Rainer Pooth

Validated Assessment Scales for the Lower Face

Background Aging in the lower face leads to lines, wrinkles, depression of the corners of the mouth, and changes in lip volume and lip shape, with increased sagging of the skin of the jawline. Refined, easy‐to‐use, validated, objective standards assessing the severity of these changes are required in clinical research and practice. Objective To establish the reliability of eight lower face scales assessing nasolabial folds, marionette lines, upper and lower lip fullness, lip wrinkles (at rest and dynamic), the oral commissure and jawline, aesthetic areas, and the lower face unit. Methods and Materials Four 5‐point rating scales were developed to objectively assess upper and lower lip wrinkles, oral commissures, and the jawline. Twelve experts rated identical lower face photographs of 50 subjects in two separate rating cycles using eight 5‐point scales. Inter‐ and intrarater reliability of responses was assessed. Results Interrater reliability was substantial or almost perfect for all lower face scales, aesthetic areas, and the lower face unit. Intrarater reliability was high for all scales, areas and the lower face unit. Conclusion Our rating scales are reliable tools for valid and reproducible assessment of the aging process in lower face areas.

A validated lip fullness grading scale.

OBJECTIVES To develop the Lip Fullness Grading Scale for objective quantification of lip volume for a reliable assessment and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify fullness of upper and lower lip separately. Nine experts rated photographs of 35 subjects, twice, separately for upper and lower lip. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS Agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the fullness of the upper and lower lip for which patients commonly seek correction. This scale is well stratified, with low intra- and interrater variability.

A validated grading scale for crow's feet.

OBJECTIVE To develop the Crows Feet Grading Scale for objective quantification of the severity of lateral canthal lines and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of lateral canthal lines at rest and at maximum contracture of the orbicularis oculi. Nine experts rated photographs of 35 subjects, twice, with regard to the aspect crows feet in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was significantly high. Furthermore, the test–retest correlation coefficients were high for each expert after an overnight interval, demonstrating low inter- and intraevaluator variability. CONCLUSION The 5-point photonumeric scale generated spans the severity of the type of crows feet for which patients most commonly seek correction. The scale is well stratified for consistent rating.

A validated grading scale for forehead lines.

BACKGROUND As with other facial wrinkles, the gradual loss and disorganization of collagen fibers and elastin, connective tissues that provide underlying support for skin, cause horizontal forehead rhytides in large part. OBJECTIVES To develop the Forehead Lines Grading Scale for objective quantification of horizontal forehead rhytides at rest and with expression and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS The Forehead Lines Grading Scale is a 5-point photonumeric rating scale that was developed to objectively quantify resting (static) and hyperkinetic (dynamic) forehead lines. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was highly significant. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of forehead lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

A Validated Grading Scale for Marionette Lines

BACKGROUND Melomental folds, or marionette lines, are one of the consequences of facial aging. The curvilinear wrinkles formed because of facial movements and the aging process extend downward from the oral commissures. OBJECTIVES To develop the Marionette Lines Grading Scale for objective quantification of the severity of melomental folds and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of melomental folds. Nine experts rated photographs of 35 subjects, twice, with regard to marionette lines in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of marionette lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

Validated Assessment Scales for the Mid Face

Background The improvement of aesthetic treatment options for age‐related mid face changes, such as volume loss, and the increase in patient expectations necessitates the development of more‐complex and globally accepted assessment tools. Objective To develop three grading scales for objective assessment of the infraorbital hollow and upper and lower cheek fullness and to establish the reliability of these scales for clinical research and practice. Methods and Materials Three 5‐point rating scales were developed to assess infraorbital hollow and upper and lower cheek fullness objectively. Twelve experts rated identical mid face photographs of 50 subjects in two separate rating cycles using the mid face scales. Test responses of raters were analyzed to assess intra‐ and interrater reliability. Results Interrater reliability was substantial for the infraorbital hollow, upper cheek fullness, and lower cheek fullness scales. Intrarater reliability was high for all three scales. Both of the cheek fullness scales yielded higher reliabilities when three rather than two views were used to assess the volume changes of the cheek. Conclusion The mid face scales are reliable tools for valid and reproducible assessment of age‐related mid face changes.

Validated Composite Assessment Scales for the Global Face

Background Twenty grading scales have been developed to assess age‐related facial changes. Until now, the validity with regard to the patients actual age and the clinical importance of combined measurement tools to describe facial aging was unclear. Objective To investigate the reliability and validity of a total face score and three global face assessment scales for estimated age, estimated aesthetic treatment effort, and signs of aging in the facial units. Materials and Methods Descriptive, reliability, correlation, and principal component analyses based on the assessment of 50 subjects by 12 raters using the 20 grading scales and the global face assessment scales. Results Inter‐ and intrarater reliability was high for the total face score and for the scales on estimated age and aesthetic treatment effort. Actual age was highly correlated with these three measures. Facial aging was indicated particularly by scales of the lower face. Conclusion The aesthetic grading scales and global scales on estimated age and aesthetic treatment effort are reliable and valid instruments. The results suggest that a more‐comprehensive evaluation of the human face and its age‐related changes can help to identify important areas of facial aging and to define optimal aesthetic treatment strategies.

A validated brow positioning grading scale.

BACKGROUND One of the first areas to show facial aging is the periorbital region, where brow malposition contributes to the overall appearance of aging. Movement and positioning of the brows are also sex specific. Men may desire a low brow, whereas women may prefer high, arched brows. OBJECTIVES To develop the Brow Positioning Grading Scale for objective quantification of eyebrow position and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify positioning of eyebrows at rest. Nine experts rated photographs of 35 subjects twice with regard to positioning of the eyebrow in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. The test–retest correlation coefficients were acceptable for each expert. CONCLUSION The 5-point photonumeric scale generated spans the positioning of the eyebrow for which patients commonly seek correction. The scale is well stratified for consistent rating.

A Validated Hand Grading Scale

BACKGROUND Following the popularity of facial cosmetic procedures to reverse the signs of aging, cosmetic procedures that rejuvenate the hand are being sought. Irregular surface pigmentation, prominence of superficial veins and tendons, thinning of the dermis, and loss of subcutaneous fat typically characterize aging of the hand. OBJECTIVES To develop the Hand Grading Scale for objective quantification of the severity of hand aging and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS The Hand Grading Scale is a 5-point photonumeric rating scale that was developed to objectively quantify the severity of aging of the hand. Nine experts rated photographs of 35 subjects, twice, with regard to the aspect “hand aging” in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was considerably high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of hand aging for which patients most commonly seek correction. The scale is well stratified for consistent rating.

Validated Assessment Scale for Neck Volume

Background Sagging of the neck aesthetic area is an important indicator of age. The development of complex and globally accepted tools for proper assessment of the change in neck volume is an essential contribution to aesthetic research and the routine clinical setting. Objective To develop a grading scale for the objective assessment of the neck volume and to establish the reliability of this scale for clinical research and practice. Materials and Methods A 5‐point rating scale was developed to assess neck volume objectively. Twelve experts rated frontal and lateral neck photographs of 50 subjects in two separate rating cycles using the neck volume scale. Responses of raters were analyzed to assess inter‐ and intrarater reliability. Results Interrater reliability for the neck volume scale was almost perfect, with intraclass correlation coefficients for the first and second rating cycles of 0.85 and 0.84, respectively. Intrarater reliability for the neck volume scale was high (0.90) and Pearson correlation coefficients ranged between 0.88 and 0.95 and were statistically significant. Conclusion The neck volume scale demonstrates optimal reliability for clinical research and practice.