Outcomes Research in Facial Plastic Surgery: a Review and New Directions
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Aesth. Plast. Surg. 24:192–197, 2000 DOI: 10.1007/s002660010031 © 2000 Springer-Verlag New York Inc. Outcomes Research in Facial Plastic Surgery: 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 plastic surgery, 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 surgeon, 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 skin 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 oncology, 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 surgeons 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 reconstructive surgery, 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. Medicine, 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 cancer 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