Italian Translation and Cultural Adaptation of the FACE-Q Skin Cancer Module

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The concept of health-related quality of life (QOL) captures the patient's perspective on how the illness and its treatment affect their well-being. The FACE-Q Skin Cancer Module represents a validated patient-reported outcome (PRO) instrument, specifically developed for patients undergoing facial skin cancer surgery. Methods. Upon authorization and licensing from the Q-Portfolio ® team, the authors engaged the process of translation and cultural adaptation of this questionnaire into Italian, in accordance with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and World Health Organization (WHO) guidelines. Results. In the first step, two Italian translations are produced and reconciled into one. In the second step, the reconciled Italian version is reverse-translated into English. As third step, the back-translation was reviewed and approved by the Q-Portfolio team. A representative sample of the questionnaire’s potential target was interviewed, and final refinements were made in the fourth and final step. At the end of these phases, a validated and conceptually equivalent Italian version of the FACE-Q Skin Cancer Module was achieved. Conclusions. This tool is currently ready and available for clinical and research purposes. The introduction of an Italian version marks a significant step towards enhancing its accessibility and relevance, ensuring tangible benefits for both clinicians and patients. INTRODUCTION The prevalence of both Malignant melanoma (MM) and non-melanoma skin cancer (NMSC) has seen a steady rise in recent decades 1 . Among these, cutaneous melanoma stands out as potentially the most lethal skin tumor 2 . Nevertheless, the prognosis for patients diagnosed with localized tumors is remarkably positive, boasting a 5-year survival rate of over 99% 3 . The primary treatment approach, wide local excision following an excisional biopsy 4 , however, poses a risk of considerable disfigurement, especially when the tumor is facially located. Cutaneous basal cell carcinoma (cBCC) and squamous cell carcinoma (cSCC), which constitute 95% of all malignant skin tumors, much less frequently lead to metastasis or disease-related death. Yet, they can inflict significant morbidity due to their potential for local destruction and the considerable deformity that can follow surgical intervention 5 . The concept of health-related quality of life (QOL) captures the patient's perspective on how the illness and its treatment affect their physical, psychological, and social well-being 6 . Since physical appearance significantly influences emotions and social interactions, scars from facial surgeries can profoundly affect self-perception, representing a critical but often undervalued outcome of treatment. Patient-reported outcome (PRO) instruments, such as questionnaires, are designed to measure these subjective effects 7 . The FACE-Q Skin Cancer Module is specifically developed for patients undergoing surgery for facial skin cancers. It has been validated using contemporary psychometric methods 7 . In this paper, we underscore the clinical and scientific significance of patient-reported outcomes, as captured through high-quality questionnaires. We detail the process of creating a validated, conceptually equivalent Italian version of the FACE-Q module for skin cancer, enhancing its applicability and utility for Italian-speaking patients and clinicians. MATERIALS & METHODS Authorization and licensing were obtained from the Q-Portfolio® team to produce the official Italian version of the FACE-Q module for skin cancer. The process was carried out and completed according to the Q-Portfolio guidelines®, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and World Health Organization (WHO) best-practice guidelines for the translation and cultural adaptation of patient-reported outcome instruments 1 . As first step, two forward translators (Italian native speakers, fluent in English) produced two independent Italian translations of the questionnaire. By support and mediation of a third party, a reconciled version was obtained. As second step, a back translator (English native speaker, fluent in Italian) re-translated the reconciled version into English. As third step, the back-translation was reviewed and approved by the Q-Portfolio team. As fourth and final step, the Authors proceeded to the cognitive debriefing ; the sample interviewed was intended to be representative of the questionnaire’s potential target. Based on patients’ feedback, the translation was ulteriorly refined to improve comprehension. RESULTS The FACE-Q Skin Cancer Module, comprising 56 questions across 7 scales, underwent a meticulous translation process to ensure cultural and linguistic appropriateness for Italian speakers. The initial forward translations were closely aligned, differing mainly in word order and syntax. Translators encountered challenges with a few English terms—such as "self-conscious," "look like," and "even"—due to the absence of direct semantic equivalents in Italian. Subsequent back translation highlighted minor discrepancies (e.g., "contour" vs. "profile" and "bothered by" vs. "suffered from"), which were harmonized through consensus between the project manager and the translators, receiving the Q-Portfolio team's endorsement. The cognitive debriefing phase engaged 25 diverse participants (12 women and 13 men), all of whom had experienced facial skin cancer and subsequent excisional/reconstructive surgery. Their ages ranged from 34 to 87, with an average of 62.48 years. The participants' educational backgrounds varied, including 13 with primary/middle school diplomas, 9 with high school diplomas, and 3 with university degrees. They represented a wide geographical cross-section of Italy, hailing from 17 of the 20 regions, thus a broad spectrum of dialects and cultural nuances was considered. Feedback from these participants indicated that the questionnaire was generally clear and comprehensible. However, they suggested simplifying the complex instructions and response options in the initial scales (concerning cancer worry and appearance-related distress), leading to modifications for enhanced clarity. The rest of the module was found to be easily understood and the questions straightforward to answer. After incorporating these adjustments and resolving minor linguistic nuances ("a little" vs. "in disagreement"), the revised module was presented to the Q-Portfolio team for final approval. This process ensured the Italian version of the FACE-Q Skin Cancer Module was semantically faithful to the original English version, ready for clinical and research use with native Italian speakers. DISCUSSION Malignant melanoma (MM) and non-melanoma skin cancer (NMSC) are the most common types of skin cancer and the incidence of both is rising worldwide 2 . Despite representing only 3.5% of total body surface area, the face is overrepresented in terms of incidence per anatomical site 3 . As a consequence, surgical management of facial skin malignancies has significantly increased over the last decades 4 . Since most cases of cBCCs, cSCCs and early-stage cutaneous melanomas have good prognosis and decreasing mortality rates 2 , 5 , most patients will deal with the consequences of skin cancer surgery for great periods of time. Alongside physician-evaluated endpoints (i.e. survival rate, local control rate and complication rate) 6 , a change in quality of life (QOL) is a well-known major health outcome of cancer diagnosis and treatment 7 . QOL denotes the emotional, physical, aesthetic, and functional consequences of cancer diagnosis and treatment and their impact on the patient’s daily functioning 6 . Skin tumors located in the facial region and scarring from facial surgery are reportedly associated with significant psychologic morbidity 8 , 9 . The analysis of subjective items – such as the patient’s perspective on their aesthetic outcome and overall care – requires comprehensive and specifically designed patient-reported outcome (PRO) instruments 10 . Out of the Q-Portfolio questionnaires, in 2010 Klassen et al developed a validated psychometric evaluation instrument for patients undergoing facial aesthetic surgery: the FACE-Q (English version) 11 . The copyright of the original and all subsequent authorized translated versions of the questionnaires is held by Memorial Sloan Kettering Cancer Center (New York, NY) 11 , 12 . With a 3-phased approach (literature review, international field-study, psychometric study), the FACE-Q Skin Cancer Module was developed and published in 2018. This module was specifically designed for patients undergoing surgical procedures for facial skin cancers. All scales were validated for clinical use in the skin cancer population 10 . The updated module consists of 56 questions grouped in 7 scales (cancer worry, appearance-related distress, appraisal of scars, satisfaction with facial appearance, satisfaction with information: appearance, sun protection behavior, adverse effects checklist) 13 . Items are scored using the Rasch Measurement Theory to yield an overall score for the concept between 0 (worst) and 100 (best) 14 , 15 . Several authorized translations of the updated FACE-Q Skin Cancer Module are currently available (British English 16 , Dutch 13 , French, German, Brazilian Portuguese 17 , Spanish and Turkish); still the Italian adaptation of this tool was lacking. Upon authorization and licensing from the Q-Portfolio team, the Authors engaged in the process of adaptation of the English version into Italian. The description of such process and subsequent results constitutes the aim of this paper. According to the copyright holder’s directions, a conceptual – rather than literal – translation is warranted. A combination of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and World Health Organization (WHO) guidelines provides a reliable blueprint for the linguistic validation and cultural adaptation process 18 , 19 . Following the Q-Portfolio team instructions, the Authors designated two fluent in English Italian native speakers as forward translators . Each one produced an independent translation of the official English version of the Module at issue. The two versions mainly differed for word order and syntax; and both translators strived in conveying the message of few English terms that lack a unique Italian semantic equivalent (i.e.: “self-conscious”, “look like”, “even”). Nevertheless, by support and supervision of a third-party mediator, a reconciled version was comfortably obtained. The latter was then re-translated into English by the back translator (fluent in Italian, English native speaker) and submitted to the Q-Portfolio team. Minor inconsistences emerged between original and back-translated version (i.e.: “contour” vs “profile”, “even” vs “regular”, “smooth” vs “harmonic”, “bothered by” vs “suffered”). All discrepancies were resolved by a consensus between Project Manager and the three translators, and then submitted to the Q-Portfolio team for approval. The last stage of the process is the cognitive debriefing; the approved version was presented to a sample of patients in order to validate its clarity, intelligibility and effectiveness. According to the Q-Portfolio Team guidelines, the required minimum number of participants is set at 5. Nevertheless, for this study the authors recruited a total of 25 patients in order to enclose patients of different sexes, ages and levels of education. In addition, the number of participants allowed to consider the wide sociolinguistic and dialectal variation that is observed in Italy 20 , covering a total of 17 out of 20 regions, spreading from Northern to Southern Italy. The main purpose was to reach a sample as representative as possible of the potential target of this Questionnaire within the Italian population. The interviewed sample found the version overall straightforward and comprehensible, with minor refinements to improve clarity. Finally, the resulting Italian version of the questionnaire was aligned as closely as possible with the English version by minor changes (i.e.: the expression 'a little', which does not have an exact translation, has been replaced by the expression 'in disagreement’, which is semantically similar). At the end of phase 4, a conceptually equivalent Italian version of the FACE-Q Skin Cancer Module was achieved and finally available for use by clinicians. The World Health Organization constitution defines health as “a state of complete physical, mental and social well-being ant not merely the absence of disease or infirmity” 21 . Accordingly, effective cancer extirpation and successful reconstruction are paramount clinician-reported outcomes, but not exhaustive for an all-rounded evaluation of the cure provided. The FACE-Q Skin Cancer Module, now available in an official Italian version, represents a reliable tool in the hands of the physician for reporting and analyzing the patients’ perspective on their disease, the treatment received, and the consequent impact on their quality of life. CONCLUSIONS The FACE-Q Skin Cancer Module stands as a pioneering tool for plastic surgeons, maxillofacial surgeons and dermatologists, enabling them to comprehensively evaluate treatment outcomes. Until recently, however, an authorized Italian version of this module was missing, limiting its applicability within native-Italian-speaker patients. The authors filled this gap by securing authorization and meticulously following the copyright holder’s guidelines to produce the official Italian translation and cultural adaptation of the FACE-Q Skin Cancer Module. The introduction of an Italian version marks a significant step towards enhancing its accessibility and relevance, ensuring tangible benefits for both clinicians and patients. The availability of the Italian version of the module not only facilitates a more targeted and culturally appropriate approach in evaluating clinical outcomes but also promotes a deeper understanding of the needs and perceptions of patients that are Italian native speakers, thereby improving the quality of care provided. This revision aims to highlight the innovation the FACE-Q Skin Cancer Module represents, and the importance of its cultural and linguistic adaptation for the Italian context, underscoring the added value for healthcare professionals and their patients. Declarations COMPETING INTERESTS The authors have no relevant financial or non-financial interests to disclose. FUNDING The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. AUTHOR CONTRIBUTIONS All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by the first author. The first draft of the manuscript was written by the first author and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. ETHICS Because of the nature of this study, ethical approval was not required. CONSENT TO PARTICIPATE Informed consent was obtained from all individual participants included in the study. References Radiation: Ultraviolet (UV) radiation and skin cancer. Accessed August 25, 2023. https://www.who.int/news-room/questions-and-answers/item/radiation-ultraviolet-(uv)-radiation-and-skin-cancer1. Wild D, Grove A, Martin M, et al. Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures: Report of the ISPOR Task Force for Translation and Cultural Adaptation. Value Health . 2005;8(2):94-104. doi:10.1111/j.1524-4733.2005.04054.x Leiter U, Eigentler T, Garbe C. Epidemiology of Skin Cancer. In: Reichrath J, ed. Sunlight, Vitamin D and Skin Cancer . Springer; 2014:120-140. doi:10.1007/978-1-4939-0437-2_7 Larson DL, Larson JD. Head and neck melanoma. Clin Plast Surg . 2010;37(1):73-77. doi:10.1016/j.cps.2009.08.005 Donaldson MR, Coldiron BM. Dermatologists perform the majority of cutaneous reconstructions in the Medicare population: Numbers and trends from 2004 to 2009. J Am Acad Dermatol . 2013;68(5):803-808. doi:10.1016/j.jaad.2013.01.026 Baade PD, Whiteman DC, Janda M, et al. Long-term deaths from melanoma according to tumor thickness at diagnosis. Int J Cancer . 2020;147(5):1391-1396. doi:10.1002/ijc.32930 Peisker A, Raschke GF, Guentsch A, Roshanghias K, Eichmann F, Schultze-Mosgau S. Longterm quality of life after oncologic surgery and microvascular free flap reconstruction in patients with oral squamous cell carcinoma. Med Oral Patol Oral Cir Bucal . 2016;21(4):e420-e424. doi:10.4317/medoral.21111 Butow PN, Coates AS, Dunn SM. Psychosocial predictors of survival in metastatic melanoma. J Clin Oncol Off J Am Soc Clin Oncol . 1999;17(7):2256-2263. doi:10.1200/JCO.1999.17.7.2256 Steinbauer J, Koller M, Kohl E, Karrer S, Landthaler M, Szeimies RM. Quality of life in health care of non-melanoma skin cancer – results of a pilot study. JDDG J Dtsch Dermatol Ges . 2011;9(2):129-135. doi:10.1111/j.1610-0387.2010.07547.x Dropkin M jo. Body Image and Quality of Life After Head and Neck Cancer Surgery. Cancer Pract . 1999;7(6):309-313. doi:10.1046/j.1523-5394.1999.76006.x Lee E h., Klassen A f., Cano S j., Nehal K s., Pusic A l. FACE-Q Skin Cancer Module for measuring patient-reported outcomes following facial skin cancer surgery. Br J Dermatol . 2018;179(1):88-94. doi:10.1111/bjd.16671 Klassen AF, Cano SJ, Scott A, Snell L, Pusic AL. Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q. Facial Plast Surg FPS . 2010;26(4):303-309. doi:10.1055/s-0030-1262313 admqportfolio. FACE-Q | Aesthetics - Q-Portfolio MEASURING WHAT MATTERS TO PATIENTS. Published May 11, 2017. Accessed December 27, 2023. https://qportfolio.org/face-q/aesthetics/ Ottenhof MJ, Lardinois AJPM, Brouwer P, et al. Patient-reported Outcome Measures: The FACE-Q Skin Cancer Module: The Dutch Translation and Linguistic Validation. Plast Reconstr Surg – Glob Open . 2019;7(10):e2325. doi:10.1097/GOX.0000000000002325 Petrillo J, Cano SJ, McLeod LD, Coon CD. Using Classical Test Theory, Item Response Theory, and Rasch Measurement Theory to Evaluate Patient-Reported Outcome Measures: A Comparison of Worked Examples. Value Health . 2015;18(1):25-34. doi:10.1016/j.jval.2014.10.005 Rasch G. Probabilistic Models for Some Intelligence and Attainment Tests . MESA Press, 5835 S; 1993. Dobbs T, Hutchings HA, Whitaker IS. UK-based prospective cohort study to anglicise and validate the FACE-Q Skin Cancer Module in patients with facial skin cancer undergoing surgical reconstruction: the PROMISCR (Patient-Reported Outcome Measure in Skin Cancer Reconstruction) study. BMJ Open . 2017;7(9):e016182. doi:10.1136/bmjopen-2017-016182 Bustillo AMB, Lobato RC, Luitgards BF, Camargo CP, Gemperli R, Ishida LC. Translation, Cross-Cultural Adaptation and Linguistic Validation of the FACE-Q Questionnaire for Brazilian Portuguese. Aesthetic Plast Surg . 2019;43(4):930-937. doi:10.1007/s00266-019-01399-1 Koller M, West K. Linguistic Validation Manual for Patient-Reported Outcomes (PRO) Instruments, By C. Acquadro, K. Conway, C. Girourdet & I. Mear, MAPI ResearchTrust, Lyon, France, 2004,184 pp, ISBN: 2-9522021-0-9, price €70/$90. Qual Life Res - QUAL LIFE RES . 2005;14:1791-1792. doi:10.1007/s11136-005-5367-1 Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform . 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010 Cerruti M. Regional varieties of Italian in the linguistic repertoire. 2011;2011(210):9-28. doi:10.1515/ijsl.2011.028 Constitution of the World Health Organization. Accessed December 27, 2023. https://www.who.int/about/accountability/governance/constitution Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 27 Nov, 2024 Read the published version in European Journal of Plastic Surgery → Version 1 posted Editorial decision: Revision requested 05 Nov, 2024 Reviews received at journal 05 Nov, 2024 Reviewers agreed at journal 05 Nov, 2024 Reviewers invited by journal 22 Oct, 2024 Editor assigned by journal 26 Sep, 2024 Submission checks completed at journal 26 Sep, 2024 First submitted to journal 24 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5147565","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":374260269,"identity":"0b41da31-9fd1-40e7-b66a-24b0f0a268e8","order_by":0,"name":"Silvia 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XXIII","correspondingAuthor":false,"prefix":"","firstName":"Marcello","middleName":"","lastName":"Carminati","suffix":""},{"id":374260278,"identity":"2c97ab38-75bf-4587-ab4f-f1d78289f768","order_by":8,"name":"Luigi Valdatta","email":"","orcid":"","institution":"Department of Biotechnology and Life Sciences, University of Insubria","correspondingAuthor":false,"prefix":"","firstName":"Luigi","middleName":"","lastName":"Valdatta","suffix":""}],"badges":[],"createdAt":"2024-09-24 20:53:15","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5147565/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5147565/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00238-024-02253-7","type":"published","date":"2024-11-27T15:58:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":70388864,"identity":"bfb1b159-5581-41d1-af0e-5bd22aa8931b","added_by":"auto","created_at":"2024-12-02 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Among these, cutaneous melanoma stands out as potentially the most lethal skin tumor\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Nevertheless, the prognosis for patients diagnosed with localized tumors is remarkably positive, boasting a 5-year survival rate of over 99%\u003csup\u003e3\u003c/sup\u003e. The primary treatment approach, wide local excision following an excisional biopsy\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, however, poses a risk of considerable disfigurement, especially when the tumor is facially located.\u003c/p\u003e \u003cp\u003eCutaneous basal cell carcinoma (cBCC) and squamous cell carcinoma (cSCC), which constitute 95% of all malignant skin tumors, much less frequently lead to metastasis or disease-related death. Yet, they can inflict significant morbidity due to their potential for local destruction and the considerable deformity that can follow surgical intervention\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe concept of health-related quality of life (QOL) captures the patient's perspective on how the illness and its treatment affect their physical, psychological, and social well-being\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e. Since physical appearance significantly influences emotions and social interactions, scars from facial surgeries can profoundly affect self-perception, representing a critical but often undervalued outcome of treatment.\u003c/p\u003e \u003cp\u003ePatient-reported outcome (PRO) instruments, such as questionnaires, are designed to measure these subjective effects\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The FACE-Q Skin Cancer Module is specifically developed for patients undergoing surgery for facial skin cancers. It has been validated using contemporary psychometric methods\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eIn this paper, we underscore the clinical and scientific significance of patient-reported outcomes, as captured through high-quality questionnaires. We detail the process of creating a validated, conceptually equivalent Italian version of the FACE-Q module for skin cancer, enhancing its applicability and utility for Italian-speaking patients and clinicians.\u003c/p\u003e"},{"header":"MATERIALS \u0026 METHODS","content":"\u003cp\u003eAuthorization and licensing were obtained from the Q-Portfolio\u0026reg; team to produce the official Italian version of the FACE-Q module for skin cancer. The process was carried out and completed according to the Q-Portfolio guidelines\u0026reg;, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and World Health Organization (WHO) best-practice guidelines for the translation and cultural adaptation of patient-reported outcome instruments\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eAs first step, two \u003cem\u003eforward translators\u003c/em\u003e (Italian native speakers, fluent in English) produced two independent Italian translations of the questionnaire. By support and mediation of a third party, a reconciled version was obtained. As second step, a \u003cem\u003eback translator\u003c/em\u003e (English native speaker, fluent in Italian) re-translated the reconciled version into English. As third step, the back-translation was reviewed and approved by the Q-Portfolio team. As fourth and final step, the Authors proceeded to the \u003cem\u003ecognitive debriefing\u003c/em\u003e; the sample interviewed was intended to be representative of the questionnaire\u0026rsquo;s potential target. Based on patients\u0026rsquo; feedback, the translation was ulteriorly refined to improve comprehension.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eThe FACE-Q Skin Cancer Module, comprising 56 questions across 7 scales, underwent a meticulous translation process to ensure cultural and linguistic appropriateness for Italian speakers. The initial forward translations were closely aligned, differing mainly in word order and syntax. Translators encountered challenges with a few English terms\u0026mdash;such as \"self-conscious,\" \"look like,\" and \"even\"\u0026mdash;due to the absence of direct semantic equivalents in Italian. Subsequent back translation highlighted minor discrepancies (e.g., \"contour\" vs. \"profile\" and \"bothered by\" vs. \"suffered from\"), which were harmonized through consensus between the project manager and the translators, receiving the Q-Portfolio team's endorsement.\u003c/p\u003e \u003cp\u003e The cognitive debriefing phase engaged 25 diverse participants (12 women and 13 men), all of whom had experienced facial skin cancer and subsequent excisional/reconstructive surgery. Their ages ranged from 34 to 87, with an average of 62.48 years. The participants' educational backgrounds varied, including 13 with primary/middle school diplomas, 9 with high school diplomas, and 3 with university degrees. They represented a wide geographical cross-section of Italy, hailing from 17 of the 20 regions, thus a broad spectrum of dialects and cultural nuances was considered.\u003c/p\u003e \u003cp\u003eFeedback from these participants indicated that the questionnaire was generally clear and comprehensible. However, they suggested simplifying the complex instructions and response options in the initial scales (concerning cancer worry and appearance-related distress), leading to modifications for enhanced clarity. The rest of the module was found to be easily understood and the questions straightforward to answer.\u003c/p\u003e \u003cp\u003eAfter incorporating these adjustments and resolving minor linguistic nuances (\"a little\" vs. \"in disagreement\"), the revised module was presented to the Q-Portfolio team for final approval. This process ensured the Italian version of the FACE-Q Skin Cancer Module was semantically faithful to the original English version, ready for clinical and research use with native Italian speakers.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eMalignant melanoma (MM) and non-melanoma skin cancer (NMSC) are the most common types of skin cancer and the incidence of both is rising worldwide\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Despite representing only 3.5% of total body surface area, the face is overrepresented in terms of incidence per anatomical site\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. As a consequence, surgical management of facial skin malignancies has significantly increased over the last decades\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Since most cases of cBCCs, cSCCs and early-stage cutaneous melanomas have good prognosis and decreasing mortality rates\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, most patients will deal with the consequences of skin cancer surgery for great periods of time.\u003c/p\u003e \u003cp\u003eAlongside physician-evaluated endpoints (i.e. survival rate, local control rate and complication rate)\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e, a change in quality of life (QOL) is a well-known major health outcome of cancer diagnosis and treatment\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. QOL denotes the emotional, physical, aesthetic, and functional consequences of cancer diagnosis and treatment and their impact on the patient\u0026rsquo;s daily functioning\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSkin tumors located in the facial region and scarring from facial surgery are reportedly associated with significant psychologic morbidity\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. The analysis of subjective items \u0026ndash; such as the patient\u0026rsquo;s perspective on their aesthetic outcome and overall care \u0026ndash; requires comprehensive and specifically designed patient-reported outcome (PRO) instruments\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eOut of the Q-Portfolio questionnaires, in 2010 Klassen et al developed a validated psychometric evaluation instrument for patients undergoing facial aesthetic surgery: the FACE-Q (English version)\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe copyright of the original and all subsequent authorized translated versions of the questionnaires is held by \u003cem\u003eMemorial Sloan Kettering Cancer Center (New York, NY)\u003c/em\u003e\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003e With a 3-phased approach (literature review, international field-study, psychometric study), the FACE-Q Skin Cancer Module was developed and published in 2018. This module was specifically designed for patients undergoing surgical procedures for facial skin cancers. All scales were validated for clinical use in the skin cancer population\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e. The updated module consists of 56 questions grouped in 7 scales (cancer worry, appearance-related distress, appraisal of scars, satisfaction with facial appearance, satisfaction with information: appearance, sun protection behavior, adverse effects checklist)\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. Items are scored using the Rasch Measurement Theory to yield an overall score for the concept between 0 (worst) and 100 (best)\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e,\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eSeveral authorized translations of the updated FACE-Q Skin Cancer Module are currently available (British English\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e, Dutch\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e, French, German, Brazilian Portuguese\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e, Spanish and Turkish); still the Italian adaptation of this tool was lacking.\u003c/p\u003e \u003cp\u003eUpon authorization and licensing from the Q-Portfolio team, the Authors engaged in the process of adaptation of the English version into Italian. The description of such process and subsequent results constitutes the aim of this paper.\u003c/p\u003e \u003cp\u003eAccording to the copyright holder\u0026rsquo;s directions, a conceptual \u0026ndash; rather than literal \u0026ndash; translation is warranted. A combination of the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and World Health Organization (WHO) guidelines provides a reliable blueprint for the linguistic validation and cultural adaptation process\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eFollowing the Q-Portfolio team instructions, the Authors designated two fluent in English Italian native speakers as \u003cem\u003eforward translators\u003c/em\u003e. Each one produced an independent translation of the official English version of the Module at issue. The two versions mainly differed for word order and syntax; and both translators strived in conveying the message of few English terms that lack a unique Italian semantic equivalent (i.e.: \u0026ldquo;self-conscious\u0026rdquo;, \u0026ldquo;look like\u0026rdquo;, \u0026ldquo;even\u0026rdquo;). Nevertheless, by support and supervision of a third-party mediator, a reconciled version was comfortably obtained. The latter was then re-translated into English by the \u003cem\u003eback translator\u003c/em\u003e (fluent in Italian, English native speaker) and submitted to the Q-Portfolio team. Minor inconsistences emerged between original and back-translated version (i.e.: \u0026ldquo;contour\u0026rdquo; vs \u0026ldquo;profile\u0026rdquo;, \u0026ldquo;even\u0026rdquo; vs \u0026ldquo;regular\u0026rdquo;, \u0026ldquo;smooth\u0026rdquo; vs \u0026ldquo;harmonic\u0026rdquo;, \u0026ldquo;bothered by\u0026rdquo; vs \u0026ldquo;suffered\u0026rdquo;). All discrepancies were resolved by a consensus between Project Manager and the three translators, and then submitted to the Q-Portfolio team for approval.\u003c/p\u003e \u003cp\u003e The last stage of the process is the cognitive debriefing; the approved version was presented to a sample of patients in order to validate its clarity, intelligibility and effectiveness. According to the Q-Portfolio Team guidelines, the required minimum number of participants is set at 5. Nevertheless, for this study the authors recruited a total of 25 patients in order to enclose patients of different sexes, ages and levels of education. In addition, the number of participants allowed to consider the wide sociolinguistic and dialectal variation that is observed in Italy\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e, covering a total of 17 out of 20 regions, spreading from Northern to Southern Italy. The main purpose was to reach a sample as representative as possible of the potential target of this Questionnaire within the Italian population. The interviewed sample found the version overall straightforward and comprehensible, with minor refinements to improve clarity.\u003c/p\u003e \u003cp\u003eFinally, the resulting Italian version of the questionnaire was aligned as closely as possible with the English version by minor changes (i.e.: the expression 'a little', which does not have an exact translation, has been replaced by the expression 'in disagreement\u0026rsquo;, which is semantically similar).\u003c/p\u003e \u003cp\u003eAt the end of phase 4, a conceptually equivalent Italian version of the FACE-Q Skin Cancer Module was achieved and finally available for use by clinicians.\u003c/p\u003e \u003cp\u003eThe World Health Organization constitution defines \u003cem\u003ehealth\u003c/em\u003e as \u0026ldquo;a state of complete physical, mental and social well-being ant not merely the absence of disease or infirmity\u0026rdquo;\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. Accordingly, effective cancer extirpation and successful reconstruction are paramount clinician-reported outcomes, but not exhaustive for an all-rounded evaluation of the cure provided. The FACE-Q Skin Cancer Module, now available in an official Italian version, represents a reliable tool in the hands of the physician for reporting and analyzing the patients\u0026rsquo; perspective on their disease, the treatment received, and the consequent impact on their quality of life.\u003c/p\u003e"},{"header":"CONCLUSIONS","content":"\u003cp\u003eThe FACE-Q Skin Cancer Module stands as a pioneering tool for plastic surgeons, maxillofacial surgeons and dermatologists, enabling them to comprehensively evaluate treatment outcomes. Until recently, however, an authorized Italian version of this module was missing, limiting its applicability within native-Italian-speaker patients. The authors filled this gap by securing authorization and meticulously following the copyright holder\u0026rsquo;s guidelines to produce the official Italian translation and cultural adaptation of the FACE-Q Skin Cancer Module.\u003c/p\u003e \u003cp\u003eThe introduction of an Italian version marks a significant step towards enhancing its accessibility and relevance, ensuring tangible benefits for both clinicians and patients. The availability of the Italian version of the module not only facilitates a more targeted and culturally appropriate approach in evaluating clinical outcomes but also promotes a deeper understanding of the needs and perceptions of patients that are Italian native speakers, thereby improving the quality of care provided.\u003c/p\u003e \u003cp\u003eThis revision aims to highlight the innovation the FACE-Q Skin Cancer Module represents, and the importance of its cultural and linguistic adaptation for the Italian context, underscoring the added value for healthcare professionals and their patients.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAUTHOR CONTRIBUTIONS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by the first author. The first draft of the manuscript was written by the first author and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBecause of the nature of this study, ethical approval was not required.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT TO PARTICIPATE\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all individual participants included in the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRadiation: Ultraviolet (UV) radiation and skin cancer. Accessed August 25, 2023. https://www.who.int/news-room/questions-and-answers/item/radiation-ultraviolet-(uv)-radiation-and-skin-cancer1. Wild D, Grove A, Martin M, et al. Principles of Good Practice for the Translation and Cultural Adaptation Process for Patient-Reported Outcomes (PRO) Measures: Report of the ISPOR Task Force for Translation and Cultural Adaptation. \u003cem\u003eValue Health\u003c/em\u003e. 2005;8(2):94-104. doi:10.1111/j.1524-4733.2005.04054.x\u003c/li\u003e\n\u003cli\u003eLeiter U, Eigentler T, Garbe C. Epidemiology of Skin Cancer. In: Reichrath J, ed. \u003cem\u003eSunlight, Vitamin D and Skin Cancer\u003c/em\u003e. Springer; 2014:120-140. doi:10.1007/978-1-4939-0437-2_7\u003c/li\u003e\n\u003cli\u003eLarson DL, Larson JD. Head and neck melanoma. \u003cem\u003eClin Plast Surg\u003c/em\u003e. 2010;37(1):73-77. doi:10.1016/j.cps.2009.08.005\u003c/li\u003e\n\u003cli\u003eDonaldson MR, Coldiron BM. Dermatologists perform the majority of cutaneous reconstructions in the Medicare population: Numbers and trends from 2004 to 2009. \u003cem\u003eJ Am Acad Dermatol\u003c/em\u003e. 2013;68(5):803-808. doi:10.1016/j.jaad.2013.01.026\u003c/li\u003e\n\u003cli\u003eBaade PD, Whiteman DC, Janda M, et al. Long-term deaths from melanoma according to tumor thickness at diagnosis. \u003cem\u003eInt J Cancer\u003c/em\u003e. 2020;147(5):1391-1396. doi:10.1002/ijc.32930\u003c/li\u003e\n\u003cli\u003ePeisker A, Raschke GF, Guentsch A, Roshanghias K, Eichmann F, Schultze-Mosgau S. Longterm quality of life after oncologic surgery and microvascular free flap reconstruction in patients with oral squamous cell carcinoma. \u003cem\u003eMed Oral Patol Oral Cir Bucal\u003c/em\u003e. 2016;21(4):e420-e424. doi:10.4317/medoral.21111\u003c/li\u003e\n\u003cli\u003eButow PN, Coates AS, Dunn SM. Psychosocial predictors of survival in metastatic melanoma. \u003cem\u003eJ Clin Oncol Off J Am Soc Clin Oncol\u003c/em\u003e. 1999;17(7):2256-2263. doi:10.1200/JCO.1999.17.7.2256\u003c/li\u003e\n\u003cli\u003eSteinbauer J, Koller M, Kohl E, Karrer S, Landthaler M, Szeimies RM. Quality of life in health care of non-melanoma skin cancer \u0026ndash; results of a pilot study. \u003cem\u003eJDDG J Dtsch Dermatol Ges\u003c/em\u003e. 2011;9(2):129-135. doi:10.1111/j.1610-0387.2010.07547.x\u003c/li\u003e\n\u003cli\u003eDropkin M jo. Body Image and Quality of Life After Head and Neck Cancer Surgery. \u003cem\u003eCancer Pract\u003c/em\u003e. 1999;7(6):309-313. doi:10.1046/j.1523-5394.1999.76006.x\u003c/li\u003e\n\u003cli\u003eLee E h., Klassen A f., Cano S j., Nehal K s., Pusic A l. FACE-Q Skin Cancer Module for measuring patient-reported outcomes following facial skin cancer surgery. \u003cem\u003eBr J Dermatol\u003c/em\u003e. 2018;179(1):88-94. doi:10.1111/bjd.16671\u003c/li\u003e\n\u003cli\u003eKlassen AF, Cano SJ, Scott A, Snell L, Pusic AL. Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q. \u003cem\u003eFacial Plast Surg FPS\u003c/em\u003e. 2010;26(4):303-309. doi:10.1055/s-0030-1262313\u003c/li\u003e\n\u003cli\u003eadmqportfolio. FACE-Q | Aesthetics - Q-Portfolio MEASURING WHAT MATTERS TO PATIENTS. Published May 11, 2017. Accessed December 27, 2023. https://qportfolio.org/face-q/aesthetics/\u003c/li\u003e\n\u003cli\u003eOttenhof MJ, Lardinois AJPM, Brouwer P, et al. Patient-reported Outcome Measures: The FACE-Q Skin Cancer Module: The Dutch Translation and Linguistic Validation. \u003cem\u003ePlast Reconstr Surg \u0026ndash; Glob Open\u003c/em\u003e. 2019;7(10):e2325. doi:10.1097/GOX.0000000000002325\u003c/li\u003e\n\u003cli\u003ePetrillo J, Cano SJ, McLeod LD, Coon CD. Using Classical Test Theory, Item Response Theory, and Rasch Measurement Theory to Evaluate Patient-Reported Outcome Measures: A Comparison of Worked Examples. \u003cem\u003eValue Health\u003c/em\u003e. 2015;18(1):25-34. doi:10.1016/j.jval.2014.10.005\u003c/li\u003e\n\u003cli\u003eRasch G. \u003cem\u003eProbabilistic Models for Some Intelligence and Attainment Tests\u003c/em\u003e. MESA Press, 5835 S; 1993.\u003c/li\u003e\n\u003cli\u003eDobbs T, Hutchings HA, Whitaker IS. UK-based prospective cohort study to anglicise and validate the FACE-Q Skin Cancer Module in patients with facial skin cancer undergoing surgical reconstruction: the PROMISCR (Patient-Reported Outcome Measure in Skin Cancer Reconstruction) study. \u003cem\u003eBMJ Open\u003c/em\u003e. 2017;7(9):e016182. doi:10.1136/bmjopen-2017-016182\u003c/li\u003e\n\u003cli\u003eBustillo AMB, Lobato RC, Luitgards BF, Camargo CP, Gemperli R, Ishida LC. Translation, Cross-Cultural Adaptation and Linguistic Validation of the FACE-Q Questionnaire for Brazilian Portuguese. \u003cem\u003eAesthetic Plast Surg\u003c/em\u003e. 2019;43(4):930-937. doi:10.1007/s00266-019-01399-1\u003c/li\u003e\n\u003cli\u003eKoller M, West K. Linguistic Validation Manual for Patient-Reported Outcomes (PRO) Instruments, By C. Acquadro, K. Conway, C. Girourdet \u0026amp; I. Mear, MAPI ResearchTrust, Lyon, France, 2004,184 pp, ISBN: 2-9522021-0-9, price \u0026euro;70/$90. \u003cem\u003eQual Life Res - QUAL LIFE RES\u003c/em\u003e. 2005;14:1791-1792. doi:10.1007/s11136-005-5367-1\u003c/li\u003e\n\u003cli\u003eHarris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)\u0026mdash;A metadata-driven methodology and workflow process for providing translational research informatics support. \u003cem\u003eJ Biomed Inform\u003c/em\u003e. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010\u003c/li\u003e\n\u003cli\u003eCerruti M. Regional varieties of Italian in the linguistic repertoire. 2011;2011(210):9-28. doi:10.1515/ijsl.2011.028\u003c/li\u003e\n\u003cli\u003eConstitution of the World Health Organization. Accessed December 27, 2023. https://www.who.int/about/accountability/governance/constitution\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-5147565/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5147565/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground.\u003c/strong\u003e The concept of health-related quality of life (QOL) captures the patient's perspective on how the illness and its treatment affect their well-being. The FACE-Q Skin Cancer Module represents a validated patient-reported outcome (PRO) instrument, specifically developed for patients undergoing facial skin cancer surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods.\u003c/strong\u003e Upon authorization and licensing from the Q-Portfolio\u003csup\u003e®\u003c/sup\u003e team, the authors engaged the process of translation and cultural adaptation of this questionnaire into Italian, in accordance with the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and World Health Organization (WHO) guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults.\u003c/strong\u003e In the first step, two Italian translations are produced and reconciled into one. In the second step, the reconciled Italian version is reverse-translated into English. As third step, the back-translation was reviewed and approved by the Q-Portfolio team. A representative sample of the questionnaire’s potential target was interviewed, and final refinements were made in the fourth and final step. At the end of these phases, a validated and conceptually equivalent Italian version of the FACE-Q Skin Cancer Module was achieved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions.\u003c/strong\u003e This tool is currently ready and available for clinical and research purposes. The introduction of an Italian version marks a significant step towards enhancing its accessibility and relevance, ensuring tangible benefits for both clinicians and patients.\u003c/p\u003e","manuscriptTitle":"Italian Translation and Cultural Adaptation of the FACE-Q Skin Cancer Module","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-13 10:41:34","doi":"10.21203/rs.3.rs-5147565/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-05T08:54:20+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-05T08:53:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"146325072860247420799431716877590816243","date":"2024-11-05T08:45:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-10-22T07:59:40+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-26T08:48:33+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-26T08:47:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Plastic Surgery","date":"2024-09-24T20:41:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-plastic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejps","sideBox":"Learn more about [European Journal of Plastic Surgery](https://link.springer.com/journal/238)","snPcode":"238","submissionUrl":"https://submission.nature.com/new-submission/238/3","title":"European Journal of Plastic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"c69bcccc-1023-4a63-a09a-1965d8c11c5d","owner":[],"postedDate":"November 13th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-02T17:22:44+00:00","versionOfRecord":{"articleIdentity":"rs-5147565","link":"https://doi.org/10.1007/s00238-024-02253-7","journal":{"identity":"european-journal-of-plastic-surgery","isVorOnly":false,"title":"European Journal of Plastic Surgery"},"publishedOn":"2024-11-27 15:58:11","publishedOnDateReadable":"November 27th, 2024"},"versionCreatedAt":"2024-11-13 10:41:34","video":"","vorDoi":"10.1007/s00238-024-02253-7","vorDoiUrl":"https://doi.org/10.1007/s00238-024-02253-7","workflowStages":[]},"version":"v1","identity":"rs-5147565","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5147565","identity":"rs-5147565","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}