All providers agree that managing patient expectations is key to patient satisfaction. This is especially true – although nuanced – for those who practice aesthetic medicine. How can aesthetic providers ensure patient satisfaction when no two people will view improvement the same way? These two recently published, peer-reviewed clinical trials from Facial Plastic Surgery & Aesthetic Medicine and the Journal of Cosmetic Dermatology explore the role perception plays in patient satisfaction.
MORPHING TECHNOLOGY CREATES A CLEARER PICTURE
The ability to manipulate digital images, also called “morphing,” has become widespread in medicine, and aesthetic physicians are at the forefront of harnessing this technology as a tool to improve patient satisfaction.
Steven Pearlman, MD, director of Pearlman Plastic Surgery (New York City, N.Y.), has been using computer imaging in his practice for more than 30 years (first two-dimensional imaging, and now three-dimensional imaging). He uses it to help his patients get an idea of what their aesthetic result will look like, but the process is not as simple, accurate or effective as one might first suspect. This limits the usefulness of computer imaging in the clinical setting, according to Dr. Pearlman, who co-authored the investigation1 published in Facial Plastic Surgery & Aesthetic Medicine that compared pre-procedure computer-assisted image manipulation for the prediction of outcomes to equivalent images of the final surgical result, to quantify accuracy.
“It is a great tool, but for many procedures – even surgical ones – a software simulated outcome will not be accurate enough to be useful for precise micro-millimeter changes,” he explained. “That is why there is so much criticism that says it sets up unrealistic expectations, making it inappropriate to use as a sales tool.”
Instead, Dr. Pearlman insists it should be used as a communication tool. “We use it to help patients make the right choices by visualizing what they might look like in a way that promotes a better choice,” he expanded.
The study’s subject cohort (n=21, 15 women, mean age 27 years) were primary rhinoplasty patients undergoing dorsal hump reduction with a full follow-up; the sample size was chosen for conven
ience. For each image, the software mapped five equidistant points along the nasion-tip line; the nasion and nasal tip were chosen manually by the surgeon. The mean difference between the points from the morphed image to the post-procedure image was obtained and used to provide a single numerical value representing incongruity between the images. Differences were statistically examined via paired t-test. The mean difference between the two images was 0.43 mm (2.63 mm – 2.20 mm). Results were not statistically significant.
Dr. Pearlman notes that the nasal dorsum in dorsal hump reduction was studied because it is not only the most common aspect of nasal anatomy that patients want corrected – it is also an area where computer imaging can be used accurately. “We show what their nose might look like after surgery because, very often, the patient has limited ability to self-visualize that result,” he explained. “Some patients just want the hump reduced because they think it will solve their problem, but other aspects may need correction. The patient will not be able to see this for themselves until after the procedure – unless we can offer an acceptably accurate simulated image. Once they see it, they have a much more informed perspective on exactly what else might need work – when in their mind, they were only able to see the hump. As in the study, we use a standardized tool to capture the images and established medical imaging software for the task.”
Regardless of the study’s outcomes, Dr. Pearlman believes the results are still clinically relevant. “Whether you consider the accuracy of the projected result versus the actual surgical result, or vice versa, is irrelevant,” he emphasized. “The data suggests that one can successfully rely on the computer imaging morphed image to help you and the patient be on the same page during the consultation in nasal hump reduction cases, maximizing the chance that the patient has realistic expectations to inform their choices more fully. In these cases, literally nine out of ten patients who just want the hump removed also need tip work, and so the imaging can help patients more easily visualize why we need to do that to give them the result they are really looking for.”
This technology can also weed out any patients who may not be a good fit for the procedure, according to Dr. Pearlman. “It can help us discern who might have unrealistic expectations no matter what we do, in which case we would want to steer away from the procedure.”
Reference:
1. Harounian J, Tham T, Dodhia S, Pearlman S. Accuracy of surgeon predictions in rhinoplasty outcomes using computer imaging: a quantitative analysis of dorsal height. Facial Plast Surg Aesthet Med. 2022 May; Online ahead of print.
Editor’s Note: The original article Accuracy of Surgeon Predictions in Rhinoplasty Outcomes Using Computer Imaging: A Quantitative Analysis of Dorsal Height, is open access and available online at: https://www.liebertpub.com/doi/ abs/10.1089/fpsam.2022.0020
HIGHER DOSES, EXTENDED PATIENT SATISFACTION
Outside of safety and efficacy, patient satisfaction is one of the most common parameters examined when comparing injectable neurotoxins – and for good reason.
“My practice success is based mostly on patient happiness with outcomes and the impact they feel these have on their lives, not on my outcomes going into journals or putting me on the podium,” said Steven Dayan, MD, a facial plastic surgeon (Chicago, Ill.) and lead author of a study1 published in the Journal of Cosmetic Dermatology, which looked at subject satisfaction with results using higher than standard doses of injectable neurotoxin (specifically AbobotulinumtoxinA, or ABO).
“My patients do not really care about that, they care about how they look and feel – and what others think of how they look, considering first impressions and professionalism. We cannot forget that aspect,” he added.
Dr. Dayan notes that there could be some disadvantages to higher dosing of injectable neurotoxins, even if the results were predictable. “First there is the cost; extra units equal more money,” he explained. “In theory a novice could induce ptosis, but, then again, a novice could make any mistake. We have decades of experience behind the many solid training programs out there; one certainly would not want to start out with higher doses until they gained enough experience to be comfortable. If higher doses mean increased longevity of results, it also could mean increased longevity of adverse events – and a longer period of patient dissatisfaction. But if one could predictably get longer lasting results, that is useful information for our armamentarium.”
One goal of the study, according to Dr. Dayan, was to employ validated scales such as the Global Aesthetic Improvement Scale (GAIS) and the FACE-Q questionnaire. “With these relatively subjective measures of investigator-reported improvement, as well as patient reported improvement in appearance, satisfaction and quality of life, we need to use solid and recognized scales,” he said. “For patient perception, there is nothing more validated than FACE-Q, which captures how patients feel about themselves – improvement of which is our ultimate aim.”
Another strength of the study: The large subject pool of 399 patients across ten sites. “Between the sample size, sites and scales, it is an impressive protocol,” noted Dr. Dayan.
According to the data, ABO-dosed patients who received single treatments dosed at 50 to 125 units yielded statistically significant improvement with high patient satisfaction and reported psychological wellbeing persistent over the 36-week trial. “Higher doses did trend better and seemed to last longer, but again we had a wide range of doses between 50 and 125 units; the numbers are there but the differences are not profound,” Dr. Dayan said. “Nevertheless, it does suggest that higher doses will improve the longevity of outcomes. Also, we saw the same trend with perceived age versus current age; higher doses tended to reduce the perceived age more, and the effect lasted longer.”
Adverse events during the investigation were rare and non-serious.
“The next step would be further study to tease out optimal doses for these longer outcomes using scientifically validated measurements,” he concluded.
Reference:
1. Dayan S, Joseph J, Moradi A, Lorenc ZP, et al. Subject satisfaction and psychological well-being with escalating abobotulinumtoxinA injection dose for the treatment of moderate to severe glabellar lines. J Cosmet Dermatol. 2022;21(6):2407-2416.
Editor’s Note: The original article Subject Satisfaction and Psychological Well-being with Escalating Abobotulinumtoxina Injection Dose for the Treatment of Moderate to Severe Glabellar Lines, is open access and available online at: https://pubmed.ncbi.nlm.nih.gov/35266281/
