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The Measure of Face-Lift Patient Satisfaction: The Owsley Facelift Satisfaction Survey with a Long-Term Follow-Up Study
Abstract
Patient satisfaction is a major factor in determining success in aesthetic surgery. To the authors' knowledge, a long-term study measuring patient satisfaction with face-lift surgery has not been published. The authors' study was designed to measure patient satisfaction with the overall experience of a face lift and to assess the patient's level of satisfaction 10 to 15 years after surgery.
Three hundred ninety-four consecutive patients were identified who had face lifts performed by the senior author (J.Q.O.) between January 1, 1994, and January 1, 1999. Contact was achieved with 146 patients (37 percent), and 131 patients (90 percent) agreed to participate by completing a four-page survey. Eighty-nine patients (68 percent) returned the survey.
One year after face-lift surgery, 87 patients (97.8 percent) described the improvement of their facial appearance as very good or beyond expectations. After an average follow-up of 12.6 years, 61 patients (68.5 percent) rated their current degree of improvement as very good or beyond expectations, and 61 patients (68.5 percent) felt 10 or more years had been added to their youthful appearance. Thirty-four patients (31 percent) indicated disappointment in some aspect of the face lift.
This work assesses the long-term satisfaction of face-lift patients who had a superficial musculoaponeurotic system-platysma face lift. The results suggest a high degree of satisfaction following face-lift surgery at short-term and long-term follow-up. The authors recognize that recall bias may be present when recalling the satisfaction at 1 year postoperatively. We present the survey questionnaire as a template for future research in face-lift patients.
... The most importance outcome for cosmetic procedures is patient satisfaction which is influenced by a variety of factors including aesthetic outcomes, interactions with the physician and staff throughout the experience, and the postoperative recovery course. A few validated outcome measures exist for facelifts, including the Facelift Outcomes Evaluation, Face-Q, and Owsley Facelift Outcomes Evaluation; however, they are not conventionally used in the literature, making it difficult to evaluate outcomes of various techniques [4,9,18,19]. Social media use for both patients and physicians has become prominent throughout the field of cosmetic surgery. ...
... Rates of patient satisfaction were consistent across the various measures utilized, with 92.24% of reviews categorized as positive, 91.91% of patients deeming their facelift ''worth it,'' and 93.02% of patients giving their physician an overall five out of fivestar rating. Previous literature evaluating patient perspectives on facelift outcomes through surveys such as the Facelift Outcomes Evaluation, the Owsley Facelift Satisfaction Survey, and the Face-Q, reported similar findings of 85.9%, 92.1%, and 90.5% patient postoperative satisfaction, respectively [19][20][21]. Satisfaction with facelifts as measured by percent ''worth it'' is comparable to satisfaction with blepharoplasty and rhinoplasty which were reported as ''worth it'' by 93.5% and 93.8% of patients on RealSelf, respectively [10,22]. A similar study performed for breast reconstruction reported a 89.4% ''worth it'' rate by patients [23]. ...
Background
Facelifts are one of the most common facial aesthetic surgery procedures. Patient satisfaction determines success of most aesthetic surgery but has been historically difficult to assess.
Objective
This study evaluated reviews by facelift patients on the aesthetic surgery social media website RealSelf.com to determine positive and negative factors underlying patient satisfaction following facelifts.
Methods
Facelift reviews were gathered from RealSelf.com with an automated web crawler. Reviews were categorized as positive or negative and by the primary and secondary reasons for the positive or negative review. Patient “worth it” and star ratings, physician specialty, and cost of procedure were also collected.
Results
A total of 2153 facelift reviews were collected. Overall, 1986 (92.24%) were positive and 167 (7.76%) were negative. The most common overall reasons for a positive review were aesthetic results ( n =1571, 79.10%) and bedside manner ( n =1488, 74.92%). The most common overall reasons for a negative review were outcome ( n =137, 82.04%) and bedside manner ( n =82, 49.10%). Most facelifts were performed by plastic surgeons ( n =1796, 83.42%). The greatest 5-star rating percentages were seen for oral and maxillofacial surgeons ( n =29, 93.55%), otolaryngologists ( n =96, 92.31%), and plastic surgeons ( n =1642, 91.43%). Of patients who provided a “worth it” rating, 1216 (91.91%) stated that their facelift was “worth it.”
Conclusion
Overall patient sentiment toward facelifts was positive. The factors most commonly affecting a positive patient experience were bedside manner and aesthetic results. Negative patient reviews were primarily attributed to dissatisfaction with aesthetic outcomes. Social media serves as a valuable tool for evaluating patient satisfaction with aesthetic surgery.
Level of Evidence IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
... In our study just like in most previous reports [20][21][22] women account for almost 90% of face and neck lift patients. ...
... In the literature hypertrophic scarring after facelift surgery varies between 2-18% [22,28,29]. No hypertrophic scarring was found in this study due to tension free wound closure and a pure Caucasian patient collective. ...
The neck is an often-neglected part of body lift procedures after massive weight loss. The objective of this study was to classify massive weight loss patients undergoing direct neck lift procedures and provide a standardized Treatment algorithm. A retrospective review of all neck lift procedures performed between January of 2012 and December of 2019 was conducted. Patients were classified as follows: Grade I, no skin excess with remaining preplatysmal fat and no platysmal laxity; Grade IIa, moderate submental skin excess with subplatysmal fat deposits and platysmal laxity; Grade IIb, moderate anterior
neck skin excess with no fat deposits and platysmal laxity; Grade III, considerable anterior skin excess with no or limited fat deposits and platysmal laxity and bands. Grade I patients had Liposuction, Grade IIa patients Submental Neck Lift with anterior fat excision and central platysmaplasty, Grade IIb Submental Neck Lift with central platysmaplasty, and Grade III patients Median Z-Plasty with fat excision (if needed) and central platysmal resection and tightening. Thirty-one patients were included for analysis. One underwent liposuction, twenty-five a Submental Neck Lift and five a Median Z-Plasty. Concomitant
surgery was carried out in all cases. A recurrent skin laxity occurred in 2 (11.8%) patients, so in local anesthesia an operative revision was required. A standardized algorithmic approach for neck lift in massive weight loss patients may optimize the result without increasing the complication rate. Direct neck lift procedures prove to be reliable techniques with rare complication rates that can be performed together with other postbariatric procedures.
... Although women made up at least 90% of the patient population in four different rhytidectomy studies [11][12][13], this study is ...
... There was one incidence of hypertrophic scarring in a 72-year-old male who had no complaints and did not want any treatment. Previous studies of standard face and neck lift have reported an incidence of hypertrophic scarring from less than 2% to as high as 18% [13,[20][21][22]. ...
Background:
Major problems with cervicoplasty by direct skin excision include the subjective nature of skin markings preoperatively and the confusing array of procedures offered. This technique incorporates curved incisions, resulting in a wave-like scar, which is why the procedure is called a "wave-plasty".
Methods:
This prospective study includes 37 patients who underwent wave-plasty procedures from 2004 to 2015. Skin pinching technique was used to mark the anterior neck preoperatively in a reproducible fashion. Intra-operatively, redundant skin was excised, along with excess fat when necessary, and closed to form a wave-shaped scar. Patients were asked to follow up at 1 week, 6 weeks, and 6 months after surgery.
Results:
The mean operation time was 70.8 minutes. The majority (81.3%) was satisfied with their progress. On a scale of 1 to 10 (1 being the worst, and 10 being the best), the scars were objectively graded on average 5.5 when viewed from the front and 7.3 when seen from the side 6 months after surgery. Complications consisted of one partial wound dehiscence (2.3%), one incidence of hypertrophic scarring (2.3%), and two cases of under-resection requiring revision (5.4%).
Conclusions:
In select patients, surgical rejuvenation of the neck may be obtained through wave-like incisions to remove redundant cervical skin when other options are not available. The technique is reproducible, easily teachable and carries low morbidity and high patient satisfaction in carefully chosen patients.
... In 2010, the Plastic and Reconstructive Surgery Journal found high patient satisfaction in the short-term and long-term follow-up. 97.8% of patients were satisfied with their facial appearance a year after their facelift procedures [34]. The Aesthetic Plastic Surgery National Databank stated that a facelift in 2021 costs an average of $9,127 [7]. ...
... This is consistent with previous studies utilizing questionnaires to assess the changes in self-esteem and satisfaction at 6 months after facelift surgery. [36][37][38][39][40] The most common postoperative complications were hematoma and ecchymosis (18%). Ten percent of patients had infection requiring treatment, 8% had contour irregularities or asymmetry, and the rest varied between seroma, emesis, nerve or vascular injury, and scars requiring revision (8%). ...
Permanent fillers were previously used to fix wrinkles associated with aging as they were considered a reasonable choice for facial rejuvenation. However, the subsequent removal of permanent fillers is of great concern to surgeons before performing a facelift surgery. Many studies have evaluated the outcomes of facelift surgery; however, we sought to evaluate the outcomes of facelift surgery which required removal of fillers beforehand.
Methods:
This retrospective cohort study evaluated the outcomes of 50 patients with regard to patient satisfaction and postoperative complications of facelift surgery with removal of permanent filler under local anesthesia. A short scar rhytidectomy with superficial muscular aponeurotic system plication was performed. Preoperative and postoperative photographs were analyzed by two independent surgeons to report asymmetry scores ranging from one to three (one none, two slight, and three obvious asymmetries). Patient satisfaction scores were also recorded.
Results:
The preoperative presentations of the permanent filler were asymmetry (82%) and disfiguring facial edema (26%). Removing fillers under local anesthesia is generally tolerable, with 56% of patients tolerating rhytidectomy. The degree of the participants' satisfaction after follow-up was satisfactory; two-thirds of patients (62%) were satisfied. There was a significant difference between surgeons' preoperative and postoperative assessment of asymmetry scores (P < 0.05).
Conclusions:
Permanent filler removal with concomitant face-neck lift surgery has satisfactory outcomes. The procedure length was primarily determined by the patient's skin characteristics and the severity of the local condition.
... Conversely, younger patients tend to have greater duration of satisfactory results. 86,88,89 The literature also generally supports complete neck undermining and midline platysmal plication with or without platysma transection as the best means of surgical treatment. 5,86,87,90,91 In the review of Rohrich et al of their large facelift database, 10% of his facelift patients were secondary facelift patients. ...
Although previous publications have reviewed face and neck-lift anatomy and technique from different perspectives, seldom were the most-relevant anatomical details and widely practiced techniques comprehensively summarized in a single work. As a result, the beginner is left with a plethora of varied publications that require sorting, re-arrangement, and critical reading. A recent survey of US plastic surgery residents and program directors disclosed less facility with facelift surgery when compared to aesthetic surgery of the breast and trunk.
To this end four of the widely practiced facelift techniques (ie, MACS-lift, lateral-SMASectomy, extended-SMAS, and composite rhytidectomy) are described in an easy review format. The highlights of each are formatted followed by a summary of complications. Finally, the merits and limitations of these individual techniques are thoroughly compared and discussed.
... 10 Several patient satisfaction surveys have been developed previously, for example, the Owsley Facelift Satisfaction Survey was designed and used in several studies to measure patient satisfaction with facelift procedures. 2,4,11 These surveys, however, were not rigorously scientifically developed and thus do not appear to have consistent widespread use. This has led do the development of more scientifically reliable patient-reported outcome (PRO) instruments in plastic surgery. ...
Importance: Social media has become a mainstream method of allowing patients to report and rate their satisfaction with cosmetic procedures and providers. To date, very few studies have published patient-reported satisfaction with the rhytidectomy procedure. Objective: We sought to perform a social media analysis of the rhytidectomy procedure. Design, Setting, and Participants: Data were extracted from 1876 consecutive rhytidectomy online reviews completed by individuals on "facelift" from the RealSelf website, from April 2017 to June 2019. Patients who did not undergo the procedure were excluded. Main Outcomes and Measures: Reasons for pursuing surgery, choosing a surgeon, and liking the surgical outcome were identified. Surgical and demographic variables, cost, and overall "Worth It" scores were recorded. Data were analyzed using SPSS Version 25. Valid frequencies and percentages are presented excluding missing data. Results: Of the data that could be extracted from 1876 RealSelf reviews, the majority of reviewers were female (88.3%), aged between 60 and 69 years (40.1%). Predominant reasons reviewers chose their surgeons related to favorable surgeon personality/demeanor (20.0%) and establishing a positive rapport with the surgeon during the consultation who was able to answer the patients' questions. In total, 85.0% (1045) of reviewers felt surgery was "Worth It," whereas 0.7% (8) were undecided and 14.4% (177) felt it was not worth it. The aggregate "Worth It Rating" of rhytidectomy, using RealSelf's methodology (i.e., not including unsure responses) was 96.9. The main reasons those who liked their surgical outcome related to reviewers looking younger and "fresher" (31.1%), natural or "not fake" (18.4%), and developing positive emotional responses including feeling more confident and happier (18.2%). Of those who did not feel the surgery was "Worth It," postoperative scarring, short-lasting results, and ineffective and/or poor results were common reasons why reviewers did not like their outcome. Conclusions and Relevance: The overall satisfaction with rhytidectomy surgery was high within this cohort, which is in keeping with satisfaction rates reported in the literature. Many patients chose their surgeon based on favorable personality traits and emotional connections rather than other factors.
... It should be mentioned that in aesthetic surgery the most susceptible to iatrogenic injures are the branches of the temporal and frontal area, due to the fact that those branches are not so much ramified and few connections are characteristic for those branches. The high risk of frontotemporal branch lesion in facelift was pointed out by [9], and explanation was given by [10], who mentioned that the precise localization of the frontal division of the facial nerve is still problematic, for there were not established high fidelity landmarks that can be used for that purpose and [10] proposed to consider as landmarks the veins of the temporofrontal area. ...
... The second question focused on patient satisfaction ratings about four separate areas of the face by the It has been stated that patient satisfaction is the predominant factor for determining success in aesthetic surgery. [5,6] Few studies have highlighted the satisfaction or not of patients who underwent a traditional facelift; [7][8][9] however, to the best of our knowledge, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet. Our study was designed to measure individual patient satisfaction with the overall experience of a traditional facelift and a midface lift, in order to find out from each patient their level of satisfaction 1 and 5 years after the operation, and to compare the results to assess the benefits of the midface lift. ...
Context:
Several studies showed, from the clinical point of view, the advantages of the various techniques and surgical approaches to obtain facial rejuvenation. A few studies have highlighted the satisfaction or not of patients who underwent a traditional facelift; however, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet.
Aims:
The aim of this study is to measure individual patient satisfaction with the midface lift, to find out from each patient his/her level of satisfaction 1 and 5 years after the operation and to compare the results to assess the benefits of the surgery.
Background:
Several studies showed, from a clinical point of view, the advantages of the various techniques and surgical approaches to obtain facial rejuvenation; however, a long-term follow-up study measuring patient satisfaction with midface-lift surgery has not been published yet.
Materials and methods:
Between January 2005 and January 2010, 163 patients underwent a midface lift. All patients were asked to complete a standardised survey 1 and 5 years after surgery, in order to measure outcomes among facial aesthetic patients.
Statistical analysis used:
The paired t-test.
Results:
All patients reported an improvement as a result of the midface lift. Statistically significant differences in judgement criteria were found for malar eminence and nasojugal groove. Almost all of the patients turned out to be completely satisfied with their appearance with the new look.
Conclusions:
Patients were extremely satisfied with their decision to undergo a midface lift and with the outcomes and quality of life following the procedure.
... Facelifting is a crucial tool in the daily practice of a plastic surgeon. Ten to 15 years ago the facelifting procedures were requested by a small patient population in Europe [1]. Today it is widely requested and standard repertoire of every aesthetic surgeon. ...
Objective: The MACS facelift alone shows poor results on the medial neck in cases of pronounced, rigid platysmabands (McKinney III–IV°). The original MACS (“Minimal Access Cranial Suspension”) facelift delirs excellent results on the midface and leads to sustainably improved outcome on the neck by adding a fourth suture on the platysma. McKinney type I–II platysmabands can be treated only by lateral approach of the ‘fourth suture’, type III–IV should be treated with closed platysma myotomy before.Methods: Between October 2007 and November 2013 a number of 219 patients were treated with the MACS facelift technique accomplished by a fourth suture on the platysma and liposuction or optional lipectomy on the neck. On 47 patients closed transcutaneous platysma myotomy was performed.Results: Surgery time lasted on average 2.5 hours and was performed under sedation with local anesthesia in 85%. Recovery time ranged between 14 to 16 days until the patients were back to work. Due to their health status 54% of our patients had an inpatient arrangement for one night and 46% an outpatient arrangement.Conclusion: The modification of the MACS lift with the ‘fourth suture’ on the platysma keeps the benefits of the original technique but improves the aesthetic outcome on the neck.
... Several studies have investigated the results of various treatments for the aging face, including face-lift surgery, with a primary focus on patient satisfaction. 2,3 While these reports offer important insight into the nature of these interventions, it becomes difficult to extrapolate generalizable meaning from the data reported given the diversity of survey instruments, study protocols, patient populations, and surgical techniques, among a multitude of other factors. As a result, the development and use of validated instruments has become an essential focus of outcomes research. ...
Importance
It is well understood that optimal psychological health is imperative to success in aesthetic surgical procedures. Self-esteem is a very sensitive psychological factor that can influence patients’ motivations for seeking surgery as well as their perceptions of outcomes.Objective
To use the Rosenberg Self-Esteem Scale (RSES) to correlate the outcome of rhytidectomy as perceived by the patient to further understand the association of self-esteem and the results of aesthetic facial rejuvenation.Design, Setting, and Participants
A prospective study was conducted of 59 consecutive patients undergoing rhytidectomy perfomed by a single surgeon at a private practice from July 1 to October 31, 2013. The RSES was used to establish preoperative baseline scores and scores at a 6-month postoperative follow-up. A paired t test was used to compare statistical data before and after surgery. Change in self-esteem and the patient’s evaluation of the surgical outcome was assessed. Analysis was conducted from July 1 to December 1, 2014.Main Outcomes and Measures
Patients’ change in self-esteem level after rhytidectomy, as assessed by the RSES.Results
Of the 59 patients, 50 completed a 6-month postoperative questionnaire; mean age was 58 years (range, 37-73 years); 48 were women; and 44 were nonsmokers. The mean difference between baseline and 6-month scores showed an increase of 0.3 (baseline, 24.3; 6-month follow-up, 24.6), which was not statistically significant (P = .69). Subdivision of patients into groups by self-esteem level showed a statistically significant improvement in self-esteem after surgery in the group with low self-esteem, with a mean difference in the RSES score of 3.7 (P = .01), whereas the group with high self-esteem showed a decrease in the RSES score of –3.1 (P = .03) and the group with average self-esteem showed a nonsignificant increase of 0.5 in the RSES score (P = .59). The perceived change in youthful appearance (mean, 8.9 years) did not correlate with self-esteem changes.Conclusions and Revelance
Patient’s self-esteem before surgery may partially determine the quality-of-life outcome after surgery. Patients with low preoperative self-esteem saw an increase in self-esteem after surgery, those with average preoperative self-esteem experienced no change, and those with high preoperative self-esteem experienced a decrease in self-esteem after surgery. In our study, self-esteem measurements did not correlate directly with the positive effect of the surgical outcome, as patients showed no mean change in self-esteem, but patients thought that they appeared a mean of 8.9 years younger after their face-lift surgery. These findings underscore the complex nature of the human psyche as it relates to aesthetic surgery and demonstrates that patients exhibit a wide spectrum of psychological reactions after face-lift surgery.Level of Evidence
2.
... Facelifting is a crucial tool in the daily practice of a plastic surgeon. Ten to 15 years ago the facelifting procedures were requested by a small patient population in Europe [1]. Today it is widely requested and standard repertoire of every aesthetic surgeon. ...
Ein Schwachpunkt der klassischen MACS-Lift-Technik ist der relativ geringe Liftingeffekt im medialen und submandibulären Halsbereich, welcher zu suboptimalen ästhetischen Ergebnissen führt – insbesondere in Fällen ausgeprägten zervikalen Hautüberschusses und/oder harter Platysmabänder. Um diese Limitierung zu überwinden, beschreiben wir eine Modifikation der Originaltechnik, welche den Verjüngungseffekt im Halsbereich maximiert und die erwiesenen Vorteile der kurzen und kaum sichtbaren Narben beibehält. Die Modifikation der Technik durch Einführung einer vierten SMAS-Naht zur lateralen Platysmaplikation über eine 3–4 cm nach kaudal erweiterte Dissektion unterhalb der Mandibula führt zu einem stärker akzentuierten submandibulären Winkel und einer besser definierten Kieferlinie. In Kombination mit einer extensiven submandibulären Liposuktion/Lipektomie und – je nach Fall – der geschlossen Platysmamyotomie wird submandibulär ein konkaver Raum geschaffen, welcher die Einschlagung großer Mengen zervikalen Hautüberschusses ermöglicht und damit in den meisten Fällen eine zusätzliche anteriore oder posteriore Zervikoplastik obsolet macht („konvex wird konkav“).
... Friel et al. [20] published a study on face-lift patient satisfaction. We created our own method of evaluation based on this publication. ...
Background
The retaining ligaments of the face support the facial soft tissue in a normal anatomic position, thereby resisting gravitational change. In this study, a technique utilizing surgical plication of the superficial musculoaponeurotic system (SMAS) to the retaining ligaments of the face and finger-assisted malar elevation (FAME) dissection of the midface is presented.
Methods
The anatomy of the facial retaining ligaments was studied in 20 half-faces of ten fresh cadavers, and the localization of the ligaments was examined macroscopically. Surgical correction of facial aging with plication of the SMAS to the retaining ligaments and FAME dissection of the midface has been performed in 74 face-lift patients since 2006. Outcomes were determined by case notes, clinical review, and a patient questionnaire.
Results
The studied ligaments (zygomatic and masseteric) were present in all cadaver dissections. The zygomatic ligament was located 4.3–5.5 cm from the tragus and originates near the inferior border of the anterior zygomatic arch. The masseteric ligament was located 3.7–5.2 cm from the tragus below the junction of the zygomatic arch and masseter muscle. All the patients answered a satisfaction questionnaire and reported high levels of satisfaction at least 1 year after treatment.
Conclusions
We have identified the facial retaining ligaments in all cadaver dissections and their relationship with other structures of the face are described here. This study demonstrates that our face-lift technique is safe and produces highly predictable and natural results.
Level of Evidence IV
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www. springer. com/ 00266.
Background:
Measuring satisfaction with aesthetic treatment and health related quality of life of patients has become one of the indicators of the success of aesthetic interventions. Therefore, the aim of our study was to examine and compare the satisfaction of patients and surgeons with combined Aptos thread lifting treatment, fat grafting and laser treatment.
Methods:
In total, 48 patients underwent a combination Aptos thread lifting, fat grafting and laser treatment from August 2020 to august 2021. The outcome of treatment was assessed using the Global Scale of Aesthetic Improvement, both subjectively (patient satisfaction assessments) and objectively (blind surgeons assessments).
Results:
The study included 48 respondents, with an average age of 51.8 years, of whom 90% were women. The average intervention time was 66 min. Patient satisfaction was highest in the first month after treatment (mean, 4.7/5.0), and consequently tends to decline up to 1 year after treatment (3.8/5.0). The trend of the results on the objective assessment was stable during the entire follow-up period (4.5/5.0 after first month; 4.1/5.0 after one year).
Conclusion:
Our results show what is the key period when the patient has a subjective need to request reintervention. The duty of the aesthetic physician is to help the patient understand and choose the most appropriate evidence-based rejuvenation treatment.
Level of evidence iv:
Level of evidence IV Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine Ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.
Background:
Early relapse is an adverse outcome of facelift surgery. The rate of early relapse is an indirect measure of the longevity and efficacy of facelift techniques. However, early relapse after facelift is ill-defined, under-evaluated, and under-reported, and literature data on the subject are dispersed. In this systematic review, we aimed to analyze facelift studies using relapse-related outcomes (RROs). Our secondary aim was to highlight the importance of early relapse as an essential outcome measure.
Methods:
The study design was a systematic review of the English literature and meta-analysis of RROs after facelift surgery. RROs that occurred within the first 2 years after surgery were considered "early". Performance, analysis, and reporting were performed in accordance with the PRISMA guidelines. The systematic search was conducted using the PubMed database as of February 2020. Initial screening was performed using the keywords "facelift", "rhytidectomy", "surgical rejuvenation", "face lift", "rhytidoplasty", and "facial rejuvenation". Articles were excluded by using a set of inclusion and exclusion criteria.
Results:
RROs were reported only in 4.4% (19/433) of the papers that underwent full-text review. The frequency of RROs ranged between 0.2 and 50% among facelift papers. The weighted median rate of RROs after facelift surgery was found to be 2.4% in the meta-analysis.
Conclusions:
Future research on preventive measures will be successful upon acknowledgment of the actual prevalence of this problem. Consensus on its definition and objective criteria for its diagnosis are required for further progress.
Level of evidence iii:
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
Aesthetic plastic surgery is a most unusual and unique subspecialty. Unlike other medical and surgical specialties driven primarily by objective medical diagnosis and outcome, aesthetic surgery is patient driven; it represents a special exercise in professional competence by adapting objective medical standards to a mostly subjective field. Given the subjectivity of facial beauty and of the projected aesthetic intervention outcome, in addition to be able to determine beauty of the final result as precisely and objectively as possible, it is also essential to be able to assess patient's satisfaction. However, lack of standardized facial measurements and clear definition of aesthetic outcome and beauty are still major obstacles preventing real change in the consultation dynamics to help better serve patients' expectations. Because of the tremendous increase in demand for all types of facial aesthetic procedures, an objective understanding of aesthetics and beauty is becoming of utmost importance. Recognition of the importance of science and evidence-based medicine is long overdue in our specialty. This study aims at identifying the most recently available evidence-based measures to quantitatively assess beauty and measure outcome of rhytidoplasty that can be useful in everyday aesthetic practice.
Background:
Patients desire face-lifting procedures primarily to appear younger, more refreshed, and attractive. Because there are few objective studies assessing the success of face-lift surgery, the authors used artificial intelligence, in the form of convolutional neural network algorithms alongside FACE-Q patient-reported outcomes, to evaluate perceived age reduction and patient satisfaction following face-lift surgery.
Methods:
Standardized preoperative and postoperative (1 year) images of 50 consecutive patients who underwent face-lift procedures (platysmaplasty, superficial musculoaponeurotic system-ectomy, cheek minimal access cranial suspension malar lift, or fat grafting) were used by four neural networks (trained to identify age based on facial features) to estimate age reduction after surgery. In addition, FACE-Q surveys were used to measure patient-reported facial aesthetic outcome. Patient satisfaction was compared to age reduction.
Results:
The neural network preoperative age accuracy score demonstrated that all four neural networks were accurate in identifying ages (mean score, 100.8). Patient self-appraisal age reduction reported a greater age reduction than neural network age reduction after a face lift (-6.7 years versus -4.3 years). FACE-Q scores demonstrated a high level of patient satisfaction for facial appearance (75.1 ± 8.1), quality of life (82.4 ± 8.3), and satisfaction with outcome (79.0 ± 6.3). Finally, there was a positive correlation between neural network age reduction and patient satisfaction.
Conclusion:
Artificial intelligence algorithms can reliably estimate the reduction in apparent age after face-lift surgery; this estimated age reduction correlates with patient satisfaction.
Clinical question/level of evidence:
Diagnostic, IV.
Facelift techniques widely vary with known individual surgeon modifications of and preference for particular techniques. This article provides an overview of the history of the superficial musculoaponeurotic system (SMAS), the changes of aging related to the soft tissues of the face, and the history of facelift procedures, including techniques to address the SMAS. In addition, a description of past studies and literature analyzing techniques of facelift procedures, safety of interventions involving the SMAS, low, extended, and high SMAS techniques, and evaluations of patient satisfaction with facelift outcomes including use of the FACE-Q are discussed. After review of the existing literature, a knowledge of the process of aging, and its effect on facial soft tissues, there is data to support SMAS flaps as a safe, effective, and logical means to handle the SMAS in facelifts. There is a paucity of the literature directly comparing differing techniques, particularly regarding SMAS flaps, leading to a challenging review but significant opportunity for additional study.
This paper presents an extensive literature review of the psychology of facelift patients as it has evolved over the past 50 years. Earlier studies revealed significant levels of pre and perioperative depression. Facelift patients generally exhibit emotional and social concerns about facial appearance that are higher than the general population. Many are undergoing midlife situational stresses and may lack the positive characteristics to deal with them. The most common diagnoses seen include depression, impulsivity, unstable personality, and passive dependence, albeit not necessarily serious. Improvement in body image is the major driver for surgery. Characteristics of female patients as defined by their age are described. These include the younger emotionally dependent group, the worker group of middle age, and the older grief group. Male patients are seen to have a higher level of psychological dysfunction, but a higher improvement in postoperative quality of life. Motivations for surgery include increasing self-esteem, making new friends, improving relationships, and getting better jobs. Overall patient satisfaction is more than 95%, with improvement seen in positive changes in their life, increased self-confidence and self-esteem, decreased self-consciousness about their appearance, and overall improvement in quality of life. Postoperative psychological reactions are seen in about half the patients, these primarily being anxiety and depression of varying degrees. Predictors of patient satisfaction include the desire for self-image improvement in contradistinction to a change in life situation. Negative predictors include male sex, young age, unrealistic expectations, relationship disturbances, and preexisting psychological pathology. The importance of good patient selection in achieving a satisfied patient is outlined and emphasized.
Introduction:
In aesthetic clinical practice surgical outcome is best measured by patient satisfaction and quality of life (QoL). For many years there has been a lack of validated questionnaires. Recently the FACE-Q was introduced and we present the largest series of facelift patients evaluated by FACE-Q with the longest follow-up to date.
Materials/methods:
200 consecutive patients were identified who underwent high SMAS facelifts, with or without additional facial rejuvenation procedures, between Jan 2005 and Jan 2015. Patients were sent eight FACE-Q scales and were asked to answer questions in regards to their satisfaction. Rank analysis of covariance was used to compare different subgroups.
Results:
38% response rate. Combination of facelift with other procedures resulted in higher satisfaction than facelift alone (p<0.05). Patients who underwent lipofilling as part of their facelift showed higher satisfaction than patients without lipofilling in three subscales(p<0.05).
Conclusion:
Facial rejuvenation surgery, combining a high SMAS facelift with lipofilling and/or other facial rejuvenation procedures resulted in a high level of patient satisfaction. The authors recommend the implementation of the FACE-Q to physicians involved in aesthetic facial surgery, to validate their clinical outcomes from a patients persepective.
Background:
The most common features of aging in the anterior neck are skin laxity and anterior platysma bands. Most techniques for neck correction fail to obtain lasting corrections of these despite promising early improvement. We have been using a major procedure to obtain the best results, combining full neck undermining with complete platysma transection and midline platysma approximation. Even using this technique we have had concerns about the long term results, and were aware of the absence of published studies of results using this technique.
Methods:
A prospective study was conducted on 150 consecutive neck lift patients operated by the same senior surgeon between 2010-2014 with the aim of evaluating patient satisfaction and recurrence rates of anterior skin laxity and platysma bands.Patients were reviewed at 3 months (138 cases) and at one year (96 cases). At both time intervals the patients completed questionnaires on level of satisfaction and eventual complaints regarding their surgical treatment, while being objectively evaluated for skin excess and the presence of recurrent bands.
Results:
At a year 76% of the patients were satisfied with the outcome using this technique, although satisfaction had been 100% at 3 months. However only 52% showed no anterior neck skin excess and 55% had no recurrence of bands a year after surgery.
Conclusions:
In spite of obtaining satisfactory results in most patients, this technique has several downsides: it is time consuming, there is the risk of iatrogenic deformities unless carried out precisely, the postoperative recovery is often very long, and there is a significant failure to maintain long term correction. After 25 years experience and with these deficiencies a reconsideration of the most appropriate procedure for correction of the anterior neck is warranted.
The primary purpose of the facelift is to restore the shape, volume, and contours of the youthful face. Facelift surgery has evolved over the years into multiple techniques to accomplish the same results. This article discusses the common controversies in facelift surgery and evaluates the best available evidence to guide surgical decision-making. In regard to the salient question of whether there is a “best” technique, the literature suggests that the options are generally equal in efficacy. This highlights the need for high-quality research with standardized preoperative assessment and evaluation of postoperative results to better assess outcomes.
Las técnicas actuales de rejuvenecimiento facial son producto de años de refinamiento técnico y la máxima expresión de la destreza del cirujano plástico moderno. El rejuvenecimiento del tercio medio facial ha retomado interés recientemente dado que permite reposicionar en bloque los tejidos de la región malar a su posición juvenil original. Como efecto agregado, atenúa el surco nasogeniano por tracción tisular secundaria. Para lograr este efecto se han descrito múltiples abordajes, planos de disección y métodos de fijación tisular. Las más recientes tendencias quirúrgicas han cambiado el objetivo de la ritidoplastia clásica de ser un procedimiento ablativo, al reposicionamiento volumétrico sin tensión. Este cambio de paradigma permite renovar la arquitectura facial propia del paciente, brindando un resultado más natural, más duradero y con menos complicaciones. Nuestro objetivo es presentar una alternativa quirúrgica para la ritidoplastia manipulando independientemente los vectores tisulares, y permitiendo el restablecimiento volumétrico tridimensional de la región malar. Esto brinda un resultado natural, juvenil y duradero sin el efecto de cara contra el viento que otras técnicas de ritidoplastia ofrecen. Nos permite además tratar la región frontal y cervical en el mismo procedimiento quirúrgico, contribuyendo a un rejuvenecimiento facial integral.
Background:
Choosing the ideal face lift technique for a patient presents an added challenge for the plastic surgeon. With the multitude of well-established variations of this procedure, it would be beneficial to define which facialplasty techniques produces the most optimal result. By comparing the postoperative results from two of the most popularized face lift incision techniques in monozygotic twins it is hypothesized that the 'best' technique may be determined.
Methods:
Four sets of identical twins and one set of identical triplets underwent face lift surgery by the senior author (D.E.A.). Incision technique selection was randomized, with the first born twin receiving the full incision operation. Short and long-term postoperative photographs were taken at approximately one and five years and subsequently graded by eight board certified plastic surgeons with over 100 years of combined experience.
Results:
Data obtained from this study suggests that no difference between these incisions exists at the shorter-term follow up. However, analysis of the long-term follow-up revealed a significant difference, between the average scores assigned to the neck region, with the full incision technique receiving a higher score.
Conclusions:
These findings suggest that at the short term follow up both the short scar and full incision techniques yield comparable results. However, at the longer term follow up a significant difference appears between the two procedures exclusively in the neck region. While a shorter incision is appealing to the patient and surgeon, this study suggests that the full incision may offer a superior long-term result in the neck.
Ageing, Corporeality and Embodiment outlines and develops an argument about the emergence of a new ageing during the second half of the twentieth century and its realisation through the processes of embodiment. The authors argue that ageing as a unitary social process and agedness as a distinct social location have lost much of their purchase on the social imagination. Instead, this work asserts that later life has become as much a field for not becoming old as of old age. The volume locates the origins of this transformation in the cultural ferment of the 1960s, when new forms of embodiment concerned with identity and the care of the self arose as mass phenomena. Over time, these new forms of embodiment have been extended, changing the traditional relationship between body, age and society by making struggles over the care of the self central to the cultures of later life.
Purpose It has been stated that patient satisfaction is the crucial factor for determining success in plastic surgery. The convergence of medical science and computer vision has made easier to satisfy patients who wants to have plastic surgery. In this paper, we try to apply 3D face modeling in plastic surgical area. Materials and Methods The author introduces a method for accurate 3D face modeling techniques using a statistical model-based 3D face modeling approach in a mirror system. Results We could successfully obtain highly accurate 3D face shape results. Conclusion The method suggested could be used for acquiring 3D face models from 2D face image and the result obtained from this could be effectively used for plastic surgical areas.
Background:
With a growing sphere of influence in the modern world, online social media serves as a readily accessible interface for communication of information. Aesthetic medicine is one of many industries increasingly influenced by social media, as evidenced by the popular website, "RealSelf," an online community founded in 2006 that compiles ratings, reviews, photographs, and expert physician commentary for nearly 300 cosmetic treatments.
Objective:
To investigate the current preferences of patients regarding cosmetic non-surgical, surgical, and dental treatments on RealSelf and in the documented medical literature.
Methods:
On a single day of data collection, all cosmetic treatments or procedures reviewed on the RealSelf website were tabulated, including name, percent "worth it" rating, total number of reviews, and average cost. Patient satisfaction rates documented in the current medical literature for each cosmetic treatment or procedure were also recorded. Statistical t-testingcomparing RealSelf ratings and satisfaction rates in the literature was performed for each category-non-surgical, surgical, and dental.
Results:
The top ten most-commonly reviewed non-surgical treatments, top ten most-commonly reviewed surgical procedures, and top 5 most-commonly reviewed dental treatments, along with documented satisfaction rates in the medical literature for each treatment or procedure were recorded in table format and ranked by RealSelf "worth it" rating. Paired t-testing revealed that satisfaction rates documented in the literature were significantly higher than RealSelf "worth it" ratings for both non-surgical cosmetic treatments (p=0.00076) and surgical cosmetic procedures (p=0.00056), with no statistically significant difference for dental treatments.
Conclusions:
For prospective patients interested in cosmetic treatments or procedures, social media sites such as RealSelf may offer information helpful to decision-making as well enable cosmetic treatment providers to build reputations and expand practices. "Worth it" ratings on RealSelf may, in fact, represent a more transparent view of cosmetic treatment or procedural outcomes relative to the high satisfaction rates documented in medical literature. Massive online communication of patient experiences made possible through social media will continue to influence the practice of medicine, both aesthetic and otherwise.
Facelifting is one of the most common operative procedures for facial aging and perhaps the procedure most synonymous with plastic surgery in the mind of the lay public, but no verifiable documentation of patient satisfaction exists in the literature. This study is the first to examine facelift outcomes and patient satisfaction using a validated questionnaire.
105 patients undergoing a facelift performed by the senior author (CHT) using a high, extended-SMAS with submental platysma approximation technique were asked to complete anonymously the FACE-Q by email. FACE-Q scores were assessed for each domain (range 0 - 100), with higher scores indicating greater satisfaction with appearance or superior quality of life.
53 patients completed the FACE-Q (50.5% response rate). Patients demonstrated high satisfaction with facial appearance (mean 80.7, SD 22.3), and quality of life, including social confidence (mean 90.4, SD 16.6), psychological well-being (mean 92.8, SD 14.3), and early life impact (mean 92.2, SD 16.4). Patients also reported extremely high satisfaction with their decision to undergo facelifting (mean 90.5, SD 15.9). On average, patients felt they looked 6.9 years younger than their actual age. Patients were most satisfied with the appearance of their nasolabial folds (mean 86.2, SD 18.5), cheeks (mean 86.1, SD 25.4), and lower face/jawline (mean 86.0, SD 20.6), compared to their necks (mean 78.1, SD 25.6) and area under the chin (mean 67.9, SD 32.3).
Patients who responded in this study were extremely satisfied with their decision to undergo facelifting and the outcomes and quality of life following the procedure.
Midfacial aging involves a complex interplay between the aging osseous skeleton, facial retaining ligaments, soft tissue envelope, facial fat compartments, and the overlying skin. The authors describe a classification of midfacial aging that can help direct the appropriate surgical technique for rejuvenation utilizing evidence based medicine. Procedures discussed include endoscopic midface lifting, autologous fat grafting, deep plane rhytidectomy, alloplastic midfacial implants, and lower blepharoplasty with fat transposition to the lid cheek junction.
Copyright © 2015 Elsevier Inc. All rights reserved.
Face-lift surgery when combined with perioral phenol-croton oil peel is an underappreciated tool for face rejuvenation. The procedure results in significant central face skin tightening and wrinkle reduction.
A retrospective review of 47 consecutive patients who underwent simultaneous face lift and perioral peel was performed. The objective measures used to evaluate the change in appearance of the patients included (1) a validated patient satisfaction questionnaire, (2) an evaluation of apparent age, and (3) an evaluation of perioral wrinkles by independent reviewers using a validated model. The assessment of apparent age was performed as follows: preoperative and postoperative photographs were shown randomly to six reviewers, who were asked to estimate the patient's age. The apparent age was compared with the patient's actual age, and the reduction in apparent age was calculated. Improvement in perioral rhytides was evaluated by using the Glogau classification system (range, 1 to 4).
Survey results documented overall patient satisfaction, which was rated as 6.5 on a scale of 1 to 7 (with higher scores indicating greater satisfaction). Patients' postoperative apparent age estimate was 8.2 years younger than their real age (p = 0.0002). The Glogau classification system score demonstrated a mean reduction of 1.15 (3.3 preoperatively as compared with 2.15 postoperatively, p < 0.0001).
Outcomes measurements, including patient satisfaction, objective evaluation of wrinkle improvement, and significant reduction in apparent age, document the power of this technique.
Therapeutic, IV.
Objective:
To aid the aesthetic surgeon in midface analysis and selection of treatment plans offering the greatest likelihood of success in midface rejuvenation.
Methods:
We performed a retrospective review of all patients who underwent surgical midface rejuvenation by a single surgeon. We recorded demographics, history, procedures, outcomes, and complications. Results of physical examination and photography were used to classify patients by volume loss, midface ptosis, skin elasticity, and skeletal anatomy. Outcome was determined by patient satisfaction at the 12-month follow-up; unsatisfactory results were further analyzed by a blinded independent expert with more than 15 years' experience.
Results:
We included 150 patients. Mean patient age was 51 years; 93.3% were women, and 20.7% had undergone previous procedures, including malar implants, autologous fat grafting, rhytidectomy, midface-lift, and extended lower blepharoplasty. Multimodality treatment was used in 34.0%. Patient dissatisfaction was encountered in 14.0% of cases; the expert concurred in each case. Autologous fat grafting alone demonstrated the greatest propensity for dissatisfaction (4 of 12 cases [33%]). Rate of dissatisfaction was significantly higher with malar hypoplasia (41% vs 7%; P < .001) or loss of elasticity (16% vs 3%; P = .01) but was not highly correlated with age (r = 0.15).
Conclusions:
Successful midface rejuvenation requires accurate diagnosis and avoidance of anatomic pitfalls. Many patients require multimodality therapy, including lifting and volumizing techniques. Unsatisfactory results are most common when midfacial aging is accompanied by skeletal insufficiency or loss of elasticity. Respective consideration of these defects should be given to placement of malar implants and rhytidectomy approaches targeting the midface.
Background
A wide variety of surveys have been used to validate the satisfaction of patients who underwent aesthetic surgery. However, such studies are often limited by patient number and number of surgeons. Social media now allows patients, on a large scale, to discuss and rate their satisfaction with procedures. The views of aesthetic procedures patients expressed in social media provide unique insight into patient satisfaction.
Methods
The “worth it” percentage, average cost, and number of respondents were recorded on October 16, 2011, for all topics evaluated on the aesthetic procedure social media site www. realself. com. Procedures were divided into categories: surgical, liposuction, nonsurgical, and dental. For each group, procedures with the most respondents were chosen and ordered by “worth it” score. A literature search was performed for the most commonly rated surgical procedures and the satisfaction rates were compared.
Results
A total of 16,949 evaluations of 159 aesthetic surgery topics were recorded. A correlation between cost of the procedure and percentage of respondents indicating that the procedure was “worth it” was not found. The highest-rated surgical procedure was abdominoplasty, with 93 % of the 1,589 self-selected respondents expressing that abdominoplasty was “worth it.” The average self-reported cost was 200. The satisfaction scores in the literature for commonly rated surgical procedures ranged from 62 to 97.6 %. No statistically significant correlations between literature satisfaction scores and realself.com “worth it” scores were found.
Conclusions
Abdominoplasty had the highest “worth it” rating among aesthetic surgical procedures. Aesthetic surgeons should be wary that satisfaction scores reported in the literature might not correlate with commonly achieved results. Social media has opened a new door into how procedures are evaluated and perceived.
Level of Evidence III
This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the table of contents or the online instructions to authors www. springer. com/ 00266.
Purpose of review To evaluate the current evidence-based medicine for rhytidectomy. Specific techniques and their scientific rationale are explored. The authors' practice modifications based on this evidence will be reviewed. Recent findings The utilities of short scar facelift techniques are validated. Specific indications for the deep plane technique are also discussed. Summary The reader will understand the rationale for choosing specific rhytidectomy techniques for young patients, older patients and specific anatomic findings.
Surgical facial rejuvenation (face lift) remains the aesthetic standard for correction of the anatomical changes of the aging face and for long-lasting results. However, younger patients (younger than 50 years) with early facial aging are often fearful of or discouraged from face-lift surgery in favor of simpler yet short-lived nonsurgical and surgical options. The superficial musculoaponeurotic system-platysma face lift is associated with a high degree of patient satisfaction at 1 year (97.8 percent) and at 12.6 years (68.5 percent). When the satisfaction scores were subdivided into three age groups (younger than 50, 50 to 60, and older than 60 years), the authors found greater satisfaction among the younger age group at the early and long-term intervals. To illustrate these observations, the authors analyzed the photographic results of their survey patients and compared them with their survey results.
The photographic results of the patients from our Owsley Facelift Satisfaction Survey were analyzed and stratified into the three age groups. Six patients (two per age group) were included for analysis and are presented for review.
Patient-rated survey results show that the younger age group consistently scored higher positive ratings, longer lasting aesthetic improvement of their five main anatomical areas of correction, and greater overall satisfaction at long-term follow-up.
Younger patients with early or minimal signs of facial aging should be considered candidates for surgical facial rejuvenation ("maintenance face lifts") and are the preferred candidates. This age group of patients has consistently positive overall satisfaction with longer lasting facial aesthetic correction.
Therapeutic, III.
Maintaining projection and achieving patient satisfaction are two key challenges in nipple reconstruction. Skin flap techniques such as CV and star flaps are currently favoured. The "Hamburger" technique was described in 2007 using stacked conchal cartilage discs within a skin flap construct, but no longer-term outcomes have been published. We evaluate both projection and patient satisfaction following nipple reconstruction using this technique. Twenty-three nipple reconstructions performed between 2007 and 2009 were reviewed. A standard pre-tattooed cylinder skin pattern was used with 3 punch biopsies of conchal cartilage harvested through a post-auricular incision. At follow up, reconstructed nipples and donor sites were examined. Nipple projection was measured bilaterally. Patients completed a short questionnaire. Mean follow up was 24 months (9-31). Mean projection was 3.3 mm (range 0-5 mm) and was well matched to the contralateral nipple. No donor site keloid scarring was observed, however cartilage defects were easily palpable in all cases. Patients were satisfied or very satisfied with overall cosmesis in 91% of cases. They were satisfied or very satisfied with projection in 57% of cases. All patients found the donor site acceptable. With the "hamburger" technique medium-term projection was maintained in most cases and was comparable to published data for other techniques with or without cartilage. Patient satisfaction was high even when projection was not well maintained. This suggests that patient satisfaction and projection are not necessarily related. Donor site morbidity was low.
The ideal face lift has the longest efficacy, the fewest complications, and ultimately, the highest patient satisfaction. With so many different techniques, there exists a need to make this comparison and to establish which approaches may work best in various groups. To date, there has been no systematic review to study the efficacy and complication rates among different face-lift techniques. This study aims to make this comparison.
A systematic search of the English language literature listed in the MEDLINE (Ovid MEDLINE 1950 to November of 2009 with Daily Update), PubMed, and Cochrane Central Register of Controlled Trials (CENTRAL) databases yielded trials on comparison of different face-lift techniques in their efficacy and complication rates. All relevant articles' reference sections were studied for additional relevant publications.
The keyword search yielded 39 articles. Eighteen more articles were retrieved from reference sections of relevant articles. Only 10 articles made a direct comparison of efficacy between face-lift techniques, and only five articles made a direct comparison of complications between face-lift techniques.
Although this systematic review revealed a lack of quality data in comparing the efficacy and safety among different face-lift techniques, it is important to review and pool the existing studies to improve patient outcomes. This analysis has also shown the need for better studies, especially randomized, prospective, controlled studies, and a need for a standardized method of efficacy analysis and patient-reported outcomes measures to allow objective comparison of face-lift techniques.
This prospective study assessed outcomes in patients undergoing a deep-plane face lift and other simultaneous facial cosmetic procedures. It is the first prospective outcome study to assess and compare these patients and provide data on patient satisfaction and quality of life—the most important determinants of surgical success.
From 2002 to 2007, in-person interviews were conducted with 93 patients who attended a follow-up appointment at least 1 month after surgery from a total of 122 consecutive patients treated with a deep-plane face lift and other facial rejuvenation procedures (response rate, 76 percent). Questions were asked in six categories: patient data, indications, recovery, results, complications, and psychological effects. Responses were analyzed in four groups: face lift alone; face lift and blepharoplasties; face lift and forehead lift; and face lift, blepharoplasties, and endoscopic forehead lift.
The average subjective reduction in apparent age was 11.9 years (range, 0 to 27.5 years). Seventy-seven patients (82.8 percent) reported an improvement in self-esteem, and 64 patients (69.6 percent) reported an improved quality of life. There was no significant correlation between result rating and procedure groups, age, gender, smoking history, previous face lift, body mass index, or the occurrence of a complication.
Despite a significant recovery period, patient satisfaction was high, with 96.7 percent of patients reporting a more youthful appearance after surgery. Scar dissatisfaction was rare (2.2 percent). With proper patient preparation and education, facial rejuvenation effectively meets patient expectations. These findings support the recommendation of surgical facial rejuvenation to patients who wish to look younger.
Measuring patient-reported outcomes has become increasingly important in cosmetic and reconstructive breast surgery. The objective of this study was to develop a new patient-reported outcome measure to assess the unique outcomes of breast surgery patients.
Patient interviews, focus groups, expert panels, and a literature review were used to develop a conceptual framework and a list of questionnaire items. Three procedure-specific questionnaires (augmentation, reduction, and reconstruction) were developed and cognitive debriefing interviews used to pilot each questionnaire. Revised questionnaires were field tested with 1950 women at five centers in the United States and Canada (response rate, 72 percent); 491 patients also completed a test-retest questionnaire. Rasch measurement methods were used to construct scales, and traditional psychometric analyses, following currently recommended procedures and criteria, were performed to allow for comparison with existing measures.
The conceptual framework included six domains: satisfaction with breasts, overall outcome, and process of care, and psychosocial, physical, and sexual well-being. Independent scales were constructed for these domains. This new patient-reported outcome measure "system" (the BREAST-Q) contains three modules (augmentation, reconstruction, and reduction), each with a preoperative and postoperative version. Each scale fulfilled Rasch and traditional psychometric criteria (including person separation index 0.76 to 0.95; Cronbach's alpha 0.81 to 0.96; and test-retest reproducibility 0.73 to 0.96).
The BREAST-Q can be used to study the impact and effectiveness of breast surgery from the patient's perspective. By quantifying satisfaction and important aspects of health-related quality of life, the BREAST-Q has the potential to support advocacy, quality metrics, and an evidence-based approach to surgical practice.
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.
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.
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 alpha), and responsiveness to change was statistically significant for each instrument tested (P< or =.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.
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.
This article reviews the technique of SMAS-platysma face lift. The deep layer lift with the SMAS-platysma myocutaneous flap of the anterior neck and lower face facilitates correction of submental deformities without the necessity of direct approach with a submental incision. Wide superficial undermining of the upper and mid-cheek skin which is pulled laterally for correction of the nasolabial fold achieves a bidirectional facelift.
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 α), 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.
Expander/implant and autogenous tissue breast reconstructions have different aging processes, and the time when these processes stabilize is unclear. The authors' goal was to evaluate long-term patient-reported aesthetic satisfaction with expander/implant and autogenous breast reconstruction.
The authors surveyed a cross-section of University of Michigan women who underwent postmastectomy breast reconstruction (response rate, 73 percent) between 1988 and 2006 [110 expander/implant and 109 transverse rectus abdominis myocutaneous (TRAM) reconstructions]. Each group was stratified into three postreconstructive periods: short term (<or=5 years), intermediate (6 to 8 years), and long term (>8 years). Validated satisfaction items were scored on a 5-point Likert scale; scores were dichotomized into positive and negative responses. Logistic regression assessed satisfaction by procedure, while controlling for sociodemographic and clinical variables.
Mean follow-up time after reconstruction was 6.5 years (range, 1 to 18 years). Procedure type had no effect on short-term aesthetic satisfaction. However, in the long term, reconstruction type considerably affected satisfaction. Although satisfaction with TRAM reconstruction remained relatively constant, satisfaction with expander/implants was significantly less among those patients in the long term. Patients who had undergone implant reconstruction more than 8 years earlier, compared with those who undergone implant reconstruction less than 5 years earlier, were significantly less satisfied with breast appearance (odds ratio, 0.10; 95% CI, 0.02 to 0.48), softness (odds ratio, 0.14; 95% CI, 0.03 to 0.64), and size (odds ratio, 0.13; 95% CI, 0.03 to 0.62).
In the long term, TRAM patients, compared with expander/implant patients, appear to have significantly greater aesthetic satisfaction. These long-term data have important implications for women's health in the survivorship period and will help women navigate the complex decision-making process of breast reconstruction.
Patient satisfaction and improved quality of life are the predominant considerations determining success in cosmetic surgery. However, few studies have examined patients' perceptions of their appearance following cosmetic facial surgery and/or nonsurgical facial rejuvenation. This study identified patient-reported outcome measures developed and validated for use in patients undergoing surgical and/or nonsurgical cosmetic procedures.
A systematic review of the English-language literature was performed. Patient-reported outcome measures designed to assess patient satisfaction and/or quality of life following surgical and/or nonsurgical cosmetic procedures were identified. Qualifying instruments were assessed for content and adherence to international guidelines for development and validation.
From 442 articles, 47 patient-reported outcome measures assessing facial appearance after a cosmetic procedure were identified. Only nine questionnaires satisfied inclusion and exclusion criteria. These measures were subdivided into the following categories: rhinoplasty (Rhinoplasty Outcomes Evaluation, Glasgow Benefit Inventory, Facial Appearance Sorting Test), skin rejuvenation (Facial Lines Treatment Satisfaction Questionnaire, Skin Rejuvenation Outcomes Evaluation, Facial Lines Outcomes Questionnaire), face lift (Facelift Outcomes Evaluation), blepharoplasty (Rhinoplasty Outcomes Evaluation), and general appearance (Derriford Appearance Scale 59). None of these measures satisfied all guidelines. All measures were limited by either their development, their validation, or their content.
Valid, reliable, and responsive instruments designed to measure patient-reported outcomes following surgical and nonsurgical facial rejuvenation are lacking. A patient-reported outcome measure that represents perceptions of facial cosmetic surgery patients and satisfies accepted health measurement criteria is needed. It would facilitate comparison of techniques and quantification of positive effects, and aid surgeons seeking to quantify outcomes in their own practices.
The technique of platysma-fascial rhytidectomy is based upon the anatomy of the platysma muscle and the superficial facial fascia. The operative procedure is described in detail, and the advantages and disadvantages of this method are listed.
The technique of SMAS-platysma facelift has been reviewed. The deep layer lift with the SMAS-platysma myocutaneous flap of the anterior neck and lower face facilitates correction of submental deformities without the necessity of direct approach with a submental incision. Wide superficial undermining of the upper and mid-cheek skin which is pulled laterally for correction of the nasolabial fold achieves a bidirectional facelift. The author's experience over six years with 460 patients who had a SMAS-platysma facelift indicates that the operation can be performed safely with a low incidence of complications.
The anatomic presence of a discrete malar fat pad has not been widely recognized. In his paper on the "deep plane rhytidectomy," Hamra describes the increased thickness of the subcutaneous fat over the anterior midface. Cadaver and clinical studies confirm the consistent presence of a localized subcutaneous malar fat pad overlying the body of the zygoma and maxilla. Downward displacement of the infraorbital skin and underlying malar fat pad causes an increased prominence of the nasolabial fold. The surgical dissection of the malar fat pad starts from the malar eminence at the plane of the orbicularis oculi muscle and superficial to the origin of the zygomaticus and levator muscles, which are invested by the SMAS. There is an easily dissected plane deep to the fat pad that extends to the nasolabial crease. Surgical correction of the prominent nasolabial fold is enhanced by undermining the malar fat pad and advancing it laterally by traction on the skin flap with additional upward fixation by sutures between the lateral edge of the fat pad and the subcutaneous fascia at the lateral malar eminence.
The malar fat pad suspension technique is a safe and effective method for rejuvenation of the aging midface. When combined with the SMAS-platysma rotation flap face-lift as a multi-vector technique, most of the changes that occur with aging are addressed and corrected in an anatomic fashion, resulting in an aesthetically pleasing result. Careful attention to the tension and position of the suspension suture enhances the improvement of the infraorbital flattening as well as correcting the excessive prominence of the nasolabial fold.
The superficial musculoaponeurotic system (SMAS) platysma rotation flap with platysmal transection from the deep surface has been the author's face-lift technique to correct jowls, submental laxity, and platysma bands since 1982. An outcome study of 10 consecutive face-lift operations is presented to demonstrate the efficacy of correction of lower face and neck aging and the duration of the improvement. Reappearance of platysma bands has been the earliest and most frequent sign of recurrent aging changes. A technique for directly dealing with platysma bands in the submental and cervicomental location is described, and follow-up results up to 3 years are shown. (Plast. Reconstr. Surg. 105: 302, 2000.) (C)2000American Society of Plastic Surgeons
The superficial musculoaponeurotic system (SMAS) platysma rotation flap with platysmal transection from the deep surface has been the author's face-lift technique to correct jowls, submental laxity, and platysma bands since 1982. An outcome study of 10 consecutive face-lift operations is presented to demonstrate the efficacy of correction of lower face and neck aging and the duration of the improvement. Reappearance of platysma bands has been the earliest and most frequent sign of recurrent aging changes. A technique for directly dealing with platysma bands in the submental and cervicomental location is described, and follow-up results up to 3 years are shown.
Outcomes research is a fast-growing field of study that focuses on patient-related aspects of medical or surgical outcomes such as satisfaction and quality of life. In the realm of facial plastic surgery, many outcomes are subjective evaluations based on the patient and physician's judgment as to the surgical result, but little has been done to quantify these qualitative results in an objective manner. This paper discusses the basis for outcomes research and suggests its application to the field of facial plastic surgery. Four new facial plastic outcomes instruments have been developed and are provided for the potential use in measuring the quality of life results of rhytidectomy, rhinoplasty, blepharoplasty, and skin rejuvenation procedures.
Most of the advances of the past decade in face lift technique have been directed to correcting the aging changes of the midface. With many midface lift techniques, patients typically experienced a prolonged period of periorbital ecchymosis and edema. Pessa's description of the anatomy of the malar septum has led to modifications of the senior author's (J.Q.O.) malar fat pad lift technique, designed to minimize postoperative ecchymosis and edema following mobilization of the malar fat pad. Preoperatively, markings of the cutaneous insertion of the malar septum are placed at the infraorbital location. This line approximates the caudal margin of the musculus orbicularis oculi. Dissection under the malar fat pad is performed sharply under direct visualization. Care is taken to stay caudal to the malar septum insertion as marked on the skin. Refinements in the dissection of the midface malar fat pad have not altered the effective repositioning achieved. By leaving the malar septum intact, the amount of postoperative edema and ecchymosis is less than formerly associated with the dissection over the infraorbital orbicularis. With rare exception, patients were able to resume their usual activities and employment after a recovery period of 10 to 21 days postoperatively.
Outcomes research examines the end results of medical interventions, taking into account patients' experiences, preferences, and values. The purpose of assessing outcomes is to provide evidence on which to base clinical decisions. The assessment of outcomes in aesthetic surgery is especially pertinent because patient satisfaction is the predominant factor in determining success. In cosmetic surgery, various scales have been used to assess outcomes. Unfortunately, none of these methods has achieved widespread use. The adoption of broadly accepted, relevant scales to measure outcomes would be advantageous, because this would allow the comparison of techniques, quantification of positive effects, and identification of patients unlikely to benefit from surgery. The purpose of this study was to critically review the present literature to identify the appropriate instruments to assess outcomes in aesthetic surgery. After a comprehensive review of aesthetic surgery outcome instruments, the authors identified body-image and quality-of-life measures to be of the greatest value in determining aesthetic surgery outcomes. These conclusions were based on a critical evaluation of the feasibility, validity, reliability, and sensitivity to change of these measures. The Multidimensional Body-States Relations Questionnaire (MBSRQ), a psychological assessment of body image, was selected as a potential candidate for further study. Two additional body-image assessment instruments, the Facial Appearance Sorting Test (FAST) and the Breast Chest Ratings Scale (BCRS), may be useful in the assessment of rhinoplasty and breast surgery, respectively. The Derriford Scale (DAS59), an instrument that assesses appearance-related quality of life, was also selected. In addition, the authors recommend the use of a generic, utility-based quality-of-life instrument, such as the Health Utilities Index (HUI) or the EuroQol (EQ-5D).
Controversy exists as to whether the changes of midface aging (elongation of the lower eyelid caused by infraorbital hollowing, flattening of the malar eminence, and increased prominence of the nasolabial fold) are attributable to gravitational migration of the check fat or to fat atrophy.
The anatomical explanation of the gravitational migration of the malar fat pad is based on previously reported magnetic resonance imaging studies of the midface cheek fat in young and older subjects and histologic studies of the superficial fascia in face-lift patients.
Clinical and laboratory observation of the midface malar fat pad suggests that, during repeated movements of animation, levator muscle contraction and shortening produces tissue expansion pressures within the overlying cheek fat pad that cause the acutely prominent nasolabial fold of animation.
Over time, chronic recurrent tissue expansion of the skin of the lower anterior cheek combined with stretching of the supporting intrafat pad fascial septa results in downward migration of the malar fat pad, causing infraorbital flattening and permanent prominence of the nasolabial fold. Although not the primary cause of facial aging changes, fat atrophy may contribute secondarily in those individuals whose faces become thinner as they age.
Measuring outcomesinaestheticsurgery:Acomprehensivereviewofthe literature
- S Ching
- A Thoma
- Re Mccabe
- Antony
Ching S, Thoma A, McCabe RE, Antony MM. Measuring outcomesinaestheticsurgery:Acomprehensivereviewofthe literature. Plast Reconstr Surg. 2003;111:469–480