Face-Lift Satisfaction Using the FACE-Q Outcomes

COSMETIC Outcomes Article Face-Lift Satisfaction Using the FACE-Q Sammy Sinno, M.D. Jonathan Schwitzer, B.S. Lavinia Anzai, B.S. Charles H. Thorne, M.D. New York, N.Y. Background: Face lifting is one of the most common operative procedures for facial aging and perhaps the procedure most synonymous with plastic surgery in the minds of the lay public, but no verifiable documentation of patient satisfaction exists in the literature. This study is the first to examine face-lift outcomes and patient satisfaction using a validated questionnaire. Methods: One hundred five patients undergoing a face lift performed by the senior author (C.H.T.) using a high, extended–superficial musculoaponeurotic system with submental platysma approximation technique were asked to complete anonymously the FACE-Q by e-mail. FACE-Q scores were assessed for each domain (range, 0 to 100), with higher scores indicating greater satisfaction with appearance or superior quality of life. Results: Fifty-three patients completed the FACE-Q (50.5 percent response rate). Patients demonstrated high satisfaction with facial appearance (mean ± SD, 80.7 ± 22.3), and quality of life, including social confidence (90.4 ± 16.6), psychological well-being (92.8 ± 14.3), and early life impact (92.2 ± 16.4). Patients also reported extremely high satisfaction with their decision to undergo face lifting (90.5 ± 15.9). On average, patients felt they appeared 6.9 years younger than their actual age. Patients were most satisfied with the appearance of their nasolabial folds (86.2 ± 18.5), cheeks (86.1 ± 25.4), and lower face/ jawline (86.0 ± 20.6), compared with their necks (78.1 ± 25.6) and area under the chin (67.9 ± 32.3). Conclusion: Patients who responded in this study were extremely satisfied with their decision to undergo face lifting and the outcomes and quality of life following the procedure. (Plast. Reconstr. Surg. 136: 239, 2015.) F ace lifts are among the most common operations for facial aging and perhaps the procedure most synonymous with plastic surgery in the minds of the lay public. Nearly 130,000 face lifts were performed in the United States last year.1 A limited number of studies have attempted to assess patient outcomes after face lifting,2,3 but the lack of a standardized outcome tool has made assessment of patient satisfaction difficult. Recently, the FACE-Q has been established as a validated tool for evaluating patient satisfaction and outcomes in aesthetic facial surgery.4–10 Our goal was to use a validated questionnaire to assess patient-reported satisfaction after face lifting. PATIENTS AND METHODS One hundred five patients undergoing a face lift between 2011 and 2014 performed by the From New York University Institute of Reconstructive Plastic Surgery and Lenox Hill Hospital Plastic Surgery. Received for publication November 19, 2014; accepted January 15, 2015. Copyright © 2015 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000001412 senior author (C.H.T.) using a high, extended superficial musculoaponeurotic system (SMAS) technique with submental dissection and platysmaplasty were asked to complete, anonymously, the FACE-Q following the procedure. The FACE-Q is a new patient-reported outcome instrument composed of numerous independently functioning scales designed to measure outcomes among facial aesthetic patients.4–11 Patients were asked to complete the following FACE-Q scales: 1. Satisfaction with Facial Appearance Overall: Measures patient satisfaction with the overall appearance of their face. 2. Social Function: Has a series of positively worded statements that measure social confidence. 3. Psychological Well-being: Measures psychological well-being in terms of a series of positively worded statements. Disclosure: The authors have no financial interest to declare in relation to the content of this article. www.PRSJournal.com 239 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • August 2015 4. Satisfaction with Outcome: Measures patient satisfaction with the overall outcome of the procedure. 5. Satisfaction with Decision: Measures patient satisfaction with their decision to undergo the procedure. 6. Early Life Impact: Assesses patient recovery following the procedure. 7. Aging Appraisal Visual Analogue Scale: Asks patients how old they believe they appear compared with their actual age (patients answer in years). 8. Area-Specific Appearance Appraisal: Patients were also asked to complete the following five scales that evaluate satisfaction with specific facial areas: cheeks, nasolabial folds, lower face and jawline, area under chin, and neck. All FACE-Q scales ask patients to answer items with facial appearance in mind. Patients were sent the FACE-Q scales electronically by means of an e-mail from the senior author (C.H.T.) emphasizing the anonymous nature of this study. Raschtransformed scores (range, 0 to 100) were assessed for each domain.12 Higher FACE-Q scores indicate greater satisfaction with appearance, process of care (outcome or decision), or superior quality of life (social confidence, psychological well-being, or early life impact). Data analysis was conducting using IBM SPSS Version 21.0 software (IBM Corp, Armonk, N.Y.). RESULTS Fifty-three patients completed the FACE-Q, for a 50.5 percent response rate. Patients ranged in age from 50 to 80 years, with a mean of 63.0 years (Table 1). The follow-up interval ranged from 3 to 72 months. Appearance Appraisal Following a face lift, patients demonstrated high levels of satisfaction with facial appearance overall (mean ± SD, 80.7 ± 22.3) (Table 2). Regarding the specific area appearance appraisal, Table 1. Patient Demographics FACE-Q Scale No. (%) No. of patients Sex Female Male Age, yr Mean ± SD Range 53 53 (100) — 63.0 ± 6.1 50–80 Table 2. FACE-Q Scores FACE-Q Domain and Scale Appearance Appraisal Satisfaction with Facial Appearance Overall Satisfaction with Cheeks Appraisal of Nasolabial Folds Satisfaction with Lower Face and Jawline Appraisal of Area Under Chin Appraisal of Neck Quality of Life Social Function (Confidence) Psychological Well-Being Early Life Impact Aging Appraisal Visual Analogue Scale, yr Process of Care Satisfaction with Outcome Satisfaction with Decision Mean ± SD Score 80.7 ± 22.3 86.1 ± 25.4 86.3 ± 18.5 86.0 ± 20.6 67.9 ± 32.3 78.1 ± 25.6 90.4 ± 16.6 92.8 ± 14.3 92.2 ± 16.4 −6.9 ± 5.4 77.2 ± 17.7 90.5 ± 15.9 patients demonstrated high levels of satisfaction in all areas evaluated. However, patients were most satisfied with the appearance of their nasolabial folds (86.2 ± 18.5), cheeks (86.1 ± 25.4), lower face and jawline (86.0 ± 20.6), compared with satisfaction with the appearance of their necks (78.1 ± 25.6) and area under the chin (67.9 ± 32.3). Quality of Life Patients also exhibited high levels of quality of life, including in social confidence (90.4 ± 16.6), psychological well-being (92.8 ± 14.3), and early life impact of the procedure (92.2 ± 16.4). On average, patients felt they appeared 6.9 years younger than their actual age, with 40 of 45 patients (88.8 percent) believing they appeared at least 5 years younger than their actual age. Process of Care Patients reported high satisfaction with the decision to undergo and the outcome of the procedure. DISCUSSION The evolution of the modern face lift began with Skoog, who described a subfascial dissection.13 Mitz and Peyronie soon after described the superficial musculoaponeurotic system.14 Subsequently, numerous techniques have been described that include a variety of skin incisions, dissection planes and boundaries, and fixation techniques. Instead of one technique being superior to another, it is likely that a competent, experienced surgeon using one of several techniques can produce a satisfactory result in the appropriately selected patient. 240 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Volume 136, Number 2 • Face-Lift Satisfaction Using the FACE-Q Although several studies have attempted to compare outcomes between various techniques, a systematic review by Chang et al. concluded that there is a paucity of high-quality data to determine the safety and efficacy among techniques.15 The authors also pointed out the need for a validated patient-reported outcomes measure to best allow for comparison. Other patient satisfaction surveys for face lifting have been used previously but were not developed scientifically as rigorous patient outcome measures.16–18 A systematic review of all patient-reported outcome measures for facial rejuvenation revealed the need for an instrument to most accurately obtain patient satisfaction and outcomes in facial surgery.19 The FACE-Q was subsequently developed as a validated questionnaire to assess patient satisfaction and outcomes for various procedures in facial cosmetic surgery.4–6,8–10 The extended SMAS dissection is the face-lift technique most commonly used by the senior author. It involves a transverse incision in the SMAS above the zygomatic arch and preauricular vertical incision along the sternocleidomastoid muscle. The SMAS in the cheek and the platysma are elevated in continuity. Dissection is extended over the zygomaticus major muscle in the malar region and beyond the anterior edge of the parotid gland in the cheek, releasing the retaining ligaments. The SMAS-platysma flap is then rotated superiorly and posteriorly.20–23 The flap is redraped as vertically as possible with fixation along a line extending from the ear to the malar eminence. Once fixed superiorly in this fashion, the flap is fixed to the mastoid periosteum. All fixation is performed with Vicryl (Ethicon, Inc., Somerville, N.J.) sutures. Fat grafting is performed on an individual patient basis but in much smaller volumes than has been reported in the literature (seldom more than 10 cc per case). The patients also had a submental incision with approximation of the platysma muscles in the midline using a single layer of buried, interrupted Vicryl sutures. Liposuction and/or direct excision of preplatysmal, subplatysmal, and jowl fat is performed on an individual basis. The results of the present study show high patient satisfaction with overall facial appearance, nasolabial folds, lower face, and jawline. Confidence, psychological well-being, and early life impact after the face lift were also rated high. Patients on average felt they appeared 6.9 years younger, which is 3.8 years younger than another report in the literature.24 The neck and area underneath the chin had favorable but lower satisfaction scores.25 Of note, the senior author’s primary goal when performing the extended SMAS flap is to improve the contour of the jawline, which correlated with higher scores. We were surprised to learn how much patients were satisfied with the appearance of their nasolabial folds, an area that the senior author believes is not significantly improved by his technique. This may be an example of the common phenomenon of patients perceiving things differently from the surgeon. Similarly, the patients reported less satisfaction with the neck and higher satisfaction with the jawline, two areas that the surgeon sees as related. It may be that the patients are referring to the lower neck where rhytides and excess skin are not improved by face lifting, rather than the enhanced appearance of the upper neck from a cleaner jawline. This study makes no attempt to establish the relative efficacy of the high, extended SMAS technique compared with any other technique. Rather, the sole purpose is to assess satisfaction after face lifting generally, using a validated questionnaire, because no such study has been reported. It is likely that a sample of the same surgeon’s patients taken after a longer interval between surgery and completion of the FACE-Q would yield different results. It is also likely that factors such as the relationship the patients have with the surgeon, the urban environment where the senior author practices, and the age and socioeconomic status of the patients influenced their satisfaction. Other samples of face-lift patients from other parts of the world may have resulted in different outcomes, even if the results were identical. In this study, the patients knew that their responses were anonymous. The e-mailed responses were collated without any knowledge of the origin of any individual response and without communicating any information about any response to the authors. It is possible that the more dissatisfied patients did not complete the questionnaire. The responses might have been more positive if the patients thought their surgeon would see or receive information about their answers. Limitations of this study include lack of preoperative sampling. Having patients complete the FACE-Q in the office during follow-up would have guaranteed a higher response rate and likely generated more positive responses. Future studies should assess satisfaction after longer follow-up compared with the short follow-up in this study. In addition, one could assess patient outcomes when one or more procedures are combined (i.e., face lifts versus face lift with blepharoplasty versus brow lift). Finally, although patient satisfaction was high, the evaluation of prospective data may allow us to focus on areas where satisfaction is less, to refine techniques and improve outcomes. 241 Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited. Plastic and Reconstructive Surgery • August 2015 Satisfaction after face lifting, or any cosmetic procedure, is enormously complex. The number of factors that impact an individual’s satisfaction is so large that it would be impossible to match groups sufficiently to compare one technique versus another. Even if those factors could be identified, they would be virtually impossible to quantify; patients’ baseline attractiveness, happiness, expectations, personal relationships, selfimage, and personal relationships are probably more important than the choice of a particular technique in determining subjective satisfaction. CONCLUSIONS Patients who responded in this study were extremely satisfied with their decision to undergo face lifting and the outcomes and quality of life following the procedure. In this era where the search for noninvasive alternatives to face lifting is relentless, this study demonstrates that face lifting should not be discarded as the standard against which other procedures are compared until a time when other procedures can demonstrate comparable satisfaction. Charles H. Thorne, M.D. 812 Park Avenue New York, N.Y. [email protected] 7. 8. 9. 10. 11. 12. 13. 14. 15. ACKNOWLEDGMENT The authors would like to thank Andrea Pusic, M.D., for all of her contributions to this study. 16. 17. REFERENCES 1. Hotta TA. ASAPS (American Society of Aesthetic Plastic Surgery)–2013 Annual Statistics. Plast Surg Nurs. 2014;34:47–48. 2. Friel MT, Shaw RE, Trovato MJ, Owsley JQ. The measure of face-lift patient satisfaction: The Owsley Facelift Satisfaction Survey with a long-term follow-up study. Plast Reconstr Surg. 2010;126:245–257. 3. Ellenbogen R. A 15-year follow-up study of the non-SMAS skin-tightening facelift with midface defatting: Equal or better than deeper plane procedures in result, duration, safety, and patient satisfaction. Clin Plast Surg. 1997;24:247–267. 4. Klassen AF, Cano SJ, Schwitzer J, Scott A, Pusic AL. 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