0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review | Evidence-Based Dermatology

Influence of Surgical and Minimally Invasive Facial Cosmetic Procedures on Psychosocial Outcomes:  A Systematic Review FREE

Sotonye Imadojemu, MD, MBE1,2; David B. Sarwer, PhD3,4,5; Ivona Percec, MD, PhD4,5,6; Seema S. Sonnad, PhD7; Jennifer E. Goldsack, MChem8; Morgan Berman, BA4; Joseph F. Sobanko, MD5,9
[+] Author Affiliations
1Department of Medicine, University of Pennsylvania, Philadelphia
2Department of Dermatology, University of Pennsylvania, Philadelphia
3Department of Psychiatry, University of Pennsylvania, Philadelphia
4Department of Surgery, University of Pennsylvania, Philadelphia
5Edwin & Fannie Gray Hall Center for Human Appearance, University of Pennsylvania, Philadelphia
6Division of Plastic Surgery, University of Pennsylvania, Philadelphia
7The Value Institute, Christiana Care Health System, Newark, Delaware
8Department of History and Sociology of Science and Medicine, University of Pennsylvania, Philadelphia
9Division of Dermatologic Surgery, University of Pennsylvania, Philadelphia
JAMA Dermatol. 2013;149(11):1325-1333. doi:10.1001/jamadermatol.2013.6812.
Text Size: A A A
Published online

Importance  Millions of surgical and minimally invasive cosmetic procedures of the face are performed each year, but objective clinical measures that evaluate surgical procedures, such as complication rates, have limited utility when applied to cosmetic procedures. While there may be subjective improvements in appearance, it is important to determine if these interventions have an impact on patients in other realms such as psychosocial functioning. This is particularly important in light of the Patient Protection and Affordable Care Act and its emphasis on patient-centered outcomes and effectiveness.

Objectives  To review the literature investigating the impact of facial cosmetic surgery and minimally invasive procedures on relevant psychological variables to guide clinical practice and set norms for clinical performance.

Evidence Review  English-language randomized clinical trials and prospective cohort studies that preoperatively and postoperatively assessed psychological variables in at least 10 patients seeking surgical or minimally invasive cosmetic procedures of the face.

Findings  Only 1 study investigating minimally invasive procedures was identified. Most studies reported modest improvement in psychosocial functioning, which included quality of life, self-esteem, and body image. Unfortunately, the overall quality of evidence is limited owing to an absence of control groups, short follow-up periods, or loss to follow-up.

Conclusions and Relevance  The current literature suggests that a number of psychosocial domains may improve following facial cosmetic surgery, although the quality of this evidence is limited (grade of recommendation 2A). Despite the dramatic rise in nonsurgical cosmetic procedures, there is a paucity of information regarding the impact of chemodenervation and soft-tissue augmentation on psychosocial functioning.

Figures in this Article

The demand for cosmetic procedures has increased dramatically in the past decade. As such, in 2011, Americans spent nearly $10.4 billion on a total of 13.8 million elective surgical and nonsurgical procedures.1,2 Objective clinical measures conventionally used to evaluate surgical procedures, such as postoperative complication rates, have limited utility when applied to cosmetic procedures. Unlike many other medical interventions, these elective procedures have little, if any, impact on morbidity and mortality.3 While there are imaging devices and scales that have been published to assess objective improvement in appearance after cosmetic intervention, few have been implemented in clinical practice.46

Beyond subjective improvement of appearance, it has been argued that cosmetic procedures have the ability to affect psychosocial functioning.7 Thus, the use of patient-reported outcomes becomes critically important when evaluating the success of elective cosmetic procedures.810 An abundance of research has been conducted investigating the psychological variables in patients seeking cosmetic surgical procedures.1116 Much of this research has focused on cosmetic breast augmentation.17,18 These studies have consistently shown that women undergoing these procedures experience improved body image. The effect on other psychosocial domains, such as self-esteem and quality of life (QOL), has been less conclusive.

The occurrence of facial cosmetic procedures performed in the United States is rising steadily, but knowledge about the impact of these procedures on psychosocial functioning remains limited.19,20 Most pertinent to the contemporary aesthetic physician is the increasing use of minimally invasive procedures such as chemodenervation and soft-tissue augmentation. While common cosmetic surgical procedures like rhinoplasty and blepharoplasty decreased nearly 40% over 10 years, botulinum toxin injections increased by 621% in the same period.2 Other minimally invasive procedures such as augmentation with soft-tissue fillers have experienced similar growth.

Prior review articles of psychosocial outcomes following cosmetic surgery have shown insufficient evidence to comment conclusively on the effectiveness of cosmetic procedures as a psychosocial intervention.10,15,2023 However, these reviews focused on total body aesthetic surgery without a specific focus on nonsurgical facial cosmetic procedures. With the recent dramatic rise in facial surgical and nonsurgical aesthetic procedures, a review of the literature specific to these procedures is timely.

This article details the findings of a systematic review undertaken to address the following question: do relevant psychosocial domains of patients improve after surgical or minimally invasive facial cosmetic procedures? Psychosocial domains is a broad term with several interconnected components. Recurring domains that are commonly addressed in the field of elective cosmetic surgery include body image, self-esteem, and QOL, all of which were included in this study.24,25

Search Strategy

The study was approved by the institutional review board at the University of Pennsylvania. A comprehensive systematic review of the English-language literature was performed using the following electronic databases: Medline, PsycINFO, CINAHL, and EMBASE. The query for all databases was “(cosmetic OR aesthetic) AND (surgery OR procedure OR minimally invasive) AND (quality-of-life OR self-esteem OR body-image).” References of retrieved articles were scanned for additional studies. The latest search date was February 17, 2012. A 16-year date range (1996-2012) was reviewed.

Inclusion criteria consisted of the following: (1) patients were 16 years or older and seeking surgical or minimally invasive cosmetic procedures of the face; (2) studies with randomized, controlled, or prospective cohort designs; (3) specific psychological variables measured preoperatively and postoperatively with validated psychometric measures (eg, body image, QOL, self-esteem). Articles identified from searches were examined to find those with a focus on the psychosocial aspects of cosmetic surgical procedures and minimally invasive procedures. We then excluded articles describing medical conditions, surgical techniques, reconstructive surgery, dental and orthodontic procedures, or transgender surgery. Studies that measured only patient satisfaction or included fewer than 10 facial procedure participants were excluded.

The article screening process was performed as follows: One investigator (S.I.) carried out the initial searches and screened the discovered titles. Three investigators (S.I., J.E.G., and M.B.) independently reviewed the abstracts of the relevant citations and assessed them for eligibility. Decisions about eligibility were recorded and compared. Disagreements were resolved by discussion. Twenty-five potentially relevant studies were identified from the initial searches. Subsequently, 2 authors (S.I. and M.B.) independently screened the full-text articles for eligibility using a standardized data abstraction form with inclusion and exclusion criteria. Any disagreements were again resolved by discussion, resulting in 16 included articles (Figure).

Place holder to copy figure label and caption
Figure.
Flowchart of the Search and Selection Process

Note that 4 databases were searched and 6203 articles were initially identified. Sixteen articles were included after the screening process.

Graphic Jump Location
Data Extraction

A standardized data extraction protocol was applied to each study. Two authors (S.I. and M.B.) independently reviewed the studies for eligibility and were blinded to each other, meeting only to compare findings after completing the extraction process. Discrepancies in opinion about an article were reviewed, and a consensus was achieved. The two authors then independently evaluated the studies for outcome measures, study design, and analytic methods. The data extracted included author, date, country and language, surgical procedures, minimally invasive procedures, participants (including selection criteria and demographics where available), details of study design and methodology (including use of controls, sample size, outcomes assessed, validated assessments used, length of follow-up, and treatment of attrition), and results. The data were arranged in evidence tables (Table 1). Because the studies were too heterogeneous in design and outcome measures to allow quantitative pooling of data for meta-analysis, a critical analysis of the evidence is provided for each psychosocial variable and grouped by surgical vs minimally invasive procedure.

Table Graphic Jump LocationTable 1.  Studies Examining Psychosocial Domains in Patients Undergoing Facial Cosmetic Procedures
Study Characteristics

Initial database searches identified 6203 articles. We eliminated 6113 titles because they were not relevant to psychosocial outcomes of facial cosmetic procedures, leaving 90 abstracts for review. A flowchart of the search and selection process is shown in the Figure. Seventeen articles met all inclusion criteria, but 1 was excluded because it presented a different aspect of the same study.41 Two studies were follow-up studies of previous study groups.37,40 A summary of the characteristics of the 16 included studies is given in Table 1.

Of the 16 articles, 5 (31%) were from the United States and Canada.28,31,3537 The remaining 11 studies were from 8 different countries. The majority of studies (11 of 16 [69%]) examined rhinoplasty individually or aggregated with other cosmetic procedures. A total of 9 facial cosmetic procedures were included in the analysis. Half of the studies (8 of 16) compared outcomes across facial and body contour procedures. Studies evaluating patients seeking these interventions specifically for medical benefit were not included in order to minimize confounding variables.

Methodologic Quality

The extracted studies were graded according to the SORT (strength of recommendation taxonomy) scale published by Ebell and colleagues.42 This classification emphasizes the use of patient-oriented outcomes and allows for structured evaluation of the strength of a recommendation based on 3 tiers of study quality. In the present analysis, we identified a single level 1 study, which randomized participants to receive treatment with botulinum toxin A or placebo saline injections.28 All other articles were level 2 prospective cohort studies. Almost one-third (5 of 16) used control or comparison groups.3,28,33,39,40 The remaining 11 reports assessed outcomes by comparison with data from the general population (n = 2)30,34 or did not include a comparison group (n = 9).26,27,29,31,32,3538 Summaries of the quality of evidence and evidence-based recommendations for clinical practice are given in Tables 2, 3, and 4.

Table Graphic Jump LocationTable 2.  Summary of Findings for the Outcomes and Measures Used
Table Graphic Jump LocationTable 3.  Evaluating Quality and Limitations of Studiesa
Table Graphic Jump LocationTable 4.  Summary of the Evidence and Quality of Evidence-Based Recommendations for Clinical Practice
Patient Characteristics

In every study, participants were patients seeking consultation or on the waiting list for facial cosmetic procedures. These participants underwent the surgery or procedure during the study period, and sample sizes ranged from 53 to 259 participants. A total of 1021 facial cosmetic participants were included in this analysis, with the number of subjects in each article ranging from 14 to 225. Follow-up length ranged from 3 to 60 months. Of the 16 studies, 9 (56%) had a loss to follow-up rate greater than 20%,30,3234,3638,40,44 often owing to the inability to contact study participants. In all but 1 study,38 the majority of the study population was female. Of the 16 studies, 6 (38%) collected and reported demographic information on the study participants.3,27,29,34,36,37

Psychosocial Outcomes by Procedure

In this section, we review the findings for QOL, self-esteem, and body image, presenting composite results before addressing the studies that presented data for individual procedures.

Quality of Life

Nine articles evaluated QOL outcomes (Table 1 and Table 2).

Minimally Invasive Procedures

  • Botulinum Toxin Injections: Dayan and colleagues28 implemented an experimental, placebo-controlled design, using the Quality of Life Enjoyment and Satisfaction Questionnaire to measure QOL in patients that received either botulinum toxin or saline injections in the glabellar, forehead, and lateral canthal rhytids. The group found a significant improvement in the overall life satisfaction and contentment subscale throughout the 3-month follow-up period for the intervention group compared with the placebo group. While these positive findings are encouraging, the Quality of Life Enjoyment and Satisfaction Questionnaire tool is not widely known or used in the QOL literature.

  • Laser Resurfacing: Rankin and colleagues35 measured QOL in patients seeking laser resurfacing and other cosmetic procedures using the Health Measurement Questionnaire. This group observed significant improvement from baseline scores through 6 months after the procedure. However, the authors presented data in aggregate and did not comment on laser resurfacing in particular.

Surgical Procedures

  • Rhinoplasty: Most of the studies of QOL (6 of 7) showed a statistically significant improvement in QOL after rhinoplasty in at least 1 subscale of the measurement tool used.27,29,30,32,34,35 Klassen and colleagues30 demonstrated significant improvements in 3 of 8 subscales of health status on the Short Form 36 Health Survey (SF-36), while Fatemi and colleagues29 revealed significant improvements in 4 of 8 subscales of the same validated tool. Interestingly, neither study that used the SF-36 found improvements in physical role or general health subscales. Cingi and colleagues27 detected significant improvements in 3 of 6 subscales of the European QOL measurement tool. These data, along with studies that included rhinoplasty in their aggregated data, present modest evidence that rhinoplasty can improve patient QOL.

  • Rhytidectomy: Of the 5 studies that examined QOL outcomes after rhytidectomy, 4 found a statistically significant improvement in QOL.26,32,34,35 Alves and colleagues,26 in the only study to report data on rhytidectomy individually, found significant improvement in 4 of 8 subscales of the SF-36. These improvements were more likely to be seen 6 months postoperatively than at the initial postoperative assessment point at month 2. This may suggest that time to assessment is an important factor in the experience of QOL benefits. Alternatively, patients may have completely healed with no residual edema or bruising at this later time point.

  • Blepharoplasty: Two studies32,37 assessed changes in QOL in blepharoplasty patients. One study found an improvement in QOL, as assessed by the EuroQol 5 Dimensions Visual Analogue Scale.32 In contrast, Sarwer and colleagues37 found no statistically significant changes in QOL as assessed by the Body Image Quality of Life Inventory, a more specific measure of how body image concerns are related to general QOL.

  • Other Procedures: Klassen and colleagues30 compared QOL in patients seeking otoplasty with the population normative data and found improvement in 3 variables using the SF-36. Meningaud and colleagues32 used the EuroQol 5 Dimensions and found an improvement in only the anxiety/depression subscale. While few studies measured QOL in facial cosmetic procedures other than rhinoplasty and rhytidectomy, it appears that certain aspects of QOL may improve after treatment.

Body Image

Seven articles evaluated body image outcomes (Table 2).

Minimally Invasive Procedures

We found no studies of minimally invasive procedures that examined body image.

Surgical Procedures

  • Rhinoplasty: Of the 5 studies of body image in rhinoplasty patients, 4 reported a statistically significant improvement after surgery.27,31,33,37 Moss and Harris33 used the Derriford Appearance Scale 24 and compared the treatment group with age- and sex-matched controls presenting for non–appearance-altering surgery patients. This controlled study represents the strongest evidence about the relationship between rhinoplasty and body image. The rhinoplasty group had a significantly lower baseline body image compared with controls. Following treatment, this measure increased to a level comparable to that of controls postoperatively. This improvement was maintained 12 months after surgery. Litner and colleagues31 and Cingi and colleagues27 also reported robust improvement in body image. These studies have methodological limitations, which include lack of control groups,27,31 substantial loss to follow-up (44%),33 and brevity of follow up (3 months).31

  • Rhytidectomy: Only 1 study analyzed the relationship between body image and rhytidectomy.31 The study assessed body image with the Derriford Appearance Scale 24 and found significant improvement in 5 of 6 subscales. Rhytidectomy patients had an overall improvement of 20% on measure. Interestingly, those with concerns related to facial aging and those in the highest age subgroup exhibited the lowest baseline scores, indicating the least amount of appearance-related emotional concern. However, this study is limited by a lack of a control group and brevity of follow up (3 months).

  • Blepharoplasty: Of the 4 studies that included blepharoplasty in their analysis of body image, 3 reported a significant improvement in their study population.29,39,40 Sarwer and colleagues36 were unable to detect any differences in body image in their study. Unfortunately, these articles did not provide procedure-specific data; thus, it is difficult to conclusively state if the improvement reported is specific to this procedure.

  • Other Procedures: We found no studies that examined the relationship between body image and other facial cosmetic surgery procedures.

Self-esteem

Nine articles evaluated changes in self-esteem after cosmetic procedures (Table 2).

Minimally Invasive Procedures

  • Botulinum Toxin Injections: Per the placebo-controlled experiment protocol noted previously in the “Quality of Life” subsection, Dayan and colleagues28 measured self-esteem using the Heatherton and Polivy State Self-esteem Scale in both botulinum toxin and control populations. There was a significant improvement in total self-esteem at 2 weeks and the “feeling good about one’s self” and “self-perceived appearance” subscales at 2 weeks and 3 months after procedure compared with the placebo group.

Surgical Procedures

  • Rhinoplasty: Of the 4 studies comparing preoperative and postoperative self-esteem in rhinoplasty patients, 3 detected a statistically significant improvement after surgery.29,30,38 One study included 75 participants seeking rhinoplasty and assessed changes in self-esteem using the Rosenberg Self-esteem Scale (RSES) 6 months after surgery.29 A significant difference in self-esteem was detected. Klassen and colleagues30 used the RSES scale to measure self-esteem in 33 rhinoplasty patients. They discovered a significant, moderate to large change in postoperative self-esteem with an effect size of 0.58. Sheard and colleagues38 evaluated 53 rhinoplasty patients using the Self-esteem Inventory and also found significant postoperative improvement. These studies have methodological limitations, including lack of control groups,29,30,38 substantial loss to follow-up (30%30 and 27%38), and brevity of follow-up (4 months38). One study that presented data in aggregate (Sarwer and colleagues37) did not find statistically significant change in postoperative self-esteem. However, the trend toward improvement reported may or may not be specific to this procedure.

  • Rhytidectomy: Of 2 studies examining the relationship between rhytidectomy and self-esteem, 1 reported a significant postoperative improvement.26 Alves and colleagues26 used the RSES and reported significant improvement in self-esteem at 6 months (P = .001). This study, however, is limited by its lack of an appropriate control group.

  • Blepharoplasty: Of 4 studies examining the relationship between blepharoplasty and self-esteem, 3 reported an improvement after blepharoplasty.3,39,40 Viana and colleagues3 used the RSES (Portuguese version: RSES-EPM) to measure self-esteem in 50 blepharoplasty patients and in 25 noncosmetic, surgery-seeking controls. They followed patients and controls for 12 months and detected a significant improvement months after surgery (P = .001). This study is methodologically sound with the use of controls, adequate follow-up length (6 and 12 months) and low attrition rate. Von Soest et al39,40 used the RSES to examine blepharoplasty aggregated with other body contour procedures. While this group reported significant improvements in self-esteem, it is difficult to conclusively state if the improvement reported is specific to this procedure.

  • Other Procedures: One study investigated the link between otoplasty and self-esteem.36 Klassen and colleagues30 examined the self-esteem of 23 patients seeking otoplasty using the RSES scale and reported a significant improvement 6 months after otoplasty (P < .001).

The soaring demand for facial cosmetic procedures—both surgical and nonsurgical—has highlighted the importance of assessing treatment outcomes based on patient-reported measures. The authors sought to determine if patient-reported psychological variables improve after surgical and minimally invasive (nonsurgical) facial cosmetic procedures. Based on this systematic review of the literature, the evidence suggests that a number of psychosocial domains improve following facial cosmetic procedures, although the quality of this evidence is limited (recommendation level 2A, primarily based on level 2 studies).43

The procedure-specific studies in this review detected QOL improvements after rhytidectomy26 and rhinoplasty.27,29 Self-esteem improvements were seen in procedure-specific studies that examined rhytidectomy,26 blepharoplasty,3 and rhinoplasty.29,38 In the single minimally invasive cosmetic procedure study included in this analysis, Dayan and colleagues28 demonstrated an increase in self-esteem and QOL after chemodenervation with botulinum toxin. The only procedure-specific study investigating body image revealed a significant improvement in this construct after rhinoplasty (Table 2).27 However, these procedure-specific studies comprised a minority (38%) of the articles included in this review.

The remaining studies aggregated data from numerous procedures. Meningaud and colleagues32 only examined facial cosmetic procedures. Overall, this group detected a slight improvement in QOL. Finally, of the 8 studies that provided combined analyses of facial and body contour surgical procedures, most found improvements in QOL,30,34,35 body image,31,33,37,39,40 and self-esteem.30,39 It should be noted that self-esteem significantly increased in the long-term follow-up of the cohort in the study by von Soest at al,40 but significance was lost when the subject data were compared with the control group.

While the landscape of cosmetic interventions seems to be changing, with the majority of all cosmetic procedures now comprising minimally invasive procedures, the medical community must determine if these cosmetic interventions have a positive impact on patients beyond aesthetic rejuvenation. This is particularly important in light of the Patient Protection and Affordable Care Act (Pub L No. 111-148, 124 Stat 119-1025) and its emphasis on patient-centered outcomes and effectiveness. Furthermore, if there are potential positive psychosocial gains from these procedures, it will be important to identify those patients most likely to benefit in order to properly screen and preoperatively stratify patients. Finally, numerous ethical challenges in cosmetic practice may be better addressed with this information.45 For example, without sound scientific evidence, is it appropriate to have a physician counsel their patient that a cosmetic procedure will not only make them “look better” but also “feel better”?

Prior reviews on this topic have failed to conclusively state that cosmetic interventions can positively affect psychosocial functioning.10,2023 It is important to note that many of these studies focused their efforts on total body cosmetic surgery rather than specifically addressing surgical and nonsurgical facial cosmetic procedures.15,21,22,46 Based on the 16 included studies in this review, there is reasonable evidence to conclude that surgical cosmetic procedures of the face may positively affect psychological outcomes. Only 1 study investigated minimally invasive cosmetic procedures, and this too suggests that chemodenervation with botulinum toxin can positively affect QOL and self-esteem.28

There are notable limitations to the majority of studies in this review (Table 3). Primarily, studies suffered from poor definition of sample and control groups. Only 1 study adequately defined the sample and control populations,34 and only 3 studies provided baseline psychosocial statuses of their patients.3,33,39 Other limitations that were commonly encountered in the included studies were high attrition rates and varied follow-up times. While we scrutinized each article for evidence quality and risk of bias, we are unable to control for publication bias because there may be a tendency to publish articles that report positive findings. Finally, more than two-thirds of the studies were performed outside of the United States, and it is difficult to generalize the results of these foreign studies to an American population.

Future studies should include controls that are similar to the subjects: they should be similarly concerned with their appearance and be pursuing cosmetic enhancement. Subjects and controls should be matched for age, sex, education level, socioeconomic status, and physical features such as race, age, and body mass index. Ideally, individuals not undergoing procedures should be used as comparators and should be assessed at the same time intervals as the sample population to control for variation due to repeated administration of measures and the effect of time on the outcomes of interest. Normative data from the general population is inadequate because it cannot control for regional and temporal variation in attitudes toward cosmetic enhancement.

Researchers also should use objective, and preferably validated, measures of the appropriateness of a potential participant for the intervention of interest. None of the included studies sufficiently characterized, either in words or pictures, the appearance of their sample and control populations. Most studies only indicated the mean age, sex distribution, and an interest in surgical or minimally invasive cosmetic enhancement. Body mass index is helpful, but other objective preoperative measures exist, such as wrinkle burden.4750 These will also measure the objective improvement, which can then be correlated with psychosocial measures, thus creating a predictive model of those who would benefit the most from such procedures. Less ideal but potentially helpful are measures of apparent age and subjective attractiveness before cosmetic enhancement.

Of note, this review aimed to critically analyze the data on minimally invasive and surgical facial cosmetic enhancement and compare the outcomes of those procedural interventions. However, we were unable to perform this analysis owing to the heterogeneity of studies and the lack of minimally invasive studies. We identified only 1 high-quality, procedure-specific study investigating minimally invasive procedures. This confirms the dearth of rigorous data regarding the effects of minimally invasive facial procedures on psychosocial outcomes and adds urgency to the mission of dermatologists, plastic surgeons, and otolaryngologists to conduct methodologically robust research in this field.

The demand for cosmetic procedures has dramatically increased in the past decade. Because of their minimal downtime and low adverse effect profile, nonsurgical facial cosmetic procedures have become particularly popular for patients. We sought to determine if patient-reported psychological variables improve after surgical or minimally invasive (nonsurgical) facial cosmetic procedures. Based on this systematic review of the literature, the evidence suggests that a number of psychosocial domains improve following facial cosmetic procedures, although the quality of this evidence is limited (recommendation level 2A, based on mostly level 2 studies). Importantly, there is a paucity of information regarding the impact of chemodenervation and soft-tissue augmentation on psychosocial functioning. More rigorous studies on these procedures will generate stronger recommendations regarding their impact on psychosocial functioning.

Section Editor: Michael Bigby, MD; Assistant Section Editors: Olivier Chosidow, MD, PhD; Robert P. Dellavalle, MD, PhD, MSPH; Daihung Do, MD; Urbà González, MD, PhD; Catalin M. Popescu, MD, PhD; Hywel Williams, MSc, PhD, FRCP.

Corresponding Author: Joseph F. Sobanko, MD, Perelman Center for Advanced Medicine, Hospital of the University of Pennsylvania, 3400 Civic Center Blvd 1-330S, Philadelphia, PA 19104 (Joseph.Sobanko@uphs.upenn.edu).

Accepted for Publication: July 12, 2013.

Published Online: September 25, 2013. doi:10.1001/jamadermatol.2013.6812.

Author Contributions: Drs Imadojemu and Sobanko had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Imadojemu, Sarwer, Percec, Sonnad, Sobanko.

Acquisition of data: Imadojemu, Goldsack, Berman, Sobanko.

Analysis and interpretation of data: Imadojemu, Sonnad, Sobanko.

Drafting of the manuscript: Imadojemu, Sarwer, Percec, Goldsack, Berman, Sobanko.

Critical revision of the manuscript for important intellectual content: Imadojemu, Sarwer, Percec, Sonnad, Sobanko.

Statistical analysis: Sonnad.

Obtained funding: Percec.

Administrative, technical, or material support: Sarwer, Goldsack, Berman.

Study supervision: Percec, Sonnad, Sobanko.

Conflict of Interest Disclosures: Dr Sarwer discloses that he has consulting relationships with Allergan, BaroNova, Enteromedic, Ethicon Endo-Surgery and Galderma. No other disclosures were reported.

Sobanko  JF, Imadojemu  S, Miller  CJ.  Epidemiology of cosmetic procedures: an update for dermatologists. Cur Derm Rep. 2012;1(1):4-13.
Link to Article
American Society of Plastic Surgeons. 2011 Plastic Surgery Procedural Statistics. http://www.plasticsurgery.org/news-and-resources/2011-statistics-.html. Accessed September 6, 2013.
Viana  GA, Osaki  MH, Nishi  M.  Effect of lower blepharoplasty on self-esteem. Dermatol Surg. 2010;36(8):1266-1272.
PubMed   |  Link to Article
Carruthers  A, Carruthers  J.  A validated facial grading scale: the future of facial ageing measurement tools? J Cosmet Laser Ther. 2010;12(5):235-241.
PubMed   |  Link to Article
Conkling  N, Bishawi  M, Phillips  BT, Bui  DT, Khan  SU, Dagum  AB.  Subjective rating of cosmetic treatment with botulinum toxin type A: do existing measures demonstrate interobserver validity? Ann Plast Surg. 2012;69(4):350-355.
PubMed   |  Link to Article
Lorenc  ZP, Bank  D, Kane  M, Lin  X, Smith  S.  Validation of a four-point photographic scale for the assessment of midface volume loss and/or contour deficiency. Plast Reconstr Surg. 2012;130(6):1330-1336.
PubMed   |  Link to Article
Cash  TF. Body-image change in cosmetic plastic surgery. In: Cash  TF, Pruzinsky  T, eds. Body Images: Development, Deviance, and Change. New York, NY: Guilford Press; 1990:217-236.
Cano  SJ, Browne  JP, Lamping  DL.  Patient-based measures of outcome in plastic surgery: current approaches and future directions. Br J Plast Surg. 2004;57(1):1-11.
PubMed   |  Link to Article
Alsarraf  R.  Outcomes research in facial plastic surgery: a review and new directions. Aesthetic Plast Surg. 2000;24(3):192-197.
PubMed   |  Link to Article
Most  SP, Alsarraf  R, Larrabee  WF  Jr.  Outcomes of facial cosmetic procedures. Facial Plast Surg. 2002;18(2):119-124. Review.
PubMed   |  Link to Article
Sarwer  DB, Crerand  CE, Magee  L.  Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral Maxillofac Surg Clin North Am. 2010;22(4):445-453.
PubMed   |  Link to Article
Crerand  CECT, Whitaker  LA. Cosmetic surgery of the face. In: Sarwer  DB, Pruzinsky  T, Cash  TF, Goldwyn  RM, Persing  JA, Whitaker  LA, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical and Ethical Perspectives. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:233-249.
Sarwer  DB, Crerand  CE.  Body image and cosmetic medical treatments. Body Image. 2004;1(1):99-111.
PubMed   |  Link to Article
Sarwer  DBDE, Gibbons  LM. Cosmetic surgery of the body. In: Sarwer  DB, Pruzinsky  T, Cash  TF,  et al, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical and Ethical Perspectives. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:251-266.
Sarwer  DB, Wadden  TA, Pertschuk  MJ, Whitaker  LA.  The psychology of cosmetic surgery: a review and reconceptualization. Clin Psychol Rev. 1998;18(1):1-22.
PubMed   |  Link to Article
Sarwer  DB, Wadden  TA, Pertschuk  MJ, Whitaker  LA.  Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101(6):1644-1649.
PubMed   |  Link to Article
Sarwer  DB, Crerand  CE.  Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5(1):50-58.
PubMed   |  Link to Article
Sarwer  DB.  The psychological aspects of cosmetic breast augmentation. Plast Reconstr Surg. 2007;120(7)(suppl 1):110S-117S.
PubMed   |  Link to Article
Ching  S, Thoma  A, McCabe  RE, Antony  MM.  Measuring outcomes in aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg. 2003;111(1):469-482.
PubMed   |  Link to Article
Kosowski  TR, McCarthy  C, Reavey  PL,  et al.  A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009;123(6):1819-1827.
PubMed   |  Link to Article
Sarwer  DB, Pertschuk  MJ, Wadden  TA, Whitaker  LA.  Psychological investigations in cosmetic surgery: a look back and a look ahead. Plast Reconstr Surg. 1998;101(4):1136-1142.
PubMed   |  Link to Article
Cook  SA, Rosser  R, Salmon  P.  Is cosmetic surgery an effective psychotherapeutic intervention? a systematic review of the evidence. J Plast Reconstr Aesthet Surg. 2006;59(11):1133-1151.
PubMed   |  Link to Article
Honigman  RJ, Phillips  KA, Castle  DJ.  A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113(4):1229-1237.
PubMed   |  Link to Article
Moss  TP.  The relationships between objective and subjective ratings of disfigurement severity, and psychological adjustment. Body Image. 2005;2(2):151-159.
PubMed   |  Link to Article
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(2):345-353.
PubMed   |  Link to Article
Alves  MC, Abla  LE, Santos  RdeA, Ferreira  LM.  Quality of life and self-esteem outcomes following rhytidoplasty. Ann Plast Surg. 2005;54(5):511-516.
PubMed   |  Link to Article
Cingi  C, Songu  M, Bal  C.  Outcomes research in rhinoplasty: body image and quality of life. Am J Rhinol Allergy. 2011;25(4):263-267.
PubMed   |  Link to Article
Dayan  SH, Arkins  JP, Patel  AB, Gal  TJ.  A double-blind, randomized, placebo-controlled health-outcomes survey of the effect of botulinum toxin type a injections on quality of life and self-esteem. Dermatol Surg. 2010;36(suppl 4):2088-2097.
PubMed   |  Link to Article
Fatemi  MJ, Rajabi  F, Moosavi  SJ, Soltani  M.  Quality of life among Iranian adults before and after rhinoplasty. Aesthetic Plast Surg. 2012;36(2):448-452.
PubMed   |  Link to Article
Klassen  A, Jenkinson  C, Fitzpatrick  R, Goodacre  T.  Patients’ health related quality of life before and after aesthetic surgery. Br J Plast Surg. 1996;49(7):433-438.
PubMed   |  Link to Article
Litner  JA, Rotenberg  BW, Dennis  M, Adamson  PA.  Impact of cosmetic facial surgery on satisfaction with appearance and quality of life. Arch Facial Plast Surg. 2008;10(2):79-83.
PubMed   |  Link to Article
Meningaud  JP, Benadiba  L, Servant  JM, Herve  C, Bertrand  JC, Pelicier  Y.  Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery. J Craniomaxillofac Surg. 2003;31(1):46-50.
PubMed   |  Link to Article
Moss  TP, Harris  DL.  Psychological change after aesthetic plastic surgery: a prospective controlled outcome study. Psychol Health Med. 2009;14(5):567-572.
PubMed   |  Link to Article
Papadopulos  NA, Kovacs  L, Krammer  S, Herschbach  P, Henrich  G, Biemer  E.  Quality of life following aesthetic plastic surgery: a prospective study. J Plast Reconstr Aesthet Surg. 2007;60(8):915-921.
PubMed   |  Link to Article
Rankin  M, Borah  GL, Perry  AW, Wey  PD.  Quality-of-life outcomes after cosmetic surgery. Plast Reconstr Surg. 1998;102(6):2139-2147.
PubMed   |  Link to Article
Sarwer  DB, Wadden  TA, Whitaker  LA.  An investigation of changes in body image following cosmetic surgery. Plast Reconstr Surg. 2002;109(1):363-371.
PubMed   |  Link to Article
Sarwer  DB, Infield  AL, Baker  JL,  et al.  Two-year results of a prospective, multi-site investigation of patient satisfaction and psychosocial status following cosmetic surgery. Aesthet Surg J. 2008;28(3):245-250.
PubMed   |  Link to Article
Sheard  C, Jones  NS, Quraishi  MS, Herbert  M.  A prospective study of the psychological effects of rhinoplasty. Clin Otolaryngol Allied Sci. 1996;21(3):232-236.
PubMed   |  Link to Article
von Soest  T, Kvalem  IL, Roald  HE, Skolleborg  KC.  The effects of cosmetic surgery on body image, self-esteem, and psychological problems. J Plast Reconstr Aesthet Surg. 2009;62(10):1238-1244.
PubMed   |  Link to Article
von Soest  T, Kvalem  IL, Skolleborg  KC, Roald  HE.  Psychosocial changes after cosmetic surgery: a 5-year follow-up study. Plast Reconstr Surg. 2011;128(3):765-772.
PubMed   |  Link to Article
Viana  GA, Osaki  MH, Nishi  M.  Clinical outcomes, patients’ satisfaction and aesthetic results after lower eyelid blepharoplasty. Rev Col Bras Cir. 2011;38(5):317-322.
PubMed   |  Link to Article
Ebell  MH, Siwek  J, Weiss  BD,  et al.  Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548-556.
PubMed
Robinson  JK, Dellavalle  RP, Bigby  M, Callen  JP.  Systematic reviews: grading recommendations and evidence quality. Arch Dermatol. 2008;144(1):97-99.
PubMed   |  Link to Article
Brown  BC, Moss  TP, McGrouther  DA, Bayat  A.  Skin scar preconceptions must be challenged: importance of self-perception in skin scarring. J Plast Reconstr Aesthet Surg. 2010;63(6):1022-1029.
PubMed   |  Link to Article
Newburger  AE, Caplan  AL.  Taking ethics seriously in cosmetic dermatology. Arch Dermatol. 2006;142(12):1641-1642.
PubMed   |  Link to Article
Grossbart  TA, Sarwer  DB.  Cosmetic surgery: surgical tools—psychosocial goals. Semin Cutan Med Surg. 1999;18(2):101-111.
PubMed   |  Link to Article
Glogau  RG.  Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg. 1996;15(3):134-138.
PubMed   |  Link to Article
Carruthers  A, Carruthers  J, Hardas  B,  et al.  A validated grading scale for crow’s feet. Dermatol Surg. 2008;34(suppl 2):S173-S178.
PubMed   |  Link to Article
Carruthers  A, Carruthers  J, Hardas  B,  et al.  A validated grading scale for forehead lines. Dermatol Surg. 2008;34(suppl 2):S155-S160.
PubMed   |  Link to Article
Meningaud  JP, Lantieri  L, Bertrand  JC.  Rhinoplasty: an outcome research. Plast Reconstr Surg. 2008;121(1):251-257.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
Flowchart of the Search and Selection Process

Note that 4 databases were searched and 6203 articles were initially identified. Sixteen articles were included after the screening process.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1.  Studies Examining Psychosocial Domains in Patients Undergoing Facial Cosmetic Procedures
Table Graphic Jump LocationTable 2.  Summary of Findings for the Outcomes and Measures Used
Table Graphic Jump LocationTable 3.  Evaluating Quality and Limitations of Studiesa
Table Graphic Jump LocationTable 4.  Summary of the Evidence and Quality of Evidence-Based Recommendations for Clinical Practice

References

Sobanko  JF, Imadojemu  S, Miller  CJ.  Epidemiology of cosmetic procedures: an update for dermatologists. Cur Derm Rep. 2012;1(1):4-13.
Link to Article
American Society of Plastic Surgeons. 2011 Plastic Surgery Procedural Statistics. http://www.plasticsurgery.org/news-and-resources/2011-statistics-.html. Accessed September 6, 2013.
Viana  GA, Osaki  MH, Nishi  M.  Effect of lower blepharoplasty on self-esteem. Dermatol Surg. 2010;36(8):1266-1272.
PubMed   |  Link to Article
Carruthers  A, Carruthers  J.  A validated facial grading scale: the future of facial ageing measurement tools? J Cosmet Laser Ther. 2010;12(5):235-241.
PubMed   |  Link to Article
Conkling  N, Bishawi  M, Phillips  BT, Bui  DT, Khan  SU, Dagum  AB.  Subjective rating of cosmetic treatment with botulinum toxin type A: do existing measures demonstrate interobserver validity? Ann Plast Surg. 2012;69(4):350-355.
PubMed   |  Link to Article
Lorenc  ZP, Bank  D, Kane  M, Lin  X, Smith  S.  Validation of a four-point photographic scale for the assessment of midface volume loss and/or contour deficiency. Plast Reconstr Surg. 2012;130(6):1330-1336.
PubMed   |  Link to Article
Cash  TF. Body-image change in cosmetic plastic surgery. In: Cash  TF, Pruzinsky  T, eds. Body Images: Development, Deviance, and Change. New York, NY: Guilford Press; 1990:217-236.
Cano  SJ, Browne  JP, Lamping  DL.  Patient-based measures of outcome in plastic surgery: current approaches and future directions. Br J Plast Surg. 2004;57(1):1-11.
PubMed   |  Link to Article
Alsarraf  R.  Outcomes research in facial plastic surgery: a review and new directions. Aesthetic Plast Surg. 2000;24(3):192-197.
PubMed   |  Link to Article
Most  SP, Alsarraf  R, Larrabee  WF  Jr.  Outcomes of facial cosmetic procedures. Facial Plast Surg. 2002;18(2):119-124. Review.
PubMed   |  Link to Article
Sarwer  DB, Crerand  CE, Magee  L.  Body dysmorphic disorder in patients who seek appearance-enhancing medical treatments. Oral Maxillofac Surg Clin North Am. 2010;22(4):445-453.
PubMed   |  Link to Article
Crerand  CECT, Whitaker  LA. Cosmetic surgery of the face. In: Sarwer  DB, Pruzinsky  T, Cash  TF, Goldwyn  RM, Persing  JA, Whitaker  LA, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical and Ethical Perspectives. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:233-249.
Sarwer  DB, Crerand  CE.  Body image and cosmetic medical treatments. Body Image. 2004;1(1):99-111.
PubMed   |  Link to Article
Sarwer  DBDE, Gibbons  LM. Cosmetic surgery of the body. In: Sarwer  DB, Pruzinsky  T, Cash  TF,  et al, eds. Psychological Aspects of Reconstructive and Cosmetic Plastic Surgery: Clinical, Empirical and Ethical Perspectives. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:251-266.
Sarwer  DB, Wadden  TA, Pertschuk  MJ, Whitaker  LA.  The psychology of cosmetic surgery: a review and reconceptualization. Clin Psychol Rev. 1998;18(1):1-22.
PubMed   |  Link to Article
Sarwer  DB, Wadden  TA, Pertschuk  MJ, Whitaker  LA.  Body image dissatisfaction and body dysmorphic disorder in 100 cosmetic surgery patients. Plast Reconstr Surg. 1998;101(6):1644-1649.
PubMed   |  Link to Article
Sarwer  DB, Crerand  CE.  Body dysmorphic disorder and appearance enhancing medical treatments. Body Image. 2008;5(1):50-58.
PubMed   |  Link to Article
Sarwer  DB.  The psychological aspects of cosmetic breast augmentation. Plast Reconstr Surg. 2007;120(7)(suppl 1):110S-117S.
PubMed   |  Link to Article
Ching  S, Thoma  A, McCabe  RE, Antony  MM.  Measuring outcomes in aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg. 2003;111(1):469-482.
PubMed   |  Link to Article
Kosowski  TR, McCarthy  C, Reavey  PL,  et al.  A systematic review of patient-reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009;123(6):1819-1827.
PubMed   |  Link to Article
Sarwer  DB, Pertschuk  MJ, Wadden  TA, Whitaker  LA.  Psychological investigations in cosmetic surgery: a look back and a look ahead. Plast Reconstr Surg. 1998;101(4):1136-1142.
PubMed   |  Link to Article
Cook  SA, Rosser  R, Salmon  P.  Is cosmetic surgery an effective psychotherapeutic intervention? a systematic review of the evidence. J Plast Reconstr Aesthet Surg. 2006;59(11):1133-1151.
PubMed   |  Link to Article
Honigman  RJ, Phillips  KA, Castle  DJ.  A review of psychosocial outcomes for patients seeking cosmetic surgery. Plast Reconstr Surg. 2004;113(4):1229-1237.
PubMed   |  Link to Article
Moss  TP.  The relationships between objective and subjective ratings of disfigurement severity, and psychological adjustment. Body Image. 2005;2(2):151-159.
PubMed   |  Link to Article
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(2):345-353.
PubMed   |  Link to Article
Alves  MC, Abla  LE, Santos  RdeA, Ferreira  LM.  Quality of life and self-esteem outcomes following rhytidoplasty. Ann Plast Surg. 2005;54(5):511-516.
PubMed   |  Link to Article
Cingi  C, Songu  M, Bal  C.  Outcomes research in rhinoplasty: body image and quality of life. Am J Rhinol Allergy. 2011;25(4):263-267.
PubMed   |  Link to Article
Dayan  SH, Arkins  JP, Patel  AB, Gal  TJ.  A double-blind, randomized, placebo-controlled health-outcomes survey of the effect of botulinum toxin type a injections on quality of life and self-esteem. Dermatol Surg. 2010;36(suppl 4):2088-2097.
PubMed   |  Link to Article
Fatemi  MJ, Rajabi  F, Moosavi  SJ, Soltani  M.  Quality of life among Iranian adults before and after rhinoplasty. Aesthetic Plast Surg. 2012;36(2):448-452.
PubMed   |  Link to Article
Klassen  A, Jenkinson  C, Fitzpatrick  R, Goodacre  T.  Patients’ health related quality of life before and after aesthetic surgery. Br J Plast Surg. 1996;49(7):433-438.
PubMed   |  Link to Article
Litner  JA, Rotenberg  BW, Dennis  M, Adamson  PA.  Impact of cosmetic facial surgery on satisfaction with appearance and quality of life. Arch Facial Plast Surg. 2008;10(2):79-83.
PubMed   |  Link to Article
Meningaud  JP, Benadiba  L, Servant  JM, Herve  C, Bertrand  JC, Pelicier  Y.  Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery. J Craniomaxillofac Surg. 2003;31(1):46-50.
PubMed   |  Link to Article
Moss  TP, Harris  DL.  Psychological change after aesthetic plastic surgery: a prospective controlled outcome study. Psychol Health Med. 2009;14(5):567-572.
PubMed   |  Link to Article
Papadopulos  NA, Kovacs  L, Krammer  S, Herschbach  P, Henrich  G, Biemer  E.  Quality of life following aesthetic plastic surgery: a prospective study. J Plast Reconstr Aesthet Surg. 2007;60(8):915-921.
PubMed   |  Link to Article
Rankin  M, Borah  GL, Perry  AW, Wey  PD.  Quality-of-life outcomes after cosmetic surgery. Plast Reconstr Surg. 1998;102(6):2139-2147.
PubMed   |  Link to Article
Sarwer  DB, Wadden  TA, Whitaker  LA.  An investigation of changes in body image following cosmetic surgery. Plast Reconstr Surg. 2002;109(1):363-371.
PubMed   |  Link to Article
Sarwer  DB, Infield  AL, Baker  JL,  et al.  Two-year results of a prospective, multi-site investigation of patient satisfaction and psychosocial status following cosmetic surgery. Aesthet Surg J. 2008;28(3):245-250.
PubMed   |  Link to Article
Sheard  C, Jones  NS, Quraishi  MS, Herbert  M.  A prospective study of the psychological effects of rhinoplasty. Clin Otolaryngol Allied Sci. 1996;21(3):232-236.
PubMed   |  Link to Article
von Soest  T, Kvalem  IL, Roald  HE, Skolleborg  KC.  The effects of cosmetic surgery on body image, self-esteem, and psychological problems. J Plast Reconstr Aesthet Surg. 2009;62(10):1238-1244.
PubMed   |  Link to Article
von Soest  T, Kvalem  IL, Skolleborg  KC, Roald  HE.  Psychosocial changes after cosmetic surgery: a 5-year follow-up study. Plast Reconstr Surg. 2011;128(3):765-772.
PubMed   |  Link to Article
Viana  GA, Osaki  MH, Nishi  M.  Clinical outcomes, patients’ satisfaction and aesthetic results after lower eyelid blepharoplasty. Rev Col Bras Cir. 2011;38(5):317-322.
PubMed   |  Link to Article
Ebell  MH, Siwek  J, Weiss  BD,  et al.  Strength of recommendation taxonomy (SORT): a patient-centered approach to grading evidence in the medical literature. Am Fam Physician. 2004;69(3):548-556.
PubMed
Robinson  JK, Dellavalle  RP, Bigby  M, Callen  JP.  Systematic reviews: grading recommendations and evidence quality. Arch Dermatol. 2008;144(1):97-99.
PubMed   |  Link to Article
Brown  BC, Moss  TP, McGrouther  DA, Bayat  A.  Skin scar preconceptions must be challenged: importance of self-perception in skin scarring. J Plast Reconstr Aesthet Surg. 2010;63(6):1022-1029.
PubMed   |  Link to Article
Newburger  AE, Caplan  AL.  Taking ethics seriously in cosmetic dermatology. Arch Dermatol. 2006;142(12):1641-1642.
PubMed   |  Link to Article
Grossbart  TA, Sarwer  DB.  Cosmetic surgery: surgical tools—psychosocial goals. Semin Cutan Med Surg. 1999;18(2):101-111.
PubMed   |  Link to Article
Glogau  RG.  Aesthetic and anatomic analysis of the aging skin. Semin Cutan Med Surg. 1996;15(3):134-138.
PubMed   |  Link to Article
Carruthers  A, Carruthers  J, Hardas  B,  et al.  A validated grading scale for crow’s feet. Dermatol Surg. 2008;34(suppl 2):S173-S178.
PubMed   |  Link to Article
Carruthers  A, Carruthers  J, Hardas  B,  et al.  A validated grading scale for forehead lines. Dermatol Surg. 2008;34(suppl 2):S155-S160.
PubMed   |  Link to Article
Meningaud  JP, Lantieri  L, Bertrand  JC.  Rhinoplasty: an outcome research. Plast Reconstr Surg. 2008;121(1):251-257.
PubMed   |  Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles