The Objective Eye: An Oxymoron?

The Objective Eye: An Oxymoron? Things are, for each person, the way he perceives them. -Plato, 427 to 347 BC I am always intrigued by topics in aesthetic surgery that blur the lines between medicine, social science, physics, and philosophy. That is one reason I found the article “Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients” so fascinating.1 Frautschi et al have done an excellent job in designing a study to meet the needs of aesthetic surgeons and patients for outcome measures that go beyond self-reported patient satisfaction surveys. They also are thorough and transparent in pointing out their study’s limitations, some of which might well be considered unavoidable. Pure objectivity should always be the scientist’s goal but, particularly with regard to visual assessments, may be an ideal that is unattainable. The stated purpose of the study was to examine whether a visual estimate of age by objective observers represents a reliable and valid measure for evaluation of facelift outcomes. Ten blinded reviewers, at several 3-month intervals, assessed randomly ordered photographs of 20 pre- and postoperative facelift patients, assigning an estimate of age based on each photograph. Frautschi et al found that the value of apparent age (AA) assessment produced from a single reviewer could not be considered a reliable/highly reproducible outcome measure but that group data produced good reliability. At the same time, the study raises provocative questions about how our inherent subjectivity impacts the question of objective scientific knowledge. Given that 70% of a human being’s sense receptors are in the eyes, scientific perception is largely based on visual evaluation.2 Yet what a particular individual “sees” not only has to do with what he or she is looking at but also with that person’s previous visual-conceptual experiences and what has been learned from those experiences.3 While this statement applies to perception on its most basic levels, it also encompasses the influence of purposefully acquired knowledge. For example, Frautschi et al acknowledge that their reviewers all were involved in the plastic surgery field and therefore might be more likely to notice the stigmata of facial procedures which could, in turn, influence their AA assessments. This kind of dilemma is not unusual. Scientists frequently are faced with the challenge of overcoming bias based on their own educational and practical experience—the very things that, theoretically, should enable them to make better and more accurate judgments. I found it notable as well that, in the study’s gender analysis of reviewers, it was discovered that female reviewers were more likely to assign older postoperative age and decreased apparent age reduction. It stands to reason, based on cultural conditioning if nothing else, that men and women may sometimes “see” things differently. It would be interesting, also, to find out whether members of different cultural and ethnic groups might demonstrate significant differences in visual-based outcome assessments. Age is another factor that may influence perception. While reviewer age could not be analyzed independently in the present study, other aesthetic surgery research has found a difference in self-reported outcome assessment based on age. In a survey of postoperative satisfaction among rhinoplasty patients, it was found that there was no statistically significant mean difference in patients’ satisfaction scores according to sex, follow-up period, or type of procedure performed, but there was a difference according to age, with younger patients (<30 years of age) more likely to assess a less satisfactory outcome.4 Obviously, perception is a highly individual phenomenon, dependent on a variety of factors. Science has confirmed that one of the most important of these factors is expectation. Whether in the context of research or clinical practice, it is important for aesthetic surgeons to keep in mind the extent to which expectations color our patients’ and our own perceptions. At the physiological level, the number of neurons in the brain dedicated to analyzing, synthesizing, and altering incoming sensory signals is far greater than the number of incoming sensory neurons, suggesting the dominance of brain functions and expectations over raw sensory data.5 On the psychological level, we all have our own individual perceptual set, which is the tendency to perceive or notice certain aspects of sensory data and ignore others. There are a number of factors that influence perceptual set, including emotion, motivation, culture, and expectations.6 Expectations can predispose one to make a more or less positive assessment, regardless of objectively based criteria. What I, as a plastic surgeon, feel to be an outstanding aesthetic result may, for a variety of reasons, fail to meet my patient’s expectations. In that case, all the “objective” assessments in the world may have little impact on that particular patient’s happiness. While I cannot control all variables affecting my patient’s perception of her result, there are certain steps I can take, in general, to help improve patient satisfaction. I can select patients with attention to both their physical and psychological suitability for surgery; engage in active and ongoing two-way communication to establish and document appropriate, achievable operative goals; encourage realistic expectations by explicitly defining what they are and are not; properly manage complications, both medically and interpersonally, through dedicated patient support; and provide effective follow up that manages problems expeditiously. I was interested in the authors’ finding that the mean AA reduction (the tendency to look younger after surgery) was 5.23 ± 2.81 years (range, 0.7-10.8 years) at a mean postoperative photo follow up of 9.2 months. It goes without saying that AA reduction on an individual basis is dependent on a variety of factors including the patient’s preoperative condition and the particular techniques employed in the rejuvenation process. The reported mean AA reduction is excellent and provides important validation of the benefits of facelift surgery. At the same time, the wide range of scores reinforces the idea that it is preferable to advise a patient she will look “better for her age” after surgery rather than try to project how many years younger she is likely to appear—even though patients frequently ask for a prediction. Remembering that what matters most is not the “objective” analysis but how the patient ultimately views her own result can help surgeons to guide patient perceptions for more satisfying outcomes. Aesthetic surgery, being so dependent on visual assessment of outcomes, is particularly vulnerable to the pitfalls of subjectivity. Yet if aesthetic plastic surgery is to be an evidence-based discipline,7 we cannot escape the necessity of developing validated outcome measures. We may not be able to totally objectify our evaluations, but we must make every effort to eliminate as many potential biases as possible. And for those that cannot be eliminated, we must be meticulous in identifying and acknowledging them in our research conclusions. I applaud Frautschi et al for defining reliability and validity—rather than the arguable construct of “objectivity”—as the elements determining the ultimate value of outcome research, particularly that which is focused on visual assessment. Their careful approach to defining the study’s goals and limitations, as well as establishing the reliability of AA as a measurement tool, is a significant contribution to aesthetic surgery outcome research. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Frautschi RS, Duraes EF, Tadisina KK, Couto RA, Zins JE. Apparent age is a reliable assessment tool in 20 facelift patients. Aesthet Surg J . 2018: 38( 4): 347- 356. 2. Jarrard RD. The myth of objectivity. Scientific Methods . University of Utah, Department of Geology and Geophysics; 2001. http://emotionalcompetency.com/sci/sm6.htm. Accessed November 28, 2017. 3. Kuhn TS. The Structure of Scientific Revolutions . University of Chicago Press; 1962: 112. 4. Arima LM, Velasco LC, Tiago RS. Influence of age on rhinoplasty outcomes evaluation: a preliminary study. Aesthetic Plast Surg . 2012; 36( 2): 248- 253. Google Scholar CrossRef Search ADS PubMed  5. Lieff J. How does expectation affect perception. Searching for the Mind . http://jonlieffmd.com/blog/how-does-expectation-affect-perception. Accessed November 28, 2017. 6. Allport FH. Theories of Perception and the Concept of Structure . New York: Wiley; 1955. https://simplypsychology.org/perceptual-set.html. Accessed November 30, 2017. 7. Nahai F. Evidence-based medicine in aesthetic surgery. Aesthet Surg J . 2011; 31( 1): 135- 136. Google Scholar CrossRef Search ADS PubMed  © 2018 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

The Objective Eye: An Oxymoron?

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Publisher
Mosby Inc.
Copyright
© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
eISSN
1527-330X
D.O.I.
10.1093/asj/sjx257
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Abstract

Things are, for each person, the way he perceives them. -Plato, 427 to 347 BC I am always intrigued by topics in aesthetic surgery that blur the lines between medicine, social science, physics, and philosophy. That is one reason I found the article “Apparent Age is a Reliable Assessment Tool in 20 Facelift Patients” so fascinating.1 Frautschi et al have done an excellent job in designing a study to meet the needs of aesthetic surgeons and patients for outcome measures that go beyond self-reported patient satisfaction surveys. They also are thorough and transparent in pointing out their study’s limitations, some of which might well be considered unavoidable. Pure objectivity should always be the scientist’s goal but, particularly with regard to visual assessments, may be an ideal that is unattainable. The stated purpose of the study was to examine whether a visual estimate of age by objective observers represents a reliable and valid measure for evaluation of facelift outcomes. Ten blinded reviewers, at several 3-month intervals, assessed randomly ordered photographs of 20 pre- and postoperative facelift patients, assigning an estimate of age based on each photograph. Frautschi et al found that the value of apparent age (AA) assessment produced from a single reviewer could not be considered a reliable/highly reproducible outcome measure but that group data produced good reliability. At the same time, the study raises provocative questions about how our inherent subjectivity impacts the question of objective scientific knowledge. Given that 70% of a human being’s sense receptors are in the eyes, scientific perception is largely based on visual evaluation.2 Yet what a particular individual “sees” not only has to do with what he or she is looking at but also with that person’s previous visual-conceptual experiences and what has been learned from those experiences.3 While this statement applies to perception on its most basic levels, it also encompasses the influence of purposefully acquired knowledge. For example, Frautschi et al acknowledge that their reviewers all were involved in the plastic surgery field and therefore might be more likely to notice the stigmata of facial procedures which could, in turn, influence their AA assessments. This kind of dilemma is not unusual. Scientists frequently are faced with the challenge of overcoming bias based on their own educational and practical experience—the very things that, theoretically, should enable them to make better and more accurate judgments. I found it notable as well that, in the study’s gender analysis of reviewers, it was discovered that female reviewers were more likely to assign older postoperative age and decreased apparent age reduction. It stands to reason, based on cultural conditioning if nothing else, that men and women may sometimes “see” things differently. It would be interesting, also, to find out whether members of different cultural and ethnic groups might demonstrate significant differences in visual-based outcome assessments. Age is another factor that may influence perception. While reviewer age could not be analyzed independently in the present study, other aesthetic surgery research has found a difference in self-reported outcome assessment based on age. In a survey of postoperative satisfaction among rhinoplasty patients, it was found that there was no statistically significant mean difference in patients’ satisfaction scores according to sex, follow-up period, or type of procedure performed, but there was a difference according to age, with younger patients (<30 years of age) more likely to assess a less satisfactory outcome.4 Obviously, perception is a highly individual phenomenon, dependent on a variety of factors. Science has confirmed that one of the most important of these factors is expectation. Whether in the context of research or clinical practice, it is important for aesthetic surgeons to keep in mind the extent to which expectations color our patients’ and our own perceptions. At the physiological level, the number of neurons in the brain dedicated to analyzing, synthesizing, and altering incoming sensory signals is far greater than the number of incoming sensory neurons, suggesting the dominance of brain functions and expectations over raw sensory data.5 On the psychological level, we all have our own individual perceptual set, which is the tendency to perceive or notice certain aspects of sensory data and ignore others. There are a number of factors that influence perceptual set, including emotion, motivation, culture, and expectations.6 Expectations can predispose one to make a more or less positive assessment, regardless of objectively based criteria. What I, as a plastic surgeon, feel to be an outstanding aesthetic result may, for a variety of reasons, fail to meet my patient’s expectations. In that case, all the “objective” assessments in the world may have little impact on that particular patient’s happiness. While I cannot control all variables affecting my patient’s perception of her result, there are certain steps I can take, in general, to help improve patient satisfaction. I can select patients with attention to both their physical and psychological suitability for surgery; engage in active and ongoing two-way communication to establish and document appropriate, achievable operative goals; encourage realistic expectations by explicitly defining what they are and are not; properly manage complications, both medically and interpersonally, through dedicated patient support; and provide effective follow up that manages problems expeditiously. I was interested in the authors’ finding that the mean AA reduction (the tendency to look younger after surgery) was 5.23 ± 2.81 years (range, 0.7-10.8 years) at a mean postoperative photo follow up of 9.2 months. It goes without saying that AA reduction on an individual basis is dependent on a variety of factors including the patient’s preoperative condition and the particular techniques employed in the rejuvenation process. The reported mean AA reduction is excellent and provides important validation of the benefits of facelift surgery. At the same time, the wide range of scores reinforces the idea that it is preferable to advise a patient she will look “better for her age” after surgery rather than try to project how many years younger she is likely to appear—even though patients frequently ask for a prediction. Remembering that what matters most is not the “objective” analysis but how the patient ultimately views her own result can help surgeons to guide patient perceptions for more satisfying outcomes. Aesthetic surgery, being so dependent on visual assessment of outcomes, is particularly vulnerable to the pitfalls of subjectivity. Yet if aesthetic plastic surgery is to be an evidence-based discipline,7 we cannot escape the necessity of developing validated outcome measures. We may not be able to totally objectify our evaluations, but we must make every effort to eliminate as many potential biases as possible. And for those that cannot be eliminated, we must be meticulous in identifying and acknowledging them in our research conclusions. I applaud Frautschi et al for defining reliability and validity—rather than the arguable construct of “objectivity”—as the elements determining the ultimate value of outcome research, particularly that which is focused on visual assessment. Their careful approach to defining the study’s goals and limitations, as well as establishing the reliability of AA as a measurement tool, is a significant contribution to aesthetic surgery outcome research. Disclosures The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The author received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Frautschi RS, Duraes EF, Tadisina KK, Couto RA, Zins JE. Apparent age is a reliable assessment tool in 20 facelift patients. Aesthet Surg J . 2018: 38( 4): 347- 356. 2. Jarrard RD. The myth of objectivity. Scientific Methods . University of Utah, Department of Geology and Geophysics; 2001. http://emotionalcompetency.com/sci/sm6.htm. Accessed November 28, 2017. 3. Kuhn TS. The Structure of Scientific Revolutions . University of Chicago Press; 1962: 112. 4. Arima LM, Velasco LC, Tiago RS. Influence of age on rhinoplasty outcomes evaluation: a preliminary study. Aesthetic Plast Surg . 2012; 36( 2): 248- 253. Google Scholar CrossRef Search ADS PubMed  5. Lieff J. How does expectation affect perception. Searching for the Mind . http://jonlieffmd.com/blog/how-does-expectation-affect-perception. Accessed November 28, 2017. 6. Allport FH. Theories of Perception and the Concept of Structure . New York: Wiley; 1955. https://simplypsychology.org/perceptual-set.html. Accessed November 30, 2017. 7. Nahai F. Evidence-based medicine in aesthetic surgery. Aesthet Surg J . 2011; 31( 1): 135- 136. Google Scholar CrossRef Search ADS PubMed  © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

Journal

Aesthetic Surgery JournalOxford University Press

Published: Apr 1, 2018

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