Sinno et al.1 claim that “no verifiable documentation of patient satisfaction exists in the literature” and that their study “is the first to examine face-lift outcomes and patient satisfaction using a validated questionnaire.” Study limitations merit comment. Importantly, the FACE-Q assesses appearance (how patients “look right now”2) and quality of life at the time of the questionnaire. Responders took the test only once. “Satisfaction with facial appearance”2,3 is not the same as patient satisfaction with the result, the most important determinant of surgical success.4–6 Really, two questionnaires are needed, one before surgery and one after, to determine whether the surgery had any real effect on perceived age. The authors want to know the effect of surgery but are not asking for this information. Examples of more direct questions contained in ad hoc surveys5 include the following: Are you satisfied with the result of your surgery? Do you appear younger? Has the surgery improved your quality of life? Assessing patient satisfaction need not be “enormously complex”1; it can be as straightforward as asking the patient.5
Validity is simply the ability of a test to measure what it intends to measure.6–8 Validity is not an intrinsic test property; it is a relative quality best determined by the user.7,8 Too often, claims of validity are code for “we have done the analyses and you can take our word for it.” The FACE-Q developers looked for a correlation between high facial appearance scores and low perceived age scores to support their claim to validity.2,9 Does such a single test of correlation, chosen by the investigators, really impart validity for the test as a whole? After all, patients who believe they have an attractive facial appearance are also likely to believe they appear youthful.
Methodologic deficiencies weaken the FACE-Q, including the heterogeneity of the database that included nonconsecutive patients recruited by numerous clinics,2,3 discrepancies in reported group sizes,2,3 missing data,3 inclusion of face-lift candidates who may not have undergone face lifts,2 a low (44 percent) response rate,2 comparison of preoperative and postoperative data from different patients,9 and inclusion of 100 patients that were part of a trial by an unnamed medical device company.2 Similar to the BREAST-Q,4 the FACE-Q provides general indices, on a scale of 0 to 100.1 It is too blunt an instrument to compare face-lift techniques as originally proposed.2
Like the BREAST-Q, the FACE-Q is promoted in our professional journals10 and on the home page of the American Society for Aesthetic Plastic Surgery Web site, along with the claim, “setting a higher bar in patient reported outcome measurement.”11 Its development has been the subject of at least five publications,2,3,9,12,13 although the actual test questions and scales remain unpublished. The test questions are missing because this test is proprietary.13 Copyrighting a questionnaire sets a worrisome precedent for our specialty.14 Following this trend, another investigator recently patented his method for measuring change in lip size after augmentation.15 As plastic surgeons patent their methods, their innovations become less accessible. Medical advancement depends on physicians’ willingness to give as they have received.14 To protect this freedom, patenting medical innovations is prohibited by our professional societies.14,16
Plastic surgery questionnaires are meant to be surveys, not tests.8 Psychometrics literally means “mind measure.” Psychometrics are useful when designing psychological test questions to arrive at a single index, such as scholastic aptitude or an intelligence quotient.7 The need is much different in plastic surgery. Such a general index is meaningless to patients who have specific concerns, such as the length of recovery and scarring.5,12 Mailing or e-mailing test booklets to patients is prone to inadequate response rates.1–4 The authors’ response rate was only 50.5 percent,1 well below the 80 percent benchmark for evidence-based medicine.17 Personal interviews are rewarded with greater patient compliance and more thoughtful and complete answers.5
The FACE-Q developers claim that their device was “developed according to international guidelines for patient-reported outcome instrument development.”13 However, the referenced guidelines18 do not include psychometric testing or Rasch modeling. Existing statistical tests are sufficient.5,8 Outsourcing data for interpretation by the test developers (as was done in this study1) is unnecessary and paternalistic. Plastic surgeons are unfamiliar with the psychometric jargon that permeates the “Q” literature.8 Unfortunately, insistence on psychometrics may stifle plastic surgeons’ interest in performing their own outcome studies,8 which is a shame. Outcome studies do not need to be complicated to be useful.5,8 In fact, the reverse is true; simplicity is a virtue. There is no better education than conducting outcome surveys with one’s patients.
The author has no financial interest in any of the products, devices, or drugs mentioned in this correspondence. The author has no conflicts of interest to disclose. There was no outside funding for this study.
Eric Swanson, M.D.
11413 Ash Street
Leawood, Kan. 66211
1. Sinno S, Schwitzer J, Anzai L, Thorne CH. Face-lift satisfaction using the FACE-Q. Plast Reconstr Surg. 2015;136:249–242.
2. Klassen AF, Cano SJ, Scott AM, Pusic AL. Measuring outcomes that matter to face-lift patients: Development and validation of FACE-Q appearance appraisal scales and adverse effects checklist for the lower face and neck. Plast Reconstr Surg. 2014;133:21–30.
3. Pusic AL, Klassen AF, Scott AM, Cano SJ. Development and psychometric evaluation of the FACE-Q satisfaction with appearance scale: A new patient-reported outcome instrument for facial aesthetics patients. Clin Plast Surg. 2013;40:249–260.
4. Cano SJ, Klassen AF, Scott AM, Cordeiro PG, Pusic AL. The BREAST-Q: Further validation in independent clinical samples. Plast Reconstr Surg. 2012;129:293–302.
5. Swanson E. Outcome analysis in 93 facial rejuvenation patients treated with a deep-plane face lift. Plast Reconstr Surg. 2011;127:823–834.
6. Pusic AL, Lemaine V, Klassen AF, Scott AM, Cano SJ. Patient-reported outcome measures in plastic surgery: Use and interpretation in evidence-based medicine. Plast Reconstr Surg. 2011;127:1361–1367.
7. Murphy KR, Davidshofer CO. Psychological Testing: Principles and Applications.
2005.6th ed. Upper Saddle River, NJ; Pearson/Prentice Hall.
8. Swanson E. Validity, reliability, and the questionable role of psychometrics in plastic surgery. Plast Reconstr Surg Glob Open 2014;2:e161.
9. Panchapakesan V, Klassen AF, Cano SJ, Scott AM, Pusic AL. Development and psychometric evaluation of the FACE-Q Aging Appraisal Scale and Patient-Perceived Age Visual Analog Scale. Aesthet Surg J. 2013;33:1099–1109.
12. Klassen AF, Cano SJ, Scott A, Snell L, Pusic AL. Measuring patient-reported outcomes in facial aesthetic patients: Development of the FACE-Q. Facial Plast Surg. 2010;26:303–309.
13. Klassen AF, Cano SJ, Schwitzer JA, Scott AM, Pusic AL. FACE-Q scales for health-related quality of life, early life impact, satisfaction with outcomes, and decision to have treatment: Development and validation. Plast Reconstr Surg. 2015;135:375–386.
14. Swanson E. The commercialization of plastic surgery. Aesthet Surg J. 2013;33:1065–1068.
17. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Therapy. Evidence-Based Medicine
. 2000:2nd ed. Toronto: Churchill Livingstone; 105–153.
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