Aesth. Plast. Surg. 24:192–197, 2000 DOI: 10.1007/s002660010031

© 2000 Springer-Verlag New York Inc.

Outcomes Research in Facial Plastic : A Review and New Directions

Ramsey Alsarraf, M.D., M.P.H. Seattle, Washington, USA

Abstract. Outcomes research is a fast-growing field of study illnesses such as otitis media, acute sinusitis, or obstruc- that focuses on patient-related aspects of medical or surgical tive sleep apnea [4–8]. However, there are few specific outcomes such as satisfaction and quality of life. In the realm outcomes studies in the field of facial plastic and recon- of facial , many outcomes are subjective evalu- structive surgery, despite the fact that patient satisfaction ations based on the patient and physician’s judgment as to the is the ultimate goal of most facial plastic surgery proce- surgical result, but little has been done to quantify these quali- dures. Wilkins et al. [1] have highlighted the importance tative results in an objective manner. This paper discusses the of outcomes research for the plastic , yet there is basis for outcomes research and suggests its application to the little evidence that the quantification of the costs and field of facial plastic surgery. Four new facial plastic outcomes effectiveness of plastic surgery procedures has been fur- instruments have been developed and are provided for the po- ther emphasized in recent years. tential use in measuring the quality of life results of rhytidec- The outcomes of any surgical procedure can be de- tomy, rhinoplasty, blepharoplasty, and rejuvenation pro- fined in a myriad of ways. Surgical results may be mea- cedures. sured in quantitative or qualitative terms. Unlike the realm of head and neck , measurements such as Key words: Outcomes research—Facial plastic surgery— the morbidity or mortality of a given intervention mean Quality of life little in the field of facial plastic surgery, where many procedures are elective or cosmetic in nature. Often the only means of assessing outcome in this setting is the subjective analysis of the patient as well as the evalua- “...plastic have arrived at a vital crossroads. By tak- ing an active part in outcomes research and in . . . health-care tion of the operating surgeon. Thus, in many cases the policy . . . we can assist in keeping medical decisions where facial plastic surgeon is left with no quantitative evalu- they belong—in the hands of patients and their physicians” [1]. ation of the results of his or her procedure. This lack of quantitative data makes comparing different techniques difficult. Similarly, it may be difficult for different sur- Outcomes research is characterized by the evaluation geons to compare their results when each is measuring of the patient-related results of medical interventions, surgical outcome by his or her own subjective endpoints. with an emphasis on both the effectiveness of outcomes In facial plastic and , particu- in terms of patient satisfaction or quality of life, and the larly aesthetic facial plastic surgery, patient satisfaction costs of attaining these positive results [2,3]. There has remains the yardstick by which a successful surgical out- been an increasing interest in this form of outcomes come is measured. A given surgeon may be satisfied with evaluation in many of the surgical subspecialties in the his or her results, but if the patients themselves are not last decade. For instance, in Otolaryngology-Head and similarly pleased then the intervention cannot totally be Neck Surgery, outcomes research has primarily been the considered a success. Certainly there are various aspects focus of the field of head and neck oncology or specific of each individual patient’s character and personality that will influence his or her own assessment of the surgical outcome. However, in a population of patients one would Correspondence to author at Department of Otolaryngology- expect that patient satisfaction should define the success Head and Neck Surgery, University of Washington School of of a series of procedures. , Seattle, WA 98195, USA This paper reviews the basic foundations of outcomes R. Alsarraf 193 research and evaluates the application of these concepts 4. Test the instrument in the appropriate clinical set- to the field of facial plastic surgery. In order to provide ting. a framework for further studies focusing on patient- Reliability (consistency, reproducibility) related outcomes, several new procedure-specific quality Validity (responsiveness to change, accuracy) of life instruments have been developed and are provided 5. Revise or amend the instrument for better quality of for the reader to use in his or her own practice. life assessment. 6. Use the final instrument for outcomes studies. Evaluation of individual patient satisfaction. Outcomes Research: Background Comparisons between different procedures. All surgeons are interested in patient outcomes. Out- There are many instruments that have been developed for comes research is the field of study that focuses on these the measurement of other nonfacial plastic outcomes in results in terms of patient-related measures such as sat- the head and neck. Illnesses such as otitis media, sinus- isfaction, functionality, and quality of life, rather than itis, obstructive sleep apnea, and head and neck solely traditional clinical measures of treatment efficacy have all been evaluated with outcomes questionnaires [1–3]. In contrast to clinical trials, outcomes research that have been shown to be reliable and valid measures of applies new methods of measuring and validating the patient-related satisfaction or quality of life [4–8]. Un- subjective experience of the patient in order to determine fortunately, there are no current instruments that have the effectiveness of a given procedure in the real-life been tested for use in the realm of facial plastic and setting [9]. Several studies in recent years have evaluated reconstructive surgery, despite the dependence of out- patient-related outcomes for a variety of Otolaryngolo- comes in this field on these primarily subjective factors. gy-Head and Neck Surgery issues. The majority of this In fact, the endpoints of many studies in the facial plastic work has been done in the field of head and neck cancer surgery literature are presented as the proportion of pa- therapy, as clinicians have realized that it is not only tients who are “satisfied” with their results, without any survival or length of life, but in addition, the quality of standardized method of comparison between various that remaining life that is most important to patients and treatment outcomes. their loved ones [5,6]. In facial plastic and reconstructive One issue that may contribute to the lack of formal surgery, a field in which mortality is not a prime concern, outcomes research in facial plastic surgery, particularly these issues of satisfaction or quality of life are of the the realm of aesthetic rather than reconstructive surgery, utmost importance. is the difficulty in attempting to organize and collect data The WHO defines health as the state of “complete in a prospective fashion in the community outpatient physical, mental, and social well-being, and not merely setting. This difficulty has been addressed in other fields the absence of disease or infirmity” [2]. In this way, the of Otolaryngology outcomes research, as the community well-being of the individual defines the ultimate goal of setting may lack the dedicated resources, time, and sup- any treating physician. This well-being is intimately re- port for research that are found in the academic setting lated not only to the physical health of the patient but the [9]. If the goal of a standardized, reliable, and valid individual’s mental or emotional satisfaction and social means of assessing patient outcomes is to be achieved, functioning as well. The facial form, and the mental, however, the facial plastic surgeon must overcome these emotional, and social consequences of this form, thus obstacles. In order to address this issue, Isenberg and contribute greatly to the overall well-being or health of Rosenfeld [9] have outlined five major problems faced in the facial plastic surgery patient. For this reason, mea- community-based outcomes research, as surveyed from suring the outcomes of facial plastic surgery in a more the private practice Otolaryngologists in their own study: comprehensive manner naturally follows from the clini- cal focus on this overall well-being, and the specific 1. An overly long and complex survey. attention that is paid to the satisfaction of the individual. 2. Lack of time during office hours. Outcomes research is performed in order to provide a 3. Cumbersome data collection requirements. quantitative assessment of otherwise subjective results. 4. Inadequate ongoing communication between the The steps in performing this form of evaluation include: principal investigator and participating physicians. 5. Lack of enthusiasm for the project. 1. Identify the specific procedure or illness to be stud- Recommendations for conducting outcomes research in ied (e.g., rhinoplasty results). the community setting include simple to use, streamlined 2. Determine the key factors that contribute to the questionnaires that require little time to complete. The satisfaction following the treatment modality. instruments provided in this paper attempt to meet these Physical (e.g., nasal appearance, nasal airway criteria, and provide the facial plastic surgery with a function) quick and easy method of data collection in the commu- Mental/Emotional (e.g., confidence, desire for nity practice setting. change) Social (e.g., family/friend, social/professional Outcomes in Facial Plastic Surgery acceptance) 3. Develop a quality of life instrument (questionnaire) In order to measure outcomes such as patient satisfaction to measure the outcome of interest (Figs. 1–4). and quality of life in the facial plastic surgery patient, 194 Outcomes in Facial Plastic Surgery

Fig. 1. Quality of life instrument. one must first identify the key aspects that constitute tant components of satisfaction, whether it is related to a such satisfaction for each treatment modality of interest. rhinoplasty, facelift, blepharoplasty, or laser resurfacing. Four common facial plastic surgery procedures include In contrast, there are also very specific physical factors rhinoplasty, rhytidectomy (facelift), blepharoplasty, and that contribute to the assessment of each individual treat- the various skin resurfacing procedures [laser, chemical ment outcome. For example, nasal airway functioning peels (Figs. 1–4)]. should be a concern for any rhinoplasty surgeon and Certainly there are factors that influence quality of life clearly affects the quality of life of the rhinoplasty pa- that are common to each of these specific interventions. tient. The appearance of being tired is a specific com- For instance, acceptance by friends and family is an im- plaint of the preoperative blepharoplasty patient that portant component of the patient’s quality of life. Simi- should be addressed with eyelid surgery. larly, the manner in which the individual’s appearance affects his or her social or professional life is also a Measuring Effectiveness common concern. There are also certain common emo- tional or mental qualities that transcend the satisfaction Outcomes can be defined in many ways, depending upon with any of these procedures. The individual’s confi- the interests of the investigating clinician and the patient dence and happiness with her appearance, and whether or population being evaluated. Most authors agree that an not she desires some change are qualities that are impor- assessment of patient-related quality of life should in- R. Alsarraf 195

Fig. 2. Quality of life instrument. clude components of physical, mental, and social func- ing point for individual facial plastic surgeons to evalu- tioning and should reflect the satisfaction and opportu- ate the outcomes of these common procedures in a quan- nity of the individual subject [1,2]. In order to compare titative fashion. This will allow further assessment of patient-related outcomes for different sorts of procedures patient satisfaction as well as provide the means by or among different surgeons, it is important to have a which new or innovative procedures can be compared standardized instrument that can be used to measure pa- with more traditional approaches. tient quality of life or satisfaction. Such an instrument Scoring of each of these instruments is straightforward should tap each of the different domains of an individu- and designed to allow the surgeon to easily compare pre- al’s quality of life and represent an assessment that cap- and postoperative measurements. Each of the six items is tures the overall satisfaction with a given intervention. scored on a 0–4 scale, with 0 representing the most nega- Four new quality of life instruments have been devel- tive response and 4 representing the most positive re- oped and are presented here for the common procedures sponse. Dividing the total score for each instrument by of facial plastic surgery: the Rhinoplasty Outcomes 24 and multiplying by 100 yields the scaled instrument Evaluation (ROE), Facelift Outcomes Evaluation (FOE), score. This range is 0–100, with 0 representing the least Blepharoplasty Outcomes Evaluation (BOE), and the patient satisfaction and 100 representing the most patient Skin Rejuvenation Outcomes Evaluation (SROE) (Figs. satisfaction. 1–4) The goal of these instruments is to provide a start- These four instruments have not yet been pilot tested 196 Outcomes in Facial Plastic Surgery

Fig. 3. Quality of life instrument. to assess their reliability and validity, however, these treatment or illness in question allows the outcomes re- tests are currently planned. If the reader is interested in searcher the method to measure patient satisfaction, participating in these pilot tests, as well as the modifi- functionality, and quality of life and use these measure- cation or amending of these questionnaires as this testing ments to compare the results for an individual subject, proceeds, he or she is encouraged to contact the author to across different surgical approaches, or between different be involved in this process. The ease and simplicity of surgeons. The development and testing of such instru- instrument administration should allow efficient valida- ments is an important step that establishes the foundation tion of these instruments, and hopefully provide the fa- on which further studies may be based. In facial plastic cial plastic surgeon with a quantitative method of out- and reconstructive surgery, there are currently no reliable come assessment. or validated instruments that are widely used for out- comes assessment. The subjective evaluation of patient satisfaction in the basic measure of success of most facial Conclusions plastic surgery procedures, yet most surgeons have no Outcomes research attempts to quantitate patient-related quantitative means of this assessment. results of treatment that are otherwise subjective and This paper attempts to outline the basic steps in evalu- difficult to understand or study in a comprehensive fash- ating outcomes in the realm of facial plastic and recon- ion. The use of standardized instruments specific to the structive surgery, similar to the outcomes research that is R. Alsarraf 197

Fig. 4. Quality of life instrument. ongoing in other fields of Otolaryngology-Head and research primer. Otolaryngol Head Neck Surg 117(4):380, Neck Surgery. Four new instruments are presented for 1997 the measurement of patient-related outcomes of rhino- 4. Alsarraf R, Jung CJ, Perkins J, Crowley C, Gates GA: Otitis plasty, facelift, blepharoplasty, and skin rejuvenation media health status evaluation: A pilot study for the inves- procedures. These instruments provide a simple and ex- tigation of cost-effective outcomes of recurrent acute otitis pedient assessment of the individual’s quality of life re- media treatment. Ann Otol Rhin Laryngol 107(2):120, 1998 5. Hassan SJ, Weymuller EA: Assessment of quality of life in lated to the procedure of interest that the surgeon may head and neck cancer patients. Head Neck 15(6):485, 1993 find useful in the quantitative evaluation of postoperative 6. Deleyiannis FW, Weymuller EA, Coltrera MD, Futran N: facial plastic surgery outcomes. Quality of life after : Are functional disabili- ties important? Head Neck 21(4):319, 1999 References 7. Rosenfeld RM: Pilot study of outcomes in pediatric rhino- sinusitis. Arch Otolaryngol Head Neck Surg 121:729, 1995 1. Wilkins EG, Lowery JC, Smith DJ: Outcomes research: A 8. Piccirillo JF, Gates GA, White DL, Schectman KB: Ob- primer for plastic surgeons. Ann Plast Surg 37(1):1, 1996 structive sleep apnea treatment outcomes pilot study. Oto- 2. Patrick DL, Erickson P: Health status and health policy: laryngol Head Neck Surg 118(6):833, 1998 Quality of life in health care evaluation and resource allo- 9. Isenberg SF, Rosenfeld RM: Problems and pitfalls in com- cation. Oxford Univ Press: NY, 1993 munity-based outcomes research. Otolaryngol Head Neck 3. Piccirillo JF, Stewart MG, Gliklich RE, Yueh B: Outcomes Surg 116(6 Pt 1):662, 1997