Quality of life (QoL) has become a leading criterion in the modern civilization, and even as a therapy objective QoL became very important. In the contemporary society more and more patients decide to undergo aesthetic operations in the absence of a pathologic indication. “Healthy” patients are seeking complete physical, psychological and social well-being, and therefore accept for example the risk of complications through “elective” operations. Plastic aesthetic surgery operations have considerably increased in the last 20 years.1 But in the past, surgeons focused mainly on complication-free results and the postoperative physical outcome.2 In contrast, patients’ expectations themselves include an optimal aesthetic result, as well as its impact to meaningful parts of their daily life. The American Medical Association defined cosmetic surgery as: “Performance to reshape normal structures of the body to improve the patient's appearance and self-esteem (…).”3 The final aim of an aesthetic operation is the improvement of the psychological feeling of the patient due to a structural rearrangement of a part of the body.4
The psychological involvement on elective operations plays a decisive role that may not be underestimated. The actual measurement of psychometric constructs is a highly advanced and rigorous science, and substantial progress has been made in applying this science to clinical medicine.5
On this background the expectations are rising on a following increase of well-being. Health professionals have to decide which treatments are justified and which are not. The procedures should provide substantial and long-lasting benefit. The improvement of quality of life should be the priority of every aesthetic surgical treatment. Therefore, it is important to have evidence for the effectiveness of different surgical treatments, especially for procedures based on patient's aesthetic incentive. Outcomes research should prove to be an evaluable investigation tool for facial plastic surgeons to demonstrate improved quality of life and functional status in their patients.6 Other authors describe it like: “The purpose of assessing outcomes is to provide evidence on which to base clinical decisions.”7
As we have shown in our previous study in 2007, quality of life does improve after plastic surgical treatments in the aspects health and appearance.8 Participants of the above-mentioned study underwent a broad spectrum of aesthetic surgical procedures. The aim of our present study was to maintain these conclusions and find out, whether there is coherence between improvement of QoL and a specific surgical procedure as well as its specific aspects. Therefore, the overall patients who underwent aesthetic surgery were subdivided into separate groups according to their operative indication. Evaluation of abdominoplasty intervention has already been described elsewhere recently,9 as well as Otoplasty.10 Whereas in the present study we examined exclusively patients who underwent transdermal blepharoplasty in the absence of any other procedure. What influence emerges aesthetic surgery in eyelids to patient's everyday life, appearance (body image), emotionality, personality, and self-esteem?
Forty-six patients who underwent transdermal blepharoplasty during 1995 and 2008 at our department fulfilled the criteria and participated in the study (follow-up 3–147 months; average 71.3 months). Only patients with aesthetic motivation for blepharoplasty were included. Tumor and reconstructive reasons for the operation were excluded, as well as noninvasive laser treatments. The operation technique has widely been described.11–14 The group of patients who participated in the study was operated exclusively in transdermal technique. Based on the circumstances that in the period of the study it was the preferential technique performed on our clinic we collected most data on transdermal operations.
Therefore we have purposely elected this patient group. A questionnaire was sent to the patients to be answered postoperatively. A phone call at the same time introduced to the questionnaire. After further 14 and 30 days the participants were contacted for another time by phone to enhance the rate of response.
The 15-page questionnaire included a self-developed part which analyzes the demographic data, social surrounding, and the patients’ subjective evaluation of the operative blepharoplasty. The second part was the FLZM (“Questions on Life Satisfaction”) questionnaire, a standardized, and for the German speaking countries validated instrument to measure quality of life.15 Psychological aspects of the operative result on our patients were examined in the third and fourth part of the questionnaire with the instruments FPI-R-L (“Freiburg Personality Inventory”)16 and RES (“Rosenberg Self-Esteem”).17
Self-Developed and Indication-Specific Questionnaire for Blepharoplasty
Initially patients were asked questions regarding demographic details, their pre- and postoperative condition, age, weight, family affairs, school graduation, profession, and health status. Questions about the situation before the operation were reviewed: regarding former interventions, satisfaction with these, information sources, the intention for the operation, and the satisfaction with the part to be operated.
Postoperative outcomes like pain, swelling, complications, and the subjective impression of the result were asked for, as well as the influence of the surgical result on everyday life and well-being.
FLZM (Questions on Life Satisfaction)
The FLZM is a self-evaluation questionnaire, which evaluates subjective quality of life (weighted satisfaction).14 It is validated and standardized for German-speaking countries. The 2 modules “general life satisfaction” and “satisfaction with health” consist of 8 items each. Patients are asked to rate the items on a 5-point scale. Results could be compared with the existing random sample representing the German “healthy” population, evaluating only the corresponding age group and gender to our study group. Norm data are available from the year 2006 for the “general” part and from 1995 for the part “health.”14
Another module included in the FLZM is the part “satisfaction with the appearance” (body image). Twenty-two parts of the body are rated by patients in the identical 5-point scale. Since this module has not been validated yet, the results were compared with our previous evaluation of the year 2007, where 228 of our aesthetic plastic surgery patients answered the questionnaire pre- and postoperatively.8 As a matter of course we just used the data from relevant patients who underwent aesthetic surgery in face.
Freiburg Personality Inventory-Revised
Psychological issues are of enormous importance in plastic surgery.18,19 This background is analyzed with the “Freiburg Personality Inventory.”15 This test is well established in German-speaking countries. The FPI-R is the eldest in Germany developed multidimensional questionnaire.20 It is widely used for clinical psychology, rehabilitation, health psychology, personality research, and as a screening instrument for personal characteristics. As a standardized questionnaire it has a high objectivity in accomplishment and analysis. It is a multidimensional test, which allows the self-assessment of personality's characteristics. It was proposed in 1970 by Fahrenberg and Selg.21 In the following years it was modified through development methodically, and more scales were added. The revised version of the FPI was proposed in 2001.15 Out of 12 items with a total of 138 questions we used the scale “emotionality and extraversion” in our study to gain more information about the emotional stability of the participants’ personality. These 14 questions were answered with “right” (counts 1) or “not right” (counts 0). Scores were added and a sum score from 0 to 4 values a very high emotional stability, scores from 5 to 7 a normal “healthy” stability, and scores from 8 to 14 an unstable emotional stability. The results of the study group were compared with the average score of the existing German norm population data.
Rosenberg Self-Esteem Scale
In the fourth part patients were asked to answer the Rosenberg self-esteem questionnaire.16 The Rosenberg Self-Esteem Scale (RSES) is the most established tool for self-esteem assessment. Designed to measure the level of an adolescent's self-esteem, it contains 10 items, which are generally scored using a 4-point response scheme ranging from 1 (strongly disagree) to 4 (strongly agree). Herewith the score ranges from 10 to 40, with 40 indicating the highest score possible. Scores higher than 30 are significant for a high self-esteem.22 Rosenberg's Self-Esteem Scale is a brief and 1-dimensional measure of global self-esteem. It has demonstrated good reliability and validity across a large number of different international sample groups. The RSES has been validated for different clinical groups, and is regularly used in treatment outcome studies. The scale has been validated for use with both, male and female adolescent, adult and elderly populations. Norm data for the German population are available.21
With the combination of these 4 measurement instruments we were able to evaluate a broad spectrum of operation outcomes that are related to quality of life, body image, personality, and self-esteem.
For the statistical analysis the software SPSS 17.0 for windows (SPSS Inc, Chicago, IL) was used. The data distribution of each variable was evaluated using the “unpaired t test” and for all tests, the overall statistical level of significance was set at P < 0.05.
Evaluation of the Self-Developed and Indication-Specific Questionnaire
All 46 patients underwent a transdermal blepharoplasty operation in the absence of any other cosmetic procedure. Follow-up was 3 to 147 months; average 71.3 months). Only 6 patients of the study group were male, 40 were female. Minimum age of the patients was 38 years while the maximum was 75 years; average 60.2 years. With 26 patients the largest group was between the age of 56 and 66 years. Maximum weight of a patient was 96 kg (BMI 27.5) and the minimum 53 kg (BMI 17.3) (average 66.3 kg [BMI 23.9]). Only 1 participant was underweight (BMI 17.3) and 1 was overweight (BMI 36.2); two-thirds of the other patients had BMI scores between 19 and 25, one-third between 25 and 29. The duration of consideration to undergo the operation was widely diversified between 1 and 10 years (average 2.7 years). Forty-one patients had the impulse by themselves to undergo the treatment and 44 were expecting to take advantage in personal well-being. Half of the patients did not have any apprehensions, 11 had fear of complications, and one-third of an unsatisfying result (with partially overlapping answers).
Twenty-seven of the participants were preoperatively very unsatisfied or rather unsatisfied with their eye section, 34 answered that preoperatively the appearance of their eye section made them look tired.
Thirty-five of the surgeries developed without any complications. Four patients reported about sensibility disorders and 3 about limited eye closure. Four reported postoperative pain and only 1 patient needed to be operated twice due to complication. As the overall effect on the patient group where complications appeared was comparable to the rest, we did not explicitly point out that group. Moreover, the satisfaction and aesthetic results of the patients were excellent! Unquestionably, a stratification of results concerning complications was performed in background, but as no severe deviation from the rest has been found we did not list the group separately. In 23.9% of the cases (11 patients) a complication appeared.
Finally, 38 of the patients would recommend the operation, and nearly 39 would undergo the procedure again. Thirty-nine of the patients were satisfied with the symmetry of the result.
Twenty-three of the participants felt simply better and 33 felt more satisfied with their body/eye section. Twenty-nine felt recovered. Twenty felt more self-confident and 25 felt more attractive postoperatively. Eight felt easier to spend time in society. Thirty-eight patients reported that the strain was definitely worth it.
Evaluation of the FLZM
According to the manual of this questionnaire, we calculated the weighted satisfaction for each item and the sum scores of the 3 modules.14 In a second step we compared these data to the representative random sample, evaluated in the German population in year 2006.14
We found a significant improvement in the single item “work” (P = 0.02) (Table 1).
In the module “general life satisfaction” statistical improvement in the items “mobility” (P < 0.001) and “independence from assistance” (P < 0.001) was found (Table 2).
The evaluation of the module “satisfaction with the appearance” (“body image”) was analogous to the previous questionnaires, which means even in this part weighted satisfaction was calculated first and compared afterward. Statistical differences of the questionnaires’ body image part (appearance) have not been found. The data we compared our results with are preoperative T0 scores of our previous study from 2007 (Table 3). Consequently, in the item “eye section,” which is the most related to our patient category, an improvement was found postoperatively.
Evaluation of the Freiburg Personality Inventory-Revised
The FPI-R questionnaire regarding emotionality and self-assessment, resulted in significant better scores (mean 4.96/ P = 0.02) compared with the German norm data.23 Herewith we proved that the emotional stability can take advantage due to aesthetic interventions at the eyelids (Table 4).
Evaluation of the Rosenberg Self-Esteem Scale
Results of the RSES show statistical significant better scores (mean 35.4/P < 0.001) compared with the German norm population.21,24 Even in this part we saw that plastic aesthetic interventions in face, in our case blepharoplasty, have a positive influence on the personal self-esteem (Table 5).
Cosmetic surgery is often discussed as a low priority intervention.25 It is criticized as frivolous and lacking in substantive benefit. Is there an indication given or not? Is it possible to take enormous advantage in personal well-being of patients through such an elective surgery? Therefore it is remarkable relevant to evaluate the postoperative effect. It is important to know if there is a significant improvement of quality of life after the surgical procedure, because QoL, and herewith patient satisfaction, is the predominant factor by which success is defined. As we showed in 2007,8 there is an increase of quality of life in different aspects of life following aesthetic surgical interventions. Further, it has been assumed that a positive change in physical appearance for the patient will lead to an improvement in their psychological well-being, including their self-confidence and self-esteem.26 Subject to this study was a group of patients who underwent a broad spectrum of aesthetic plastic surgical operations (breast reduction, breast augmentation or mastopexies, liposuctions, abdominoplasties, face and neck rhytidectomies, rhinoplasties, etc.).
We now proved that blepharoplasty, evaluated in a separate and specific study, does improve quality of life of our patients, compared with a random sample. The results of this study strengthen the hypothesis that cosmetic surgery is able to afford positive changes in quality of life, personality, and self-esteem. Furthermore, the postoperative complications of the procedure were lower than expected and very well tolerated by patients.
Mellington and Khooshabeh27 showed in their study with only 15 patients and a follow-up of only 18 months an increase of QoL in terms of visual function. A “quality of life and visual function” questionnaire was used which is not validated till present. A correlation between patient's self-reported preoperative functional impairment and postsurgical functional status was made. However, no standardized questionnaires for QoL were used and no comparison with similar data pre and postoperative was made.
Cahill et al28 reviewed 13 studies concerning blepharoplasty with a result of significant improvement of vision, peripheral vision, and quality of life activities. No reference of which QoL questionnaires or measurement instruments in these studies have been used is given.28
Similar to the studies mentioned above was the study design of Jacobsen et al.29
Main focus was given on functional benefits postoperatively. Questionnaire items “were based on symptom criteria and other functional and psychological parameters….” whereas patient satisfaction with the result was evaluated with only 1 single question, not even a questionnaire!
Bahceci30 evaluated the headache-related quality of life following blepharoplasty. Priority of the study was to detect the reasons for tension-type headache. The Headache Impact Test was used, which is a very specific questionnaire, asking exclusively about headache affecting daily life in 6 questions. Misleadingly, even the editors of Headache Impact Test themselves do not claim investigation of quality of life for their own questionnaire! The designation is never used.
Bensoussan et al31 reviewed 28 studies concerning the impact of quality of life following cosmetic surgery over 50 years. In conclusion, procedures and tools employed in cosmetic surgery research studies were remarkably diverse, thus yielding difficulties with data analysis. Therefore, future research needs to focus on refining measurement techniques, including developing cosmetic surgery–specific QOL measures. That is exactly what we did in our study!
Chen and Song evaluated 200 blepharoplasty cases of young Asians retrospective with the Face-Q questionnaire.32 This questionnaire is not standardized, due to the fact that it is a construction kit of over 40 scales, where single items can either be used or excluded. It provides the “ability to tailor a version of the questionnaire to suit their needs.” Therefore the questionnaire is not operation specific and no comparison with norm data is possible!
Federici et al examined blepharoptosis surgery patients’ upper eyelid position and superior visual field height, as well as subjective visual function and health related quality of life functional status before and after ptosis surgery. An increase of functional status was mentioned postoperative.33 Nevertheless, the same not validated and not standardized questionnaire was used as in the study mentioned above from Mellington et al.
Asano et al investigated QoL in 21 patients with blephraoptosis before and after surgical treatment with a questionnaire adapted to the VFQ “Visual Function Questionnaire.”34 Even in this study neither a standardized questionnaire was used, nor was the data compared with representative norm data.
The combination of standardized questionnaires for our study was carefully chosen by a research group of psychologists and surgeons from a large variety of questionnaires.
All of the contributors have developed multiple quality of life studies and recognize a broad spectrum of assessment instruments. As a consequence the selection of our questionnaires is a very severe considered decision. This is a retrospective designed study and validated and standardized questionnaires and data are therefore compared with national norm population. Our standardized questionnaires are characterized by validation through German norm population data. This is an enormous important aspect. Despite the missing preoperative data, the comparison of results to national norm population data and not to aesthetic patients is very important for psychologists and psychiatrists just for that reason!
Furthermore, in accordance with the definition of quality of life, we compared the results to national norm data. Quality of life is defined as a multifactorial term in the context of culture, tradition, and value systems in which patients live as well as in relation to their goals, expectations, standards, and concerns. And it is affected by local factors. Therefore, we compared the results with the data of our country, same gender, and same age.
During the past, postoperative measurements were orientated mainly to the interests of surgeons themselves.35 The result of a surgical intervention cannot totally be considered a success if only the surgeon is satisfied. Patients themselves should be pleased with the performance as well.36 Technical aspects of aesthetic surgery are important but the satisfaction of the patient with the postoperative result is the determining factor for the success of the treatment.
There has not been done a lot to evaluate the patient's opinion on the surgical result.37 However, clinical research should be characterized by the evaluation of the patient-related results of medical interventions; and with an emphasis on the effectiveness of outcomes in terms of patient satisfaction or quality of life.38,39
In the last years interest in patient-related results has risen continuously since quality of life gains more and more importance in our society. As far as we know there are no other reports in the literature evaluating the quality of life and psychological effects with standardized and validated questionnaires, following elective aesthetic surgery in face.
The circumstance that some of the resulting scores of this study are lower than the norm population is associated with the patient's category. Aesthetic patients are highly sophisticated and ambitious, and are expecting an extraordinary or even excellent result of the operation. Even though the subjective outcome of the elective operation is estimated very well by patients, it does not necessarily lead to an improvement in quality of life. The item “leisure time, hobbies” developed with a statistical significant lower score than the norm population. In our opinion it is reasonable due to the fact that nearly all participants were in retirement age or near of it, and their priorities are not assigned to that item.
For these reasons, in our opinion it would be very important to continue and perform a prospective study, to compare pre- and postoperative scores of the same patient category.
Blepharoplasty positively influences the patient's quality of life postoperatively. In our QoL study after transdermal blepharoplasty, data were compared with standardized norm data concerning satisfaction with life generally, with health and with appearance (body image), thus covering a wide range of items and parameters of everyday life concerning QoL. The sum score of the FLZM module general life reached higher sores in comparison with the norm population. Furthermore, the participants of our study profit from a well-balanced emotional stability (P = 0.02) according to the FPI-R and have a high self-esteem (P < 0.001) as measured with the RES after the intervention. Through these findings we showed an improvement in different parameters of everyday life and a positive influence on patient's psychological condition.
Finally, we showed that elective aesthetic surgery is very well tolerated by our patients, has a low complication rate, and brings an appropriate high satisfaction with the aesthetic result. Nevertheless, a prospective study is still needed in our opinion, for the better understanding of the impact of blepharoplasty on the QoL of our patients.
The authors thank Dr med Vesna Mirceva, currently Dermatologist in Athens, Greece, and Prof Dr med Edgar Biemer, Plastic Surgeon, Professor Emeritus of the Munich Technical University, Munich, Germany. Their fruitful discussions on planning this evaluation as we started to think about this idea at the very beginning were important afterward for the final study design.
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