DISCUSSION Discussion: Patient-Reported Outcomes in Weight Loss and Body Contouring Surgery: A Cross-Sectional Analysis Using the BODY-Q Samuel J. Lin, M.D., M.B.A. Boston, Mass.
I
had the pleasure of reviewing “Patient-Reported Outcomes in Weight Loss and Body Contouring Surgery: A Cross-Sectional Analysis Using the BODY-Q” by Poulsen et al. Patient-reported outcome has emerged as one of the key drivers in this arena of evidence based medicine and relies on the subjective assessment of the patient with the existing condition undergoing treatment for the specific treatment. It differs from other types of objectified outcomes assessments such as utility-based outcomes (e.g., time tradeoff, visual analogue scale) in plastic surgery that rely on a population-based sampling of “patients” who do not have the existing condition being studied and do not undergo treatment.1–13 Critiques for utilitybased studies may be related to not having actual patients but a strength of the method, because the subjects are not “biased” with the existing condition and treatment. Conversely, critiques of patient-reported outcomes may center on the inherent “bias” that actual patients with the existing condition have who then quantify their experience over time. Nonetheless, the downstream effects following the BREAST-Q has caused the emergence of other patient-reported outcomes– related instruments (e.g., FACE-Q).14–16 The authors of this article aimed to assess quality of life in patients undergoing weight loss surgery measured by the BODY-Q. The BODY-Q is a newly developed patient-reported outcomes instrument designed specifically to measure outcomes over the entire patient journey, from obesity to the post–body contouring surgery period. This aspect is unique in that the article chronologically follows these patients along their entire course of weight loss to body contouring. Between June of 2015 and June of 2016, a total of 493 patients completed the BODY-Q. Patients were in different From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School. Received for publication April 26, 2017; accepted May 1, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003651
groups, before bariatric surgery to the post–body contouring surgery period. The response rate for the bariatric group was 83 percent, and the response rate for the body contouring group was 72 percent. Pre–bariatric surgery patients constituted 19 percent of the group, post–bariatric surgery patients constituted 20 percent, pre–body contouring surgery patients constituted 28 percent, and post–body contouring surgery patients constituted 33 percent. The mean quality-of-life scores were significantly lower in the pre–bariatric surgery group compared with the post–body contouring group. The authors conclude that their study provides evidence to suggest that body contouring plays an important role in the weight loss “journey” and that patients need access to treatment. The authors acknowledge areas of future study that could be investigated; the measurements are all from different patients, with only a relatively small number of patients filling in the questionnaire at different time points (Table 3). It appears that the number of assessments completed per participant significantly dropped off after the first one. I wonder how this could affect results and whether the results would change when objectifying results per step of the process of before to after weight loss followed by body contouring procedures. I agree with the authors that areas of limitation also center on the methodology and lack of longitudinal assessment; in other words, the authors have an important longitudinal study design for assessing patients throughout the entire journey of weight loss, follow-up, surgery after weight loss, and final follow-up but do not have longitudinal assessment in the same patient. A longitudinal study would have provided a different perspective. What are the implications Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
501
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017 if patients do not undergo body contouring? Nonetheless, I also wonder what inherent bias there may or may not be when the same respondents have already answered the same survey multiple times. Except for abdominal contouring, the number of procedures performed on other anatomical areas is smaller; I wonder how a power calculation would have identified minimum numbers of different areas. The lack of an objective scale for the determination of skin excess also makes the analysis challenging. In the absence of an objective scale, the authors used a patient-reported outcomes instrument that had the patients rank their degree of discomfort with having extra skin/ subcutaneous tissue. Perhaps not having a Likertbased scale (Table 1) and using other methods would be a more helpful means of objectively measuring extra skin preoperatively. In other thoughts, I wonder whether there may be an associative trend when correlating comorbidity, marital status, and education independently related to patient-reported outcomes. I commend the authors for embarking on a long-term project related to bariatric surgery and body contouring after weight loss. It is a challenge but an opportunity to have this well-thought-out plan to have longer term follow-up. The results are favorable in general terms for body contouring at these time points, and I anticipate that longitudinal data are likely forthcoming and will be important as practitioners and hospital systems may be tasked with justifying and providing more bundled care in the future. Samuel J. Lin, M.D., M.B.A. 110 Francis Street, Suite 5A Boston, Mass. 02215 [email protected]
REFERENCES 1. Ibrahim AM, Sinno HH, Izadpanah A, et al. Nipple-areolar complex reconstruction following postmastectomy breast
reconstruction: A comparative utility assessment study. Plast Reconstr Surg Glob Open 2015;3:e380. 2. Ibrahim AM, Sinno HH, Izadpanah A, et al. Population preferences of undergoing brachioplasty for arm laxity. Ann Plast Surg. 2014;73(Suppl 2):S149–S152. 3. Ibrahim AM, Sinno HH, Izadpanah A, et al. Mastopexy for breast ptosis: Utility outcomes of population preferences. Plast Surg (Oakv.) 2015;23:103–107. 4. Izadpanah A, Sinno H, Vorstenbosch J, Lee BT, Lin SJ. Thigh laxity after massive weight loss: A utilities outcomes assessment. Ann Plast Surg. 2013;71:304–307. 5. Sinno H, Izadpanah A, Thibaudeau S, et al. The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: A utility outcomes score assessment. Ann Plast Surg. 2012;69:431–434. 6. Sinno H, Thibaudeau S, Izadpanah A, et al. Utility outcome scores for unilateral facial paralysis. Ann Plast Surg. 2012;69:435–438. 7. Sinno H, Thibaudeau S, Tahiri Y, et al. Utility assessment of body contouring after massive weight loss. Aesthetic Plast Surg. 2011;35:724–730. 8. Sinno H, Izadpanah A, Tahiri Y, et al. The impact of living with severe lower extremity lymphedema: A utility outcomes score assessment. Ann Plast Surg. 2014;73:210–214. 9. Sinno H, Dionisopoulos T, Slavin SA, Ibrahim AM, Chung KC, Lin SJ. The utility of outcome studies in plastic surgery. Plast Reconstr Surg Glob Open 2014;2:e189. 10. Sinno H, Izadpanah A, Vorstenbosch J, et al. Living with a unilateral mastectomy defect: A utility assessment and outcomes study. J Reconstr Microsurg. 2014;30:313–318. 11. Sinno HH, Ibrahim AM, Izadpanah A, et al. Utility outcome assessment of the aging neck following massive weight loss. Otolaryngol Head Neck Surg. 2012;147:26–32. 12. Sinno H, Tahiri Y, Thibaudeau S, et al. Cleft lip and palate: An objective measure outcome study. Plast Reconstr Surg. 2012;130:408–414. 13. Sinno H, Izadpanah A, Thibaudeau S, Christodoulou G, Lin SJ, Dionisopoulos T. An objective assessment of the perceived quality of life of living with bilateral mastectomy defect. Breast 2013;22:168–172. 14. Pusic AL, Reavey PL, Klassen AF, Scott A, McCarthy C, Cano SJ. Measuring patient outcomes in breast augmentation: Introducing the BREAST-Q Augmentation module. Clin Plast Surg. 2009;36:23–32, v. 15. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345–353. 16. 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.
502 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
I
had the pleasure of reviewing “Patient-Reported Outcomes in Weight Loss and Body Contouring Surgery: A Cross-Sectional Analysis Using the BODY-Q” by Poulsen et al. Patient-reported outcome has emerged as one of the key drivers in this arena of evidence based medicine and relies on the subjective assessment of the patient with the existing condition undergoing treatment for the specific treatment. It differs from other types of objectified outcomes assessments such as utility-based outcomes (e.g., time tradeoff, visual analogue scale) in plastic surgery that rely on a population-based sampling of “patients” who do not have the existing condition being studied and do not undergo treatment.1–13 Critiques for utilitybased studies may be related to not having actual patients but a strength of the method, because the subjects are not “biased” with the existing condition and treatment. Conversely, critiques of patient-reported outcomes may center on the inherent “bias” that actual patients with the existing condition have who then quantify their experience over time. Nonetheless, the downstream effects following the BREAST-Q has caused the emergence of other patient-reported outcomes– related instruments (e.g., FACE-Q).14–16 The authors of this article aimed to assess quality of life in patients undergoing weight loss surgery measured by the BODY-Q. The BODY-Q is a newly developed patient-reported outcomes instrument designed specifically to measure outcomes over the entire patient journey, from obesity to the post–body contouring surgery period. This aspect is unique in that the article chronologically follows these patients along their entire course of weight loss to body contouring. Between June of 2015 and June of 2016, a total of 493 patients completed the BODY-Q. Patients were in different From the Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School. Received for publication April 26, 2017; accepted May 1, 2017. Copyright © 2017 by the American Society of Plastic Surgeons DOI: 10.1097/PRS.0000000000003651
groups, before bariatric surgery to the post–body contouring surgery period. The response rate for the bariatric group was 83 percent, and the response rate for the body contouring group was 72 percent. Pre–bariatric surgery patients constituted 19 percent of the group, post–bariatric surgery patients constituted 20 percent, pre–body contouring surgery patients constituted 28 percent, and post–body contouring surgery patients constituted 33 percent. The mean quality-of-life scores were significantly lower in the pre–bariatric surgery group compared with the post–body contouring group. The authors conclude that their study provides evidence to suggest that body contouring plays an important role in the weight loss “journey” and that patients need access to treatment. The authors acknowledge areas of future study that could be investigated; the measurements are all from different patients, with only a relatively small number of patients filling in the questionnaire at different time points (Table 3). It appears that the number of assessments completed per participant significantly dropped off after the first one. I wonder how this could affect results and whether the results would change when objectifying results per step of the process of before to after weight loss followed by body contouring procedures. I agree with the authors that areas of limitation also center on the methodology and lack of longitudinal assessment; in other words, the authors have an important longitudinal study design for assessing patients throughout the entire journey of weight loss, follow-up, surgery after weight loss, and final follow-up but do not have longitudinal assessment in the same patient. A longitudinal study would have provided a different perspective. What are the implications Disclosure: The author has no financial interest to declare in relation to the content of this Discussion or of the associated article.
www.PRSJournal.com
501
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • September 2017 if patients do not undergo body contouring? Nonetheless, I also wonder what inherent bias there may or may not be when the same respondents have already answered the same survey multiple times. Except for abdominal contouring, the number of procedures performed on other anatomical areas is smaller; I wonder how a power calculation would have identified minimum numbers of different areas. The lack of an objective scale for the determination of skin excess also makes the analysis challenging. In the absence of an objective scale, the authors used a patient-reported outcomes instrument that had the patients rank their degree of discomfort with having extra skin/ subcutaneous tissue. Perhaps not having a Likertbased scale (Table 1) and using other methods would be a more helpful means of objectively measuring extra skin preoperatively. In other thoughts, I wonder whether there may be an associative trend when correlating comorbidity, marital status, and education independently related to patient-reported outcomes. I commend the authors for embarking on a long-term project related to bariatric surgery and body contouring after weight loss. It is a challenge but an opportunity to have this well-thought-out plan to have longer term follow-up. The results are favorable in general terms for body contouring at these time points, and I anticipate that longitudinal data are likely forthcoming and will be important as practitioners and hospital systems may be tasked with justifying and providing more bundled care in the future. Samuel J. Lin, M.D., M.B.A. 110 Francis Street, Suite 5A Boston, Mass. 02215 [email protected]
REFERENCES 1. Ibrahim AM, Sinno HH, Izadpanah A, et al. Nipple-areolar complex reconstruction following postmastectomy breast
reconstruction: A comparative utility assessment study. Plast Reconstr Surg Glob Open 2015;3:e380. 2. Ibrahim AM, Sinno HH, Izadpanah A, et al. Population preferences of undergoing brachioplasty for arm laxity. Ann Plast Surg. 2014;73(Suppl 2):S149–S152. 3. Ibrahim AM, Sinno HH, Izadpanah A, et al. Mastopexy for breast ptosis: Utility outcomes of population preferences. Plast Surg (Oakv.) 2015;23:103–107. 4. Izadpanah A, Sinno H, Vorstenbosch J, Lee BT, Lin SJ. Thigh laxity after massive weight loss: A utilities outcomes assessment. Ann Plast Surg. 2013;71:304–307. 5. Sinno H, Izadpanah A, Thibaudeau S, et al. The impact of living with a functional and aesthetic nasal deformity after primary rhinoplasty: A utility outcomes score assessment. Ann Plast Surg. 2012;69:431–434. 6. Sinno H, Thibaudeau S, Izadpanah A, et al. Utility outcome scores for unilateral facial paralysis. Ann Plast Surg. 2012;69:435–438. 7. Sinno H, Thibaudeau S, Tahiri Y, et al. Utility assessment of body contouring after massive weight loss. Aesthetic Plast Surg. 2011;35:724–730. 8. Sinno H, Izadpanah A, Tahiri Y, et al. The impact of living with severe lower extremity lymphedema: A utility outcomes score assessment. Ann Plast Surg. 2014;73:210–214. 9. Sinno H, Dionisopoulos T, Slavin SA, Ibrahim AM, Chung KC, Lin SJ. The utility of outcome studies in plastic surgery. Plast Reconstr Surg Glob Open 2014;2:e189. 10. Sinno H, Izadpanah A, Vorstenbosch J, et al. Living with a unilateral mastectomy defect: A utility assessment and outcomes study. J Reconstr Microsurg. 2014;30:313–318. 11. Sinno HH, Ibrahim AM, Izadpanah A, et al. Utility outcome assessment of the aging neck following massive weight loss. Otolaryngol Head Neck Surg. 2012;147:26–32. 12. Sinno H, Tahiri Y, Thibaudeau S, et al. Cleft lip and palate: An objective measure outcome study. Plast Reconstr Surg. 2012;130:408–414. 13. Sinno H, Izadpanah A, Thibaudeau S, Christodoulou G, Lin SJ, Dionisopoulos T. An objective assessment of the perceived quality of life of living with bilateral mastectomy defect. Breast 2013;22:168–172. 14. Pusic AL, Reavey PL, Klassen AF, Scott A, McCarthy C, Cano SJ. Measuring patient outcomes in breast augmentation: Introducing the BREAST-Q Augmentation module. Clin Plast Surg. 2009;36:23–32, v. 15. Pusic AL, Klassen AF, Scott AM, Klok JA, Cordeiro PG, Cano SJ. Development of a new patient-reported outcome measure for breast surgery: The BREAST-Q. Plast Reconstr Surg. 2009;124:345–353. 16. 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.
502 Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
