In part, the lack of knowledge about the impact of cosmetic surgery reflects the inherent difficulty in assigning objective measures to the improvement of appearance or to the “creation” of beauty. These measures are subjective, preference driven, and highly individual by nature. Conventional assessment of the success of medical procedures has focused on the more readily measurable parameters of mortality, morbidity, and physiologic function. Although these assessments are undoubtedly important for any surgical procedure, they do not provide a meaningful assessment of aesthetic outcomes. Against this background, a variety of methods for measuring the success of cosmetic procedures has been investigated, including anthropometric assessments, subjective assessments by patients and surgeons, and outcomes research.

Outcomes research may be defined as “the science of measuring patient experience.”² It examines the end results of treatment, but in contrast to other methods, it focuses specifically on the patient’s experience, perspective, and values.³ Assessment of outcomes is particularly relevant following cosmetic procedures because it provides an objective evaluation of the success of treatment. More importantly, it permits quantification of patients’ satisfaction with the results. This is a key measure; it is arguable whether a procedure that has been technically successful, but with which the patient remains dissatisfied, may be regarded as having achieved the objectives of treatment.

Outcomes research therefore seeks to identify and define standardized, validated instruments for objective evaluation of the changes achieved with cosmetic procedures. This chapter provides an overview of the importance of patient satisfaction as an outcome measure, examines some of the instruments used to assess this, and identifies ongoing challenges for the future, including the development of suitable instruments for assessing outcomes in patients of darker racial ethnic groups.

Early studies in cosmetic surgery assessed the efficacy of treatment using a variety of physical measures. These included subjective evaluation of patient photographs documenting the time course, or results, of treatment or healing; comparisons of physical measurements taken before and after cosmetic procedures; and optical profilometry, used to quantify the changes achieved by surgery. The drawback to these methods is that they do not take patient experience, attitudes, or values into account. A more recent review of patient satisfaction following surgical cosmetic procedures showed that in 36 studies, most patients were pleased with the outcomes of treatment and felt better about themselves, with improvements seen in self-worth, distress and shyness, and quality of life.⁴

Despite the enormous increase in cosmetic surgery procedures in the United States, there is a dearth of data in plastic surgery and cosmetic dermatologic surgery assessing patient satisfaction outcomes. A study of 30
patients who underwent botulinum toxin A injection demonstrated that more than 80% of individuals considered their treatment beneficial, and all patients would recommend treatment “completely” or “mostly.” Outcomes were assessed using the Freiburg questionnaire on aesthetic dermatology and cosmetic surgery.⁵ In addition, Augustin et al.⁶ assessed patient satisfaction in a group of patients treated with tumescent liposuction. The Freiberg questions on aesthetic dermatology and cosmetic surgery were also used for this study. Of 300 patients, 159 (53%) returned their questionnaires. Satisfaction with tumescent liposuction was high in 85% of patients. Eighty percent regarded the procedure as nonstressful. Other studies of outcomes in facial procedures, including skin resurfacing, concluded that there are few well-designed studies using objective, validated assessment tools.⁷

Enhancing an individual’s appearance using cosmetic procedures has important beneficial effects that extend far beyond the physical improvements achieved by treatment. During the past several decades, a number of studies have demonstrated that aesthetic surgery can have a positive impact on patients’ self-confidence, body image, psychosocial well-being, and sexual function, as measured by a variety of methods.

It has been suggested that cosmetic surgery may best be regarded as “body image surgery,”⁸ and it is clear that poor body image may be the impetus for patients to seek cosmetic surgery in the first instance.⁹ Perhaps unsurprisingly, most patients appear to be satisfied with the results of aesthetic procedures and feel better about themselves afterward. It is well documented that patients report positive effects on self-image following a variety of cosmetic surgery procedures, as well as reduced dissatisfaction with body image and appearance. Such changes are manifested by improvement in negative thoughts, feelings, and behaviors relating to the specific body feature that has undergone alteration.^{10,11,12,13,14,15,16,17,18,19,20,21} In addition, there is evidence to suggest that cosmetic surgery can lead to improvements in areas of psychological functioning, such as depressive symptoms²² and quality of life.^21,22

The impact of aesthetic procedures on sexual function is also well documented. As long ago as 1974, a study published by Baker et al. showed that many women reported enhanced self-confidence, psychosocial health, and sexual relations following breast augmentation.²³ Patients were more likely to alter their style of clothing to wear more provocative styles, to report more pleasure in sexual relationships, and to have an overall improved feeling of sexual adequacy.²³

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