The article presents an objective view of evidence-based medicine application to aesthetic surgery. The challenges are discussed and the points that create them are analyzed. Psychological and external factors in decision-making for aesthetic surgery are presented. The handling of surgical complications is presented as an example affecting reporting of outcomes.
Key points
- •
The assessment of aesthetic surgery outcomes still has the basic, yet fundamental, question to answer: whose perspective on outcomes—the patient’s or the physician’s—is of primary importance?
- •
Because scientific data are difficult to distill from the aesthetic literature, significant challenges exist to integrate evidence-based medicine principles into the art of aesthetic surgery.
- •
Aesthetic surgery is an unusual doctor-patient relationship in which the patient is the sole consumer of elective services with no third-party payer involvement.
- •
The traditional balance of power between the physician and patient shifts toward the patient in elective procedures, elevating the importance of patient satisfaction with the surgical outcome.
- •
Evidence-based research is absolutely necessary to ensure high-quality care, and better study designs and measures will help create clinically meaningful outcomes.
Introduction
Evidence-based medicine (EBM) is being embraced by plastic surgery. Patient values are combined with scientific data to complement a plastic surgeon’s clinical experience. Aesthetic surgeons have also supported the EBM movement by attending the EBM summit convened by plastic surgery leadership in Colorado Springs in 2010. However, because scientific data are difficult to distill from the aesthetic literature, there are significant challenges to integrating EBM principles into the art of aesthetic surgery. The primary dilemmas are to define the desired goals of aesthetic surgery and determine how outcomes can be measured; these challenges still face this subspecialty of plastic surgery.
Aesthetic surgery outcomes can be grouped into two primary domains: (1) complications and revisional surgery and (2) satisfaction with aesthetic outcomes.
Similar to other surgical fields, complications are well-defined, but revisional surgery rates can be variable depending on a surgeon’s and a patient’s willingness and desire for revisional surgery. Measuring satisfaction, however, is much more complex. Whose perspective takes primary importance—the patient or the surgeon? If the surgeon is satisfied with the aesthetic results, but the patient is not, is that a good outcome? What if the patient, not the surgeon, believes the outcome is good? Furthermore, patients’ and surgeons’ concept of beauty will vary dramatically across racial and/or ethnic backgrounds, geographic regions, and socioeconomic status.
Introduction
Evidence-based medicine (EBM) is being embraced by plastic surgery. Patient values are combined with scientific data to complement a plastic surgeon’s clinical experience. Aesthetic surgeons have also supported the EBM movement by attending the EBM summit convened by plastic surgery leadership in Colorado Springs in 2010. However, because scientific data are difficult to distill from the aesthetic literature, there are significant challenges to integrating EBM principles into the art of aesthetic surgery. The primary dilemmas are to define the desired goals of aesthetic surgery and determine how outcomes can be measured; these challenges still face this subspecialty of plastic surgery.
Aesthetic surgery outcomes can be grouped into two primary domains: (1) complications and revisional surgery and (2) satisfaction with aesthetic outcomes.
Similar to other surgical fields, complications are well-defined, but revisional surgery rates can be variable depending on a surgeon’s and a patient’s willingness and desire for revisional surgery. Measuring satisfaction, however, is much more complex. Whose perspective takes primary importance—the patient or the surgeon? If the surgeon is satisfied with the aesthetic results, but the patient is not, is that a good outcome? What if the patient, not the surgeon, believes the outcome is good? Furthermore, patients’ and surgeons’ concept of beauty will vary dramatically across racial and/or ethnic backgrounds, geographic regions, and socioeconomic status.
Conceptual framework
When assessing any surgical outcome, whether aesthetic or reconstructive in nature, a conceptual framework should guide the research. The conceptual framework is a process-of-care roadmap that incorporates patient and external factors that can influence surgical outcomes. Examples of conceptual frameworks that could be used to assess aesthetic surgery outcomes are the Transtheoretical Model, Stages of Change Construct, and the Health Belief Model. The Transtheoretical Model and Stages of Change Construct propose that patients move through a series of steps or stages when making decisions and taking actions about their health and the health care they receive. The stages are defined by their differing degrees of intention, readiness, and preparation to engage in a new behavior or action. This model has historically been applied to behavior modification and self-management, such as smoking cessation and weight loss. For example, a patient may engage in smoking behavior with little intention to stop. External influences, such as a primary care physician, may increase the patient’s awareness of the harmful effects of this behavior, leading the patient to transition into a greater degree of readiness to stop. The patient may then engage in other activities to prepare to stop smoking, such as the use of medication or acupuncture. This model of health behavior has been used to understand and explain the natural history of decision-making for breast cancer reconstruction. Surgeons could consider using it as a decision-making framework for aesthetic surgery when contemplating a potential body-enhancement procedure. The model describes the surgical decision-making process along a continuum defined by four stages: pre-contemplation , contemplation , preparation, and action . Fig. 1 describes the relationship between these stages of decision-making and the independent variables in the model.
With aesthetic surgery, the precontemplation stage is defined by either a lack of knowledge or lack of desire for cosmetic procedures. For example, a person with an aging face may have come across an article describing the use of Botox in alleviating the prominent frown lines associated with old age, setting the stage for research into this potential treatment avenue by this particular individual.
The contemplation stage is defined by thinking about and talking to others about cosmetic surgery. Patients in this stage are actively considering treatment issues and are motivated by higher levels of problem recognition, increasing knowledge, and changing attitudes. For example, patients in the contemplation stage may engage in role-playing that involves imagining their significant other’s reaction to their body-contouring procedure. This can be a powerful motivator to proceeding to the next stage.
The preparation stage involves action-oriented activities motivated by the desire for an aesthetic change in appearance, such as obtaining a surgical consultation, evaluating treatment options, and learning about financial costs. This stage involves a greater readiness to undergo treatment and encompasses both cognitive and behavioral factors. The action stage is defined by receiving or not receiving surgery.
Health Belief Model
Several constructs from the Health Belief Model may affect the Stages of Change decision-making process for aesthetic surgery. Patient knowledge and attitudes play a central role across the continuum of decision-making. For example, among postpartum women, the transition to the contemplation stage could be motivated by increasing recognition that they have a problem with their rectus muscle diastasis and abdominal contour. Postpartum women may also become self-conscious over time about the physical appearance of their breasts, which may impact their sexuality. Or they may begin to feel inconvenienced by the clothing limitations from postpartum breast involution and/or ptosis. On the other hand, patient knowledge and attitudes may hinder consideration (contemplation) and initiation (preparation) of treatment. Limited knowledge about treatment effects, such as the restoration of body image and sexuality, may inhibit consideration. Concerns about the treatment outcomes, such as the impact of breast augmentation on mammography screening, may also deter consideration of cosmetic surgery.
External Influence Factors
External influence factors (physicians, significant others, family and/or friends, and media) play an important role in the knowledge and attitudes of patients, thereby influencing the decision-making process. The attitudes of primary care physicians and obstetricians and/or gynecologists, for example, can influence a woman in the contemplation stage for breast augmentation. For example, some physicians have misconceptions that breast implants are unsafe; these provider attitudes can impede a woman from moving from the contemplation to the preparation stage. In the preparation stage, the plastic surgeon–patient relationship can have a significant impact. For example, a woman who desires breast enhancement may have decided against it or delayed it because of a mismatch between the surgeon’s and her own desired outcome or because of a lack of treatment choice between implant type, pocket location, incision location, or size. Family members can also play a crucial role, especially if they have experienced cosmetic surgery themselves. In addition, a significant other is a key component to this process. For example, a married woman may be less likely to be concerned about the scars from an augmentation-mastopexy compared with a woman who is not in a stable relationship. Finally, the media does have an influential role in transitioning women through the four stages. The negative press that breast implants received in the 1990s may slow a woman’s progression to the preparation stage. On the other hand, the cultural pressure to reach ideal beauty standards (especially with the emphasis on breasts) that is reinforced by print, television, and radio media may facilitate a woman’s progression to the contemplation stage for cosmetic breast procedures.
Clinical Factors
Clinical factors may also influence physician recommendations and patient attitudes toward surgery. For example, a physician may not be willing to perform an augmentation without mastopexy in a woman with grade 3 breast ptosis, despite her concerns about visible scarring. Obesity, nicotine use, and chronic illnesses are significantly associated with higher surgical complication rates, which may affect the decision-making process for the risk-adverse patient or physician. For example, a surgeon may not be willing to perform a rhytidectomy in a patient who uses nicotine.
Predisposing Factors
Predisposing factors influence a patient’s knowledge and attitudes and, because the decision for aesthetic surgery is preference-sensitive, the decision will be heavily influenced by the cultural context in which it is made. For example, African-American and white individuals may have different attitudes toward sexuality, social relationships, and body image that lead to different decisions about cosmetic surgery. For example, African-Americans tend to place a greater emphasis on buttocks appearance, whereas whites are generally more concerned about breast aesthetics. Other predisposing factors, such as age and education, may be associated with underlying attitudes and preferences that influence a patient’s decisions about aesthetic surgery. For example, as women increase in age, receipt of cosmetic surgery increases. Age, through the association with knowledge, body image, and financial means, may play an important motivating role in the decision-making process.
Enabling Factors
Enabling factors are likely important issues influencing progression from contemplation to preparation and action. Socioeconomic status and access issues related to finances, availability of services, and the accommodation and acceptability of services may influence a patient’s decision-making. In addition, having assistance with family responsibilities greatly enables the decision for elective surgery, especially among the postpartum population.
Related posts:
Patient-Reported Outcomes Instruments
The Outcomes Movement and Evidence-Based Medicine in Plastic Surgery
Development and Psychometric Evaluation of the FACE-Q Satisfaction with Appearance Scale
Measuring Outcomes in Craniofacial and Pediatric Plastic Surgery
Measuring Outcomes in Hand Surgery
Measuring Outcomes in Lower Limb Surgery
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
