Perception of Hair Transplant for Androgenetic Alopecia

Impact of Hair Transplantation on Quality of Life

BACKGROUND

Alopecia is defined as partial or complete hair loss. The most common form is androgenetic alopecia, which occurs in both men and women. Despite the nonsurgical options available for treatment, the only permanent solution is hair transplantation. Hair loss has been shown to have significant psychological consequences associated with loss of self-confidence, poor self-image and difficulties in social functioning. We aim to examine the effect of hair transplantation on quality of life and psychosocial functioning.

METHODS

Forty-eight patients with androgenetic alopecia were enrolled in this two-center prospective study and underwent hair transplantation by the Follicular Unit Extraction method. Different questionnaires were used to assess their quality of life and other psychosocial parameters before and after hair transplantation.

RESULTS

According to SF-36 Physical and Mental Health Score patients showed significant improvement in life quality after hair transplantation. Diener's Life Satisfaction Scale (DASS-21) revealed increased life satisfaction after the procedure. Stress and anxiety DASS-21 subscales showed significantly reduced results; while, the DASS-21 depression scale and MSPSS were not significantly changed.

CONCLUSION

Taken together, quality of life and psychosocial functioning increased after hair transplantation. Structured abstract is required. Please provide.I insert name of paragraphs within abstract as follows: background, methods, results, conclusion Level of Evidence II: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Use of Activated Platelet-Rich Plasma (A-PRP) on Alopecia: A Systematic Review and Meta-Analysis

Alopecia affects perceptions of age, beauty, success, and adaptability. Hair loss can be caused by genetic, physiological, environmental, and immunologic factors. The current treatment for alopecia is varied. This systematic review and meta-analysis evaluates activated platelet rich plasma (A-PRP) for alopecia treatment. The objective of this review was to assess the clinical efficacy and safety of A-PRP injections in alopecia patients. We compared the safety, limitations, and outcomes of A-PRP use with those of previous research on alopecia. We searched PubMed, EMBASE, the Cochrane Database, and Google Scholar for relevant articles. We included all primary clinical studies involving patients that evaluated A-PRP. Twenty-nine articles, which included 864 patients, met the eligibility criteria and were analyzed for qualitative review. Our review found 27 studies that indicated A-PRP was significantly effective in treating alopecia, especially for improving hair density before and after therapy (n = 184, mean difference [MD] = 46.5, I2 = 88%, 95% CI: 29.63, 63.37, P < .00001), as well as when comparison was made between treatment and control groups (n = 88, MD = 31.61, I2 = 80%, 95% CI: 6.99, 56.22, P = .01), and of terminal hair density between treatment and control groups (n = 55, MD = 26.03, I2 = 25%, 95% CI: 8.08, 43.98, P = .004); hair counts after therapy (n = 85, MD = 12.79, I2 = 83%, 95% CI: -5.53, 31.12, P = .0006); promoting hair regrowth; folliculogenesis; reducing hair loss; combining with follicular unit extraction (FUE) surgery; and initiating the hair cycle. Two studies did not report significant results. This is the first systematic review and meta-analysis of A-PRP as a treatment option for alopecia. A-PRP appears to be a promising and safe method for treating alopecia.

LEVEL OF EVIDENCE: 4

Assessment of quality of life and self-esteem in male patients with androgenetic alopecia before and after hair transplantation

BACKGROUND

Patients with androgenetic alopecia experience a significant decrease in self-esteem and quality of life. There are several methods by which these factors may be improved.

AIMS

Determining whether patients feel better about themselves with a better quality of life after undergoing hair transplant procedure.

PATIENTS/METHODS

35 people were chosen from Jordan Skin and Hair Clinic in Tehran, Iran. Following hair transplant, follow-up subjects had their quality of life and level of self-esteem assessed using the Rosenberg Self-Esteem Scale (RSES) and Dermatology Life Quality Index (DLQI), respectively. The means of quantitative results were compared using paired T-test. The chi-square test was done to compare preoperative and postoperative characteristics qualitatively. Differences were regarded significant if p < 0.05. Analysis of covariance was applied to evaluate the effect of marital status and educational level on outcome variables (ANCOVA).

RESULTS

Our findings showed a statistically significant difference (p < 0.001) between pre- and post-operative hair transplantation for quality of life, and mean score increased to 2.17. There was a statistically significant difference between the two groups, with an average self-esteem score on RSES rising to 5.35 (p < 0.001). A statistically significant link between educational achievement and quality of life was found (p < 0.001).

CONCLUSION

This study found postoperative psychological aspects of AGA patients significantly improve than preoperative. Our results show that there is a statistically significant difference between the self-esteem and quality of life of AGA patients before and after hair restoration surgery.

An assessment for measuring loneliness, anxiety, and depression in male patients with androgenetic alopecia undergoing hair transplantation surgery: A before-after study

BACKGROUND

Androgenetic alopecia has a significant influence on the patients' loneliness, anxiety, and depression, although there are numerous strategies to improve the patients' loneliness, anxiety, and depression.

AIMS

Determine whether hair transplant operation improves loneliness, anxiety, and depression in patients.

PATIENTS/METHODS

There were 35 patients recruited from the clinic. Using questionnaires (UCLA and HADS), the subjects were evaluated for their levels of loneliness, anxiety, and depression before and after hair transplant. To compare the means of quantitative outcomes, a paired t-test was administered. The Chi-square test was employed to compare qualitatively the preoperative and postoperative measures. An analysis of covariance (ANCOVA) was used to assess the impact of marital status and educational level on outcome variables. If p < 0.05, differences were deemed significant.

RESULTS

Our findings demonstrated a statistically significant difference (p < 0.001) between pre- and post-operative hair transplantation for HADS-anxiety and depression, with the mean anxiety and depression score improving to 3.32. In terms of the UCLA, there was a statistically significant change between the two groups (p < 0.001), and the average loneliness score improved to 4.48. There was also a statistically significant relationship between marital status and loneliness (p < 0.001), educational level and loneliness (p < 0.001), anxiety and depression (p < 0.001).

CONCLUSION

This research found that hair transplantation surgery improves psychosocial outcomes, with affected patients experiencing less loneliness, anxiety, and sadness after surgery than before.

Health Utility Measures Among Patients with Androgenetic Alopecia After Hair Transplant

BACKGROUND

Hair loss causes significant psychosocial distress to patients. Health utility measurements offer an objective, quantitative assessment of health-related quality of life (QOL).

METHODS

We performed a prospective cohort study on patients with hair loss between January 1, 2018 and December 31, 2020. Patient metrics were compared with layperson perception of alopecia, prospectively collected between August 1 and December 31, 2017. Health utility measures were quantified using the visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO) in quality-adjusted life-years (QALYs) and relative to the minimal clinically important difference (MCID). Bonferroni correction to the significance threshold was performed.

RESULTS

Thirty-one patients with alopecia were compared with 237 laypeople. Patient metrics for female hair loss were all significantly lower than laypeople measures (VAS QALYs 0.65 ± 0.21 vs. 0.83 ± 0.18, p = 0.0001). Mean SG QALYs were lower for patients in the male alopecia state (0.86 ± 0.23 vs. 0.96 ± 0.12, p = 0.0278). Post-hair transplant improvement in TTO was significantly greater for patients (+ 0.08 ± 0.12 vs. + 0.02 ± 0.09, p = 0.0070) and significantly more often exceeded the MCID (45.2% vs. 16.9%, p = 0.0006).

CONCLUSIONS

Alopecia negatively impacts QOL, and the true patient experience is more taxing than what is perceived by laypeople. Hair transplantation improves QOL more for male patients than common perception.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

GAN-Based ROI Image Translation Method for Predicting Image after Hair Transplant Surgery

In this paper, we propose a new deep learning-based image translation method to predict and generate images after hair transplant surgery from images before hair transplant surgery. Since existing image translation models use a naive strategy that trains the whole distribution of translation, the image translation models using the original image as the input data result in converting not only the hair transplant surgery region, which is the region of interest (ROI) for image translation, but also the other image regions, which are not the ROI. To solve this problem, we proposed a novel generative adversarial network (GAN)-based ROI image translation method, which converts only the ROI and retains the image for the non-ROI. Specifically, by performing image translation and image segmentation independently, the proposed method generates predictive images from the distribution of images after hair transplant surgery and specifies the ROI to be used for generated images. In addition, by applying the ensemble method to image segmentation, we propose a more robust method through complementing the shortages of various image segmentation models. From the experimental results using a real medical image dataset, e.g., 1394 images before hair transplantation and 896 images after hair transplantation, to train the GAN model, we show that the proposed GAN-based ROI image translation method performed better than the other GAN-based image translation methods, e.g., by 23% in SSIM (Structural Similarity Index Measure), 452% in IoU (Intersection over Union), and 42% in FID (Frechet Inception Distance), on average. Furthermore, the ensemble method that we propose not only improves ROI detection performance but also shows consistent performances in generating better predictive images from preoperative images taken from diverse angles.

Observer-Reported Outcomes and Cosmetic Procedures: A Systematic Review

BACKGROUND

Cosmetic procedures have demonstrated beneficial effects on physical appearance based on anatomic markers as well as patient-perceived self-image and quality of life. Recent studies of observer-reported outcomes (OROs) suggest an additional benefit from aesthetic interventions.

OBJECTIVE

The authors aimed to review the evidence of OROs from cosmetic procedures performed on the head and neck.

PATIENTS, METHODS AND MATERIALS

PubMed, Embase, and Cochrane Library databases were searched for relevant studies, yielding 24 included original investigations.

RESULTS

These studies captured 686 total patients, 8,257 observer evaluations, and a variety of interventions including face-lifts, blepharoplasty, rhinoplasty, and minimally invasive treatments including botulinum toxins and hyaluronic acid fillers. Forty-one distinct reported OROs were grouped into 12 descriptive domains. Domains were further grouped into 3 higher-order categories: aesthetics and wellness, social capacities, and skills and competencies. Improved perception after cosmetic intervention is most reproducibly demonstrated for the following ORO domains: age, attractiveness, sociability, relationship success, and occupational and financial competency.

CONCLUSION

The synthesized findings imply a tertiary layer of benefit for cosmetic intervention beyond anatomical and patient-centered outcomes through enhanced perceptions of others. These findings may inform the pre-procedure risk-benefit discussion with patients of cosmetic medicine and drive future research into longitudinal outcomes.

Proposed mechanisms of low-level light therapy in the treatment of androgenetic alopecia

Androgenetic alopecia (AGA) is a global challenge, affecting a large number of people worldwide. Efficacy of the existed treatments can barely meet the demands of patients. Patients who are poorly responding to those treatments are seeking for a more effective and suitable technique to treat their disease. Low-level light therapy (LLLT) is a newly developed technique, which has been proved to stimulate hair growth. Based on the function principle of LLLT in other domains and refer to the published literatures, we write this review to neaten and elucidate the possible mechanism of LLLT in the treatment of AGA. A review of published literature which is associated with keywords LLLT, photobiomodulation, AGA, treatment, hair growth, and mechanism was performed to elucidate the proposed mechanism of LLLT in the treatment of AGA. The present study shows that LLLT can accelerate hair growth in AGA patients. The proposed mechanism of LLLT in treating AGA may vary among different specialists. But we can summarize the consensual mechanisms as follows; low-level light absorbed by chromophores can lead to the production of nitric oxide (NO) and the modulation of reactive oxygen species (ROS). These mobilized molecules subsequently activate redox-related signaling pathways in hair follicle cells and perifollicular cells. Finally, these activated cells participate in the regrowth of hair follicle. Even though the efficacy of LLLT in the treatment of AGA in both men and women has already been confirmed, the present studies focusing on discovering LLLT are still inadequate and unsystematic. More studies are needed to standardize the optimum treatment parameters applied in promoting hair growth and determine the long-term safety and efficacy of LLLT. Current recognitions about the mechanisms of LLLT, mainly focused on the molecules that may take effect, neglected different cellular components that are functional in the hair follicle macro-environment.

Investigation of optimum transplant and extraction density based on the data from the donor area of Chinese androgenetic alopecia patients: a multicenter, retrospective study

The rise in the incidence of androgenetic alopecia (AGA) in China has increased the inclination toward hair transplantation. To calculate the optimum density of hair follicles needed covering both the hairless area and the safe donor area (SDA), 119 male patients with AGA were recruited into this multicenter investigation. We evaluated the mean diameter and the number of hair follicles (HFs) and follicular units (FUs) in the SDA of AGA. The mean density of HFs was 137.45 ± 30.11 hair/cm² and the FUs was 76.82 ± 12.09 FUs/cm². The mean diameter of the hair was 0.97 ± 0.01 mm in the SDA. We obtained the decisive factors in the restoration of the scalp by building a geometric model and summarizing it in a new formula. This study showed that the length and direction of the hair play a vital role in restoring the bald area with hair transplantation. The density of 55.00 ± 10.00 hair/cm² (30.00 ± 5.00 FUs/cm²) for the transplanted area and no less than 106.88 hair/cm² (60.00 FUs/cm²) for SDA is regarded as an optimum parameter for hair transplantation of AGA.

Efficacy of Platelet-rich Plasma for Treating Androgenic Alopecia of Varying Grades

BACKGROUND AND OBJECTIVES

Platelet-rich plasma (PRP) has received growing attention as a valuable therapeutic tool in androgenetic alopecia (AGA). However, knowledge regarding specific effectiveness and satisfaction of PRP for different grades of AGA in male pattern hair loss (MPHL) and female pattern hair loss (FPHL) is missing. This study aims to ascertain and compare the efficacy and safety of PRP treatment for different grades of AGA in males and females over 6 months.

METHODS

In this study, 51 MPHL patients with Norwood-Hamilton stage II-V and 42 FPHL patients with Ludwig stage I to III were enrolled for 6 monthly sessions of PRP injections. A longitudinal analysis was used to compare the hair density, thickness, and hair pull test over 6 months for MPHL and FPHL through generalized estimating equation (GEE) models. Phototrichograms of scalp inflammation and oil secretion, global photographs and overall patient satisfaction were also assessed.

RESULTS

Consequently, improvement of hair density, hair thickness, hair pull test, the level of scalp inflammation and oil secretion were observed with statistical significance in all stages for both MPHL and FPHL at 6 months. Noteworthy, lower level of alopecia (Grade II, III in MPHL and Grade I in FPHL) had better response to PRP, and also had a better tendency of increment of hair growth than that of high-grade patients with prolonged treatment.

CONCLUSIONS

PRP injections, as an efficacious and reliable therapy, can be recommended for Grade II and Grade III in MPHL and Grade I in FPHL.

Association of Hair Loss With Health Utility Measurements Before and After Hair Transplant Surgery in Men and Women

Importance

Androgenetic alopecia is a highly prevalent condition across both sexes and can be surgically corrected through hair transplant. Health utility scores, which represent quantitative estimates of individual preferences for a given state of health, are a measure of health-related quality of life. The health utility scores for sex-specific alopecia and the posttransplant state have not previously been quantified.

Objective

To obtain health utility measurements for the objective assessment of sex-specific alopecia and hair transplant surgery and to analyze layperson perception of alopecia compared with other chronic health conditions.

Design, Setting, and Participants

A prospective clinical study was conducted from August 1 to December 31, 2017, at the Harvard Decision Science Laboratory. Adult casual observers (n = 308) completed an internet-based health utility questionnaire. Health states were presented using still patient images and a description of 5 health states, including monocular blindness, binocular blindness, male alopecia, female alopecia, and male posttransplant state.

Main Outcomes and Measures

Health utility measures of sex-specific alopecia, posttransplant state, and monocular and binocular blindness were measured by visual analog scale (VAS), standard gamble (SG), and time trade-off (TTO) in quality-adjusted life-years (QALYs). Groups were analyzed with 1-way analysis of variance and post hoc Tukey pairwise comparison.

Results

The 308 participants included 157 (51.0%) women with a mean (SD) age of 30.8 (13.5) years. Mean (SD) health utility measures included 0.85 (0.18) QALYs for the VAS, 0.93 (0.17) QALYs for the SG, and 0.93 (0.17) QALYs for the TTO in male alopecia; 0.83 (0.19) QALYs for the VAS, 0.92 (0.17) QALYs for the SG, and 0.91 (0.18) QALYs for the TTO in female alopecia; and 0.93 (0.11) QALYs for the VAS, 0.95 (0.15) QALYs for the SG, and 0.95 (0.16) QALYs for the TTO in a man in the posttransplant state. The mean (SD) health utility of monocular blindness was 0.76 (0.17) QALYs for the VAS, 0.87 (0.21) QALYs for the SG, and 0.86 (0.20) QALYs for the TTO. The health utility score for the posttransplant state was significantly improved compared with the health utility score for alopecia in both sexes (female VAS: +0.10 [95% CI, 0.06-0.14; P < .001]; male VAS, +0.08 [95% CI, 0.04-0.12; P < .001]). Hair loss in women and men demonstrated significantly lower QALYs on the VAS compared with the posttransplant state (female: -0.10 [95% CI, -0.14 to -0.06; P < .001]; male: -0.08 [95% CI, -0.12 to -0.04; P < .001]).

Conclusions and Relevance

Alopecia has a meaningful negative influence on health utility measures in both sexes. Hair transplant surgery significantly increases health utility measures compared with untreated alopecia in both sexes as rated among layperson observers.

Level of Evidence

NA.

New idea for hair transplantation to preserve more donor hair follicles

Higher risk of rapid progression in alopecia or male pattern baldness was observed in men who had family history. This could result from accumulation of DHT in hair follicles. Hair follicles on frontal region are more vulnerable to DHT. With development of minimal invasive hair transplantation surgery, hair follicles transplantation could be performed from frontal or occipital region to frontal region. However, limited hair follicles remained a problem. With development of technology of vitrification, we suggested extracting hair follicles from frontal region without affecting the appearance and preserving them with vitrification when the patient was young. When alopecia progressively developed, these extracted hair follicles would increase the donor number of hair follicles used for transplantation, which could extend longer dense hair appearance.

Assessing patient satisfaction among ABHRS surgeons: Opportunities to improve

BACKGROUND/OBJECTIVE

Online physician-rating websites are being increasingly used by patients to gauge physicians' quality of service. The objective of this study is to assess the impact of residency training background of hair restoration surgeons and to identify themes of patient reviews using online physician-rating portals.

METHOD

From July 1, 2018 to July 18, 2018, a list of American Board of Hair Restoration Surgery (ABHRS) physicians was compiled. Each member's name was searched on Healthgrades.com and Yelp.com websites, and profile reviews were analyzed for themes of patient satisfaction and dissatisfaction.

RESULTS

Eighty-six ABHRS-certified surgeons were identified on the ABHRS physician directory practicing in the United States. Eleven different residency training backgrounds are represented. Surgeons were given significantly higher ratings on Healthgrades (4.63 vs 3.77, P < 0.001), and nonsurgeons were given significantly higher ratings on Yelp (4.31 vs 4.11, P = 0.036). A total of 567 five-star reviews and 59 one-star reviews were analyzed for content across both physician review portals. The most commonly cited topics included results, office staff, physician's bedside manner, comfort during procedure, patient-perceived physician's honesty, patient-perceived physician's knowledge, cost/financing options, recovery time, and wait time/scheduling.

CONCLUSIONS

Significant, yet inconsistent differences in ratings were found between surgical and nonsurgical residency backgrounds across online physician-rating portals. Understanding drivers of positive and negative reviews may help surgeons improve patient satisfaction.

Perception of upper lip augmentation utilizing simulated photography

BACKGROUND

No head to head comparison is available between surgical lip lifting and upper lip filler injections to decide which technique yields the best results in patients. Despite the growing popularity of upper lip augmentation, its effect on societal perceptions of attractiveness, successfulness and overall health in woman is unknown.

METHODS

Blinded casual observers viewed three versions of independent images of 15 unique patient lower faces for a total of 45 images. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses.

RESULTS

Two hundred and seventeen random observers with an average age of 47 years (standard deviation, 15.9) rated the images. The majority of observers were females (n=183, 84%) of white race (n=174, 80%) and had at least some college education (n=202, 93%). The marginal mean score for perceived attractiveness from the natural condition was 1.5 points (95% confidence interval [CI], 0.9-2.18) higher than perceived attractiveness from the simulated upper lip filler injection condition, and 2.6 points higher (95% CI, 1.95-3.24) than the simulated upper lip lift condition. There was a moderate to strong correlation between the scores of the same observer.

CONCLUSIONS

Simulated upper lip augmentation is amenable to social perception analysis. Scores of the same observer for attractiveness, successfulness, and overall health are strongly correlated. Overall, the natural condition had the highest scores in all categories, followed by simulated upper lip filler, and lastly simulated upper lip lift.

Types of hairline recession in androgenetic alopecia and perceptions of aging in Asian males

BACKGROUND

Cranial hair loss is one of the characteristics of age. Hairline recession has been confirmed adversely to affect the perceptions of age in Western males. However, comparatively little is known about the effect of frontal recession on the perceived facial age (PFA) of East Asian males. Moreover, specific roles of different types of hairline recession in PFA of different age groups still remain a mystery.

OBJECTIVE

To investigate and quantify the effect of different types of hairline recession on PFA in East Asian young males of different age groups.

METHODS

Thirty non-bald males were selected and divided equally into three groups (20s, 30s, and 40s). With the aid of modern software, the frontoparietal area of facial images from 30 experimenters was modified into three basic types of hair loss (M₂ , C₂ , and U₂ ) according to the basic and specific classification of androgenic alopecia. In a web-based survey, approximately 900 naive participants were asked to estimate the PFA of males from their original and modified facial images.

RESULTS

Perceived facial age increased to 1.58 ± 0.79, 4.19 ± 1.27, and 5.90 ± 1.00 years when the original facial images were modified to have hair loss types M₂ , C₂ , or U₂ , respectively. In addition, the PFA of males with hair loss type C₂ or U₂ appeared significantly older than the original facial images in the 30s group.

CONCLUSION

Different types of hairline recession can increase the PFA to different degrees in East Asian males of different age groups.

The Public Face of Rhinoplasty: Impact on Perceived Attractiveness and Personality

BACKGROUND

The authors assess the impact of rhinoplasty on public perception of a patient's appearance and personality.

METHODS

A survey was created using standardized before-and-after photographs of 10 Caucasian women who had undergone primary rhinoplasty. Photographs of two additional women who had not undergone facial surgery were randomly included as controls, for a total of 12 survey items. Preoperative and postoperative photographs were placed side by side. The survey was administered by means of crowd-sourcing. Respondents were asked to evaluate which photograph better represented 11 traits of appearance or personality, according to a seven-point Likert scale. A score of 1 meant the preoperative photograph was much better, 7 meant the postoperative photograph was much better, and 4 meant no difference. T tests and analyses of variance were used to evaluate rating changes for each trait and differences between demographic groups.

RESULTS

There were 264 responses received. Averaged scores across the 10 survey patients produced a value for each appearance or personality trait. In 10 of 11 categories (i.e., symmetry, youthfulness, facial harmony, likeability, trustworthiness, confidence, femininity, attractiveness, approachability, and intelligence), the postoperative photograph was significantly favorable compared with the preoperative photograph (p < 0.00001). The preoperative photograph was rated higher only in aggressiveness (p < 0.001). The same scores were calculated for the controls; no significant difference in any category was seen except confidence, where the right image was viewed as more confident (mean, 4.19; p < 0.005).

CONCLUSION

Aesthetic rhinoplasty improves the public perception of a person's appearance and personality in multiple aspects.

Association of Rhinoplasty With Perceived Attractiveness, Success, and Overall Health

IMPORTANCE

To date, the impact of rhinoplasty surgery on social perceptions has not been quantified.

OBJECTIVE

To measure the association of rhinoplasty with observer-graded perceived attractiveness, success, and overall health.

DESIGN, SETTING, AND PARTICIPANTS

In a web-based survey, blinded casual observers viewed independent images of 13 unique patient faces before or after rhinoplasty. Delphi method was used to select standardized patient images, confirming appropriate patient candidacy and overall surgical effect. Observers rated the attractiveness, perceived success, and perceived overall health for each patient image. Facial perception questions were answered on a visual analog scale from 0 to 100, where higher scores corresponded to more positive responses. A multivariate mixed-effects regression model was used to determine the effect of rhinoplasty while accounting for observer biases. To further characterize the effect of rhinoplasty, estimated ordinal rank change was calculated for each domain.

MAIN OUTCOMES AND MEASURES

The primary objective was to measure the effect of rhinoplasty on observer-graded perceived attractiveness, success, and overall health.

RESULTS

A total of 473 observers (mean age, 29 years [range, 18-73 years]; 305 [70.8%] were female) successfully completed the survey. On multivariate regression, patients after rhinoplasty were rated as significantly more attractive (rhinoplasty effect, 6.26; 95% CI, 5.10-7.41), more successful (rhinoplasty effect, 3.24; 95% CI, 2.32-4.17), and overall healthier (rhinoplasty effect, 3.78; 95% CI, 2.79-4.81). The ordinal rank change for an average individual's perceived attractiveness, success, and overall health was a positive shift of 14, 9, and 10 out of 100 rank positions, respectively.

CONCLUSIONS AND RELEVANCE

As perceived by casual observers, rhinoplasty surgery was associatedwith perceptions that in patients appeared significantly more attractive, more successful, and healthier. These results suggest patients undergoing rhinoplasty may derive a multifaceted benefit when partaking in social interactions. Furthermore, these results facilitate improved patient discussions aiming to provide more precise surgical expectations with an understanding that these results represent optimal outcomes.

LEVEL OF EVIDENCE

NA.

A Dual Approach to Understanding Facial Perception Before and After Blepharoplasty

Importance

Blepharoplasty consistently ranks among the most common facial plastic surgery procedure sought by both men and women. Despite the popularity of blepharoplasty, there has been little research focused on quantifying how eyelid surgery changes facial perceptions.

Objectives

To quantify the effect of blepharoplasty on facial perceptions and measure patient-reported ratings of fatigue before and after surgery to compare observer and patient perceptions.

Design, Setting, and Participants

A web-based survey experiment was conducted from January to February 2017, featuring photographs of female patients before and after blepharoplasty. Observers were randomly shown independent images of each patient and asked to rate perceived age, attractiveness, health, and energy level. Respondents saw only preoperative or postoperative photographs of each patient to reduce bias due to priming. Patient-reported outcomes were also collected.

Main Outcomes and Measures

A multivariate mixed effects regression model was used to quantify the changes in each domain after surgery. Ordinal rank change was calculated to provide a measure of clinical effect size across the domains. To analyze patient-reported outcomes, a Kruskal-Wallis test followed by Mann-Whitney tests were performed to determine if there were differences in patient-perceived tiredness based on operative status.

Results

A total of 401 participants (243 women, 152 men, and 6 not specified; mean age 25.9 years [range, 18-73 years]) successfully completed the survey and evaluated before-and-after photographs of 10 female patients (mean age, 59.8 years). The multivariable mixed effects model revealed that individuals are perceived as appearing significantly younger (-1.04 years; 95% CI, -1.70 to -0.37 years) and more attractive (coefficient, 4.92; 95% CI, 3.91-5.93) after blepharoplasty. Ratings of perceived health (coefficient, 4.33; 95% CI, 3.28-5.37) and energy level (coefficient, 9.83; 95% CI, 8.51-11.16) also improved significantly. After undergoing blepharoplasty, patients had significantly improved ratings of energy level compared with those who had not undergone blepharoplasty.

Conclusions and Relevance

This is the first study, to date, aimed at quantifying the perceptions of facial aesthetic changes following blepharoplasty. The data demonstrate that individuals are rated as appearing more youthful, attractive, and healthy following blepharoplasty. Furthermore, both patients and casual observers perceived a significant improvement in energy level following blepharoplasty, a meaningful finding as the appearance of fatigue is a chief concern of the patients before they undergo blepharoplasty.

Level of Evidence

NA.

Association Between Facial Rejuvenation and Observer Ratings of Youth, Attractiveness, Success, and Health

IMPORTANCE

Surgical procedures for the aging face-including face-lift, blepharoplasty, and brow-lift-consistently rank among the most popular cosmetic services sought by patients. Although these surgical procedures are broadly classified as procedures that restore a youthful appearance, they may improve societal perceptions of attractiveness, success, and health, conferring an even larger social benefit than just restoring a youthful appearance to the face.

OBJECTIVES

To determine if face-lift and upper facial rejuvenation surgery improve observer ratings of age, attractiveness, success, and health and to quantify the effect of facial rejuvenation surgery on each individual domain.

DESIGN, SETTING, AND PARTICIPANTS

A randomized clinical experiment was performed from August 30 to September 18, 2016, using web-based surveys featuring photographs of patients before and after facial rejuvenation surgery. Observers were randomly shown independent images of the 12 patients; within a given survey, observers saw either the preoperative or postoperative photograph of each patient to reduce the possibility of priming. Observers evaluated patient age using a slider bar ranging from 30 to 80 years that could be moved up or down in 1-year increments, and they ranked perceived attractiveness, success, and health using a 100-point visual analog scale. The bar on the 100-point scale began at 50; moving the bar to the right corresponded to a more positive rating in these measures and moving the bar to the left, a more negative rating.

MAIN OUTCOMES AND MEASURES

A multivariate mixed-effects regression model was used to understand the effect of face-lift and upper facial rejuvenation surgery on observer perceptions while accounting for individual biases of the participants. Ordinal rank change was calculated to understand the clinical effect size of changes across the various domains after surgery.

RESULTS

A total of 504 participants (333 women, 165 men, and 6 unspecified; mean age, 29 [range, 18-70] years) successfully completed the survey. A multivariate mixed-effects regression model revealed a statistically significant change in age (-4.61 years; 95% CI, -4.97 to -4.25) and attractiveness (6.72; 95% CI, 5.96-7.47) following facial rejuvenation surgery. Observer-perceived success (3.85; 95% CI, 3.12-4.57) and health (7.65; 95% CI; 6.87-8.42) also increased significantly as a result of facial rejuvenation surgery.

CONCLUSIONS AND RELEVANCE

The data presented in this study demonstrate that patients are perceived as younger and more attractive by the casual observer after undergoing face-lift and upper facial rejuvenation surgery. These procedures also improved ratings of perceived success and health in our patient population. These findings suggest that facial rejuvenation surgery conveys an even larger societal benefit than merely restoring a youthful appearance to the face.

LEVEL OF EVIDENCE

NA.