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Plastic Surgery Research Council

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Patient Interpretation Of Postoperative Results: Is There A Right Way To Ask Questions And Display Photographs?
Helen Xun, BS1, Karan Chopra, MD2, Robin Yang, MD, DDS1, Mark Codner2, Justin M. Sacks, MBA, MD, FACS1.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Mark Codner Plastic Surgery, Atlanta, GA, USA.

PURPOSE: Many plastic surgeons utilize the internet to educate patients and guide postoperative expectations. In the context of this emerging trend where experts are posting pictures to a novice population, little to no studies have been conducted on how well the untrained eye is able to appreciate plastic surgery enhancements. Consequently, the goal of this project was to determine the effect of various forms of displaying before and after photographs of facelifts on perceived cosmetic result by untrained observers. Specifically, we investigate how noticeable the persistence of a sagging jowl after facelift is to the public eye in various forms of presentations and survey methods. We use this evidence to make formalized recommendations for plastic surgeons to optimize public perceptions of positive cosmetic outcomes.
METHODS: QualtricsTM survey was distributed through Mechanical Turks. To test the subtle interpretation of the sagging jowl, we presented the outcomes in three presentation forms. In the first two scenarios, surveyors were presented with the entire face of the individual or just the mental region (pre- and post-facelift, either with or without sagging jowls, Figure 1), and asked to assess the (1) attractiveness, (2) youthfulness, and (3) friendliness on both numerical (Likert), and categorical scales. Lastly, surveyors were then provided with three photographs pictures of the same individual (before facelift, after facelift with jowls present, and after facelift altered to efface the jowls) and asked to rank them from most attractive to least attractive.
RESULTS: The survey was completed by 368 subjects, with an average age of 22 (19 to 80) years, and 207 (56.1%) were female. When post-operative facelift photos of the entire face were evaluated independently, individuals without jowls were perceived as younger than individuals with sagging jowls (p < 0.05) on a categorical scale. When just the chin was viewed, individuals with no jowls were viewed as having a better surgical outcome (p<0.05), and surveyors were more likely to agree that they would undergo the procedure (p<0.05) on categorical scales. In both cases, categorical scales revealed statistically significant differences in youthfulness, but the Likert scale did not. In side by side comparisons, the post-operative facelift without residual jowling was ranked most youthful (p<0.0001).
CONCLUSION: The present work suggests that, when assessing subtle physical findings (i.e., sagging jowls) after cosmetic surgery, categorical questions tend to achieve statistical significance more often than questioning based on the Likert scale. Findings are also very different when the feature of interest is presented in full context of the face versus isolated. Furthermore, more appreciable differences are made when directly comparing subtle features side by side. Based on these findings, we recommend that when physicians study cosmetic outcomes, to use categorical questions rather than Likert scale. Furthermore, when presenting outcomes, we recommend that physicians use side-by-side photographs compatible with both full PC view and mobile-view.


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