Jonathan A. Schwitzer

Development and Psychometric Evaluation of the FACE-Q Scales for Patients Undergoing Rhinoplasty

IMPORTANCE Rhinoplasty continues to rank among the most popular cosmetic surgical treatments. Measuring what the nose looks like has typically involved the use of observer-reported or physician-reported outcome measures (eg, photographs). While objective outcomes are important, facial appearance is subjective, and asking patients what they think about the appearance of their nose is of paramount importance. The patient perspective can be measured using patient-reported outcome instruments. OBJECTIVE To describe the development and psychometric evaluation of the FACE-Q scales and adverse effects checklist designed to measure rhinoplasty outcomes. DESIGN, SETTING, AND PARTICIPANTS A questionnaire was completed by patients recruited between July 13, 2010, and March 1, 2015. Psychometric methods were used to select the most clinically sensitive items for inclusion in item-reduced scales as well as to examine reliability, validity, and ability to detect clinical change. The setting was plastic surgery clinics in the United States, England, and Canada. Participants were preoperative and postoperative patients 18 years or older undergoing rhinoplasty. MAIN OUTCOMES AND MEASURES Responses and validation measures of the FACE-Q scales and adverse effects checklist. RESULTS In total, 158 of 169 patients invited to participate in the study were enrolled (response rate, 93.5%). The most common adverse effect was the skin of the nose looking thick or swollen. Rasch measurement theory analysis led to the refinement of a 10-item Satisfaction With Nose Scale and a 5-item Satisfaction With Nostrils Scale. The person separation index and Cronbach α were 0.91 and 0.96, respectively, for the Satisfaction With Nose Scale and 0.89 and 0.96, respectively, for the Satisfaction With Nostrils Scale. All items had ordered thresholds and good item fit. Satisfaction with the nose and nostrils was incrementally lower in participants bothered by specific adverse effects (eg, the skin of the nose looking thick or swollen). Patient satisfaction on the Satisfaction With Nose Scale and the Satisfaction With Nostrils Scale and on 3 additional FACE-Q scales (ie, Satisfaction With Facial Appearance Scale, Psychological Function Scale, and Social Function Scale) was higher after surgery than before surgery (P < .001 for all, independent samples t test). Twenty-three participants who provided preoperative and postoperative data reported improvement on all 5 scales (P ≤ .003 for all). The effect sizes ranged from 0.6 to 2.3. Significant individual-level change was reported by most participants for the Satisfaction With Nose Scale, Satisfaction With Nostrils Scale, Satisfaction With Facial Appearance Scale, and Social Function Scale. CONCLUSIONS AND RELEVANCE A FACE-Q scales rhinoplasty module can be used in clinical practice, research, and quality improvement to incorporate the patient perspective in outcome assessments. LEVEL OF EVIDENCE NA.

FACE-Q scales for health-related quality of life, early life impact, satisfaction with outcomes, and decision to have treatment: development and validation.

Background: An ever-growing range of facial cosmetic products and treatments are available, but little clinical research is being performed to determine treatment outcomes from the patient’s perspective. The FACE-Q is a patient-reported outcome instrument composed of more than 40 independently functioning scales and checklists. The aim of this article is to describe the development and psychometric evaluation of five new FACE-Q scales. Methods: FACE-Q scales were developed according to international guidelines for patient-reported outcome instrument development. The following FACE-Q scales and a single symptom checklist (Recovery Early Symptoms) were evaluated in this study: Psychological Wellbeing, Social Function, Satisfaction with Decision to Have Treatment, Satisfaction with Outcome of Treatment, and Early Life Impact of Treatment. Modern and traditional psychometric methods were used to examine reliability, validity, and responsiveness. Results: The sample included 702 participants from three studies. The FACE-Q scales were found to be reliable, valid, and responsive to clinical change. These findings were supported by Rasch measurement theory (e.g., overall chi-square values, p ≥ 0.06; Person Separation Index ≥0.81), traditional psychometric (e.g., Cronbach alpha values ≥0.90) and responsiveness (i.e., significant improvement following face lift and lip treatment) analysis. Conclusions: The FACE-Q measures concepts and symptoms important to facial aesthetic patients. The five scales and single symptom checklist described here can be used to measure what patients think about cosmetic treatments in a scientifically sound manner. As the cosmetics industry continues to expand, the patient perspective of treatment outcomes should be measured and reported. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Assessing Patient-Reported Satisfaction with Appearance and Quality of Life following Rhinoplasty Using the FACE-Q Appraisal Scales.

Background: Patient satisfaction with appearance and improved quality of life are primary outcomes in cosmetic surgery. The purpose of this study was to assess changes in patient satisfaction with facial and nose appearance, and quality of life following rhinoplasty. Methods: Patients presenting for rhinoplasty completed the FACE-Q, a new patient-reported outcome instrument composed of scales that measure outcomes in patients undergoing facial cosmetic procedures. The following FACE-Q scales were used: satisfaction with facial appearance overall, satisfaction with nose, psychological well-being, and social function. Results: Fifty-six patients completed the FACE-Q at the time of their preoperative consultation and/or at postoperative follow-up visits. Among all patients presenting for rhinoplasty, FACE-Q scores (range, 0 to 100) increased following the procedure in satisfaction with facial appearance (+26.5; p < 0.01), psychological well-being (+15.7; p < 0.01), and social function (+13.7; p = 0.03). Satisfaction with nose item scores (range, 1 to 4) all increased significantly from before to after rhinoplasty, including in satisfaction with nose appearance in the mirror (+1.4; p < 0.01), size (+1.1; p < 0.01), shape (+1.5; p < 0.01), profile (+1.6; p < 0.01), and in photographs (+1.6; p < 0.01). Similar results were seen among a subgroup of patients who completed the FACE-Q scales both before and after rhinoplasty. Conclusions: In an objective study using a validated patient-reported outcome instrument, improvements in satisfaction with facial and nose appearance and quality of life were demonstrated among rhinoplasty patients. This model supports the successful outcomes possible in rhinoplasty. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

FACE-Q eye module for measuring patient-reported outcomes following cosmetic eye treatments

Importance Aesthetic eye treatments can dramatically change a person’s appearance, but outcomes are rarely measured from the patient perspective. The patient perspective could be measured using an eye-specific patient-reported outcome measure. Objective To describe the development and psychometric evaluation of FACE-Q scales and an adverse effect checklist designed to measure outcomes following cosmetic eye treatments. Design, Setting, and Participants Pretreatment and posttreatment patients 18 years and older who had undergone facial aesthetic procedures were recruited from plastic surgery clinics in United States and Canada and completed FACE-Q scales between June 6, 2010, and July 14, 2014. We used Rasch Measurement Theory, a modern psychometric approach, to refine the scales and to examine psychometric properties. Main Outcomes and Measures The FACE-Q Eye Module, which has 4 scales that measure appearance of the eyes, upper and lower eyelids, and eyelashes. Scale scores range from 0 (worst) to 100 (best). The module also includes a checklist measuring postblepharoplasty adverse effects. Results Overall, 233 patients (81% response rate) 18 years and older participated. Adverse effects included being bothered by eyelid scars, dry eyes, and eye irritation. In Rasch Measurement Theory analysis, each scale’s items had ordered thresholds and good item fit. Person Separation Index and Cronbach &agr; were greater than or equal to 0.83. Higher scores on the eye scales correlated with fewer adverse effects (range, −0.26 to −0.36). In the pretreatment group, older age correlated with lower scores (range, −0.42 to −0.51) on the scales measure appearance of the eyes and upper and lower eyelids. Compared with the pretreatment group, posttreatment participants reported significantly better scores on the scales measuring appearance of eyes overall, as well as upper and lower eyelids. Conclusions and Relevance The FACE-Q Eye Module can be used in clinical practice, research and quality improvement to collect evidence-based outcomes data. Level of Evidence NA.

Face-Lift Satisfaction Using the FACE-Q.

Background: Face lifting is one of the most common operative procedures for facial aging and perhaps the procedure most synonymous with plastic surgery in the minds of the lay public, but no verifiable documentation of patient satisfaction exists in the literature. This study is the first to examine face-lift outcomes and patient satisfaction using a validated questionnaire. Methods: One hundred five patients undergoing a face lift performed by the senior author (C.H.T.) using a high, extended–superficial musculoaponeurotic system with submental platysma approximation technique were asked to complete anonymously the FACE-Q by e-mail. FACE-Q scores were assessed for each domain (range, 0 to 100), with higher scores indicating greater satisfaction with appearance or superior quality of life. Results: Fifty-three patients completed the FACE-Q (50.5 percent response rate). Patients demonstrated high satisfaction with facial appearance (mean ± SD, 80.7 ± 22.3), and quality of life, including social confidence (90.4 ± 16.6), psychological well-being (92.8 ± 14.3), and early life impact (92.2 ± 16.4). Patients also reported extremely high satisfaction with their decision to undergo face lifting (90.5 ± 15.9). On average, patients felt they appeared 6.9 years younger than their actual age. Patients were most satisfied with the appearance of their nasolabial folds (86.2 ± 18.5), cheeks (86.1 ± 25.4), and lower face/jawline (86.0 ± 20.6), compared with their necks (78.1 ± 25.6) and area under the chin (67.9 ± 32.3). Conclusion: Patients who responded in this study were extremely satisfied with their decision to undergo face lifting and the outcomes and quality of life following the procedure.

Assessing Demographic Differences in Patient-Perceived Improvement in Facial Appearance and Quality of Life Following Rhinoplasty

BACKGROUND As rhinoplasty patient demographics evolve, surgeons must consider the impact of demographics on patient satisfaction. OBJECTIVES The objective of this study was to identify independent demographic predictors of differences in satisfaction with appearance and quality of life following rhinoplasty utilizing the FACE-Q patient-reported outcome instrument. METHODS Patients presenting for rhinoplasty completed the following FACE-Q scales: Satisfaction with Facial Appearance, Satisfaction with Nose, Social Function, and Psychological Well-being. Higher FACE-Q scores indicate greater satisfaction with appearance or superior quality of life. Pre- and post-treatment scores were compared in the context of patient demographics. RESULTS The scales were completed by 59 patients. Women demonstrated statistically significant improvements in Satisfaction with Facial Appearance and quality of life while men only experienced significant improvement in Satisfaction with Facial appearance. Caucasians demonstrated statistically significant improvement in Satisfaction with Facial Appearance and quality of life while non-Caucasians did not. Patients younger than 35 years old were more likely to experience enhanced Satisfaction with Facial Appearance and quality of life compared with patients older than 35 years old. Patients with income ≥

Satisfaction following Unilateral Breast Reconstruction: A Comparison of Pedicled TRAM and Free Abdominal Flaps

100,000 were more likely to experience significant increases in Satisfaction with Facial Appearance and quality of life than patients with incomes <

Facelift Satisfaction Using the FACE-Q.

100,000. CONCLUSIONS In an objective study using a validated patient-reported outcome instrument, the authors were able to quantify differences in the clinically meaningful change in perception of appearance and quality of life that rhinoplasty patients gain based on demographic variables. The authors also demonstrated that these variables are potential predictors of differences in satisfaction.

Measuring Satisfaction with Appearance: Validation of the FACE-Q Scales for the Nose, Forehead, Cheekbones, and Chin.

Background: The purpose of this study was to compare patient satisfaction following unilateral pedicled transverse rectus abdominis myocutaneous (TRAM) and free abdominal flap reconstruction. Methods: Patients who underwent unilateral breast reconstruction using pedicled TRAM or free abdominal flaps (muscle-sparing TRAM or deep inferior epigastric perforator flap) and completed the BREAST-Q were identified from 2 prospectively maintained databases. BREAST-Q scores were assessed and compared for Satisfaction with Breasts, Outcome, and Physical Well-being Chest/Abdomen. Results: Of the 138 patients who completed the BREAST-Q, 84 underwent pedicled TRAM flap reconstruction and 54 underwent free abdominal flap reconstruction. Overall, pedicled TRAM flap patients scored higher than free abdominal flap patients on all 4 BREAST-Q scales. This difference reached statistical significance in Satisfaction with Breasts (+7.74; P = 0.02). Similar results were found among patients who completed the BREAST-Q at <3 years postoperation. However, among patients at ≥3 years postoperation, there were no statistically significant differences between the 2 groups, with the pedicled flap cohort scoring higher in Satisfaction with Breasts and Physical Well-being Chest and the free abdominal flap cohort scoring higher in Satisfaction with Outcome and Physical Well-being Abdomen scores. Conclusions: Patients who underwent unilateral pedicled TRAM flap reconstruction experienced greater initial breast satisfaction than patients who underwent unilateral free abdominal flap reconstruction, but satisfaction equalized between the two over time, suggesting that long-term satisfaction may be equivalent between the 2 methods of reconstruction.

Assessing Patient-Reported Outcomes Following Orthognathic Surgery and Osseous Genioplasty.

RESULTS: 53 patients completed the FACE-Q (50.5% response rate). Patients demonstrated high satisfaction with facial appearance (mean 80.7, SD 22.3), as well as enhanced 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 the decision to undergo facelifting (mean 90.5, SD 15.9). On average, patients felt they looked 6.9 years younger than their actual age. Regarding specific appearance appraisal, 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 satisfaction with the appearance of their necks (mean 78.1, SD 25.6) and area under the chin (mean 67.9, SD 32.3) (Table 1). Table 1. FACE-Q Scores.