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Public perception of “laser-assisted” blepharoplasty versus “blade-assisted” blepharoplasty

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Objective To evaluate perceptions of blade- versus laser-based blepharoplasty before and after being provided educational information. Design/Participants/Methods This interventional pre–post study included 145 randomly selected participants (Maisonneuve-Rosemont Hospital, Montreal, Canada, August 2020) who were asked about their perceptions surrounding blepharoplasty. Participants then received information about the techniques before answering final questions. Results Participants perceived no difference in outcomes for blade (37%) versus laser (40%) blepharoplasty precounselling. This increased to laser blepharoplasty postintervention (56%, p < 0.001) despite being told that there was no difference in outcomes. The higher the level of education among participants, the more likely they were to correctly believe that both techniques had similar outcomes (p = 0.049). Most participants would choose laser blepharoplasty initially (64%), and this percentage increased postintervention (81%, p < 0.001). The preintervention perception of blade blepharoplasty recovery time (20.1 ± 32.6 days) was longer than that for laser blepharoplasty (13.5 ± 32.0 days, p = 0.01) and increased for both techniques postintervention (p < 0.001). Perceived pain was lower for laser blepharoplasty. Postintervention, participants responded that additional costs of (975±975 ± 1,091) would justify laser over blade blepharoplasty. Conclusion Elucidating patient perceptions and preferences for blade- versus laser-based blepharoplasty provides surgeons with perspective on how to tailor preoperative counselling. Before and after the intervention, participants had a bias toward choosing laser blepharoplasty. The intervention seems to falsely convince people that laser blepharoplasty leads to better outcomes. Because the doctor's advice can greatly impact patients’ decisions, physicians have to be careful not to give false expectations when counselling patients. Inaccurate recall of key educational takeaways suggests that information should be vulgarized and delivered actively to patients.
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Original Article
Public perception of laser-assisted
blepharoplasty versus blade-
assisted blepharoplasty
Anne X. Nguyen,*Victoria C. Leung,
y,z
Fares Antaki,
y,z
Rac Antonios,
y,x
Isabelle Hardy,
y,z
Patrick R. Boulos
y,z
Objective: To evaluate perceptions of blade- versus laser-based blepharoplasty before and after being provided educational information.
Design/Participants/Methods: This interventional prepost study included 145 randomly selected participants (Maisonneuve-Rose-
mont Hospital, Montreal, Canada, August 2020) who were asked about their perceptions surrounding blepharoplasty. Participants then
received information about the techniques before answering nal questions.
Results: Participants perceived no difference in outcomes for blade (37%) versus laser (40%) blepharoplasty precounselling. This
increased to laser blepharoplasty postintervention (56%, p<0.001) despite being told that there was no difference in outcomes. The higher
the level of education among participants, the more likely they were to correctly believe that both techniques had similar outcomes (p= 0.049).
Most participants would choose laser blepharoplasty initially (64%), and this percentage increased postintervention (81%, p<0.001). The pre-
intervention perception of blade blepharoplasty recovery time (20.1 §32.6 days) was longer than that for laser blepharoplasty (13.5 §
32.0 days, p= 0.01) and increased for both techniques postintervention (p<0.001). Perceived pain was lower for laser blepharoplasty. Postin-
tervention, participants responded that additional costs of ($975 §$1,091) would justify laser over blade blepharoplasty.
Conclusion: Elucidating patient perceptions and preferences for blade- versus laser-based blepharoplasty provides surgeons with per-
spective on how to tailor preoperative counselling. Before and after the intervention, participants had a bias toward choosing laser blepharo-
plasty. The intervention seems to falsely convince people that laser blepharoplasty leads to better outcomes. Because the doctors advice can
greatly impact patientsdecisions, physicians have to be careful not to give false expectations when counselling patients. Inaccurate recall of
key educational takeaways suggests that information should be vulgarized and delivered actively to patients.
Blepharoplasty is the most common surgery performed on
the upper eyelids and the third most common cosmetic
procedure in North America.
1
Oculoplastic surgeons per-
form this procedure to treat dermatochalasis, a condition
characterized by excess skin of the upper or lower eyelids
withpotentialfunctional(obscurationofthevisualaxis)
or aesthetic (rejuvenation of the periocular area)
signicance.
2
In fact, blepharoplasty is growing in popularity.
1,3
Prior
studies have compared outcomes between techniques
(including laser and blade blepharoplasty),
4,5
examined
postoperative changes in visual function,
6,7
assessed atti-
tudes around payment,
8
and evaluated patient satisfaction
after blepharoplasty.
2
However, little is known about
patient perceptions, preferences, and expectations when
considering laser versus blade-based blepharoplasty. To our
knowledge, this is the rst study to compare patientsbeliefs
about the two procedures. The investigation also evaluated
if educational information modied perceptions, expecta-
tions, and preferences around the 2 techniques. This study
aims to foster a better understanding of the factors inuenc-
ing patient preference and provides insight into preopera-
tive counselling, patient selection, and, ultimately, choice
of surgical technique for surgeons performing blepharo-
plasty.
Methods
This interventional prepost study was approved by the
institutional review board of the Maisonneuve-Rosemont
Hospital and adhered to the tenets of the Declaration of
Helsinki. A power analysis using McNemar x
2
tests of sym-
metry to show changes in probabilities of frequency in con-
tingency tables revealed that a minimum of 143 participants
would be needed to detect the effect (80% power, a= 0.05,
calculations based on 1,000 simulations using sample sizes of
25200 by increments of 5 participants) when considering
conservative estimates for potential changes in question-
naire responses before and after intervention.
Study participants were recruited among patients and
accompaniers waiting for appointments at the University Cen-
tre of Ophthalmology (CUO) at the Maisonneuve-Rosemont
Hospital. Potential study participants were approached at ran-
dom by a single interviewer (A.X.N.) and were invited to
complete a one-time questionnaire between August 3 and 17,
2020. The questionnaires were completed in real time, either
online on the participantsown devices or orally by answering
questions in a separate room with the interviewer. Because
more than 500 patients are seen daily at the CUO, with, on
average, <5% with prior exposure to the oculoplastic division
(internal data), we believed the perceptions of our study
https://doi.org/10.1016/j.jcjo.2022.03.006
ISSN 0008-4182
© 2022 Canadian Ophthalmological Society.
Published by Elsevier Inc. All rights reserved. 1
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population to reect those of the general population. Excluded
participants were those who were unable to consent or to com-
plete the questionnaire.
After giving informed consent, participants were rst asked
to complete 9 questions related to their sociodemographic sta-
tus, as well as their history with eyelid and cosmetic surgery.
Following this, they completed a questionnaire designed to
evaluate perceptions of blade-ba and laser-based blepharoplasty
before and after educational information was provided about
the procedures (Appendix 1).
As a preamble to an assessment of their perceptions sur-
rounding blepharoplasty, participants were presented with the
following information about blepharoplasty: Blepharoplasty is
a surgery of the eyelids that treats excess skin, drooping eyelids,
wrinkles and bagsof the upper and lower eyelids. The goal of
blepharoplasty is to remove or reduce these imperfections.
There are two main surgical techniques involving 1. blade or
2. laser.Participants also were presented with photos of
patients before and after undergoing blepharoplasty. On com-
pletion of the rst 21 questions, study participants received
educational information regarding the similarities between
blepharoplasty by laser and by blade (e.g., level of pain and dis-
comfort during surgery, result after 36 months, and general
complications), as well as the differences between the techni-
ques (e.g., laser has less to no bleeding during the surgery lead-
ing to a probable shorter convalescence and faster return to
work or activities, has a slightly longer duration of surgery, and
is more expensive).
4,9
After receiving this information, partici-
pants were asked 3 questions that had been previously posed
in the rst section regarding choice of preferred technique, a
comparison of perceived outcomes, and duration of convales-
cence. Participants were also asked for the difference in price
that they believed would justify the benets of laser-based sur-
gery (see Appendix 1).
Sociodemographic information and familiarity with eyelid
and cosmetic surgery were summarized. In the statistical analy-
sis of responses pre-educational and posteducational interven-
tion, the primary outcome measures included percentage
change of participants indicating that the optimal surgical out-
come would be achieved by one technique versus the other
before and after the intervention, percentage change with
regard to preference for laser-assisted versus blade-assisted
blepharoplasty before and after the intervention, and change
in the difference in expected number of days of convalescence
between the 2 techniques before and after the intervention.
Secondary outcomes included a comparison of percep-
tions regarding laser-based versus blade-based techniques
with regard to durability of surgical result, cost, level of
pain, level of risk, level of technical difculty to perform,
personnel able to perform the surgery, reversibility of surgi-
cal result, and level of invasiveness.
McNemar x
2
tests of symmetry were calculated to test for
changes in the probabilities of the frequency preinterven-
tion and postintervention on the rst 2 primary outcomes
(i.e., perceived surgical outcome and preferred surgical tech-
nique). For these 2 primary outcomes, we further evaluated
their association with demographic factors (e.g., age, sex,
level of education, work type, history of aesthetic surgery,
prior level of exposure, and prior education around blepha-
roplasty surgery) using Mantelhaen tests. For our third pri-
mary outcome (expected convalescence), a mixed model
was tted to the data to see if the effect of recovery time,
type of surgery, and the interaction between recovery time
and type of surgery were statistically signicant when con-
sidering the change in expectations duration of convales-
cence. For secondary outcomes, ttests and Fisher tests were
applied according to the circumstance (continuous or cate-
gorical variables). All tests were performed in R, version
3.6.3 (R Core Team, R Foundation, Vienna, Austria). A p
value 0.05 was considered statistically signicant.
Results
Study population characteristics
A total of 145 participants completed the survey; 74 par-
ticipants (51.0%) were male, and 71 (49.0%) were female.
Their ages ranged from 17 to 90 years, with a mean age of
60.9 §16.4 years. Only 11 participants (7.6%) had previ-
ously undergone a cosmetic procedure; 18 (12.4%) were
familiar with the term blepharoplasty, and 13 (9.0%) had pre-
viously received information on blepharoplasty from a
health care professional. Most participants worked in a non-
medical eld (127 of 145; 87.6%). Regarding educational
level, 62 participants (42.8%) completed university, 32
(22.1%) completed CEGEP (a 2-year postsecondary pro-
gram equivalent to community college), and only 1 (0.7%)
did not complete high school. Additional sociodemographic
characteristics are summarized in Table 1.
Table 1Patient characteristics regarding sociodemographic
status, history of cosmetic surgery and clinical context
Sociodemographic Status Mean, n SD, %
Age 60.9 16.4
Sex
Male 74 51.0%
Female 71 49.0%
Work type
Medical 18 12.4%
Nonmedical 127 87.6%
Level of education
Elementary school 1 0.7%
High school 50 34.5%
College of Further Education (CEGEP) or equivalent 32 22.1%
University (bachelors) 38 26.2%
University (second degree) 24 16.6%
Clinical Context n (%)
Past history of plastic surgery
No 134 (92.4%)
Yes 11 (7.6%)
Ever heard of blepharoplasty
No 127 (87.6%)
Yes 18 (12.4%)
Received information on blepharoplasty
from a health care professional
No 132 (91.0%)
Yes 13 (9.0%)
Planning to undertake a blepharoplasty procedure
No 130 (89.7%)
Yes 15 (10.3%)
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Primary outcomes: change in blepharoplasty
perceptions before and after intervention
Perceived surgical outcome. Perceived surgical outcome was
signicantly altered before and after intervention (p<
0.001). Preintervention, 58 participants (40.0%) perceived
the laser technique to have a better outcome than the blade
technique, 54 (37.2%) preferred the blade over the laser,
and 33 (22.8%) considered the techniques similar
(Fig. 1A). After intervention, the overall number of indi-
viduals perceiving the laser technique to have a better surgi-
cal outcome increased to 81 (55.9%), whereas the number
of participants perceiving the blade technique to have a bet-
ter outcome decreased signicantly to 4 (2.8%, p<0.001).
There was an increase in the number of participants who
considered both techniques to be similar (n = 60; 41.4%).
Among the 58 participants who selected the laser tech-
nique as having a better outcome before the intervention,
40 participants (69.0%) maintained their perception after
the intervention, with more than a quarter now considering
the 2 techniques to be similar (n = 16; 27.6%) or shifting to
the blade technique (n = 2; 3.4%). In the group of 54 partic-
ipants who perceived the blade technique to have a better
outcome preintervention, most either switched to the laser
technique (n = 28; 51.9%) or considered results to be similar
(n = 24; 44.4%) postintervention. Among the 33 partici-
pants who considered both methods similar preintervention,
most retained their perception postintervention (n = 20;
60.6%) or changed in favour of the laser technique (n = 13;
39.4%; Fig. 1C).
Effect of patient characteristics on perceived surgical outcome.
There was a statistically signicant relationship between age
and the shift in best perceived outcome for the laser tech-
nique after the intervention (p= 0.036). While the youn-
gest participants (55 years of age) showed a signicant
shift toward the laser technique, the oldest participants
(71 years of age) maintained a perception of similar out-
comes between the 2 techniques. Males were more likely
Fig. 1Participantsperceptions on the perceived surgical outcome for blepharoplasty technique: (A) Preintervention; (B). Postinter-
vention; (C) Preintervention vs postintervention.
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Laser versus blade-assisted blepharoplastyNguyen et al.
3
than females to demonstrate a change in their beliefs prein-
tervention and postintervention (p= 0.036). Furthermore,
the higher the level of education of participants, the more
likely they were to believe that both techniques were similar
(p= 0.049).
Preferred surgical technique. Participantsperceptions
changed signicantly before and after the intervention
when asked about the technique they would choose if they
were to undergo blepharoplasty surgery (p<0.001). Ini-
tially, 93 participants (64.1%) favoured the laser technique,
29 (20.0%) preferred the blade technique, and 23 (15.9%)
considered the techniques to be similar (Fig. 2A). The trend
evolved slightly after the intervention: 118 participants
(81.4%) preferred the laser technique, only 10 (6.9%) pre-
ferred the blade technique, and 17 (11.7%) had no prefer-
ence because they considered the techniques similar
(Fig. 2B).
More specically, among the 93 participants who initially
favoured the laser technique, 84 (90.3%) continued to
favour the laser technique after the intervention, whereas
only 4 (4.3%) chose the blade technique and 5 (5.4%) did
not have any preference. Similarly, among the 29 partici-
pants who initially favoured the blade technique, most of
them (n = 19; 65.5%) changed to the laser technique after
the intervention, with only 4 (13.8%) preferring the blade
technique and 6 (20.7%) not having any preferred tech-
nique. In the group of 23 participants who considered both
methods similar before the intervention, most opted for the
laser technique (n = 15; 65.2%) or continued having no
preferred technique (n = 6; 26.1%), with only 2 (8.7%) pre-
ferring the blade technique after the intervention (Fig. 2C).
Effects of patient characteristics on preferred surgical tech-
nique. Patients who preferred the laser technique before the
intervention maintained their perception after the interven-
tion regardless of age. Among those who preferred the blade
technique before the intervention, in contrast to the results
for perceived surgical outcome, those aged 56 years and
older were more likely to select the laser technique after the
intervention (p= 0.008). Males were more likely to change
their preference to the laser technique after the intervention
Fig. 2Participantsperceptions on their preferred surgical technique: (A) Preintervention; (B) Postintervention; (C) Preintervention
versus postintervention.
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than females (p= 0.006). The higher the level of education,
the more participants were likely to choose the laser tech-
nique over the blade technique before and after the inter-
vention (p= 0.008).
Expected convalescence
Before the intervention, there was approximately a 1-
week difference in perceived recovery time associated with
blepharoplasty by the blade technique (20.1 days, SD 32.6)
versus the laser technique (13.5 days, SD 32.0),
p= 0.0138). After the intervention, this difference
increased to approximately 2 weeks (36.6 days, SD 54.4 for
the blade technique vs 22.1 days, SD 41.1) for the laser
technique, p<0.0001; Fig. 3). The average change in per-
ceived recovery time of 15.5 days for the blade technique
was statistically signicant (p<0.0001), as was the average
change in recovery time of 7.7 days for the laser technique
(p= 0.0043). The difference in change between the blade
and laser techniques was also statistically signicant
(p= 0.040).
Secondary outcomes: baseline blepharoplasty
perceptions
Durability of surgical results. The majority of participants
(n = 126; 86.9%) perceived both techniques to have the
same longevity: 65 participants (44.8%) estimated 510
years; 26 (17.9%), 1020 years; 25 (17.2%), 05 years;
and 10 (6.9%), >10 years. Among the 19 remaining partici-
pants (13.1%), most considered the result from blade-based
surgery to have a longer lifespan than laser-based surgery
(n = 11; 7.6%). This small majority favouring blade tech-
nique longevity was statistically signicant among those
who perceived there to be a difference (p<0.001, Fisher
test); however, this is based on a small number of partici-
pants (Fig. 4).
Costs associated with the surgical techniques. Before the
intervention, the majority of participants (n = 104; 71.7%)
estimated the same cost to both surgeries: 5 (3.4%) believed
that both procedures cost <$1,000 each; 19 (13.1%),
$1,000$2,000; 38 (26.2%), $2,000$3,000; 15 (10.3%),
$3,000$4,000; 11 (7.6%), $4,000$5,000; and 16
(11.0%), >$5,000. Among the participants who believed
that the costs between laser and blade surgeries differ
(n = 41; 28.3%), most (34 of 41; 82.9%) considered laser
surgery to be more expensive than blade surgery, with only
7 of 41 (17.1%) believing it to be less expensive. This differ-
ence was statistically signicant (p<0.001).
Preintervention, the participants also were asked their
preference on blade versus laser surgery when considering
prices: 121 participants (83.4%) preferred laser surgery
when there was no difference in price. When laser surgery
cost an extra $100$500 in comparison with blade surgery,
the majority (n = 111; 76.6%) still preferred laser surgery.
However, when laser surgery was at least $1,000 more
expensive than blade surgery, only 66 participants (45.5%)
still opted for the laser technique (Fig. 5).
Postintervention, the percentage of participants who pre-
ferred the laser technique increased to 93.1% (n = 135)
when there was no difference in price, 84.1% (n = 122)
Fig. 3Participantsperceptions on the recovery time for each blepharoplasty technique (blade-based versus laser-based) preinter-
vention and postintervention.
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Laser versus blade-assisted blepharoplastyNguyen et al.
when there was a difference of $100$500, and 54.5%
(n = 79) when laser surgery was at least $1,000 more expen-
sive (Fig. 5). Participants responded that on average (SD),
paying $975 ($1,091) more would justify laser surgery com-
pared with blade surgery.
While the preference for laser surgery signicantly
decreased with price (p<0.001), it increased across all price
categories postintervention. This increase was statistically
signicant when all price categories were combined
(p= 0.004). However, there was no interaction between the
price level and the prepost effect (p= 0.40), which indi-
cates that the increase in laser surgery preference after coun-
selling was not affected by a greater price difference between
the procedures.
Fig. 5Participantspreference for the laser technique according to its price preintervention versus postintervention.
Fig. 4Participantsperceptions on the durability of surgical results by blepharoplasty technique (blade versus laser).
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Level of pain. Pain was measured on a scale of 110, with
a level of 6 dened as a cut in the skin and 10 dened as a
severe headache or dental ache or worst previously experi-
enced pain.
10
The average perceived pain level was statisti-
cally signicantly lower for the laser technique (4.6 §1.9)
than for the blade technique (5.7 §1.7; p <0.001, ttest).
Level of risk. Participants were asked about the level of
risk they perceived to be associated with each technique.
Most participants (n = 121; 83.4%) attributed the same
level of risk to both surgeries: 19 (13.1%) believed that
there was no risk; 76 (52.4%), a mild risk; 23 (15.9%), a
moderate risk; and 3 (2.1%), a high risk (Fig. 6). The partic-
ipants who did not perceive the same level of risk for both
procedures mainly considered the laser technique to be less
risky than the blade technique (n = 20; 13.8%), with only 4
(2.8%) the opposite.
Level of technical difculty. Level of technical difculty
associated with the operation also was measured on scale of
110, with 1 being dened as simple and 10 difcult. The
perception of the average level of difculty was statistically
signicantly lower for the laser technique (4.2 §2.1) than
for the blade technique (5.0 §2.1, p<0.001).
Personnel able to perform the surgery. Most participants
believed that the operation could be performed by an oph-
thalmologist (112 [77.2%] for the blade technique; 115
[79.3%] for the laser technique), by a plastic surgeon (112
[77.2%] for the blade technique; 114 [78.6%] for the laser
technique), or by an oculoplastic surgeon (137 [94.5%] for
the blade technique, 136 [93.8%] for the laser technique).
A minority of participants thought that a nurse (14 [9.7%]
for the blade technique, 18 [12.4%] for the laser technique),
a general physician (21 [14.5%] for the blade technique, 24
[16.6%] for the laser technique), or a general surgeon (55
[37.9%] for the blade technique, 58 [40.0%] for the laser
technique) could perform the operation (Fig. 7).
Reversibility of surgical result. Most participants (n = 138;
95.2%) gave the same responses when questioned about
treatment reversibility for both the blade and laser techni-
ques: 64 (44.1%) believed both the laser and blade techni-
ques to be irreversible, 10 (6.9%) believed the results to be
easily reversible, 55 (37.9%) indicated reversibility with
medical treatment, and 9 (6.2%) indicated reversible results
with surgery.
Level of invasiveness. While a minority of participants
answered that the laser technique is more invasive than the
blade technique (n = 11; 7.6%) or that both techniques are
equally invasive (n = 54; 37.2%), a majority of participants
(n = 80; 55.2%) believed that the blade technique was the
more invasive technique.
Discussion
In a world in which aesthetic outcomes are becoming
increasingly important,
11
it is of utmost importance to
Fig. 6Participantsperceptions on laser-based and blade-based blepharoplastys level of risk.
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Laser versus blade-assisted blepharoplastyNguyen et al.
understand patientsknowledge of, perceptions around, and
expectations prior to undergoing surgery.
12
Preoperative
counselling can be tailored accordingly and may serve to
enhance patient satisfaction. Although previous studies
have examined differences in blepharoplasty technique, fac-
tors impacting outcomes, and patient expectations and
experiences with blepharoplasty, to our knowledge, none
has previously examined patient perceptions and preferen-
ces when considering laser-based versus blade-based blepha-
roplasty.
Our study population consisted of 145 participants
selected at random, with approximately equal representa-
tion of males and females. Most participants worked in a
nonmedical eld and had at least a level of postsecondary
education. A minority had previously undergone cosmetic
surgery or were previously exposed to blepharoplasty sur-
gery.
Our primary outcomes included evaluation of perceived
outcomes, preferred technique, and expected duration of
convalescence before and after patient counselling was pro-
vided. For all 3 outcomes, there was a statistically signicant
change before and after patient education. Preintervention,
40% of participants selected laser when asked which tech-
nique had the better outcome compared with 37% who
chose blade and 23% who stated that there was no differ-
ence (p= 0.71). There was no statistical difference between
patientsperceived surgical outcome preintervention, but
there was a statistically signicant increase favouring the
laser technique postcounselling (p<0.001). After the inter-
vention, the percentage of participants selecting the laser
technique to have the better outcome increased to 56%.
This preference for the laser technique might be related to
participantsinterpretation of technique differences: they
were mistakenly led to believe that these differences trans-
lated to different surgical outcomes.
After clearly indicating that both techniques offer the
same aesthetic result after 36 months in the educational
intervention, a greater percentage of participants stated that
they believed that both techniques had similar outcomes
(23% before receiving the intervention, 41% after). This is
in line with what was taught. However, despite receiving
the educational information, a majority of participants
(56%) still selected one technique (laser) to be associated
with a better outcome than the other. Similarly, when indi-
cating the technique that they would choose for themselves,
most participants chose the laser technique, and an even
greater majority selected the laser technique postinterven-
tion (64% before receiving the intervention, 81% after).
Participantspreference for the laser technique may be due
to the lay perception that the laser is a revolutionary tech-
nology that surpasses traditional manual surgery.
13
Because
the intervention seems to convince people that one method
leads to better outcomes than the other and that they
should choose one technique over the other, health care
providers must be mindful of their impact on patient expect-
ations when counselling them and make sure that patient
education is not tainted by other factors, such as the sur-
geons preference, potential nancial gains, and so on.
On the other hand, participants accurately identied the
laser technique as being associated with a shorter recovery
time of approximately 12 weeks.
14,15
After the interven-
tion, estimated recovery times increased for both the blade
and laser techniques. Perhaps explanations about results
becoming nal at 36 months during the intervention con-
fused the participantsperceptions of immediate postopera-
tive recovery duration.
Although our counselling indicated that both techniques
had the same pain and discomfort during the surgery and
the same general complications, the laser technique was
considered less invasive and associated with signicantly
Fig. 7Participantsperceptions on personnel able to perform the surgery by blepharoplasty technique.
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lower levels of perceived pain and technical difculty than
blade surgery. These preconceptions also may have had an
effect on answers related to outcome, preferred surgical tech-
nique, and perceived recovery time favouring the laser tech-
nique.
Males were more likely than females to change their per-
ception about surgical outcomes and preferred surgical tech-
nique after the intervention, which may be due to gender
differences in perception and recall. Females may have a
greater recall of their previous answers than males.
16
Similar
to other studies, the higher the level of education, the more
likely the participants were to correctly state that both tech-
niques had similar outcomes.
17
In addition, the higher the
level of education, the more likely the participants also were
to prefer the laser technique over the blade technique both
before and after the intervention, probably because they
were more able to appreciate that the added advantages of
the laser technique could be benecial to their lifestyle. Par-
ticipants with higher educations perceptions are in line
with and follow the same logic as what is taught.
Another important driving factor is cost. If there were no
differences in price, the majority of participants (83% before
the intervention, 93% after) would have chosen the laser
technique. While the average participant responded that an
extra $975 associated with laser surgery would justify its ben-
ets, only 55% of participants (after the intervention) chose
laser over blade surgery when the laser technique was at
least $1,000 more expensive. However, the choice of laser
surgery seemed more justied when the procedure was less
than $500 more expensive, with 84% of participants (after
the intervention) indicating they would be willing to pay
this amount. It is also interesting to note that the preference
for the laser technique signicantly increased after the inter-
vention, no matter what the price difference was.
Elucidating patient perceptions and preferences for blade-
based versus laser-based blepharoplasty provides surgeons
with perspective on how to tailor preoperative counselling.
Patient education, leading to shared decision making, fosters
better patientdoctor interactions and treatment
decisions.
2,12,18
Increasingly positive surgical outcomes also
occur when health care teams provide comprehensive edu-
cational information to patients, give recommendations,
and discuss their perceptions, expectations, and
preferences.
12,1921
Despite receiving the educational intervention explain-
ing that both techniques have similar outcomes, most par-
ticipants still perceived that the laser technique had better
surgical outcomes than the blade technique. Similar to pre-
vious ndings, this study suggests that patient recall is poor
even when presenting a summary of educational informa-
tion in lay terms.
22
Key points comparing surgical outcomes
in laser-assisted versus traditional surgical blade-assisted
blepharoplasty were not well understood and processed by
patients because a lot of the survey questions were answered
differently than the educational information given to partic-
ipants. This information-integration issue can be due to
various factors, including recalls selectivity and format
dependency (words versus numbers).
23,24
In this study, a large number of participants were exposed
to novel and unfamiliar information that had to be stored
for subsequent retrieval and use. This situation replicates
medical encounters where patients need to integrate novel
and important educational information, suggesting that
strategies to boost recall must be implemented.
25
Studies
have suggested the following practical aids to improve
patientsrecollection of key information: providing specic
medical information, giving prompt sheets to encourage
questionanswer interactions, providing visual support
through preoperative videos or pictograms, and repeated
questioning and retelling.
25
Other methods to enhance cog-
nition include providing one-on-one teaching sessions, cen-
tring the conversation around the patientsneeds and
concerns, and using tailored communication approaches.
25
In conclusion, signicant changes in perception of surgi-
cal outcome, preferred surgical technique, and anticipated
recovery time suggest that patients are impacted by counsel-
ling. Participantsinitial preference for the laser technique
was reinforced by the intervention, even to the point of
incorrectly skewing expected surgical outcomes in favour of
the laser technique. Convalescence time and cost considera-
tions also may drive the discrepancy between the educa-
tional information provided and the patientsperceptions.
Imperfect recall suggests that surgeons must emphasize key
information provided to their patients, and repetition may
be required.
Supplementary Materials
Supplementary material associated with this article can be
found in the online version at doi:10.1016/j.
jcjo.2022.03.006.
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Footnotes and Disclosure
Acknowledgements: We thank Charles-
Edouard Giguere
from the Centre de recherche de lInstitut universitaire en
sante mentale de Montreal for his statistical expertise.
Disclosure: The authors have no proprietary or commercial
interest in any materials discussed in this article.
From the *Faculty of Medicine, McGill University, Mon-
treal, Quebec, Canada;
y
Department of Ophthalmology,
University of Montreal, Montreal, Quebec, Canada;
z
University Centre of Ophthalmology, Maisonneuve-Rose-
mont Hospital, Montreal, Quebec, Canada;
x
Beirut Eye and
ENT Specialist Hospital, Beirut, Lebanon.
Originally received Jan. 25, 2022. Accepted Mar. 13, 2022.
Correspondence to Patrick Boulos, MD, Department of
Ophthalmology, Universite de Montreal, CUO Maison-
neuve-Rosemont, 5415 Boulevard de lAssomption, Mon-
treal, QC, Canada H1T 2M4. info@CliniqueO.com
ARTICLE IN PRESS
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