems for 12 months postinjury (4). Similarly, Shepherd et al. (5) documented patient experiences of anxiety, depression, and psychological distress within 3 months of sustaining mandible fractures.

Many of the orofacial injury patients in the study by Shetty et al. (3) had significant psychosocial problems including lack of health insurance, high levels of unemployment (approximately 75%), and relatively low levels of education (approximately 40% had not finished high school). Most of the injuries were the result of interpersonal assault (83%) and almost one-third of patients had previously sustained a traumatic injury, both of which may be indicative of significant social problems. Repeated experience of physical trauma is relatively common among these individuals (6) and they also frequently experience significant difficulties in return to pre-injury levels of occupational functioning (7).

Levine et al. (8), evaluating many of the critical variables reported in previous studies, compared the psychosocial functioning of adult patients who sustained traumatic facial injury with an age-matched, gender-matched, and race-matched control group of non-injured persons across a variety of psychosocial domains. Facial trauma patients reported higher rates of depression, substance abuse problems, posttraumatic stress disorder symptoms, body image concerns, and a lower overall satisfaction with life as compared to controls. In addition, facial trauma patients reported more problems in marital and occupational functioning and higher rates of contact with the legal system. Not surprisingly, they were rated as having a more negative facial appearance by independent raters, although the patients themselves did not rate their posttrauma appearance more negatively than their pretrauma appearance. Though the number of patients in this study was small (n = 20), it nevertheless documents significant group differences on a wide range of psychosocial variables.

Interestingly, while it has been frequently clinically observed that there is no necessary correlation between the degree of disfigurement and the extent of psychological response (1,9, 10) (see Cash’s chapter on body image and all three chapters on cosmetic surgery for a discussion of related issues), a recent empirical investigation of the psychological effects of minor facial lacerations documented that such injuries can have significant psychosocial effects (including self-consciousness and social anxiety) and that the degree of such disturbance was more pronounced the larger the scar (11).

PSYCHOLOGICAL RESPONSES SPECIFIC TO FACIAL TRAUMA: POSTTRAUMATIC STRESS DISORDER AND NEUROPSYCHOLOGICAL SYMPTOMS

Next, we review two areas of concern particularly relevant to facial trauma: (i) the occurrence of posttraumatic stress disorder (PTSD) symptoms; and (ii) the possible neuropsychological consequences of facial trauma.

Posttraumatic Stress Disorder (PTSD)

The primary symptoms of posttraumatic stress disorder include (i) re-experiencing of the trauma (e.g., having intrusive and distressing thoughts and/or distressing images
and dreams); (ii) avoidance of thoughts, emotions, or situations related to the trauma; and (iii) autonomic nervous system hyperarousal, including difficulties with sleeping, having an exaggerated startle response, and experiencing increased irritability and tension (12). In some instances, these symptoms are not reported by the patients, but are described by individuals close to the patients. (PTSD is also described in the chapters on pediatric and adult burn injury as well as the chapter on hand trauma.)

There have been at least three studies documenting evidence of PTSD symptoms in adult facial trauma patients (8,13, 14). Similar findings of high rates of PTSD in trauma induced facial disfigurement have been reported in pediatric plastic surgery populations (15). In an investigation of the prevalence of acute PTSD symptoms in 336 patients presenting to an urban hospital with orofacial trauma (midfacial or mandibular fractures) (14), 25% of patients met the diagnostic criteria for acute PTSD. Two other studies have found prevalence rates of 27% and 30% (8,13). It is also quite possible that a substantial portion of patients might experience subclinical forms of PTSD (i.e., not meeting the full diagnostic criteria) that can nevertheless substantially undermine the patient’s quality of life.

Several factors may suggest to the plastic surgeon that a patient is suffering from PTSD. Individuals with orofacial trauma who reported PTSD symptoms were more likely to also report pre-injury psychological problems, increased levels of pre-injury social stress, lower levels of social support, and pre-injury “exposure to and distress” with respect to prior trauma (14). Those with PTSD also were more likely to be older, female, and have experienced more injury-related pain (14). Thus, evaluating postsurgical facial trauma patients in light of the variables predictive of PTSD may help identify patients at increased risk for experiencing other forms of postinjury psychological distress (14). Identification of PTSD symptoms can lead to a further exploration and uncovering of previously unrecognized additional psychological symptoms (e.g., depression, substance abuse).

To conduct a brief screening for PTSD in facial trauma patients seeking reconstructive surgery, we suggest that the plastic surgery team use the four-item Primary Care PTSD Screen (PC-PTSD) published by The National Center for PTSD (http://www.ncptsd.org/screen_disaster.html). We have reprinted the four items in the Quality of Life Assessment for Facial Trauma Patients in Questionnaire 8-1 at the end of this chapter. We recommend administering these items to all facial trauma patients in combination with the items in Questionnaire 8-2 (General Quality of Life Assessment) described later.

Potential Neuropsychological Deficits

Any patient who has sustained an injury to the face significant enough to result in facial disfigurement also may have sustained a trauma to the brain. A concussion could result in possible long-term brain-injury related neuropsychological deficits, including cognitive, emotional, and behavioral sequelae that warrant attention (16, 17). Although concussion has been variously defined, its essential features include immediate and transient posttraumatic mental status (neural function) alterations, and may or may not include loss of consciousness (LOC). In general, headaches, nausea, dizziness, diplopia, confusion, slowed mental processing, attention problems, and/or amnesia/memory disturbances are the acute sequelae. In a global sense, the severity of a head injury can be categorized by using the Glasgow Coma Scale (GCS) (18). The GCS is a universal system of quantifying the level of consciousness or mental intactness following traumatic brain injury (TBI) by differentially rating an individual’s best motor, verbal, and eye opening responses. On a 3 to 15 point scale, a head injury is considered mild if the GCS score is greater than or equal to 13, moderate if the GCS score is between 9 and 12, and severe if the GCS score is less than or equal to 8 (19).

Other issues to be considered in the evaluation of head injury severity are evidence of, and duration of, LOC, retrograde amnesia (loss of memory for events prior to the injury), and posttraumatic amnesia (PTA: loss of memory for events after the injury) (20, 21). In a general sense, more extreme impairment suggests a more severe head injury. Moderate and severe brain injuries have obvious sequelae and are treated in the Emergency Department (ED). A mild head injury or mild traumatic brain injury (mTBI), also referred to as a concussion, is less obvious to the ED physician and may be overlooked during initial hospital treatment.

The primary mechanisms of TBI (particularly following facial trauma) include impact deceleration of the brain within the skull and impact injury to the anterior, frontal and temporal lobes, and diffuse axonal shearing (i.e., twisting, stretching, and tearing of axonal fibers from deceleration and rotational torque). These mechanisms either result in, or are associated with, a pathophysiological cascade of secondary events, including intracellular influx of calcium, reduction in potassium, and vascular and related glucose insufficiencies (20). In mTBI and concussion, these same processes may be expressed in a less identifiable form (and may not be realized on neuroimaging). Mild TBI often goes unrecognized because the more noticeable medical emergency is the facial trauma.

The Effects of Mild Head Injury

Mild head injury or concussion, particularly without LOC, was previously believed to be insufficient to cause neurologic injury. Poor outcomes and persisting symptoms were thought to be related to psychological problems and not the head trauma itself (22). Clinical research has since revealed that mild neuropsychological deficits do occur in many mild head injuries (23). While most mild head injury patients demonstrate rapid, spontaneous recovery within several days or weeks, a small percentage experience prolonged postconcussion symptoms lasting 3 months or longer. This lack of recovery following a mild head injury is referred to as postconcussive syndrome (PCS) (23).

Evaluating Patients with Head Injury

As part of the plastic surgeon’s initial presurgery assessment, the patient should be evaluated for presence and severity of head injury (LOC, retrograde amnesia, and PTA) and for PCS symptoms (see Table 8-1). Being aware of their patient’s functional (cognitive, psychological, and physical) changes, is critical to appropriate care. Certain memory problems may interfere with the patient’s ability to take medications as directed, or the patient may not process information or recall instructional procedures. If the patient has trouble concentrating, the treatment process may be much more challenging and require more patience on the part of the plastic surgery team. Assessing for and identifying these postconcussive syndrome symptoms will help reconstructive surgeons to modify the aftercare procedures they use. Sometimes, repeating and writing down presurgical and postsurgical care plans and including significant others during these discussions so that they can help remind and explain the surgeon’s plans to the patient, can be critical to treatment compliance.

To conduct a screening for possible neuropsychological deficits associated with facial trauma, we have included 13 self-report items (in addition to the four PTSD-related items) in Questionnaire 8-1 at the end of this chapter (Quality of Life Assessment for Patients Sustaining Facial Trauma). We recommend that the plastic surgeon consider administering this measure to all patients who have sustained a facial trauma to help assist in the identification of patients who may be experiencing neuropsychological problems. More clearly understanding the patient’s neuropsychological functioning (as well as their overall psychological functioning) also has implications for determining the patient’s ability to process information regarding
surgical procedures and expected surgical outcomes and may help to prevent any misunderstanding that can result in disappointment postoperatively.

TABLE 8-1 Head Injury Taxonomy

*Presence and Severity of Head Injury*		*Postconcussive Syndrome (PCS) Symptoms*
Glasgow Coma Scale (GCS) Score □ Severe Range Scores 3 4 5 6 7 8 □ Moderate Range Scores 9 10 11 12 □ Mild Range Scores 13 14 15		Neurocognitive Symptoms □ Slowed mental processing □ Inattentive □ Poor concentration □ Impaired memory □ Poor planning □ Disorganized
Loss of Consciousness (LOC)? □ No □ Yes Duration:__________________		Psychological and Behavioral Symptoms □ Depression □ Anxiety □ Irritability/impatience □ Disinhibition □ Poor judgment □ Amotivation
Retrograde Amnesia? □ No □ Yes Duration:__________________		Physical Symptoms □ Headache □ Nausea □ Dizziness □ Diplopia □ Tinnitus
Posttraumatic Amnesia (PTA)? □ No □ Yes Duration:__________________

Neuropsychological Assessment

In cases where several PCS symptoms are present, a neuropsychological evaluation is warranted. A plastic surgeon, after referring his or her patient to a clinical neuropsychologist, should expect a comprehensive evaluation. These assessments typically include a concise description of the presenting condition (based on available medical records and input from the patient and/or family members during the clinical interview part of the assessment battery), a medical and psychosocial history, and a detailed summary of the results of the formal neuropsychological testing.

The patient’s abilities and behavior that are typically assessed in any head injury neuropsychological evaluation include the following: orientation, attention/concentration, language functions, intellectual abilities, abstract reasoning, concept formation, new problem solving, mental flexibility, executive functions, learning, verbal, and spatial memory, information processing capacity and speed, visuospatial abilities, motor and sensory skills, and emotional and personality status (21). These functional areas are evaluated using paper-pencil, mechanical, and sensory-motor tests, thereby allowing the neuropsychologist to study the impact of the patient’s head injury. Computerized and Web-based neurocognitive assessment procedures can offer new precision and efficiencies in some of these evaluations and screening procedures.

The reconstructive surgeon should also expect the clinical neuropsychologist to provide feedback to the patient and/or family members. This is considered to be an integral part of the evaluation process (20). The feedback typically includes practical, supportive, and educative information about the patient’s cognitive,
behavioral, and emotional strengths and weaknesses. In addition, information is given to the patient to assist in the development of realistic expectations about their time course of recovery, coping strategies, and follow-up neuropsychological evaluations (i.e., to track neurocognitive changes).

PSYCHOLOGICAL RESPONSES TO FACIAL CANCER

The psychological experience of facial cancer patients has received even less empirical or clinical attention than the experiences of facial trauma patients (24, 25). Based on the extensive body image and physical appearance scholarship (Chapters 3 and 4), as well as clinical and published reports of patients’ experience (26, 27, 28), the psychological effects of facial cancers are believed to be quite extensive and at least as disruptive as facial trauma.

We are aware of only one study explicitly comparing plastic surgery patients undergoing treatment for facial cancer (basal cell carcinomas, squamous cell carcinomas, and malignant melanomas) with patients undergoing reconstruction for scarring resulting from injury (29). Facial cancer patients (who were no longer undergoing cancer treatment) reported lower levels of depression, anxiety, social concern, and concern about their appearance as compared to the facial trauma patients. However, despite experience with many significant problems, including disfigurement, difficulties with swallowing and eating, pain, speech problems, and dry mouth, patients with head and neck cancer nevertheless report that their overall quality of life is not significantly compromised (30, 31). Rybarczyk and Behel (32), describing the psychological adjustment to acquired disability, report that disabilities resulting from lifesaving interventions often are associated with better psychological adjustment than disabilities that occur as a result of accidents. Trauma induced disabilities are often perceived to be “random, unnecessary and unfair” resulting in blaming and anger towards one’s self or others as well as being associated with idealizing one’s pre-injury physical appearance (32) all of which serve to make the adjustment process more difficult.

Therefore, though no definitive empirical conclusions currently exist, there is some reason to believe that the psychological effects of facial cancers may be less psychologically disruptive than facial trauma. However, the clinical observation that patients with facial cancer are more likely to be older, married, and have greater concerns regarding whether they will live or die must be taken into consideration when making this comparison. Additionally, facial cancer patients who have particular predisposing personality traits may be at increased risk for compromised quality of life. For example, in patients with head and neck squamous cell carcinoma, higher levels of neuroticism were associated with lower quality of life (33) and higher levels of alcohol consumption (34). Such problems would unquestionably complicate the process of psychologically adapting to a cancer diagnosis, facial disfigurement, and surgical reconstruction.

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