by: Fulvio Urso-Baiarda BM, BCh, MA, MD, MRCS, FRCS(Plast),
William Townley MD, MBBS, MRCS, FRCS(Plast)
Olivier A. Branford MA, MBBS, PhD, MRCS, FRCS(Plast)
Rod J Rohrich, MD
In an era of evidence-based medicine, each subspecialty needs rigorous outcome assessments to justify interventions. Such justification is particularly prominent in cosmetic surgery where, in choosing to undergo treatment, patients subject themselves to surgical risks for relatively soft indications. The perceived benefit in appearance and quality of life are determined by a set of personal values relating to the nature of beauty that, ultimately, only that patient can really know.
With no absolute universal objective measure of ‘beauty’ or ‘ugliness’, how do we evaluate success or decide which treatment is most effective? Anatomical parameters such as nipple position, brow elevation or nasolabial fold depth are relevant, but only the patient can tell us how well their pre-operative expectations were met – a critical determinant of success or failure in cosmetic surgery.
Patient-Reported Outcome Measures (PROMs) refer to various tools designed to capture the patient experience. There are two types: those applicable to anyone (‘generic’); and those which target a specific disease, treatment or patient group (‘specific’). A study using PROMs should incorporate both types in order to detect small differences whilst remaining broad enough to capture all relevant events.
A good PROM needs to be:
Reliable – accurate internally and on re-testing;
Valid – correlating with other measures previously shown to be reliable;
Responsive – able to measure change in response to time or treatment;
Precise – able to discriminate between patients;
Acceptable – user-friendly; and
Feasible – time and cost-efficient.
Although many cosmetic surgery studies do seek their patient’s opinions on outcome, most – almost 70 percent in one systematic review1 – collect data using an unproven ad hoc questionnaire designed just for that study. Such data is of questionable and often no real value.
Despite the abundance of cosmetic surgery-specific PROMs, researchers have been slow to adopt them and the quality of evidence is poor.2 A systematic review assessing 35 cosmetic surgery-specific PROMs found only Breast-Q,3 Face-Q,4 and Skindex5 met all current recommendations.
The same report identified that only three generic PROMs have been used in cosmetic surgery studies: the Medical Outcome Study Short Form 36-Item Health Survey (SF-36); European Quality of Life 5D (EQ-5D); and the Health Utility Index (HUI). Of these, SF-36 is most commonly used and has been shown to be more sensitive than EQ-5D when evaluated in cosmetic patients.6
SF-36 – http://www.sf-36.org/
EQ-5D – http://www.euroqol.org/
The need to collect adequate patient-led outcome data in cosmetic surgery extends beyond the desire for better evidence-based studies. In the context of intense public scrutiny, it is vital that individual surgeons capture outcome data just as they might record complications. PROM-related data will help deliver more informative and valuable patient consultations. Plastic surgeons that can adapt to the new conditions are more likely to succeed and be rewarded with satisfied patients. With the advent and emphasis of evidence-based medicine in our major Journals lead by PRS in the past 5 years, we have seen a significant improvement in all subspecialties of plastic surgery. However, cosmetic surgery has lagged behind as many still feel that “cosmetic surgery like beauty is in the eye of the beholder not the beholdee!” It is indeed time to move forward out of this time warp and add some PROM data to all our future studies – if we can do so as it will be more meaningful to both our patients and our colleagues
Patient satisfaction is the raison d’être of cosmetic surgery. Technically perfect results are a failure if the patient does not like them, so clinical outcomes measures are inadequate without reference to a validated indicator of patient satisfaction. Several specific PROMs for cosmetic surgery are accessible, validated and compliant with contemporary FDA recommendations. The SF-36 is the most powerful generic PROM currently available although further evaluation is needed. Greater use of PROMs will help establish high quality evidence and better inform individual practice to guide advances in 21st century cosmetic surgery.
No external sources of support, funding, or benefits were received for this project by the authors, who have no commercial interest to disclose.
- Clapham PJ, Pushman AG and Chung KC.A systematic review of applying patient satisfaction outcomes in plastic surgery. Plast Reconstr Surg.2010;125:1826–1833.
- Urso-Baiarda, F,ed. Evidence-Based Cosmetic Surgery (1st Edition). New York: Nova Science Publishers; 2015.
- Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg.2009;124:345-353.
- Pusic AL, Klassen AF, Scott AM, Cano SJ. Development and psychometric evaluation of the FACE-Q satisfaction with appearance scale: A new PRO instrument for facial aesthetics patients. Clin Plast Surg. 2012;40:249-260.
- Chren MM, Lasek RJ, Quinn LM, Mostow EN, Zyzanski SJ. Skindex, a quality- of-life measure for patients with skin disease: reliability, validity, and responsiveness. J Invest Dermatol. 1996;107:707-713.
- Klassen AF, Fitzpatrick R, Jenkinson C, Goodacre T. Contrasting evidence of the effectiveness of cosmetic surgery from two health related quality of life measures. J Epid Comm Health. 1999;53: 440-441.