Reliable, scientific measurements of patient outcomes improve patient satisfaction and education, and provide support to clinical studies and research. The international team describe the BREAST-Q, FACE-Q and BODY-Q scales
In the cosmetic surgery industry, new techniques and technology are rapidly evolving. At the same time, patients are becoming savvy consumers who want valid and reliable information about treatment outcomes. People specifically want to know what other patients have experienced to be able to make informed choices about treatments and healthcare providers, as well as avoid disastrous outcomes.
To fully capture the patient perspective, clinically meaningful and scientifically sound patient-reported outcome measures (PROMs) are needed. PROMs measure concepts—such as symptoms, satisfaction and health-related quality of life—by asking the patient directly, without interpretation by a clinician or anyone else. Such measures are increasingly being be used to support patient advocacy, cost-effectiveness analysis, patient education and local, national and international research efforts.
Furthermore, when incorporated into routine clinical practice, patients are given the opportunity to report their concerns directly to their healthcare provider who can use patients’ results in real-time clinical decision-making to improve patient satisfaction and health-related quality of life.
Over the last ten years, our team has worked to develop a set of PROMs to measure the outcomes that matter to cosmetic and plastic surgery patients using state-of-the-art methods to maximise both the clinical meaning and the scientific quality of the tools produced. Importantly, patients have been involved in all stages of the development process, as are experts whose input is crucial in the design of the content of each PROM and its subsequent evaluation. Our goal has been to ensure that the PROMs we develop are valid and reliable, not only for use in health services research but also for use in clinical care with individual patients.
Our PROMs measure concepts such as appearance, body image, psychosocial wellbeing and satisfaction with care, and provide meaningful, precise and reliable feedback on important patient-centred outcomes. All PROMs are developed with strict adherence to international guidelines, such as the Medical Outcomes Trust and the US Food and Drug Administration (FDA), for instrument development.
We started the development of each PROM with a series of in-depth qualitative interviews with cosmetic and plastic surgery patients—155 patient interviews in total—and used the data to develop a set of scales composed of items that are really a set of statements that patients said to us in their interviews. Our scales measure things that patients care about, in their own words.
The end result is the development of three comprehensive PROMS called the BREAST-Q, FACE-Q and BODY-Q. Each of these plastic surgery-specific tools is composed of multiple scales that may be used to evaluate key aspect of outcome for plastic surgery patients. Importantly, the scales are designed to function independently and therefore only those scales that are most relevant to the research objectives and appropriate for the target patient population need be selected and administered.
This structure facilitates comprehensive, yet pragmatic, assessment of outcomes that matter to patients with minimal respondent burden and high response rates. All scales are scored on a 0-100 continuum, with higher scores meaning higher satisfaction or better quality of life.
The BREAST-Q, which was made available in 2008, is our most established PROM and is designed for pre- and post-operative patients. The scales can be used to evaluate patient expectations (preoperative), satisfaction with care, satisfaction with breasts and health-related quality of life. The BREAST-Q has been translated into over 12 languages and is in widespread use in international clinical trials and quality improvement programmes.
In the UK, the BREAST-Q was used by the NHS as the main outcome measure in a national mastectomy and breast reconstruction audit involving over 8,000 women who were followed up at three and 18 months. The BREAST-Q has separate modules for patients undergoing breast augmentation, mastopexy/reduction, breast conserving therapy (lumpectomy and/or radiation therapy), mastectomy and breast reconstruction.
The FACE-Q can be used to measure outcomes in any type of facial cosmetic surgery, minimally invasive cosmetic procedure or facial injectable. Treatments include: cosmetic facial surgery, such as facelift, rhinoplasty or eyelid surgery; facial injectables, such as Botox, lip and line fillers; and dermatologic procedures like laser resurfacing and chemical peels.
To measure appearance, a large number of scales have been developed that cover all parts of the face, as well as scales that measure the signs and appearance of ageing. Scales also measure health-related quality of life, adverse effects and satisfaction with care. FACE-Q scales are being used in international clinical trials and have been translated into French, German and Italian. The scales are designed for pre- and post-treatment administration so that data can be collected to evaluate the effectiveness of surgical and nonsurgical treatments.
The BODY-Q is designed for use with bariatric or body contouring surgery patients. The BODY-Q scales are fully developed and now being field-tested in Canada and the USA. They can be used to evaluate outcomes for patients undergoing bariatric, or weight-loss, surgery. The scales can also be used to measure outcomes for massive weight loss patients who undergo body contouring procedures such as abdominoplasty or arm lifts and for patients who undergo cosmetic body contouring such as liposuction.
To measure appearance, there is a range of scales that measure satisfaction with the appearance of different parts of the body, as well as scales to measure body image, quality of life and satisfaction with care.
In the UK, the recent review of the regulation of cosmetic interventions report by NHS medical director Sir Bruce Keogh identified a lack of evidence supporting the efficacy of common cosmetic procedures. Keogh called for the establishment of an aesthetic research institute to provide the necessary scientific evidence and best practice for aesthetic treatments.
With funding from the Healing Foundation and in conjunction with the British Association of Aesthetic Plastic Surgeons, the National Institute for Aesthetic Research was launched in September 2013. As the cosmetics industry continues to expand, it is vital that research is conducted to measure outcomes that matter to patients.
Our team’s PROMs were developed to reflect patients concerns and provide a set of tools that can now be used to gather data to understand the impact that cosmetic interventions have on patients in a holistic manner.
Dr Anne Klassen E: email@example.com; Dr Stefan Cano E: firstname.lastname@example.org; Dr Andrea Pusic E: email@example.com
1. Klassen AF, Cano SJ et al. “Measuring outcomes that matter to facelift patients: development and validation of FACE-Q appearance appraisal scales and adverse effects checklist.” Plast Reconstr Surg.
2. Panchapakesan V, Klassen AF, Cano SJ, Scott AM, Pusic AL. “Development and psychometric evaluation of the aging appearance appraisal scale: a new PRO instrument for facial aesthetics patients.” Aesthetic Surg. In press.
3. Pusic A, Klassen AF, Scott AM, Cano SJ. “Development and psychometric evaluation of the FACE-Q Satisfaction with Appearance Scale: A new PRO instrument for facial aesthetics patients.” Clin Plast Surg. 2013; 40:249-60.
4. Wildgoose P, Scott A et al. “Psychological screening measures for cosmetic plastic surgery patients: a systematice review.” Aesthet Surg J. 2013 Jan 1;33(1):152-9
5. Cano SJ, Klassen AF, Scott AM, Cordeiro PG, Pusic AL. “The BREAST Q: Further validation in independent clinical samples.” Plast Reconstr Surg 2012 Sept; 129:293-302.
6. Pusic AL, Klassen AF, Snell L, Cano SJ, McCarthy C, Scott A, Cemal Y, Cordeiro PG. “Measuring and managing patient expectations for breast reconstruction: Impact on quality of life and patient satisfaction.” Expert Rev Pharmacoecon Outcome Res 2012 Apr; 12:149-58.
7. Klassen AF, Cano S, Scott A et al. “Satisfaction and Quality of Life Issues in Body Contouring Surgery Patients: A qualitative study.” Obes Surg 2012 Oct; 22(10):1527-34.
8. Reavey PL, Klassen AF, Cano S, McCarthy C, Rubin JP, Shermak M, Pusic AL. “Measuring Quality-of-Life and Patient Satisfaction after Body Contouring: A systematic review of patient-reported outcome measures.” Aesthet Surg J 2011 Sept; 31:807-13.
9. Pusic A, Lemaine V, Klassen AF, Scott AM, Wedderburn W, Cano SJ. “Patient-reported outcome measures in plastic surgery: use and interpretation for evidence-based practice.” Plast Reconstr Surg 2011 Mar; 127:1361-7.
10. McCarthy CM, Klassen AF, Cano SJ, Scott A, Vanlaeken N, Lennox PA, Alderman AK, Mehrara BJ, Disa JJ, Cordeiro PG, Pusic AL. “Patient satisfaction with postmastectomy breast reconstruction: a comparison of saline and silicone implants.” Cancer 2010; 116:5584-91. Epub 2010 Nov 8.
11. Cano S, Klassen A, Scott A, Thoma A, Feeny D, Pusic A. “Health outcomes and economic measurement in breast cancer surgery: challenges and opportunities.” Expert Rev Pharmacoecon Outcomes Res. 2010; 10:583-594.
12. Klassen AF, Cano S, Pusic A. “Satisfaction and quality of life in women who undergo breast surgery: a qualitative study.” In press. BMC Women’s Health 2009; 1:9:11.
13. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. “Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q.” Plast Reconstr Surg 2009; 124:345-53.
14. Pusic AL, Reavey PL, Klassen AF, Scott A, McCarthy C, Cano S. “Measuring patient outcomes in breast augmentation: Introducing the BREAST-Q: Augmentation Module.” Clin Plast Surg 2009; 36:23-32.
15. Kosowski TR, McCarthy C, Reavey PL, Scott AM, Wilkins EG, Cano SJ, Klassen AF, Carr N, Cordeiro PG, Pusic AL. “A systematic review of patient reported outcome measures after facial cosmetic surgery and/or non-surgical facial rejuvenation.” Plast Reconstr Surg 2009; 123:1819-27.
16. Pusic AL, McCarthy C, Cano SJ, Klassen AF, Kerrigan CL. “Clinical Research in Breast Surgery: Reduction and post-mastectomy Reconstruction.” Clin Plast Surg 2008; 35:215-226.
17. Klassen AF, Cano SF, Scott A, Snell L, Pusic AL. “Measuring patient-reported outcomes in facial aesthetic patients: development of the Face-Q.” Facial Plast Surg 2010: 26:303-9. Epub 2010 Jul 27.
18. Pusic A, Chen CM, Cano S, Klassen A, McCarthy C, Collins D, Cordeiro P. “Measuring quality of life in cosmetic and reconstructive breast surgery: A systematic review of patient-reported outcome instruments.” Plast Reconstr Surg 2007; 120:823-37.