Long-Term Quality-of-Life Outcomes After Body Contouring Surgery: Phase IV Results for the Body-QoL® Cohort

Long-Term Quality-of-Life Outcomes After Body Contouring Surgery: Phase IV Results for the... Abstract Background Body contouring surgery (BCS) is becoming increasing popular for aesthetic and reconstructive purposes, particularly among patients with massive weight loss (MWL). However, data on quality of life (QoL) following the surgery are limited, especially long-term QoL. Objectives The authors evaluated the effect of BCS on QoL and the durability of this effect over time. Methods QoL was measured with the Body-QoL® instrument at 3 time points among consecutively treated patients: the day before BCS, 1 to 9 months postoperatively (short term), and 1 to 2.7 years postoperatively (long term). Total Body-QoL scores were compiled, as were scores for the instrument’s main domains: body satisfaction, sex life, self-esteem and social performance, and physical symptoms. Scores were examined for the entire study population and separately for the cosmetic and MWL cohorts. Results Fifty-seven of the 112 patients participated in the short-term assessment and 84 in the long-term assessment. Total Body-QoL scores increased significantly (P < 0.0001), from 44.0 ± 14.1 preoperatively to 85.5 ± 17.5 short-term postoperatively and to 84.4 ± 12.7 long-term postoperatively. Scores for the 2 postoperative assessments did not differ significantly. Similar results were observed for scores on each separate domain. Although preoperative scores were lower for the MWL cohort than the cosmetic cohort (33.9 ± 15.6 vs 46.1 ± 12.8; P = 0.0002), they improved substantially after BCS, approaching scores for the cosmetic cohort. Conclusions QoL increases significantly after BCS. This favorable outcome remained stable throughout long-term follow-up and was true for the cosmetic and MWL cohorts. Level of Evidence: 4 Body contouring surgery (BCS) is growing in popularity, as are aesthetic procedures in general. Between 2011 and 2015, aesthetic surgeries in the United States increased by 17%, and cosmetic medicine procedures by 44%.1 BCS is increasingly desired by patients who have experienced massive weight loss (MWL), defined as loss of at least 50% of excess body weight, resulting from bariatric surgery or lifestyle changes.2 BCS procedures range from liposuction3-5 to complete lower or upper body lift, in which substantial amounts of tissue are resected.6-8 Motivations to undergo BCS may be physical and/or nonphysical concerns. Physical dissatisfaction arises from ptosis of redundant skin, which often leads to a rash in body folds; this may be accompanied by fungal infection and undesirable body odor.10 In severe cases, mobility can be impaired.10 Nonphysical complaints include low self-esteem, low self-image, sexual impairment, and others. All such factors affect the patient’s body-related quality of life (QoL).9-13 Outcomes of BCS can be categorized as surgical (eg, procedure-related complications) and QoL/psychosocial.14 Complications of BCS have been well documented. A systematic review by Staalesen et al15 showed that complication rates after abdominoplasty range from 22% to 52%. In a recent study of 30000 patients who underwent BCS, the risk of major complications was 2.7%.16 Previous research also has demonstrated that the primary motivation to undergo BCS is decreased QoL, relating to physical complaints or dissatisfaction with body image, which in turn may lead to low self-esteem, impairment of sex life, social isolation, and the feeling of being rejected by peers.10-13 Although patient-related outcome measures (PROMs) that address these specific concerns should be utilized to measure the impact of BCS on QoL, this has not been common practice. Jabir et al14 and Staalesen et al15 noted that even though QoL appears to improve after BCS, most studies have had small sample sizes or employed nonvalidated PROMs. These investigators concluded that there is need for larger studies in which validated PROMs are utilized to assess QoL after BCS.14,15 Many studies in which QoL was measured after BCS have provided short-term findings (less than a year postoperatively), and the reliability of short-term QoL data is questionable.14 A major reason for the questionable reliability is that the final aesthetic result takes longer than 6 months to achieve because additional time is required for scar healing.17 Moreover, factors such as cognitive dissonance (eg, scoring according to preoperative expectations rather than according to the result of the procedure) may result in patients scoring higher in the short term than they would longer term.18 Van der Beek et al19 observed satisfactory QoL results 4 and 7 years after BCS in patients with MWL from bariatric surgery, which emphasizes the importance of the long-term effect of BCS. However, both 4 and 7 years would be considered long-term results. It would be prudent to compare short-term and long-term findings to ascertain differences in QoL perspectives over time. In our hospital, the Body-QoL® instrument, published and owned by senior author (S.D.) in Santiago de Chile, was developed to measure QoL among patients who have undergone BCS. To our knowledge, it is the first instrument for this purpose designed in accordance with international guidelines for creation of PROMs.13,20,21 It is the only instrument specifically for these patients that is currently available in Spanish; it also has been translated into English (Appendix A, available as Supplementary Material online at www.aestheticsurgeryjournal.com). A preliminary study with the Body-QoL instrument suggested that QoL improves significantly within 3 months of BCS.13 To investigate whether improvement in QoL is maintained over time, we assessed it both short and long term (>1 year after BCS), utilizing the Body-QoL instrument. METHODS The study was approved by the ethics committee of the institutional review board, and was conducted in accordance with guiding principles of the Declaration of Helsinki.22 Informed consent was obtained before the initial QoL assessment (which occurred in the original study13). Study Design Consecutive patients who underwent BCS at our institution (Hospital Clínico de la Universidad de Chile, Santiago, Chile) between June 1, 2013 and April 30, 2015 were before the operation asked to participate in this study. There were no exclusion criteria. The BCS procedures were abdominal liposuction, abdominoplasty, lower body lift, or a combination of 2 of these procedures. All patients who responded to the preoperative (initial) Body-QoL assessment were included and represent the total study population. Patients All patients underwent BCS by 1 of 5 surgeons at the Hospital Clínico de la Universidad de Chile, a tertiary university hospital. All male and female patients undergoing BCS were eligible to participate. All patients were ASA physical status I or II, with body mass index (BMI) <32 kg/m2. Only patients with these criteria are eligible for BCS at our hospital. Baseline Measurements Baseline data were obtained for all patients during preoperative visits. Height and weight were measured; comorbidity data were based on anamnesis. MWL was defined as a history of weight loss after bariatric surgery or lifestyle changes resulting in loss of at least 50% of excess weight. Excess weight was defined as all weight above BMI of 25 kg/m2. For anxiety or depression to be considered a comorbidity, a current or recent diagnosis by another medical professional was required. History of smoking was defined as regular smoking at the time of preoperative evaluation. Any such patient was strongly advised to stop smoking at least 1 month before the surgery. Primary Outcome The primary outcome measure was QoL score according to the Body-QoL instrument, a PROM developed earlier by the senior author of this article (S.D.).12 (Therefore, no additional permission for its use was required.) The Body-QoL questionnaire is designed specifically for patients requesting contouring of the abdominal region. Four domains are included: body satisfaction, sex life, self-esteem and social performance, and physical symptoms (Appendix A). Each domain contains 5 items that are scored by patients on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Higher scores denote better QoL. For patients unable to address items pertaining to sex life because they had not been sexually active since the operation, the mean value for the rest of the domains was substituted. The Body-QoL score was obtained 3 times: the day before surgery, approximately 3 months after surgery (short-term postoperatively), and at least 1 year following surgery (long-term postoperatively). Secondary Outcomes Secondary outcomes were associations between QoL score and demographic/anthropometric characteristics (eg, change in BMI over time), type of surgery performed, concomitant procedures (eg, rhinoplasty, augmentation mammoplasty), and history of MWL. Statistical Analyses Data analysis was performed with Stata 13.0 (Stata Statistical Software, College Station, TX) The Body-QoL score was converted from the original scale of 20 to 100 to a centigrade scale of 0 to 100 to simplify analysis and interpretation of the results. The converted score is known as the adjusted Body-QoL score. Descriptive statistics were utilized to summarize and explain the variables. Continuous variables with normal distribution were expressed as mean ± standard deviation, accompanied by range and 95% confidence intervals (CIs). Continuous variables with non-normal distribution were expressed as median and interquartile range (IQR). The normality of variables was confirmed by the Shapiro-Wilk test. Categoric variables were expressed as frequency and percentage. The 2-sample Kolmogorov-Smirnov test was applied to ascertain equality of distribution and the Kruskal-Wallis rank test to test equality of the populations. Generalized estimating equations were applied to compare overall scores and domains with possible determinant-of-outcome variables. Outcomes were adjusted for BMI because we observed a significant negative correlation between BMI and Body-QoL score in a previous study.12 For all tests, significance was defined as P < 0.05. RESULTS Participation in Postoperative QoL Assessments During the study period, 202 patients underwent abdominal BCS, 112 of whom completed the questionnaire preoperatively; this latter group constituted the overall study population. Fifty-seven (50.9%) of the 112 patients responded to the questionnaire at the short-term postoperative assessment (4.3 months; IQR, 3.0-6.8 months). Eighty-four (75.0%) patients responded to the long-term postoperative assessment (27.2 months; IQR, 16.6-31.3 [2.3 years; IQR, 1.4-2.6 years]). Patient Characteristics and Surgical Procedures The study population was entirely female. Mean age was 39.6 ± 8.1 years (range, 22-63 years), mean height was 159.6 ± 6.1 cm, and mean weight was 63.9 ± 6.7 kg. Mean BMI was 25.1 ± 2.2 kg/m2 (range, 19.3-32.0 kg/m2) at the time of surgery and 24.7 ± 2.5 kg/m2 at the long-term postoperative assessment. Twenty (17.9%) patients had MWL, with 100.7% ± 17.1% of excess weight lost (ie, weight above BMI of 25). Seven (6.3%) of them underwent gastric bypass, 11 (9.8%) had a sleeve gastrectomy, and 2 (1.8%) lost weight by lifestyle changes. Baseline characteristics of patients who participated in both postoperative assessments did not differ significantly from those of the entire study population (Table 1). Table 1. General Characteristics of the Entire Study Population and the Subgroup That Responded to All 3 QoL Assessments Characteristic   Entire study population (n = 112)  Responders to all assessments (n = 44)  P value   Age, mean ± SD, y (range)  39.6 ± 8.1 (22-63)  40.9 ± 8.4 (22-63)  0.1627  Height, mean ± SD, cm (range)  159.6 ± 6.1 (149-176)  160.0 ± 6.0 (149-172)  0.6900  Weight, mean ± SD, kg (range)  63.9 ± 6.7 (47.5-82)  65.0 ± 6.5 (53-81)  0.1969  BMI (preoperative), mean ± SD, kg/m2 (range)  25.1 ± 2.2 (19.3-32.0)  25.4 ± 2.3 (19.8-32.0)  0.2025   Massive weight loss, n (%)  20 (17.9)  9 (20.5)  0.5883   Comorbidity, n (%) Tobacco use  30 (28.3)  14 (31.8)  0.4984   Depression  6 (5.5)  3 (6.8)  0.6208   Anxiety  5 (4.6)  3 (6.8)  0.3695   Hypertension  4 (3.7)  2 (4.6)  0.6891   Diabetes mellitus  1 (0.9)  0 (0)  0.4085   Insulin resistance  5 (4.5)  2 (4.6)  0.9733   Hypothyroidism  7 (6.4)  2 (4.6)  0.5108  Characteristic   Entire study population (n = 112)  Responders to all assessments (n = 44)  P value   Age, mean ± SD, y (range)  39.6 ± 8.1 (22-63)  40.9 ± 8.4 (22-63)  0.1627  Height, mean ± SD, cm (range)  159.6 ± 6.1 (149-176)  160.0 ± 6.0 (149-172)  0.6900  Weight, mean ± SD, kg (range)  63.9 ± 6.7 (47.5-82)  65.0 ± 6.5 (53-81)  0.1969  BMI (preoperative), mean ± SD, kg/m2 (range)  25.1 ± 2.2 (19.3-32.0)  25.4 ± 2.3 (19.8-32.0)  0.2025   Massive weight loss, n (%)  20 (17.9)  9 (20.5)  0.5883   Comorbidity, n (%) Tobacco use  30 (28.3)  14 (31.8)  0.4984   Depression  6 (5.5)  3 (6.8)  0.6208   Anxiety  5 (4.6)  3 (6.8)  0.3695   Hypertension  4 (3.7)  2 (4.6)  0.6891   Diabetes mellitus  1 (0.9)  0 (0)  0.4085   Insulin resistance  5 (4.5)  2 (4.6)  0.9733   Hypothyroidism  7 (6.4)  2 (4.6)  0.5108  SD, standard deviation. View Large Most patients with ptosis grading had moderate or severe ptosis (91.4%) according to Matarasso’s classification system (Table 2).23 Table 2. Ptosis Grades and Surgical Characteristics of the Study Population (N = 112) Characteristic   n (%)  Matarasso ptosis grade   I  2 (1.8)   II  4 (3.6)   III  34 (30.4)   IV  30 (26.8)   Not specified  42 (35.7)  Type of procedure   Abdominoplasty  5 (4.5)   Lipo-abdominoplasty  95 (84.8)   Liposuction  9 (8.0)   Lower body lift  5 (4.5)  Skin resection pattern   Extended  3 (2.7)   Circumferential  7 (6.3)   Fleur-de-lis  5 (4.5)   Lockwood  21 (18.8)   Standard (fusiform)  38 (33.9)   Reverse  1 (0.9)  Not specified  37 (33.0)  Concomitant procedure (same session)   Breast augmentation  12 (10.7)   Rhinoplasty  1 (0.9)  Characteristic   n (%)  Matarasso ptosis grade   I  2 (1.8)   II  4 (3.6)   III  34 (30.4)   IV  30 (26.8)   Not specified  42 (35.7)  Type of procedure   Abdominoplasty  5 (4.5)   Lipo-abdominoplasty  95 (84.8)   Liposuction  9 (8.0)   Lower body lift  5 (4.5)  Skin resection pattern   Extended  3 (2.7)   Circumferential  7 (6.3)   Fleur-de-lis  5 (4.5)   Lockwood  21 (18.8)   Standard (fusiform)  38 (33.9)   Reverse  1 (0.9)  Not specified  37 (33.0)  Concomitant procedure (same session)   Breast augmentation  12 (10.7)   Rhinoplasty  1 (0.9)  View Large The procedures performed were lipo-abdominoplasty (n = 95; 84.8%), abdominoplasty without liposuction (n = 5; 4.5%) liposuction alone (n = 9; 8.0%), and lower body lift (n = 5; 4.5%) (Table 2). Thirteen (11.6%) patients underwent a concomitant aesthetic surgery procedure (mainly breast surgery or rhinoplasty) (Table 2). A major difference between the MWL and cosmetic cohorts pertained to the type of procedure: all lower body lifts and nearly all circumferential procedures were in patients with MWL (Table 3). Mean age was lower in the MWL cohort (38.3 ± 10.4 vs 39.9 ± 7.6; P = 0.0277). Table 3. Demographic and Surgical Characteristics of the Cosmetic and MWL Cohorts   Cosmetic (n = 92)  MWL (n = 20)    Characteristic      P value   Age, mean ± SD, y (range)  39.9 ± 7.6 (22-64)  38.3 ± 10.4 (22-63)  0.4186   Height, mean ± SD, cm (range)  63.6 ± 7.0 (47.5-86)  65.9 ± 7.3 (55-81)  0.4318   Weight, mean ± SD, kg (range)  158.9 ± 6.4 (145-176)  160.3 ± 4.9 (149-168)  0.0722   BMI (preoperative), mean ± SD, kg/m2 (range)  25.2 ± 2.1 (19.3-30.9)  25.6 ± 2.5 (22.1-32.1)  0.1604  Type of procedure, n (%)   Abdominoplasty  0 (0.0)  3 (15.0)  0.0002   Lipo-abdominoplasty  83 (90.2)  12 (60.0)  0.0003   Liposuction  9 (9.8)  0 (0.0)  0.1687   Lower body lift  0 (0.0)  5 (25.0)  <0.0001  Skin resection pattern, n (%)   Extended  1 (1.1)  2 (10.0)  0.0632   Circumferential  1 (1.1)  6 (30.0)  <0.0001   Fleur-de-lis  3 (3.3)  2 (10.0)  0.3379   Lockwood  21 (22.8)  0 (0)  0.0035   Standard (fusiform)  31 (33.7)  7 (35.0)  0.3735   Reverse  1 (1.1)  0 (0)  0.5857   Not specified  34 (37.0)  3 (15.0)      Cosmetic (n = 92)  MWL (n = 20)    Characteristic      P value   Age, mean ± SD, y (range)  39.9 ± 7.6 (22-64)  38.3 ± 10.4 (22-63)  0.4186   Height, mean ± SD, cm (range)  63.6 ± 7.0 (47.5-86)  65.9 ± 7.3 (55-81)  0.4318   Weight, mean ± SD, kg (range)  158.9 ± 6.4 (145-176)  160.3 ± 4.9 (149-168)  0.0722   BMI (preoperative), mean ± SD, kg/m2 (range)  25.2 ± 2.1 (19.3-30.9)  25.6 ± 2.5 (22.1-32.1)  0.1604  Type of procedure, n (%)   Abdominoplasty  0 (0.0)  3 (15.0)  0.0002   Lipo-abdominoplasty  83 (90.2)  12 (60.0)  0.0003   Liposuction  9 (9.8)  0 (0.0)  0.1687   Lower body lift  0 (0.0)  5 (25.0)  <0.0001  Skin resection pattern, n (%)   Extended  1 (1.1)  2 (10.0)  0.0632   Circumferential  1 (1.1)  6 (30.0)  <0.0001   Fleur-de-lis  3 (3.3)  2 (10.0)  0.3379   Lockwood  21 (22.8)  0 (0)  0.0035   Standard (fusiform)  31 (33.7)  7 (35.0)  0.3735   Reverse  1 (1.1)  0 (0)  0.5857   Not specified  34 (37.0)  3 (15.0)    MWL, massive weight loss; SD, standard deviation. View Large Primary Outcome: Total Body-QoL Score Over Time The mean adjusted Body-QoL score was 44.0 ± 14.1 (95% CI, 41.3-46.6) preoperatively, 85.5 ± 17.5 (95% CI, 80.9-90.2) short-term postoperatively, and 84.4 ± 12.7 (95% CI, 81.7-87.2) long-term postoperatively (Figure 1). The differences between the preoperative score and each postoperative score were significant (P < 0.0001). However, differences between the short-term and long-term postoperative scores were not significant (P = 0.8104). Figure 1. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years). Figure 1. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years). When comparing outcomes between the entire study population (n = 112) and the subgroup that participated in all 3 assessments (n = 44), no significant differences in Body-QoL scores were observed (Table 4), denoting strong positive correlation between these groups. Table 4. Comparison of Outcomes: Entire Study Population vs Subgroup That Responded to All 3 QoL Assessments (Per Protocol Group) Population   Basal Body-QoL Score n = 112  Short-Term Body-QoL Score n = 57  Long-Term Body-QoL Score n = 84  P value  Basal vs Short-Term n = 57  Basal vs Long-Term n = 84  Short vs Long-Term n = 50  Study Population n = 112  44.0 ± 14.1 (5.0-88.8)  85.5 ± 17.5 (23.8-100)  84.4 ± 12.7 (46.3-100)  P < 0.0001  P < 0.0001  0.8104  Per protocol n = 44  43.5 ± 16.0 (15.0-88.8)  85.5 ± 18.4 (23.8-100)  84.8 ± 13.9 (46.3-100)  P < 0.0001  P < 0.0001  0.7852  P value comparing 2 populations  P = 0.8482  P = 0.9999  P = 0.8634        Population   Basal Body-QoL Score n = 112  Short-Term Body-QoL Score n = 57  Long-Term Body-QoL Score n = 84  P value  Basal vs Short-Term n = 57  Basal vs Long-Term n = 84  Short vs Long-Term n = 50  Study Population n = 112  44.0 ± 14.1 (5.0-88.8)  85.5 ± 17.5 (23.8-100)  84.4 ± 12.7 (46.3-100)  P < 0.0001  P < 0.0001  0.8104  Per protocol n = 44  43.5 ± 16.0 (15.0-88.8)  85.5 ± 18.4 (23.8-100)  84.8 ± 13.9 (46.3-100)  P < 0.0001  P < 0.0001  0.7852  P value comparing 2 populations  P = 0.8482  P = 0.9999  P = 0.8634        SD, standard deviation. View Large Domains of the Body-QoL Tool The scores for all 4 domains were significantly better after BCS, both short and long term, than preoperatively (P < 0.0001 for each domain vs preoperative score) (Figure 2). The differences between short-term and long-term postoperative scores for each domain were not significant (Figure 2). Figure 2. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for the domains of (A) body satisfaction, (B) sex life, (C) self-esteem and social performance, and (D) physical symptoms. Figure 2. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for the domains of (A) body satisfaction, (B) sex life, (C) self-esteem and social performance, and (D) physical symptoms. MWL vs Cosmetic Patients Preoperatively, the adjusted Body-QoL score was significantly lower (P = 0.0028) for patients with MWL (MWL cohort: 33.9 ± 15.6; 95% CI, 26.6-41.2; cosmetic cohort: 46.1 ± 12.8; 95% CI, 43.5-48.8). Short-term and long-term postoperative scores were slightly lower for the MWL cohort, but the differences in scores between these cohorts were not significant (P = 0.2231 short term; P = 0.1133 long term). Significant improvement in scores from preoperative values was noted for both cohorts at both postoperative assessments. However, the differences between short-term and long-term postoperative scores for each cohort were not significant (MWL: P = 1.0; cosmetic: P = 0.5114) (Figure 3). Figure 3. View largeDownload slide Total adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for cosmetic and MWL patients. Figure 3. View largeDownload slide Total adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for cosmetic and MWL patients. Analysis by domain showed that the MWL cohort experienced significant improvement postoperatively in every domain, both short and long term. Results were comparable to those for the cosmetic cohort. Body-QoL Score Over Time The mean total Body-QoL score improved significantly from the preoperative assessment to the short-term postoperative assessment, and the improvement was maintained long term (Figure 4). A 3-parameter Gompertz function was the model that after testing different models (including sigmoid and exponential functions) did best represent the evolution of the body-QoL scores over time, since it had the highest R-squared. The Gompertz model predicted an adjusted Body-QoL score of 84.9 for women after BCS (R-squared, 0.9999). For the MWL cohort, the Gompertz model predicted a postoperative score of 80.1 (R-squared, 1.0). For the cosmetic cohort, the model predicted a postoperative score of 85.9 (R-squared, 0.9998). Therefore, according to this model, the difference in predicted postoperative scores between the MWL and cosmetic cohorts was significant (P < 0.0001). Figure 4. View largeDownload slide Body-QoL scores over time were best represented by a 3-parameter Gompertz model. Figure 4. View largeDownload slide Body-QoL scores over time were best represented by a 3-parameter Gompertz model. Association Between Body-QoL Score and Patients Characteristics Comparing preoperative scores with both postoperative scores using generalized estimating equations different associations were seen. Older age was associated with greater gains in total Body-QoL score after surgery (P < 0.0001). An increase in BMI during postoperative follow-up was associated with less improvement in the total Body-QoL score (P = 0.001). A current diagnosis of anxiety or depression also were associated with lower improvement (P = 0.014). Having a concomitant aesthetic surgery procedure at the time of BCS had a favorable impact on the improvement in Body-QoL score postoperatively (P = 0.034). DISCUSSION QoL is one of the most relevant clinical outcomes in medical practice. It should be measured with a properly designed and validated PROM instrument to effectively ascertain the patient’s perspective.11,20,21,24 Evidence suggests that BCS improves QoL by enhancing self-image, increasing self- esteem, reducing physical symptoms, and providing other favorable effects.9-13 However, the postoperative follow-up in studies that address QoL outcomes following BCS are either short, less than a year,25,26 long,19,27,28 or not provided.29-31 Therefore, insight into the comparability of short-term and long-term effects of BCS on QoL is lacking. More importantly, in most studies, the PROMs utilized to assess QoL after BCS were either not validated,31,32 or not designed specifically for patients who undergo BCS.25,29,30,33 Our group is the first to design and validate a PROM (the Body-QoL) specifically to measure the effect of BCS on QoL13; therefore, the Body-QoL instrument does not have the disadvantages of other PROMs. Since implementation of the Body-QoL tool in our practice approximately 3 years ago, we have been evaluating QoL results after BCS in a more profound and systematic manner. To our knowledge, our group is the first to provide both short-term and long-term QoL data post-BCS that are based on a systematic and rigorously designed PROM. Our research represents a substantial contribution to the field particularly because knowledge of long-term QoL outcomes after BCS had been lacking. Another strength of our study is the inclusion and independent assessment of MWL and cosmetic cohorts. Our study population was recruited during a 3-year period, and more than 55% of patients who underwent BCS in our hospital participated in the study. Moreover, 75% of the study population completed the long-term QoL assessment. Overall, the demographic characteristics of patients who participated in all 3 assessments were similar to those of the entire study population. The short-term and long-term postoperative assessments were performed at different times, and all long-term assessments occurred at least 1 year after BCS. We observed stability of the QoL effect of BCS over time, and there was no significant difference between short-term and long-term scores. Moreover, we noted that the scores over time were characteristic of a Gompertz model, reaching a stable plateau 3 months after BCS, indicative of true stability. Although the strength of the findings may be questioned due to the fact that some patients who participated in 1 postoperative assessment did not participate in the other, we believe that this issue is irrelevant because the baseline characteristics of patients who participated in all 3 assessments were comparable to those of the entire study population. The observed stability of the Body-QoL scores makes it unlikely that cognitive dissonance (eg, scoring higher at short-term postoperative assessments due to positive preoperative expectations) played a major role in our results.18 The similarity of short- and long-term scores may imply that short-term QoL scores are a reliable predictor of final (long-term) QoL outcomes of BCS. This would simplify the monitoring of QoL after surgery, particularly because follow-up typically does not last more than a year. If similarity of short- and long-term QoL results is confirmed by other BCS studies, short-term results may be a better indicator of final results than previously believed. However, further research is required to draw meaningful conclusions regarding this matter. The greatest difference between the MWL and cosmetic cohorts in our study pertained to preoperative Body-QoL scores, which were much lower for the MWL cohort. Both cohorts experienced significant and sustained improvement in QoL following BCS, and postoperative scores did not differ significantly between these cohorts. However, the cohorts differed in age; on average, patients with MWL were 4 years younger. If age had been comparable, mean preoperative scores might have been different. Our previous study showed that higher age was associated with lower preoperative QoL scores.13 Although our current findings imply that postoperative scores are comparable for MWL and cosmetic cohorts, the Gompertz model predicted a statistically significant difference in long-term scores, which were nearly 6% lower for the MWL cohort. Therefore, we do not know if the long-term scores for MWL and cosmetic subpopulations are comparable or slightly different. Further investigation is warranted. Greater improvement in QoL was associated with older age and concomitant cosmetic procedures. A diagnosis of anxiety was associated with less improvement in QoL. We believe that these factors should be examined more thoroughly in future research. Changes in body weight over time had a significant impact on QoL in our study. This is concordant with findings of Van der Beek et al19 among patients who underwent BCS after bariatric surgery; in their study, weight regain was found to be the main contributor to a decline in QoL between 3 and 7 years post-BCS.19 Because our long-term data for body weight are merely anamnestic, potential bias exists; for example, patients with high QoL might estimate their weight as lower than actual, and vice versa. Therefore, conclusions about the effect of body weight cannot be drawn from our study, but it would be interesting to explore this further in well-designed research. The primary limitation of the present study is its lack of male participants, which prevents extrapolation of the results to men. Although men were not excluded from participation, only 2 men underwent BCS during the study period, and those men did not consent to participate. The limited interest of men in BCS is not surprising, considering that 90% of cosmetic procedures are performed in women,1 and women may feel more pressure to maintain a lean juvenile figure.34,35 Another limitation of our study is that results are based solely on the Chilean population. Although we believe that our findings may indicate favorable long-term QoL outcomes for other BCS populations, the extent of improvement, the differences between MWL and cosmetic patients, and the associations with factors such as age or BMI may differ for those populations. We advocate utilization of the Body-QoL tool in other countries to broaden general knowledge about QoL following BCS. Another limitation of the study is the relatively low response rate to the short-term assessment; this occurred mainly because the registry system was not fully functional when the Body-QoL instrument was launched. Fortunately, the registry system became fully operational over time, and the response to the long-term assessment was considerable. We did not collect data relating to the effects of complications on the body-related QoL. This is considered a limitation of the study because complications could substantially impact QoL. It would be prudent to explore this topic in future research. Regardless of the limitations, our study provides new insight and high-quality data on QoL for patients after BCS. Much additional research is needed, and we will continue assessing body-related QoL in our practice. We hope that similar studies will be conducted in other facilities and countries. Another recent development in QoL assessment is the PROM designed by Klassen et al,36 known as the BODY-Q. This instrument demonstrated promising results for assessing QoL among patients who underwent BCS for cosmetic reasons or after MWL. It includes more domains than the Body-QoL, addresses all body regions affected, and involves measuring satisfaction with the treatment and the surgeon. We believe that this tool will increase knowledge about QoL after BCS, and look forward to the publication of more data obtained with it. However, we believe that for routine evaluation in medical practice, the Body-QoL tool is a quick and easy, yet strong, tool to monitor QoL outcomes. Moreover, its handiness may result in high response rates. We encourage surgeons and researchers to employ one or both of these PROMs in clinical and research efforts. The Body-QoL can be freely used for academic purposes, by individual researchers (surgeons) and nonprofit institutions, as stated in the initial publication.12 CONCLUSIONS Body-related QoL improves after BCS, whether the surgery is performed because of MWL or specifically for aesthetic concerns. The improvement is significant and remains constant long term (up to 3 years postoperatively in our Chilean population). Although patients with MWL had lower preoperative Body-QoL scores, their postoperative scores approached those of the cosmetic cohort, indicating restored self-confidence and improved physical symptoms. Certain factors contributed to less improvement in QoL, including anxiety, depression, and higher BMI when undergoing BCS. Additional research in more diverse populations is warranted. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics. Aesthet Surg J . 2016; 36( Suppl 1): 1- 29. 2. Shermak MA Chang D Magnuson TH Schweitzer MA. An outcomes analysis of patients undergoing body contouring surgery after massive weight loss. Plast Reconstr Surg . 2006; 118( 4): 1026- 1031. Google Scholar CrossRef Search ADS PubMed  3. Schrudde J. Lipexheresis (liposuction) for body contouring. Clin Plast Surg . 1984; 11( 3): 445- 456. Google Scholar PubMed  4. Kesselring UK. Regional fat aspiration for body contouring. Plast Reconstr Surg . 1983; 72( 5): 610- 619. Google Scholar CrossRef Search ADS PubMed  5. Hetter GP Herhahn F. Experience with “lipolysis”: the Illouz technique of blunt suction lipectomy in North America. Aesthetic Plast Surg . 1983; 7( 2): 69- 76. Google Scholar CrossRef Search ADS PubMed  6. Soliman S Rotemberg SC Pace Det al.  . Upper body lift. Clin Plast Surg . 2008; 35( 1): 107- 114; discussion 121. Google Scholar CrossRef Search ADS PubMed  7. Lockwood T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg . 1993; 92( 6): 1112- 1122; discussion 1123. Google Scholar CrossRef Search ADS PubMed  8. Aly A. Body Contouring After Massive Weight Loss . New York, NY: Thieme Medical Publishers; 2006. 9. de Brito MJ Nahas FX Bussolaro RA Shinmyo LM Barbosa MV Ferreira LM. Effects of abdominoplasty on female sexuality: a pilot study. J Sex Med . 2012; 9( 3): 918- 926. Google Scholar CrossRef Search ADS PubMed  10. Klassen AF Cano SJ Scott A Johnson J Pusic AL. Satisfaction and quality-of-life issues in body contouring surgery patients: a qualitative study. Obes Surg . 2012; 22( 10): 1527- 1534. Google Scholar CrossRef Search ADS PubMed  11. Klassen AF Cano SJ Scott A Tsangaris E Pusic AL. Assessing outcomes in body contouring. Clin Plast Surg . 2014; 41( 4): 645- 654. Google Scholar CrossRef Search ADS PubMed  12. Danilla S Dominguez C Cuevas Pet al.  . The Body-QoL(®):Measuring patient reported outcomes in body contouring surgery patients. Aesthetic Plast Surg . 2014; 38( 3): 575- 583. Google Scholar CrossRef Search ADS PubMed  13. Danilla S Cuevas P Aedo Set al.  . Introducing the body-QoL®: a new patient-reported outcome instrument for measuring body satisfaction-related quality of life in aesthetic and post-bariatric body contouring patients. Aesthetic Plast Surg . 2016; 40( 1): 19- 29. Google Scholar CrossRef Search ADS PubMed  14. Jabir S. Assessing improvement in quality of life and patient satisfaction following body contouring surgery in patients with massive weight loss: a critical review of outcome measures employed. Plast Surg Int . 2013; 2013: 515737. Google Scholar PubMed  15. Staalesen T Elander A Strandell A Bergh C. A systematic review of outcomes of abdominoplasty. J Plast Surg Hand Surg . 2012; 46( 3-4): 139- 144. Google Scholar CrossRef Search ADS PubMed  16. Gupta V Winocour J Rodriguez-Feo Cet al.  . Safety of aesthetic surgery in the overweight patient: analysis of 127961 patients. Aesthet Surg J . 2016; 36( 6): 718- 729. Google Scholar CrossRef Search ADS PubMed  17. Mustoe TA Cooter RD Gold MHet al.  .; International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg . 2002; 110( 2): 560- 571. Google Scholar CrossRef Search ADS PubMed  18. Davis K. Reshaping the Female Body: The Dilemma of Cosmetic Surgery . Oakland, CA: Routledge; 2013. 19. van der Beek ES Geenen R de Heer FA van der Molen AB van Ramshorst B. Quality of life long-term after body contouring surgery following bariatric surgery: sustained improvement after 7 years. Plast Reconstr Surg . 2012; 130( 5): 1133- 1139. Google Scholar CrossRef Search ADS PubMed  20. US Department of Health and Human Services FDA Center for Drug Evaluation and Research; US Department of Health and Human Services FDA Center for Biologics Evaluation and Research; US Department of Health and Human Services FDA Center for Devices and Radiological Health. Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims: draft guidance. Health Qual Life Outcomes . 2006; 4: 79. CrossRef Search ADS PubMed  21. Morley D Jenkinson C Fitzpatrick R. A structured review of patient-reported outcome measures used in cosmetic surgical procedures: report to Department of Health, 2013. http://phi.uhce.ox.ac.uk/pdf/Cosmetic%20Surgery%20PROMs%20Review2013.pdf. Accessed March 1, 2016. 22. WMA Declaration of Helsinki-Ethical Principles for Medical Research Involving Human Subjects, 2013. http://www.wma.net/es/30publications/ 10policies/b3/. Accessed June 8, 2016. 23. Matarasso A. Abdominolipoplasty. Clin Plast Surg . 1989; 16( 2): 289- 303. Google Scholar PubMed  24. Gilmartin J Bath-Hextall F Maclean J Stanton W Soldin M. Quality of life among adults following bariatric and body contouring surgery: a systematic review. JBI Database System Rev Implement Rep . 2016; 14( 11): 240- 270. Google Scholar CrossRef Search ADS PubMed  25. Song AY Rubin JP Thomas V Dudas JR Marra KG Fernstrom MH. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring) . 2006; 14( 9): 1626- 1636. Google Scholar CrossRef Search ADS PubMed  26. Stuerz K Piza H Niermann K Kinzl JF. Psychosocial impact of abdominoplasty. Obes Surg . 2008; 18( 1): 34- 38. Google Scholar CrossRef Search ADS PubMed  27. Menderes A Baytekin C Haciyanli M Yilmaz M. Dermalipectomy for body contouring after bariatric surgery in Aegean region of Turkey. Obes Surg . 2003; 13( 4): 637- 641. Google Scholar CrossRef Search ADS PubMed  28. Cintra WJr Modolin ML Gemperli R Gobbi CI Faintuch J Ferreira MC. Quality of life after abdominoplasty in women after bariatric surgery. Obes Surg . 2008; 18( 6): 728- 732. Google Scholar CrossRef Search ADS PubMed  29. Singh D Zahiri HR Janes LEet al.  . Mental and physical impact of body contouring procedures on post-bariatric surgery patients. Eplasty . 2012; 12: e47. Google Scholar PubMed  30. van der Beek ES Te Riele W Specken TF Boerma D van Ramshorst B. The impact of reconstructive procedures following bariatric surgery on patient well-being and quality of life. Obes Surg . 2010; 20( 1): 36- 41. Google Scholar CrossRef Search ADS PubMed  31. Coriddi MR Koltz PF Chen R Gusenoff JA. Changes in quality of life and functional status following abdominal contouring in the massive weight loss population. Plast Reconstr Surg . 2011; 128( 2): 520- 526. Google Scholar CrossRef Search ADS PubMed  32. Lanier VCJr. Body contouring surgery after weight reduction. South Med J . 1987; 80( 11): 1375- 1380. Google Scholar CrossRef Search ADS PubMed  33. Lazar CC Clerc I Deneuve S Auquit-Auckbur I Milliez PY. Abdominoplasty after major weight loss: improvement of quality of life and psychological status. Obes Surg . 2009; 19( 8): 1170- 1175. Google Scholar CrossRef Search ADS PubMed  34. Nerini A Matera C Stefanile C. Psychosocial predictors in consideration of cosmetic surgery among women. Aesthetic Plast Surg . 2014; 38( 2): 461- 466. Google Scholar CrossRef Search ADS PubMed  35. Fisher ML Voracek M. The shape of beauty: determinants of female physical attractiveness. J Cosmet Dermatol . 2006; 5( 2): 190- 194. Google Scholar CrossRef Search ADS PubMed  36. Klassen AF Cano SJ Alderman Aet al.  . The BODY-Q: A patient-reported outcome instrument for weight loss and body contouring treatments. Plast Reconstr Surg Glob Open . 2016; 4( 4): e679. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

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© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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Abstract

Abstract Background Body contouring surgery (BCS) is becoming increasing popular for aesthetic and reconstructive purposes, particularly among patients with massive weight loss (MWL). However, data on quality of life (QoL) following the surgery are limited, especially long-term QoL. Objectives The authors evaluated the effect of BCS on QoL and the durability of this effect over time. Methods QoL was measured with the Body-QoL® instrument at 3 time points among consecutively treated patients: the day before BCS, 1 to 9 months postoperatively (short term), and 1 to 2.7 years postoperatively (long term). Total Body-QoL scores were compiled, as were scores for the instrument’s main domains: body satisfaction, sex life, self-esteem and social performance, and physical symptoms. Scores were examined for the entire study population and separately for the cosmetic and MWL cohorts. Results Fifty-seven of the 112 patients participated in the short-term assessment and 84 in the long-term assessment. Total Body-QoL scores increased significantly (P < 0.0001), from 44.0 ± 14.1 preoperatively to 85.5 ± 17.5 short-term postoperatively and to 84.4 ± 12.7 long-term postoperatively. Scores for the 2 postoperative assessments did not differ significantly. Similar results were observed for scores on each separate domain. Although preoperative scores were lower for the MWL cohort than the cosmetic cohort (33.9 ± 15.6 vs 46.1 ± 12.8; P = 0.0002), they improved substantially after BCS, approaching scores for the cosmetic cohort. Conclusions QoL increases significantly after BCS. This favorable outcome remained stable throughout long-term follow-up and was true for the cosmetic and MWL cohorts. Level of Evidence: 4 Body contouring surgery (BCS) is growing in popularity, as are aesthetic procedures in general. Between 2011 and 2015, aesthetic surgeries in the United States increased by 17%, and cosmetic medicine procedures by 44%.1 BCS is increasingly desired by patients who have experienced massive weight loss (MWL), defined as loss of at least 50% of excess body weight, resulting from bariatric surgery or lifestyle changes.2 BCS procedures range from liposuction3-5 to complete lower or upper body lift, in which substantial amounts of tissue are resected.6-8 Motivations to undergo BCS may be physical and/or nonphysical concerns. Physical dissatisfaction arises from ptosis of redundant skin, which often leads to a rash in body folds; this may be accompanied by fungal infection and undesirable body odor.10 In severe cases, mobility can be impaired.10 Nonphysical complaints include low self-esteem, low self-image, sexual impairment, and others. All such factors affect the patient’s body-related quality of life (QoL).9-13 Outcomes of BCS can be categorized as surgical (eg, procedure-related complications) and QoL/psychosocial.14 Complications of BCS have been well documented. A systematic review by Staalesen et al15 showed that complication rates after abdominoplasty range from 22% to 52%. In a recent study of 30000 patients who underwent BCS, the risk of major complications was 2.7%.16 Previous research also has demonstrated that the primary motivation to undergo BCS is decreased QoL, relating to physical complaints or dissatisfaction with body image, which in turn may lead to low self-esteem, impairment of sex life, social isolation, and the feeling of being rejected by peers.10-13 Although patient-related outcome measures (PROMs) that address these specific concerns should be utilized to measure the impact of BCS on QoL, this has not been common practice. Jabir et al14 and Staalesen et al15 noted that even though QoL appears to improve after BCS, most studies have had small sample sizes or employed nonvalidated PROMs. These investigators concluded that there is need for larger studies in which validated PROMs are utilized to assess QoL after BCS.14,15 Many studies in which QoL was measured after BCS have provided short-term findings (less than a year postoperatively), and the reliability of short-term QoL data is questionable.14 A major reason for the questionable reliability is that the final aesthetic result takes longer than 6 months to achieve because additional time is required for scar healing.17 Moreover, factors such as cognitive dissonance (eg, scoring according to preoperative expectations rather than according to the result of the procedure) may result in patients scoring higher in the short term than they would longer term.18 Van der Beek et al19 observed satisfactory QoL results 4 and 7 years after BCS in patients with MWL from bariatric surgery, which emphasizes the importance of the long-term effect of BCS. However, both 4 and 7 years would be considered long-term results. It would be prudent to compare short-term and long-term findings to ascertain differences in QoL perspectives over time. In our hospital, the Body-QoL® instrument, published and owned by senior author (S.D.) in Santiago de Chile, was developed to measure QoL among patients who have undergone BCS. To our knowledge, it is the first instrument for this purpose designed in accordance with international guidelines for creation of PROMs.13,20,21 It is the only instrument specifically for these patients that is currently available in Spanish; it also has been translated into English (Appendix A, available as Supplementary Material online at www.aestheticsurgeryjournal.com). A preliminary study with the Body-QoL instrument suggested that QoL improves significantly within 3 months of BCS.13 To investigate whether improvement in QoL is maintained over time, we assessed it both short and long term (>1 year after BCS), utilizing the Body-QoL instrument. METHODS The study was approved by the ethics committee of the institutional review board, and was conducted in accordance with guiding principles of the Declaration of Helsinki.22 Informed consent was obtained before the initial QoL assessment (which occurred in the original study13). Study Design Consecutive patients who underwent BCS at our institution (Hospital Clínico de la Universidad de Chile, Santiago, Chile) between June 1, 2013 and April 30, 2015 were before the operation asked to participate in this study. There were no exclusion criteria. The BCS procedures were abdominal liposuction, abdominoplasty, lower body lift, or a combination of 2 of these procedures. All patients who responded to the preoperative (initial) Body-QoL assessment were included and represent the total study population. Patients All patients underwent BCS by 1 of 5 surgeons at the Hospital Clínico de la Universidad de Chile, a tertiary university hospital. All male and female patients undergoing BCS were eligible to participate. All patients were ASA physical status I or II, with body mass index (BMI) <32 kg/m2. Only patients with these criteria are eligible for BCS at our hospital. Baseline Measurements Baseline data were obtained for all patients during preoperative visits. Height and weight were measured; comorbidity data were based on anamnesis. MWL was defined as a history of weight loss after bariatric surgery or lifestyle changes resulting in loss of at least 50% of excess weight. Excess weight was defined as all weight above BMI of 25 kg/m2. For anxiety or depression to be considered a comorbidity, a current or recent diagnosis by another medical professional was required. History of smoking was defined as regular smoking at the time of preoperative evaluation. Any such patient was strongly advised to stop smoking at least 1 month before the surgery. Primary Outcome The primary outcome measure was QoL score according to the Body-QoL instrument, a PROM developed earlier by the senior author of this article (S.D.).12 (Therefore, no additional permission for its use was required.) The Body-QoL questionnaire is designed specifically for patients requesting contouring of the abdominal region. Four domains are included: body satisfaction, sex life, self-esteem and social performance, and physical symptoms (Appendix A). Each domain contains 5 items that are scored by patients on a 5-point Likert scale (1 = strongly disagree, 5 = strongly agree). Higher scores denote better QoL. For patients unable to address items pertaining to sex life because they had not been sexually active since the operation, the mean value for the rest of the domains was substituted. The Body-QoL score was obtained 3 times: the day before surgery, approximately 3 months after surgery (short-term postoperatively), and at least 1 year following surgery (long-term postoperatively). Secondary Outcomes Secondary outcomes were associations between QoL score and demographic/anthropometric characteristics (eg, change in BMI over time), type of surgery performed, concomitant procedures (eg, rhinoplasty, augmentation mammoplasty), and history of MWL. Statistical Analyses Data analysis was performed with Stata 13.0 (Stata Statistical Software, College Station, TX) The Body-QoL score was converted from the original scale of 20 to 100 to a centigrade scale of 0 to 100 to simplify analysis and interpretation of the results. The converted score is known as the adjusted Body-QoL score. Descriptive statistics were utilized to summarize and explain the variables. Continuous variables with normal distribution were expressed as mean ± standard deviation, accompanied by range and 95% confidence intervals (CIs). Continuous variables with non-normal distribution were expressed as median and interquartile range (IQR). The normality of variables was confirmed by the Shapiro-Wilk test. Categoric variables were expressed as frequency and percentage. The 2-sample Kolmogorov-Smirnov test was applied to ascertain equality of distribution and the Kruskal-Wallis rank test to test equality of the populations. Generalized estimating equations were applied to compare overall scores and domains with possible determinant-of-outcome variables. Outcomes were adjusted for BMI because we observed a significant negative correlation between BMI and Body-QoL score in a previous study.12 For all tests, significance was defined as P < 0.05. RESULTS Participation in Postoperative QoL Assessments During the study period, 202 patients underwent abdominal BCS, 112 of whom completed the questionnaire preoperatively; this latter group constituted the overall study population. Fifty-seven (50.9%) of the 112 patients responded to the questionnaire at the short-term postoperative assessment (4.3 months; IQR, 3.0-6.8 months). Eighty-four (75.0%) patients responded to the long-term postoperative assessment (27.2 months; IQR, 16.6-31.3 [2.3 years; IQR, 1.4-2.6 years]). Patient Characteristics and Surgical Procedures The study population was entirely female. Mean age was 39.6 ± 8.1 years (range, 22-63 years), mean height was 159.6 ± 6.1 cm, and mean weight was 63.9 ± 6.7 kg. Mean BMI was 25.1 ± 2.2 kg/m2 (range, 19.3-32.0 kg/m2) at the time of surgery and 24.7 ± 2.5 kg/m2 at the long-term postoperative assessment. Twenty (17.9%) patients had MWL, with 100.7% ± 17.1% of excess weight lost (ie, weight above BMI of 25). Seven (6.3%) of them underwent gastric bypass, 11 (9.8%) had a sleeve gastrectomy, and 2 (1.8%) lost weight by lifestyle changes. Baseline characteristics of patients who participated in both postoperative assessments did not differ significantly from those of the entire study population (Table 1). Table 1. General Characteristics of the Entire Study Population and the Subgroup That Responded to All 3 QoL Assessments Characteristic   Entire study population (n = 112)  Responders to all assessments (n = 44)  P value   Age, mean ± SD, y (range)  39.6 ± 8.1 (22-63)  40.9 ± 8.4 (22-63)  0.1627  Height, mean ± SD, cm (range)  159.6 ± 6.1 (149-176)  160.0 ± 6.0 (149-172)  0.6900  Weight, mean ± SD, kg (range)  63.9 ± 6.7 (47.5-82)  65.0 ± 6.5 (53-81)  0.1969  BMI (preoperative), mean ± SD, kg/m2 (range)  25.1 ± 2.2 (19.3-32.0)  25.4 ± 2.3 (19.8-32.0)  0.2025   Massive weight loss, n (%)  20 (17.9)  9 (20.5)  0.5883   Comorbidity, n (%) Tobacco use  30 (28.3)  14 (31.8)  0.4984   Depression  6 (5.5)  3 (6.8)  0.6208   Anxiety  5 (4.6)  3 (6.8)  0.3695   Hypertension  4 (3.7)  2 (4.6)  0.6891   Diabetes mellitus  1 (0.9)  0 (0)  0.4085   Insulin resistance  5 (4.5)  2 (4.6)  0.9733   Hypothyroidism  7 (6.4)  2 (4.6)  0.5108  Characteristic   Entire study population (n = 112)  Responders to all assessments (n = 44)  P value   Age, mean ± SD, y (range)  39.6 ± 8.1 (22-63)  40.9 ± 8.4 (22-63)  0.1627  Height, mean ± SD, cm (range)  159.6 ± 6.1 (149-176)  160.0 ± 6.0 (149-172)  0.6900  Weight, mean ± SD, kg (range)  63.9 ± 6.7 (47.5-82)  65.0 ± 6.5 (53-81)  0.1969  BMI (preoperative), mean ± SD, kg/m2 (range)  25.1 ± 2.2 (19.3-32.0)  25.4 ± 2.3 (19.8-32.0)  0.2025   Massive weight loss, n (%)  20 (17.9)  9 (20.5)  0.5883   Comorbidity, n (%) Tobacco use  30 (28.3)  14 (31.8)  0.4984   Depression  6 (5.5)  3 (6.8)  0.6208   Anxiety  5 (4.6)  3 (6.8)  0.3695   Hypertension  4 (3.7)  2 (4.6)  0.6891   Diabetes mellitus  1 (0.9)  0 (0)  0.4085   Insulin resistance  5 (4.5)  2 (4.6)  0.9733   Hypothyroidism  7 (6.4)  2 (4.6)  0.5108  SD, standard deviation. View Large Most patients with ptosis grading had moderate or severe ptosis (91.4%) according to Matarasso’s classification system (Table 2).23 Table 2. Ptosis Grades and Surgical Characteristics of the Study Population (N = 112) Characteristic   n (%)  Matarasso ptosis grade   I  2 (1.8)   II  4 (3.6)   III  34 (30.4)   IV  30 (26.8)   Not specified  42 (35.7)  Type of procedure   Abdominoplasty  5 (4.5)   Lipo-abdominoplasty  95 (84.8)   Liposuction  9 (8.0)   Lower body lift  5 (4.5)  Skin resection pattern   Extended  3 (2.7)   Circumferential  7 (6.3)   Fleur-de-lis  5 (4.5)   Lockwood  21 (18.8)   Standard (fusiform)  38 (33.9)   Reverse  1 (0.9)  Not specified  37 (33.0)  Concomitant procedure (same session)   Breast augmentation  12 (10.7)   Rhinoplasty  1 (0.9)  Characteristic   n (%)  Matarasso ptosis grade   I  2 (1.8)   II  4 (3.6)   III  34 (30.4)   IV  30 (26.8)   Not specified  42 (35.7)  Type of procedure   Abdominoplasty  5 (4.5)   Lipo-abdominoplasty  95 (84.8)   Liposuction  9 (8.0)   Lower body lift  5 (4.5)  Skin resection pattern   Extended  3 (2.7)   Circumferential  7 (6.3)   Fleur-de-lis  5 (4.5)   Lockwood  21 (18.8)   Standard (fusiform)  38 (33.9)   Reverse  1 (0.9)  Not specified  37 (33.0)  Concomitant procedure (same session)   Breast augmentation  12 (10.7)   Rhinoplasty  1 (0.9)  View Large The procedures performed were lipo-abdominoplasty (n = 95; 84.8%), abdominoplasty without liposuction (n = 5; 4.5%) liposuction alone (n = 9; 8.0%), and lower body lift (n = 5; 4.5%) (Table 2). Thirteen (11.6%) patients underwent a concomitant aesthetic surgery procedure (mainly breast surgery or rhinoplasty) (Table 2). A major difference between the MWL and cosmetic cohorts pertained to the type of procedure: all lower body lifts and nearly all circumferential procedures were in patients with MWL (Table 3). Mean age was lower in the MWL cohort (38.3 ± 10.4 vs 39.9 ± 7.6; P = 0.0277). Table 3. Demographic and Surgical Characteristics of the Cosmetic and MWL Cohorts   Cosmetic (n = 92)  MWL (n = 20)    Characteristic      P value   Age, mean ± SD, y (range)  39.9 ± 7.6 (22-64)  38.3 ± 10.4 (22-63)  0.4186   Height, mean ± SD, cm (range)  63.6 ± 7.0 (47.5-86)  65.9 ± 7.3 (55-81)  0.4318   Weight, mean ± SD, kg (range)  158.9 ± 6.4 (145-176)  160.3 ± 4.9 (149-168)  0.0722   BMI (preoperative), mean ± SD, kg/m2 (range)  25.2 ± 2.1 (19.3-30.9)  25.6 ± 2.5 (22.1-32.1)  0.1604  Type of procedure, n (%)   Abdominoplasty  0 (0.0)  3 (15.0)  0.0002   Lipo-abdominoplasty  83 (90.2)  12 (60.0)  0.0003   Liposuction  9 (9.8)  0 (0.0)  0.1687   Lower body lift  0 (0.0)  5 (25.0)  <0.0001  Skin resection pattern, n (%)   Extended  1 (1.1)  2 (10.0)  0.0632   Circumferential  1 (1.1)  6 (30.0)  <0.0001   Fleur-de-lis  3 (3.3)  2 (10.0)  0.3379   Lockwood  21 (22.8)  0 (0)  0.0035   Standard (fusiform)  31 (33.7)  7 (35.0)  0.3735   Reverse  1 (1.1)  0 (0)  0.5857   Not specified  34 (37.0)  3 (15.0)      Cosmetic (n = 92)  MWL (n = 20)    Characteristic      P value   Age, mean ± SD, y (range)  39.9 ± 7.6 (22-64)  38.3 ± 10.4 (22-63)  0.4186   Height, mean ± SD, cm (range)  63.6 ± 7.0 (47.5-86)  65.9 ± 7.3 (55-81)  0.4318   Weight, mean ± SD, kg (range)  158.9 ± 6.4 (145-176)  160.3 ± 4.9 (149-168)  0.0722   BMI (preoperative), mean ± SD, kg/m2 (range)  25.2 ± 2.1 (19.3-30.9)  25.6 ± 2.5 (22.1-32.1)  0.1604  Type of procedure, n (%)   Abdominoplasty  0 (0.0)  3 (15.0)  0.0002   Lipo-abdominoplasty  83 (90.2)  12 (60.0)  0.0003   Liposuction  9 (9.8)  0 (0.0)  0.1687   Lower body lift  0 (0.0)  5 (25.0)  <0.0001  Skin resection pattern, n (%)   Extended  1 (1.1)  2 (10.0)  0.0632   Circumferential  1 (1.1)  6 (30.0)  <0.0001   Fleur-de-lis  3 (3.3)  2 (10.0)  0.3379   Lockwood  21 (22.8)  0 (0)  0.0035   Standard (fusiform)  31 (33.7)  7 (35.0)  0.3735   Reverse  1 (1.1)  0 (0)  0.5857   Not specified  34 (37.0)  3 (15.0)    MWL, massive weight loss; SD, standard deviation. View Large Primary Outcome: Total Body-QoL Score Over Time The mean adjusted Body-QoL score was 44.0 ± 14.1 (95% CI, 41.3-46.6) preoperatively, 85.5 ± 17.5 (95% CI, 80.9-90.2) short-term postoperatively, and 84.4 ± 12.7 (95% CI, 81.7-87.2) long-term postoperatively (Figure 1). The differences between the preoperative score and each postoperative score were significant (P < 0.0001). However, differences between the short-term and long-term postoperative scores were not significant (P = 0.8104). Figure 1. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years). Figure 1. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years). When comparing outcomes between the entire study population (n = 112) and the subgroup that participated in all 3 assessments (n = 44), no significant differences in Body-QoL scores were observed (Table 4), denoting strong positive correlation between these groups. Table 4. Comparison of Outcomes: Entire Study Population vs Subgroup That Responded to All 3 QoL Assessments (Per Protocol Group) Population   Basal Body-QoL Score n = 112  Short-Term Body-QoL Score n = 57  Long-Term Body-QoL Score n = 84  P value  Basal vs Short-Term n = 57  Basal vs Long-Term n = 84  Short vs Long-Term n = 50  Study Population n = 112  44.0 ± 14.1 (5.0-88.8)  85.5 ± 17.5 (23.8-100)  84.4 ± 12.7 (46.3-100)  P < 0.0001  P < 0.0001  0.8104  Per protocol n = 44  43.5 ± 16.0 (15.0-88.8)  85.5 ± 18.4 (23.8-100)  84.8 ± 13.9 (46.3-100)  P < 0.0001  P < 0.0001  0.7852  P value comparing 2 populations  P = 0.8482  P = 0.9999  P = 0.8634        Population   Basal Body-QoL Score n = 112  Short-Term Body-QoL Score n = 57  Long-Term Body-QoL Score n = 84  P value  Basal vs Short-Term n = 57  Basal vs Long-Term n = 84  Short vs Long-Term n = 50  Study Population n = 112  44.0 ± 14.1 (5.0-88.8)  85.5 ± 17.5 (23.8-100)  84.4 ± 12.7 (46.3-100)  P < 0.0001  P < 0.0001  0.8104  Per protocol n = 44  43.5 ± 16.0 (15.0-88.8)  85.5 ± 18.4 (23.8-100)  84.8 ± 13.9 (46.3-100)  P < 0.0001  P < 0.0001  0.7852  P value comparing 2 populations  P = 0.8482  P = 0.9999  P = 0.8634        SD, standard deviation. View Large Domains of the Body-QoL Tool The scores for all 4 domains were significantly better after BCS, both short and long term, than preoperatively (P < 0.0001 for each domain vs preoperative score) (Figure 2). The differences between short-term and long-term postoperative scores for each domain were not significant (Figure 2). Figure 2. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for the domains of (A) body satisfaction, (B) sex life, (C) self-esteem and social performance, and (D) physical symptoms. Figure 2. View largeDownload slide Adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for the domains of (A) body satisfaction, (B) sex life, (C) self-esteem and social performance, and (D) physical symptoms. MWL vs Cosmetic Patients Preoperatively, the adjusted Body-QoL score was significantly lower (P = 0.0028) for patients with MWL (MWL cohort: 33.9 ± 15.6; 95% CI, 26.6-41.2; cosmetic cohort: 46.1 ± 12.8; 95% CI, 43.5-48.8). Short-term and long-term postoperative scores were slightly lower for the MWL cohort, but the differences in scores between these cohorts were not significant (P = 0.2231 short term; P = 0.1133 long term). Significant improvement in scores from preoperative values was noted for both cohorts at both postoperative assessments. However, the differences between short-term and long-term postoperative scores for each cohort were not significant (MWL: P = 1.0; cosmetic: P = 0.5114) (Figure 3). Figure 3. View largeDownload slide Total adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for cosmetic and MWL patients. Figure 3. View largeDownload slide Total adjusted Body-QoL scores preoperatively, short-term postoperatively (median, 4.3 months), and long-term postoperatively (median, 2.3 years) for cosmetic and MWL patients. Analysis by domain showed that the MWL cohort experienced significant improvement postoperatively in every domain, both short and long term. Results were comparable to those for the cosmetic cohort. Body-QoL Score Over Time The mean total Body-QoL score improved significantly from the preoperative assessment to the short-term postoperative assessment, and the improvement was maintained long term (Figure 4). A 3-parameter Gompertz function was the model that after testing different models (including sigmoid and exponential functions) did best represent the evolution of the body-QoL scores over time, since it had the highest R-squared. The Gompertz model predicted an adjusted Body-QoL score of 84.9 for women after BCS (R-squared, 0.9999). For the MWL cohort, the Gompertz model predicted a postoperative score of 80.1 (R-squared, 1.0). For the cosmetic cohort, the model predicted a postoperative score of 85.9 (R-squared, 0.9998). Therefore, according to this model, the difference in predicted postoperative scores between the MWL and cosmetic cohorts was significant (P < 0.0001). Figure 4. View largeDownload slide Body-QoL scores over time were best represented by a 3-parameter Gompertz model. Figure 4. View largeDownload slide Body-QoL scores over time were best represented by a 3-parameter Gompertz model. Association Between Body-QoL Score and Patients Characteristics Comparing preoperative scores with both postoperative scores using generalized estimating equations different associations were seen. Older age was associated with greater gains in total Body-QoL score after surgery (P < 0.0001). An increase in BMI during postoperative follow-up was associated with less improvement in the total Body-QoL score (P = 0.001). A current diagnosis of anxiety or depression also were associated with lower improvement (P = 0.014). Having a concomitant aesthetic surgery procedure at the time of BCS had a favorable impact on the improvement in Body-QoL score postoperatively (P = 0.034). DISCUSSION QoL is one of the most relevant clinical outcomes in medical practice. It should be measured with a properly designed and validated PROM instrument to effectively ascertain the patient’s perspective.11,20,21,24 Evidence suggests that BCS improves QoL by enhancing self-image, increasing self- esteem, reducing physical symptoms, and providing other favorable effects.9-13 However, the postoperative follow-up in studies that address QoL outcomes following BCS are either short, less than a year,25,26 long,19,27,28 or not provided.29-31 Therefore, insight into the comparability of short-term and long-term effects of BCS on QoL is lacking. More importantly, in most studies, the PROMs utilized to assess QoL after BCS were either not validated,31,32 or not designed specifically for patients who undergo BCS.25,29,30,33 Our group is the first to design and validate a PROM (the Body-QoL) specifically to measure the effect of BCS on QoL13; therefore, the Body-QoL instrument does not have the disadvantages of other PROMs. Since implementation of the Body-QoL tool in our practice approximately 3 years ago, we have been evaluating QoL results after BCS in a more profound and systematic manner. To our knowledge, our group is the first to provide both short-term and long-term QoL data post-BCS that are based on a systematic and rigorously designed PROM. Our research represents a substantial contribution to the field particularly because knowledge of long-term QoL outcomes after BCS had been lacking. Another strength of our study is the inclusion and independent assessment of MWL and cosmetic cohorts. Our study population was recruited during a 3-year period, and more than 55% of patients who underwent BCS in our hospital participated in the study. Moreover, 75% of the study population completed the long-term QoL assessment. Overall, the demographic characteristics of patients who participated in all 3 assessments were similar to those of the entire study population. The short-term and long-term postoperative assessments were performed at different times, and all long-term assessments occurred at least 1 year after BCS. We observed stability of the QoL effect of BCS over time, and there was no significant difference between short-term and long-term scores. Moreover, we noted that the scores over time were characteristic of a Gompertz model, reaching a stable plateau 3 months after BCS, indicative of true stability. Although the strength of the findings may be questioned due to the fact that some patients who participated in 1 postoperative assessment did not participate in the other, we believe that this issue is irrelevant because the baseline characteristics of patients who participated in all 3 assessments were comparable to those of the entire study population. The observed stability of the Body-QoL scores makes it unlikely that cognitive dissonance (eg, scoring higher at short-term postoperative assessments due to positive preoperative expectations) played a major role in our results.18 The similarity of short- and long-term scores may imply that short-term QoL scores are a reliable predictor of final (long-term) QoL outcomes of BCS. This would simplify the monitoring of QoL after surgery, particularly because follow-up typically does not last more than a year. If similarity of short- and long-term QoL results is confirmed by other BCS studies, short-term results may be a better indicator of final results than previously believed. However, further research is required to draw meaningful conclusions regarding this matter. The greatest difference between the MWL and cosmetic cohorts in our study pertained to preoperative Body-QoL scores, which were much lower for the MWL cohort. Both cohorts experienced significant and sustained improvement in QoL following BCS, and postoperative scores did not differ significantly between these cohorts. However, the cohorts differed in age; on average, patients with MWL were 4 years younger. If age had been comparable, mean preoperative scores might have been different. Our previous study showed that higher age was associated with lower preoperative QoL scores.13 Although our current findings imply that postoperative scores are comparable for MWL and cosmetic cohorts, the Gompertz model predicted a statistically significant difference in long-term scores, which were nearly 6% lower for the MWL cohort. Therefore, we do not know if the long-term scores for MWL and cosmetic subpopulations are comparable or slightly different. Further investigation is warranted. Greater improvement in QoL was associated with older age and concomitant cosmetic procedures. A diagnosis of anxiety was associated with less improvement in QoL. We believe that these factors should be examined more thoroughly in future research. Changes in body weight over time had a significant impact on QoL in our study. This is concordant with findings of Van der Beek et al19 among patients who underwent BCS after bariatric surgery; in their study, weight regain was found to be the main contributor to a decline in QoL between 3 and 7 years post-BCS.19 Because our long-term data for body weight are merely anamnestic, potential bias exists; for example, patients with high QoL might estimate their weight as lower than actual, and vice versa. Therefore, conclusions about the effect of body weight cannot be drawn from our study, but it would be interesting to explore this further in well-designed research. The primary limitation of the present study is its lack of male participants, which prevents extrapolation of the results to men. Although men were not excluded from participation, only 2 men underwent BCS during the study period, and those men did not consent to participate. The limited interest of men in BCS is not surprising, considering that 90% of cosmetic procedures are performed in women,1 and women may feel more pressure to maintain a lean juvenile figure.34,35 Another limitation of our study is that results are based solely on the Chilean population. Although we believe that our findings may indicate favorable long-term QoL outcomes for other BCS populations, the extent of improvement, the differences between MWL and cosmetic patients, and the associations with factors such as age or BMI may differ for those populations. We advocate utilization of the Body-QoL tool in other countries to broaden general knowledge about QoL following BCS. Another limitation of the study is the relatively low response rate to the short-term assessment; this occurred mainly because the registry system was not fully functional when the Body-QoL instrument was launched. Fortunately, the registry system became fully operational over time, and the response to the long-term assessment was considerable. We did not collect data relating to the effects of complications on the body-related QoL. This is considered a limitation of the study because complications could substantially impact QoL. It would be prudent to explore this topic in future research. Regardless of the limitations, our study provides new insight and high-quality data on QoL for patients after BCS. Much additional research is needed, and we will continue assessing body-related QoL in our practice. We hope that similar studies will be conducted in other facilities and countries. Another recent development in QoL assessment is the PROM designed by Klassen et al,36 known as the BODY-Q. This instrument demonstrated promising results for assessing QoL among patients who underwent BCS for cosmetic reasons or after MWL. It includes more domains than the Body-QoL, addresses all body regions affected, and involves measuring satisfaction with the treatment and the surgeon. We believe that this tool will increase knowledge about QoL after BCS, and look forward to the publication of more data obtained with it. However, we believe that for routine evaluation in medical practice, the Body-QoL tool is a quick and easy, yet strong, tool to monitor QoL outcomes. Moreover, its handiness may result in high response rates. We encourage surgeons and researchers to employ one or both of these PROMs in clinical and research efforts. The Body-QoL can be freely used for academic purposes, by individual researchers (surgeons) and nonprofit institutions, as stated in the initial publication.12 CONCLUSIONS Body-related QoL improves after BCS, whether the surgery is performed because of MWL or specifically for aesthetic concerns. The improvement is significant and remains constant long term (up to 3 years postoperatively in our Chilean population). Although patients with MWL had lower preoperative Body-QoL scores, their postoperative scores approached those of the cosmetic cohort, indicating restored self-confidence and improved physical symptoms. Certain factors contributed to less improvement in QoL, including anxiety, depression, and higher BMI when undergoing BCS. Additional research in more diverse populations is warranted. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Cosmetic surgery national data bank statistics. Aesthet Surg J . 2016; 36( Suppl 1): 1- 29. 2. 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Aesthetic Surgery JournalOxford University Press

Published: Mar 1, 2018

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