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minimal-incision surgery." Cosmetic surgeons in the United States were slower to recognize the possibilities for endoscopic surgery than their orthopedic colleagues, who led in repairing knees, shoulders, and elbows through minimal incisions. General surgeons and gynecologists also learned to move through the abdominal cavity and pelvis under television endoscopic control. Now cosmetic surgeons are using endoscopic techniques for forehead- and face-lifting. Breast implants are endoscopically placed from the axilla or umbilicus. Implants are checked for leaks or ruptures through a minimal incision endoscopic evaluation. Endoscopic abdominoplasties tighten the anterior abdominal wall fascia and redistribute the skin without large mcisions. The techniques of rhinoplasty surgery, a field more than 100 years old, continue to evolve and improve. The concept of open-structure rhinoplasty gives the surgeon many options not available in the classic endonasal route. Surgery is more conservative; normal anatomical relations are maintained, and structures may be stabilized and strengthened by cartilage grafts and suture techniques. Finally, new ideas and concepts flow into cosmetic surgery from oral and maxillofacial surgeons. There is a close relationship between cranial facial surgery and aesthetic surgery; the orthognathic techniques and subperiosteal approach to facial rejuvenation have been improved by oral surgeons. This brief overview suggests a clear, if sometimes erratic, trend. The notion that there can be a clear line drawn between "reconstructive" and "cosmetic" surgeries has been largely abandoned. Cosmetic surgery is flourishing in the United States as more and more Aims of the report The aim of this review is to identify patient reported outcome measures (PROMs) for use in cosmetic surgical procedures. The review assesses evidence relating to the development and validation of these instruments and make recommendations, where appropriate, regarding the most suitable instruments for use in relation to groups rather than individuals. Methods The primary source used to identify relevant articles was English-language PubMed records. PROMs identified were assessed on the initial development process, measurement performance and operational characteristics. Results The review identifies nine cosmetic surgery specific PROMs developed with patient input and that demonstrate, at least, adequate psychometric properties; the Breast Reduction Assessed Severity Scale Questionnaire (BRASSQ), Breast-Related Symptoms Questionnaire (BRSQ), BREAST-Q, Derriford Appearance Scale (DAS), Facial Lines Treatment Satisfaction Questionnaire (FTS), FACE-Q Satisfaction with Facial Appearance Scale, Patient-Reported Impact of Scars Measure (PRISM), Patient Scar Assessment Questionnaire (PSAQ) and Skindex. Three generic measures, the SF-36, EQ-5D and Healthy Utility Index, were identified as having been used for assessment of outcomes in cosmetic surgery. Conclusions The nine cosmetic surgery specific measures vary in their level of validation, and although some have yet to be tested for responsiveness, all demonstrate psychometric properties that justify their use. The three measures that stand out are the BREAST-Q, FACE-Q Satisfaction with Facial Appearance Scale and Skindex, all of which meet current recommendations for the development and validation of PROMs. For the three generic measures, little data was identified that reports their testing and validation in cosmetic surgery. Studies dedicated to the evaluation of these measures in this population are urgently required before they can be confidently recommended for use in the NHS. 5 Chapter 1: INTRODUCTION Cosmetic Surgery in the UK Latest figures from the British Association of Aesthetic Plastic Surgeons (BAAPS) indicate a significant rise in the number of cosmetic surgical procedures undertaken in the UK (British Association of Aesthetic Plastic Surgeons, 2012). Audit data from BAAPS for 2011 demonstrated a 5.8% increase in procedures when compared to figures from 2010, this equating to in excess of 43,000 cases. The assessment of outcomes in cosmetic surgery is particularly pertinent, and especially from the perspective of the patient; manifestly, the patient’s perception of the success, or otherwise, of their cosmetic procedure is paramount (Kosowski et al., 2009; Ching et al., 2003). Given such importance, it is essential that those PROMs utilised in the field of cosmetic surgery reflect the characteristics described in this opening chapter. The review that follows aims to identify those PROMs that are best placed for current use. Patient Reported Outcome Measures (PROMs) A wide range of patient-reported outcome measures (PROMs) have been developed over the last thirty years. Variously termed measures of ‘health status’, ‘health-related quality of life’, ‘functional status’, ‘patient-reported outcome’ or often just ‘outcome’, the common element is an attempt directly to capture the patient’s experience of important aspects of health through questionnaire or interview. Considerable resources and effort have been invested to make such ‘instruments’ valid measures for use in relation to a wide range of decisions and policies in health. A principle problem has been that there
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