 |
|
Measuring Cosmetic Facial Plastic Surgery Outcomes
A Pilot Study
Ramsey Alsarraf, MD, MPH;
Wayne F. Larrabee, Jr, MD, MPH;
Shelia Anderson, RN;
Craig S. Murakami, MD;
Calvin M. Johnson, Jr, MD
Arch Facial Plast Surg. 2001;3:198-201.
ABSTRACT
| |
Objective To test 4 previously published outcomes instruments (the Facelift Outcomes
Evaluation, the Rhinoplasty Outcomes Evaluation, the Blepharoplasty Outcomes
Evaluation, and the Skin Rejuvenation Outcomes Evaluation) in terms of their
reliability and validity in assessing patient-related outcomes of surgical
intervention.
Design A prospective pilot study of 78 patients in 3 similar private cosmetic
surgery centers undergoing a total of 100 face-lift, rhinoplasty, blepharoplasty,
and skin rejuvenation procedures. Patients were evaluated at 2 preoperative
and 1 postoperative time points and the instruments were analyzed with regard
to their test-retest reliability, internal consistency, and responsiveness
to change.
Results All 4 outcomes instruments had excellent reliability, consistency, and
validity scores. Test-retest reliability was 0.74 to 0.83 (Pearson correlation
coefficients), internal consistency scores were .83 to .88 (Cronbach  ),
and responsiveness to change was statistically significant for each instrument
tested (P .001). In addition, patients experienced
significant quality of life improvement, with overall satisfaction increasing
on average from 37% to more than 84% after these procedures.
Conclusions These 4 instruments are reliable and valid and can be used to accurately
assess patient-related satisfaction in studies of face-lift, rhinoplasty,
blepharoplasty, and skin resurfacing outcomes. These brief questionnaires
provide the cosmetic surgeon with quantitative tools to evaluate otherwise
subjective and purely qualitative outcomes and are recommended for use in
future prospective studies.
INTRODUCTION
QUANTITATIVE assessment of quality of life outcomes has become standard
in most fields of otolaryngology–head and neck surgery, yet to date
there has been a paucity of outcomes research activity in the realm of facial
plastic and reconstructive surgery.1-2
This lack of studies is despite the fact that most outcomes in this field,
particularly cosmetic facial plastic surgery, are entirely subjective, patient-related
assessments of satisfaction. In recent years, assessment of cost outcomes
in facial plastic surgery and general plastic surgery has found a presence
in the literature, but measurements of effectiveness have not.3-5
There is thus no quantitative manner by which to assess the outcome of cosmetic
facial plastic surgery procedures, and the physician and patient alike are
left with the qualitative measurement of patient satisfaction as the only
real means of analyzing the results of these procedures. To evaluate different
surgical techniques, differentiate between various approaches or interventions,
or compare the results of different surgeons in an objective fashion, there
must be a yardstick by which these outcomes are evaluated.
Application of outcomes research methods to facial plastic surgery thus
requires the availability of standardized instruments, or questionnaires,
that have been pilot tested to illustrate their reliability and validity in
such applications.6 One of us (R.A.) previously
developed 4 new outcomes instruments for use in the realm of cosmetic facial
plastic surgery: the Facelift Outcomes Evaluation (FOE), the Rhinoplasty Outcomes
Evaluation (ROE), the Blepharoplasty Outcomes Evaluation (BOE), and the Skin
Rejuvenation Outcomes Evaluation (SROE).2 Before
recommending their use in prospective facial plastic surgery studies, the
reliability and validity of these instruments in quantitatively assessing
quality of life outcomes for these 4 procedures must be shown. This pilot
study provides this analysis. If these instruments provide accurate measurements
of their respective cosmetic facial plastic surgery outcomes, they might be
useful tools for the quantitative evaluation of these outcomes in future prospective
studies.
PATIENTS AND METHODS
A total of 78 patients were prospectively enrolled at the 3 similar
private facial plastic surgery centers included in this pilot study (the Hedgewood
Surgical Center, New Orleans, La; the Larrabee Center for Facial Plastic Surgery,
Seattle, Wash; and the Division of Facial Plastic Surgery at Virginia Mason
Medical Center, Seattle). A total of 100 of the following 4 procedures were
performed: 35 face-lifts, 26 rhinoplasties, 30 blepharoplasties, and 9 skin
rejuvenation procedures (carbon dioxide laser resurfacing). For each procedure,
an individual outcomes instrument had been previously developed to assess
quality of life change in a quantitative manner.2
Each instrument is composed of 6 questions capturing 3 quality of life domains:
physical, mental/emotional, and social. Inclusion of these 3 domains is the
recommended methodology in the quality of life literature.7
Each question is scored on a scale from 0 to 4 and is converted to a total
score of 0 to 100 by dividing by 24 and multiplying by 100. These brief instruments
take less than 1 minute to complete and are well received by patients during
the preoperative and postoperative evaluations. For example, the ROE asks:
How well do you like the appearance of your nose?
How well are you able to breathe through your nose?
How much do you feel your friends and loved one like your nose?
Do you think your current nasal appearance limits your social or professional
activities?
How confident are you that your nasal appearance is the best that it
can be?
Would you like to surgically alter the appearance or function of your
nose?
Patients were asked to complete the appropriate outcomes instrument(s)
(1) at the time of their initial consult, (2) on the day of surgery (0.5-9.5
weeks after the initial consult; mean, 3.5 weeks), and (3) approximately 5
months after surgery (11.5-32.0 weeks after surgery; mean, 19.3 weeks). The
data from these 3 points were then analyzed to evaluate the reliability and
validity of each outcomes instrument. This analysis included assessment of
test-retest reliability via Pearson correlation coefficients, internal consistency
via the Cronbach , and validity by measuring responsiveness to change
(preoperative vs postoperative scores, paired t test).
Statistical analysis was completed using a computer software package (SPSS;
SPSS Inc, Chicago, Ill), with significance levels provided in the tables.
RESULTS
Most patients in this study were women, with an average age of 48 years
(Table 1). Most patients (78%)
underwent a primary procedure, and almost half (46%) underwent multiple procedures
at the time of their surgery. Most patients were otherwise healthy, with only
22% documenting any other significant medical history during their preoperative
evaluation. Few patients were influenced by marketing (5%), and although the
largest proportion were referred to their surgeon by friends (40%), similar
percentages were referred by other physicians (33%) or self-referred (27%).
|
|
|
|
Table 1. Cosmetic Facial Plastic Surgery Study Population Characteristics
(n = 78)
|
|
|
As for the evaluation of instrument reliability, Table 2 provides the test-retest reliability scores (Pearson correlation
coefficients) of the 2 preoperative visits for the 4 instruments. The ROE
demonstrated the best test-retest reliability (r
= 0.83; P<.001), and all 4 instruments had reliability
scores of 0.74 or greater. Average preoperative scores ranged from 32.3 to
43.7. Because these scores are measured on a scale from 0 to 100, these values
represent a 32% to 44% preoperative patient satisfaction level.
|
|
|
|
Table 2. Test-Retest Reliability Scores*
|
|
|
In terms of consistency, each of the 4 instruments demonstrated excellent
internal consistency scores (Cronbach ) as a measure of interitem correlation:
.83 for the BOE (n = 60), .84 for the ROE (n = 60), and .88 for the FOE (n
= 73) and the SROE (n = 22). The analysis of the SROE was somewhat limited
by smaller numbers of patients (n = 9) undergoing laser skin resurfacing procedures
in this study compared with the larger populations in the other 3 procedure
groups (mean n = 30).
All 4 instruments had excellent responsiveness to change after surgical
intervention, a measure of instrument validity (Table 3). The average increase in patient satisfaction after surgery
was 46.9, from a mean preoperative score of 37.6 to a postoperative score
of 84.5. The FOE, ROE, BOE, and SROE all demonstrated the ability to measure
this quality of life change after surgery, with statistically significant
increases noted for all 4 procedures (P.001 for
all). Aging face procedures had a similar increase in patient satisfaction
(47.8 points) compared with rhinoplasty alone (44.5 points). Blepharoplasty
procedures were associated with the greatest increases in patient satisfaction
(50.7 points) and rhinoplasty procedures with the least (44.5 points), but
compared with the other procedures, these differences were not statistically
significant. The highest average postoperative satisfaction score was 89.6
for the blepharoplasty procedures, and the lowest average postoperative satisfaction
score was 79.2 for the skin rejuvenation (laser resurfacing) procedures. Face-lift
and rhinoplasty procedures had excellent average postoperative satisfaction
ratings as well, at 85.9 and 83.3, respectively.
|
|
|
|
Table 3. Patient Satisfaction Validity Scores (Responsiveness to Change)*
|
|
|
COMMENT
Accurate assessment of outcomes in facial plastic surgery depends on
the use of reliable and valid outcomes instruments. It seems that the FOE,
ROE, BOE, and SROE meet these criteria, with excellent test-retest reliability
and internal consistency scores and the responsiveness to measure change after
surgical interventions. Test-retest reliability coefficients were between
0.74 and 0.83 (P.03), and Cronbach scores
were between .83 and .88, with scores of .70 or greater generally recommended
for adequate instrument reliability and internal consistency in quality of
life evaluation.7 In addition, at 5-month follow-up,
patients seemed to experience significant quality of life improvement after
each of these 4 procedures, with an average increase in patient satisfaction
from 37.6 to 84.5. The FOE, ROE, BOE, and SROE scores all responded dramatically
to the significant quality of life change after each surgical procedure, a
standard measure of instrument validity (P.001
for all).
Other fields of otolaryngology–head and neck surgery have for
years used quantitative tools for the measurement and evaluation of otherwise
subjective quality of life outcomes.8-10
In the field of facial plastic and reconstructive surgery, particularly cosmetic
facial plastic surgery, most outcomes are qualitative assessments of either
patient or physician satisfaction. For this reason, it seems that application
of outcomes research methods to the field of facial plastic surgery would
enhance the study of these results and provide a more rigorous means by which
surgical outcomes could be objectively evaluated.1
Tools such as the FOE, ROE, BOE, and SROE are essential components of this
potential application. The use of reliable and valid outcomes instruments
might allow the cosmetic facial plastic surgeon to quantitatively assess those
results that hitherto have been subject to the oftentimes vague conjecture
of "patient satisfaction."
A recent editorial11 in the plastic surgery
literature calls for an increased effort to move beyond these vague terms
and begin to characterize plastic surgery outcomes in a more objective and
quantitative manner. In this editorial, Luce11
stresses the importance of using tested and validated instruments such as
these to achieve this end. The difficulty in attaining this goal, in Luce's
mind, is the quantification of the various domains that have an impact on
quality of life. Our hope, with this study, is to provide the starting point
for this quantification. It is clear that these outcomes measures rely on
the subjective evaluation of the patient and that this evaluation might conflict
with the surgeon's own assessment of the success of a given surgical procedure.
This fact, however, does not limit the usefulness of such patient-related
measures but implicates their intrinsic worth. As discussed elsewhere, the
overriding purpose of outcomes research is to quantify and measure these otherwise
subjective and qualitative aspects of patient care. For cosmetic facial plastic
surgery, this analysis must begin with the use of reliable and valid instruments
that measure not the surgeon's evaluation of success or failure but the patient's
own estimation of this inherent value. In fact, the ever-present reliance
on terms such as "patient satisfaction" in the current plastic surgery literature
as a measure of a successful surgical outcome emphasizes the manner in which
our specialty, to a large extent, already relies on such subjectively based
assessments to determine a given procedure's success.
Limitations of this study include small numbers in the skin resurfacing
population (n = 9); however, the SROE still demonstrated good reliability,
excellent internal consistency, and a high level of responsiveness to change.
The other 3 instruments, with higher numbers of patients studied, tended to
demonstrate higher degrees of reliability and validity. Five-month follow-up
might not be long enough to capture the ultimate quality of life changes associated
with procedures such as rhinoplasty or laser skin resurfacing; however, this
period seems to demonstrate significant improvements that might be long lasting.
The purpose of this study, however, was not to assess the success or failure
of these specific procedures or individual surgeons or distinct techniques
but, rather, to assess the reliability and validity of these 4 new outcomes
instruments. For this reason, a more limited follow-up period such as 5 months
should represent enough clinical change to allow the testing of such instruments
in terms of the basic outcomes research tenets of test-retest reliability,
internal consistency, and responsiveness to change. Because we were not comparing
the outcomes of different surgical techniques in this pilot study, the use
of 3 distinct surgeons should not bias these results in any way. In addition,
there were no significant differences between the 3 surgeons included in this
pilot study with regard to the measures of instrument reliability and validity
evaluated in this analysis.
Although this study provides initial validation data with regard to
improvements in patient satisfaction and quality of life after face-lift,
rhinoplasty, blepharoplasty, and skin resurfacing procedures, the purpose
of this study was, again, not to evaluate these procedures themselves but
to demonstrate the ability of these instruments to accurately characterize
these changes. The vast improvement in patient-related quality of life that
was quantitatively documented, however, seems to parallel the qualitative
satisfaction that most cosmetic facial plastic surgery patients enjoy after
their individual procedures. With the use of reliable and valid outcomes instruments
such as the FOE, ROE, BOE, and SROE, the subjective assessment of patient
satisfaction can now find a more objective method of analysis for the cosmetic
facial plastic surgery community as a whole.
CONCLUSIONS
The FOE, ROE, BOE, and SROE are reliable and valid outcomes instruments
that accurately characterize patient-related quality of life satisfaction.
These 4 questionnaires are useful for the quantitative measurement and assessment
of cosmetic facial plastic surgery outcomes and provide the surgeon with a
more objective means of comparing various treatments, surgical techniques,
or approaches. Use of these instruments is recommended for such quantitative
evaluation in future studies.
AUTHOR INFORMATION
Accepted for publication March 28, 2001.
Corresponding author: Ramsey Alsarraf, MD, MPH, The Newbury Center,
Cosmetic Facial Plastic Surgery, 69 Newbury St, Boston, MA 02116 (e-mail: ralsarraf{at}earthlink.net).
From the Hedgewood Surgical Center, New Orleans, La (Drs Alsarraf and
Johnson); the Larrabee Center for Facial Plastic Surgery, Seattle, Wash (Dr
Larrabee and Ms Anderson); and the Division of Facial Plastic Surgery, Virginia
Mason Medical Center, Seattle (Dr Murakami). Dr Alsarraf is now with The Newbury
Center, Cosmetic Facial Plastic Surgery, Boston, Mass.
REFERENCES
| |
1. Alsarraf R, Larrabee WF Jr. Outcomes research in facial plastic surgery [editorial]. Arch Facial Plast Surg. 2001;3:7.
FREE FULL TEXT
2. Alsarraf R. Outcomes research in facial plastic surgery: a review and new directions. Aesthetic Plast Surg. 2000;24:192-197.
PUBMED
3. Alsarraf R, Larrabee W Jr, Johnson C Jr. Cost outcomes of facial plastic surgery: regional and temporal trends. Arch Facial Plast Surg. 2001;3:44-47.
FREE FULL TEXT
4. Alsarraf R, Alsarraf NW, Larrabee WF Jr, Johnson CM Jr. Cosmetic surgery procedures as luxury goods: measuring price and demand
in facial plastic surgery. Arch Facial Plast Surg. In press.
5. Krieger LM, Shaw WW. The effect of increased plastic surgeon supply on fees for aesthetic
surgery: an economic analysis. Plast Reconstr Surg. 1999;104:559-563.
PUBMED
6. Wilkins EG, Lowery JC, Smith DJ. Outcomes research: a primer for plastic surgeons. Ann Plast Surg. 1996;37:1-11.
ISI
| PUBMED
7. Patrick DL, Erickson P. Health Status and Health Policy: Quality of Life
in Health Care Evaluation and Resource Allocation. New York, NY: Oxford University Press; 1993.
8. Alsarraf R, Jung CJ, Perkins J, Crowley C, Gates GA. Otitis media health status evaluation: a pilot study for the investigation
of cost-effective outcomes of recurrent acute otitis media treatment. Ann Otol Rhinol Laryngol. 1998;107:120-128.
ISI
| PUBMED
9. Alsarraf R, Kriet JD, Weymuller EA. Quality of life outcomes following osteoplastic frontal sinus obliteration. Otolaryngol Head Neck Surg. 1999;121:435-440.
FULL TEXT
|
ISI
| PUBMED
10. Weymuller EA, Yueh B, Alsarraf R, Deleyiannis FWB, Kuntz AL, Coltrera MD. Quality of life in patients with head and neck cancer: lessons learned
from 549 prospectively evaluated patients. Arch Otolaryngol Head Neck Surg. 2000;126:329-336.
FREE FULL TEXT
11. Luce EA. Outcome studies and practice guidelines in plastic surgery [editorial]. Plast Reconstr Surg. 1999;104:1187-1190.
PUBMED
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Absorbable Suture Compared With Nonabsorbable Suture in Upper Eyelid Blepharoplasty Closure
Jaggi et al.
Arch Facial Plast Surg 2009;11:349-352.
FULL TEXT
Outcome Measures in Facial Plastic Surgery: Patient-Reported and Clinical Efficacy Measures
Rhee and McMullin
Arch Facial Plast Surg 2008;10:194-207.
ABSTRACT
| FULL TEXT
Impact of Cosmetic Facial Surgery on Satisfaction With Appearance and Quality of Life
Litner et al.
Arch Facial Plast Surg 2008;10:79-83.
ABSTRACT
| FULL TEXT
More Science--Please
Larrabee
Arch Facial Plast Surg 2008;10:8-8.
FULL TEXT
|
