Outcomes Research in Facial Plastic Surgery

[*]Since the late 1980s, there has been a wellspring of interest in outcomes research among all of the medical and surgical subspecialities. At long last, the facial plastic surgery community has embraced this field of study, and the number of outcomes studies in our field continues to grow each year. In both the cosmetic and reconstructive realms, outcomes research methodology allows the surgeon to quantify the otherwise subjective, patient-related measure of satisfaction in a way that is meaningful and comprehensive. Such quantification also allows the facial plastic surgeon to compare different surgical approaches and technical nuances to achieve the highest level of patient satisfaction and, thus, surgical success.

This issue provides a starting point for the future of outcomes research in facial plastic surgery. As such, the emphasis remains both on what has already been done and the direction that we need to go from here. A focus is provided on a wide range of inter-related fields, including biostatistics, cost analysis, outcomes instrument methodology, medicolegal and psychiatric issues as well as individual discussions of both the cosmetic and reconstructive application of these techniques. This issue would not have come to fruition without the assistance and hard work of each of its contributors, who have joined together from a variety of specialties to provide insight into this relatively new field of study. For their contributions, we are deeply indebted.

Unlike other topics in facial plastic surgery, such as discussions of individual procedures or surgical techniques of interest, the importance of the field of outcomes research applies equally to every practitioner of our art. Although not every surgeon may be interested in the subtleties and differences between a cartilage versus Gortex graft in the nasal radix, every surgeon is interested in outcomes, that is, measuring the success of their surgical results. Whether one's focus is post-traumatic reconstruction, cosmetic aging face surgery, microvascular free flaps, or functional rhinoplasty, the goal remains the achievement of a successful result. This result, oftentimes, can be measured in terms of patient satisfaction. It is the quantification and measurement of this satisfaction with which outcomes research is most intimately concerned. Other aspects of this field, such as the accurate assessment of cost outcomes or the psychological effect a given procedure may have on the individual, are important components of this field as well. However, it is the ability to define just what patient satisfaction means that is unique to outcomes research as a field of study.

If outcomes research is ubiquitously applicable and wide ranging in its importance, then why hasn't there been greater interest in applying it to facial plastic surgery, particularly facial cosmetic surgery? There are several answers to this question. To some extent, cosmetic surgery and scientific evaluation do not go hand in hand. Certainly, the components of what makes patients happy are multifactorial and varied at best. The art and science of facial cosmetic surgery must be measured in the context of a competitive marketing environment, a bevy of anecdotal rhetoric as to who or where or what is best, and the strange circumstance in which not every good result is appreciated by the patient, and not every poor result is even noticed.

Another important reason there has hitherto been little interest in outcomes research in facial plastic surgery concerns the practical logistics of performing outcomes research in any setting, particularly the cosmetic setting. Some patients may be wary of any formal evaluation of their satisfaction, whether it is because they fear that it may reveal to their surgeon their true feelings or simply that they do not want to feel studied. We feel this reasoning is, to a large extent, unfounded. Just as patients have come to accept being asked personal questions such as their past history of alcohol use, sexual activity, or illicit drug use, we have found that patients are quite accepting of outcomes evaluations, even in the private cosmetic realm. In fact, many patients seem to appreciate the fact that their surgeon is concerned with how they feel and has taken the time to assess their feelings in a scientific fashion.

The one logistical obstacle that should indeed be recognized, however, is that outcomes research is not always easy. It takes significant time, energy, and resources to develop and test an outcomes instrument, formulate a prospective trial, recruit and maintain enough patients in a study, evaluate the results of an intervention, and understand the implication of such results, and, despite all of this hard work, there will always be issues of surgeon or technique dependency, implicit bias, and a lack of standardized comparisons. These issues may be stumbling blocks, but they should not prevent the dedicated surgeon from pursuing a better understanding of how to achieve the most successful outcomes, as measured by the most satisfied patients.

We are grateful to the editors of Facial Plastic Surgery as well as Thieme Medical Publishers for allowing us the honor of guest editing an issue that highlights this exciting new field of study. As you will see, the bad news is that very little has been done to apply outcomes research in a scientific and rigorous fashion to our field. On the bright side, the good news is that a world of opportunity awaits.