Shared Decision-Making in Cosmetic Medicine and Aesthetic Surgery

Shared decision-making implementation status among dermatologists engaging in medical esthetics: a cross-sectional study in China

Objective

Shared decision-making (SDM) is a collaborative process in which patients and healthcare providers jointly make a medical decision. This cross-sectional study aimed to identify the implementation status of shared decision-making among dermatologists engaging in medical esthetics in China and to identify factors associated with the good practice of SDM among them.

Methods

From January to June 2023, a total of 1,287 dermatologists engaging in medical esthetics in China were recruited and completed the online interviews about their implementation of SDM based on the Shared Decision-Making Questionnaire for Doctors (SDM-Q-Doc). Logistic regression was used to calculate the odds ratio (OR) and 95% confidence interval (CI) to explore factors associated with the higher SDM score achievement among dermatologists with medical esthetic practice.

Results

The median value of the total SDM score was 39, and 48% (621/1278) of dermatologists with medical esthetic practice achieved at least 40 out of 45 scores. Logistic regression indicated that dermatologists aged 40-49 or ≥ 50 years and those engaging in medical esthetic practice for ≥5 years were more likely to achieve at least 40 out of 45 scores compared to dermatologists aged <30 years with less than 5 years of medical esthetic practice. The ORs were 1.82 (95% CI: 1.13-3.12), 1.94 (95% CI: 1.13-3.61), and 1.76 (95% CI: 1.34-2.31), respectively.

Conclusion

The SDM implementation level among Chinese dermatologists engaging in medical esthetics is high, especially for those who are older age and have more years of practice. Hence, it is highly recommended to promote and enhance SDM practice among younger dermatologists engaging in medical esthetics with less working experience.

Barriers and Stimulus in Shared Decision Making Among Aesthetic Dermatologists in China: Findings from a Cross-Sectional Study

Introduction

Shared decision making (SDM) is a collaborative process involving both healthcare providers and patients in making medical decisions, which gains increasing prominence in healthcare practice. But evidence on the level of SDM in medical practice and barriers as well as stimulus during the SDM implementation among aesthetic dermatologists is limited in China.

Methods

From July to August 2023, 1938 dermatologists were recruited online in China. Data were collected through an electronic questionnaire covering: (1) demographic features; (2) SDM questionnaire physician version (SDM-Q-Doc); and (3) stimulus and barriers in SDM implementation. Logistic regression was applied to explore factors associated with SDM practice, barriers, and stimulus of SDM implementation, respectively.

Results

The 1938 dermatologists included 1329 females (68.6%), with an average age of 35 years. The total SDM score ranged from 0 to 45, with a median value of 40 (IQR: 35-44), and the median stimulus score and barriers scores were 28 (IQR: 24-32) and 19 (IQR: 13-26), respectively. The prevalence of good SDM was 27.2%, logistic regression indicated that female dermatologists (odds ratio, OR=1.21, 95% confidence interval, CI: 0.96-1.51), and dermatologists with more years of aesthetic practice had a higher proportion of good SDM practice (OR was 1.44 for 5-9 years, 1.58 for 10-15 years and 1.77 for over 15 years). Moreover, female dermatologists and dermatologists with higher education level and serviced in private settings had lower barrier scores; female dermatologists and dermatologists with more years of aesthetic practice had higher stimulus scores.

Conclusion

Chinese aesthetic dermatologists appear to implement SDM at an active level, with more stimulus and less barriers in SDM implementation. The integration of SDM into clinical practice among dermatologists is beneficial both for patients and dermatologists. Moreover, SDM practice should be strongly promoted and enhanced during medical aesthetics, especially among male dermatologists, dermatologists with less working experience, and those who work at public institutions.

Effectiveness and Safety of Resilient Hyaluronic Acid (RHA) Dermal Fillers for the Correction of Moderate-to-Severe Nasolabial Folds in People of Color: Post Hoc Subgroup Analyses of US Pivotal Clinical Data

BACKGROUND

People of color (POC) are often underrepresented in clinical studies evaluating the safety and effectiveness of aesthetic products, including hyaluronic acid (HA) fillers, for which there is to date limited clinical data in POC.

OBJECTIVES

The aim of this study was to assess the safety and effectiveness of a new line of dynamic resilient HA fillers (RHA; Revance, Nashville, TN) for treating moderate-to-severe nasolabial folds (NLFs) in POC vs non-POC.

METHODS

Post hoc subgroup analyses compared the efficacy and safety of POC vs non-POC subjects treated with RHA2, RHA3, or RHA4 for correction of moderate-to-severe NLFs in the pooled per-protocol population (N = 217) in 2 clinical trials. Evaluated population cohorts were classified by Fitzpatrick skin type (FST) (high FST [IV-VI] vs low FST [I-III]) and by subject-reported race (non-White vs White) relative to baseline at 6, 9, 12, and 15 months.

RESULTS

POC consistently showed greater improvement in wrinkle severity and higher responder rates compared with non-POC, which reached statistical significance at several measured time points. Global Aesthetic Improvement Scale scores and subject satisfaction ratings were similar for POC and non-POC and remained high throughout the course of the study. Treatment-related adverse event rates were generally lower for high FSTs vs low FSTs, with no reported cases of keloidal scarring.

CONCLUSION

The RHA line of dynamic fillers is well tolerated and effective for the correction of moderate-to-severe NLFs in POC and can be confidently used in this important and growing patient population.See the abstract translated into Hindi, Portuguese, Korean, German, Italian, Arabic, Chinese, and Taiwanese online here: https://doi.org/10.1093/asj/sjad251.

LEVEL OF EVIDENCE: 2

The 3-Level Approach to Facelift Planning: A Simple Paradigm for Surgical Rejuvenation of the Face

Our role as aesthetic surgeons demands individualized surgical planning that maximizes patient input and understanding. The value of such shared decision-making (SDM) in aesthetic surgery is becoming increasingly appreciated. This is particularly true for potential patients seeking surgical rejuvenation of the face, where the volume of "educational" information available on the internet, and through various social medial channels, may be overwhelming and even misleading. Presented is a "3-Level approach to facelift planning" named for the facial subregions targeted. This novel paradigm maximizes SDM with its simplicity and reproducibility, serves as an invaluable educational tool for patients, novice and seasoned surgeons alike, and facilitates communication between senior surgeons through its descriptive standardization. LEVEL OF EVIDENCE V: 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 .

Cosmetic Injection of Illicit Foreign Materials: Imaging Features and Patterns of Migration in 413 Cases

BACKGROUND

The injection of illicit, nonregulated foreign materials is increasingly common and has negative consequences relative to the inflammatory process that ensues.

OBJECTIVES

The aim of this study was to identify anatomical and imaging characteristics after the cosmetic injection of illicit foreign materials.

METHODS

A retrospective review of clinical and imaging records was performed. The issues analyzed were the anatomical site, type of injected substance, imaging method for diagnosis, and patterns of migration.

RESULTS

Data on 413 patients were collected. Most patients were female, with a mean age of 44 years. The most commonly infiltrated region was the buttocks (n = 284; 53.58%) followed by the breast (n = 99; 18.67%). Magnetic resonance imaging was the most common method of diagnosis in those patients who had an imaging study (159 out of 168). The most frequent depth of foreign material detected by imaging was the muscular plane (n = 103; 61.30%). Migration was detected in 56.55% of patients who had an imaging study. Most infiltrated substances were unknown; biopolymers were the most commonly identified substances. Depending on the type of substance, migration rates varied from 13% to 29%; rate differences were not statistically significant (P = .712). Migration was more common when the depth of infiltration was in muscle (77.66%) than in subcutaneous tissue (23.4%); this difference was statistically significant (P < .0001).

CONCLUSIONS

Deep infiltration is related to greater migration rates, apparently regardless of the substance injected.

LEVEL OF EVIDENCE: 3

International Consensus Recommendations on the Aesthetic Usage of Ready-to-Use AbobotulinumtoxinA (Alluzience)

Alluzience (abobotulinumtoxinA RTU; Ipsen, Paris, France and Galderma SA, Lausanne, Switzerland) is the first ready-to-use (RTU) botulinum toxin type A liquid solution approved for the treatment of glabellar lines in Europe. In this article, the authors provide consensus recommendations on the aesthetic usage of abobotulinumtoxinA RTU. Members of the International Board on Alluzience convened to develop consensus on the treatment of glabellar lines as well as other facial wrinkles based on their own extensive experience. Consensus recommendations were developed to provide practical guidelines for injection of abobotulinumtoxinA RTU. General guidance on proper assessment, treatment planning, and patient education is provided, as well as specific injection guidelines per indication. Indications covered include glabellar lines, crow's feet, horizontal forehead lines, lateral eyebrow lift, lower eyelid wrinkles, bunny lines, drooping nasal tip, perioral wrinkles, drooping mouth corners, masseter hypertrophy, hollow cheek lines, dimpled chin, and platysmal bands. These guidelines provide a practical framework to support routine injection of facial muscles with Alluzience.

LEVEL OF EVIDENCE: 5

AGA practitioner challenges: A mixed-methods pilot survey

BACKGROUND

Androgenetic alopecia (AGA) practitioner care may be hampered by commercial biases and hair loss' omission from most medical curricula.

AIM AND METHOD

Between November 2020 and September 2021, 34 AGA professionals (86% British; 62% trichologists), participated in a pilot, mixed-methods, survey. Practitioner views on: 1a-1j) AGA's commercial influences (e.g., participants were quantitatively assessed on their understanding of a popular, commercially-funded, AGA study) and 2a-2h) constraints on evidenced-based AGA responding (e.g., ethical dilemmas) were assessed. Quantitative responses are reported descriptively whilst qualitative responses are categorized alongside illustrative quotes.

RESULTS

On average, (1a-1d) 42% of participants were misled by the popular AGA study and (1e) participants underestimated the extent of commercial biases in AGA research as 25%; (2a-2e). Participants also indicated that AGA treatment limitations and misinformation ethically challenged them (e.g., "[It's difficult to know when] to treat or not without being able to confirm the outcome"). (2c) Most (77%) indicated society played a powerful role in exacerbating AGA distress (e.g., "Society is hyper critical of appearance") and 30% indicated greater "treatment" accessibility was needed: (e.g., "hair loss product [should] give clear indication of what the active ingredients are and how effective they are").

CONCLUSIONS

Despite the limited sample size, these finding cohere with previous identified challenges of the AGA practitioner role. Evidence based guidance and research scrutiny tools would help practitioners overcome such challenges.

Defining Cognitive Competencies for Breast Augmentation Surgery

BACKGROUND

Breast augmentation is the most performed aesthetic procedure in the United States yet one that surgical trainees have limited exposure to. This creates a lack of confidence in performing this key procedure among graduates. It is imperative to develop novel curricula and objective measures to standardize acquiring competency.

OBJECTIVE

This qualitative study establishes various cognitive competencies and pitfalls in augmentation mammoplasty.

METHODS

Using a priori established task analysis, literary sources and operative observations, a total of 20 cognitive vignettes were developed to conduct cognitive task analyses (CTA) for breast augmentation through semistructured interviews of experts. Interviews were itemized, and verbal data were recorded, transcribed verbatim, and thematically analyzed by reviewers.

RESULTS

Eight experts were interviewed (median age 39 years, 87.5% males, with a median of 7 years in practice). A conceptual framework for breast augmentation was developed and divided into 5 operative stages containing 208 competencies and 41 pitfalls. Pitfalls were mapped to deficits in shared decision making, proper informed consent, prospective hemostasis, and awareness of anatomical landmarks and markings.

CONCLUSIONS

This work provided an inclusive framework of cognitive competencies in breast augmentation surgery to facilitate their assessment. This model guides the analysis of other procedures to transfer cognitive competencies to learners. In a transition toward competency-based education, this provides a primer to assessments that include all aspects of a surgeon's skill set.

How an Automated Patient Education Module Improves Patient Outcomes and Informs Quality-of-Care Measures for Providers Within a Minimally Invasive Aesthetic Practice

I conducted a quality improvement project to determine whether providing patient education before consultation and treatment would help meet the needs of aesthetic patients and providers. The project objective was to create an automated patient education module that provided consistent, accurate information to each patient who viewed it and would give the providers additional time to treat the patient and generate revenue. Before and during the 6-week study period, I administered three surveys and reviewed electronic health records metrics indicating patient check-in and check-out times and facility revenue. I used descriptive statistics to examine the demographics of the patients included in the study. I analyzed check-in and check-out times and facility revenue by conducting two-tailed Mann-Whitney U tests. There were a total of 201 patient visits in the 6-week period before the study and a total of 316 patient visits during the study period. Most patients were White, married women, 50- to 59-years-old, with at least some college education. The most common treatments administered were neurotoxin and dermal filler injections. After implementing the preappointment education, I found a significant reduction in the length of patient appointments (p < .001) and a significant increase in facility revenue (p < .037). I concluded that after implementing the education program, patient understanding about the intended treatment was improved. To better correlate how preappointment automated education impacts the amount of time the provider spends with patients and influences practice revenue, I recommend conducting a longer study with a greater number of patients.

The Anatomy of a Malpractice Lawsuit

Medical malpractice lawsuits can be a source of emotional, physical, and financial distress for both providers and patients. A thorough understanding of the medical malpractice process's history and current landscape will help providers navigate malpractice challenges. Given the impact and prevalence of medical malpractice, in this paper, the authors sought to dissect the intricate anatomy of a medical malpractice lawsuit. This includes a comprehensive and detailed report of tort reform, the criteria of a medical malpractice suit, and a description of the court proceedings. In addition, the authors also performed an extensive review of the medicolegal literature and have provided recommendations for healthcare providers to avoid these lawsuits in their practice.

Level of Evidence 5

Artificial Intelligence-Enabled Simulation of Gluteal Augmentation: A Helpful Tool in Preoperative Outcome Simulation?

BACKGROUND

While the buttock region is considered an esthetic hallmark, the Brazilian butt lift (BBL) remains controversially discussed in the plastic surgery community. This is due to its contentious safety profile. Thus, informed consent and patient education play a key role in preoperative planning. To this end, we aimed to program an easy-to-use, widely accessible, and low-budget algorithm that produces reliable outcome simulations.

METHODS

The conditional generative adversarial network (GAN) was trained using pre- and postoperative images from 1628 BBL patients. To validate outcome simulation, 25 GAN-generated images were assessed deploying 67 Amazon Mechanical Turk Workers (Mturks).

RESULTS

Mturks could not differentiate between GAN-generated and real patient images in approximately 49.4% of all trials.

CONCLUSION

This study presents a free-to-use, widely accessible, and reliable algorithm to visualize potential surgical outcomes that could potentially be applied in other fields of plastic surgery.

Factors Influencing Trust and Trustworthiness: Cosmetic Injectable Patient Experience Exploratory Study (CIPEES)-Part 3

Background

Despite the widely recognized importance of trust in professional relationships, it remains elusive, complex, multidimensional, and difficult to quantify due to the lack of validated tools.

Objectives

The authors sought to explore both the important factors for building trust with cosmetic injectable patients and strategies for improving levels of trustworthiness in aesthetic practitioners.

Methods

In order to explore factors in building trust with cosmetic injectable practitioners, a global study was conducted via an online survey. The Cosmetic Injectable Patient Experience Exploratory Study (CIPEES) survey assessed the relative importance of qualifications and training; reviewing of previous work (before and after photos); reputation; connection; time spent; online presence; and personal appearance of the practitioner in developing trust in a cosmetic practitioner.

Results

The CIPEES survey collected 1488 responses across 75 countries, with 66% of participants completing all 15 questions. The respondents were 95.6% female and 4.4% male, with ages ranging from 18 to >65 years old (median 33 years old). The number 1 ranked reason for being able to trust a cosmetic injector was qualifications and training, followed by the reputation of the practitioner, and time spent by the practitioner with the survey respondent. Practitioner online presence was considered the least important factor in helping develop trust.

Conclusions

The CIPEES survey results support patient trust being built through credibility, reliability, and intimacy, with low levels of practitioner self-orientation. The trustworthiness equation provides a framework for identifying practitioner weaknesses in patient relationships and actionable methods of improving trustworthiness.

Randomized control trial evaluating the use of a shared decision-making aid for older ventral hernia patients in the Geriatric Assessment and Medical Preoperative Screening (GrAMPS) Program

PURPOSE

Shared decision making (SDM) is ideally suited to abdominal wall surgery in older adults given the breadth of decision making required by the hernia surgeon and the impact on quality of life (QOL) by various treatment options. Given the paucity of literature surrounding SDM in hernia patients, the feasibility of a novel, formalized SDM aid/tool was evaluated in a pilot randomized trial.

METHODS

Patients 60 years or older with a diagnosed ventral hernia were prospectively randomized at an academic hernia center. In the experimental arm, a novel SDM tool, based on the SHARE Approach, guided the consultation. Previously validated SDM assessments and patient's hernia knowledge retention was measured.

RESULTS

Eighteen (18) patients were randomized (9 control and 9 experimental). Cohorts were well matched in age (p = 0.51), comorbidities (Charlson Comorbidity Score: p = 0.43) and frailty (mFI-11: p = 0.19; Risk Analysis Index: p = 0.33). Consultation time was 11 min longer in the experimental cohort (p < 0.01). There was a trend towards better Decisional Conflict Scores in the experimental group (p = 0.25) and the experimental cohort had improved post-visit retained hernia knowledge (p < 0.01). All patients in the experimental arm (100%) enjoyed working through the SDM aid/tool and felt it was a worthwhile exercise.

CONCLUSION

Incorporating a formalized SDM tool into a busy hernia surgical practice is feasible and well received by patients. In addition, early results suggest it improves retention of basic hernia knowledge and may reduce patient's decisional conflict. Next steps include condensing the SDM tool to enhance efficiency within the clinic and beginning a large, randomized control trial.

The Importance of Patient Mindset: Cosmetic Injectable Patient Experience Exploratory Study-Part 1

Background

To meet the needs of each individual cosmetic injectable patient, focus is moving toward a detailed, patient-centered, holistic consultation with pretreatment exploration of the patient's mindset. The Cosmetic Injectables Patient Experience Exploratory Study (CIPEES) was developed to explore patient motivation, mindset, engagement, and factors impacting the patient-practitioner relationship.

Objectives

In order to best meet the needs of individual aesthetic patients, the authors examine the variability and importance of mindset factors in patients seeking cosmetic injectables.

Methods

A study was conducted through an online survey. Participants were asked to respond to a series of statements concerning their thoughts and feelings around appearance, treatment goals, and motivating factors. Participants were asked to select one of the following: "describes me well," "somewhat describes me," or "does not describe me."

Results

In total, 1269 participants completed the relevant survey question. Respondents were 95.6% female and 4.4% male, with ages ranging from 18 to > 65 years old (median 33 years old). Responses were also analyzed according to age group. Data analysis revealed a majority of respondents seeking natural results, with a 15%-20% minority considering a "done" look to be acceptable or even ideal. High numbers of respondents reported being critical of their own appearance and concerned about a specific feature to be "fixed."

Conclusions

Exploring the nuances of patient mindset will assist practitioners in meeting the unique needs of each patient and may also help them to avoid treating patients whose requirements or expectations are outside their circle of competence.

The Importance of Functional Quality in Patient Satisfaction: Cosmetic Injectable Patient Experience Exploratory Study-Part 2

Background

Quality assessment comprises 2 distinct forms: technical quality (TQ) and functional quality (FQ). On the one hand, TQ describes accuracy and excellence, the degree to which procedures are done "correctly." On the other hand, FQ is the way services are delivered and represents how the customer perceives and experiences the treatment or service.

Objectives

To determine the relative importance of functional quality factors in the care of cosmetic injectable patients and return patronage.

Methods

The Cosmetic Injectable Patient Experience Exploratory Study (CIPEES) survey assessed reasons for return patronage to a specific cosmetic injector and the correlation between satisfaction with cosmetic results (patient assessment of TQ) and respondents' trust level in their practitioner, a marker for FQ.

Results

The CIPEES survey collected 1488 responses across 75 countries, with 66% of participants completing all 15 questions. The respondents were 95.6% female and 4.4% male, with ages ranging from 18 years to >65 years old (median 33 years old). The number one ranked reason for returning to a previous cosmetic injector (return patronage) was "Trust in my practitioner's action and ability," closely followed by "Cosmetic result/outcome from the previous treatment/s." Respondents' level of satisfaction with their cosmetic results also correlated highly with trust in their practitioners.

Conclusions

In order to maximize patient satisfaction and return patronage, healthcare practitioners should focus on improving FQ care and value it at least as high as TQ in the delivery of cosmetic injectable treatments.

Characterization of Medical Malpractice Litigation After Rhinoplasty in the United States

BACKGROUND

When complications following rhinoplasty occur or when the desired outcome is not achieved, patients may seek litigation on the premise that there was a violation in the standard of care. Knowledge of malpractice claims can inform rhinoplasty surgeons on how to minimize risk of future litigation as well as improve patient satisfaction.

OBJECTIVES

The aims of this study were to identify motives for seeking medical malpractice litigation after rhinoplasty, and to examine outcomes of malpractice litigation after rhinoplasty in the United States.

METHODS

The Westlaw legal database was reviewed for all available court decisions related to malpractice after rhinoplasty. Data collected and analyzed included plaintiff gender, location, specialty of defendant(s), plaintiff allegation, and adjudicated case outcomes.

RESULTS

Twenty-three cases were identified between 1960 and 2018, located in 12 US states; 70% of the plaintiffs were female. Otolaryngologists were cited in 11 cases, whereas 12 cases involved a plastic surgeon. All cases alleged negligence. Cases involved "technical" errors (69.6%), "unsatisfactory" outcomes (39.1%), inadequate follow-up or aftercare (30.4%), issues with the informed consent process (21.7%), unexpectedly extensive surgery (8.7%), improper medication administration (4.3%), and failure to recognize symptoms (4.3%). Twenty of the 23 adjudicated cases (86.9%) were ruled in favor of the surgeon. The main contributing factor in cases alleging malpractice was poor aesthetic outcome/disfigurement (60.7%).

CONCLUSIONS

Malpractice litigation after rhinoplasty favored the surgeon in the majority of the adjudicated cases reviewed. The principal reason for litigating was dissatisfaction with aesthetic outcomes. Rhinoplasty surgeons may mitigate possible litigation by developing a positive doctor-patient relationship, clearly understanding the patient's surgical expectations, and obtaining detailed informed consent while maintaining frequent and caring communication with the patient.

Shared Decision-making in Dermatology: A Scoping Review

Importance

Shared decision-making (SDM) can improve the quality of care for patients. The extent to which this tool has been used and the evidence supporting its use in dermatology have not been systematically examined.

Objective

To perform a scoping review of the literature regarding SDM in dermatology.

Evidence Review

Searches of Ovid MEDLINE, PsycINFO, PsycARTICLES, Sciverse Scopus, and EBM Reviews were conduced on July 11, 2019, and March 6, 2020. There were no limits on date, type of article, language, or subject for the initial search. A total of 1673 titles and abstracts were screened by 2 independent reviewers in the Covidence mixed-methods platform. Forty-one full-text studies were assessed for eligibility. For inclusion, articles needed to include a dermatologic diagnosis as well as discussion of SDM or patient decision aids. Two independent reviewers screened 29 full-text articles for inclusion and extracted qualitative data using a set of 26 predefined codes. Qualitative coding was applied to excerpts to categorize the article, define and describe advantages and disadvantages of SDM, understand patient and physician requests for SDM, and discuss methods of implementation.

Findings

Despite a small number of articles on SDM (n = 29) in dermatology, the selected literature provided consistent messages regarding the importance of SDM for dermatology and a number of strategies and tools for implementation. Medical dermatology was the most common subspecialty studied, with melanoma, psoriasis, and connective tissue diseases most examined. Only 5 publications introduced SDM tools specifically for dermatologic conditions; of these, only 2 tools were validated. Barriers to implementation that were cited included time and a lack of training for clinicians, although the literature also provided potential solutions to these issues. All articles emphasized the value of SDM for both patients and physicians.

Conclusions and Relevance

The literature regarding SDM in dermatology consistently suggests that it is a useful tool for providing patient-centered care. Established tools have been proposed since 2012. More research is needed to implement better practices, especially in dermatologic subspecialties. However, there are substantial suggestions from the literature for strategies and tools with which to begin a shared decision-making practice.

PEGASUS: the Design of an Intervention to Facilitate Shared Decision-making in Breast Reconstruction

Studies have found varying levels of satisfaction after breast reconstruction surgery with a substantial group of patients reporting some level of regret about their decision. The variable outcomes reported by women undergoing breast reconstruction surgery suggest a role for improved pre-operative communication and shared decision-making (SDM) between patient and health professional. Pragmatic approaches such as decision aids have been evaluated, but the aim of the Patient Expectations and Goals Assisting Shared Understanding of Surgery (PEGASUS) intervention is to facilitate closer interaction between the patient and clinical team. PEGASUS is a standardised two-stage process, in which patients' goals are first elicited, ranked in importance and recorded before being used to frame discussion and decision-making with the surgeon managing care. Following the Medical Research Council (MRC) model, feasibility and acceptability studies have already been reported and a 4-year multicentre randomised controlled trial of 180 participants is underway, (completion 2020). This paper therefore focuses on the design of the intervention itself, in line with recent advice that interventions, in comparison with evaluations, commonly lack a theoretical base and are often under reported. We report a retrospective application of the Capability, Opportunity, Motivation-Behaviour (COM-B) model to provide explicit detail of each step in the intervention design. This is intended to facilitate replication by other clinicians and to provide systematic guidance for others wishing to develop PEGASUS as a strategy for implementing SDM in other clinical populations. Trial Registration: ISRCTN 18000391 (DOI 10.1186/ISRCTN18000391) 27/01/2016.

Plastic Surgery and the Malpractice Industry

SUMMARY

The current status of the plastic surgeon in the medical liability spectrum and ways to avoid litigation are explored by using pooled national data from the Medical Professional Liability Association, private information from Applied Medico-Legal Solutions RRG, and a detailed literature search. The medical liability system in the United States costs $55.6 billion, or 2.4 percent of total health care spending. Plastic surgery accounts for 3.31 percent of reported claims and 3.16 percent of paid claims. Total payments for plastic surgeons represent 1.75 percent of the total paid for all specialties. Malpractice awards are relatively light for plastic surgeons. Nevertheless, they still have a 15 percent chance per year of being sued. However, 93 percent of cases will close with a dismissal or a settlement, and only 7 percent will go to trial. Of these, the plastic surgeon will prevail in 79 percent. Most importantly, 75 percent of all cases will result in no payment. To minimize the chances of a lawsuit, plastic surgeons should maintain excellent communication with their patients and participate in shared decision-making. They should take a leadership role and buy in to the performance of perioperative checklists, embrace patient education, and actively participate in Maintenance of Certification. They should be transparent in their dealings with patients by preoperatively declaring their policies on revisions, refunds, complications, and payments. Plastic surgeons must maintain complete and accurate medical records and participate in hospital-based programs of prophylaxis. They should be aware that postoperative infection is the single costliest adverse outcome and proactively deal with it.

A Pilot Study Evaluation of 3-Dimensional Imaging in Cosmetic Breast Augmentation: Results of a Single Surgeon 3.5-Year Retrospective Study Using the BREAST-Q Questionnaire

BACKGROUND

Traditional methods of breast implant size selection provide limited ability to demonstrate postoperative outcomes. Three-dimensional (3D) imaging provides an opportunity for improved patient evaluation, surgical planning, and evaluation of postoperative breast appearance.

OBJECTIVES

The authors hypothesized that preoperative 3D imaging for patients undergoing breast augmentation would improve patient satisfaction and understanding of expected surgical outcomes.

METHODS

A retrospective review of patients undergoing breast augmentation by a single surgeon over a 3.5-year period was performed. Patients presenting after the VECTRA was purchased had preoperative 3D imaging, while patients presenting before this did not. Eligible patients received a BREAST-Q questionnaire designed for postoperative evaluation of breast augmentation. They also received a second survey that evaluated expected vs actual breast outcomes.

RESULTS

In total, 120 surveys were mailed and 61 patients (50.8%) returned the survey. The 3D imaged group had improved BREAST-Q scores regarding satisfaction with outcome, surgeon, and physical well-being compared with the group that did not. The imaged group also had higher size, shape, and overall breast correlation scores, confidence in implant size selection scores, and communication with surgeon scores. The differences between the 2 groups were not statistically significant.

CONCLUSIONS

Three-dimensional imaging is a valuable tool in breast surgery. Although this study showed improvement in patient satisfaction and predicted outcome scores in the 3D imaged group, the results were not statistically significant. With the majority of patients reporting that they would choose 3D imaging, it appears to instill confidence in patients regarding both surgeon and implant selection.

LEVEL OF EVIDENCE 4

A Practical Guideline for the Implementation of Shared Decision-making in Complex Ventral Incisional Hernia Repair

BACKGROUND

Although obtaining preoperative procedural consent is required to meet legal and ethical obligations, consent is often relegated to a unidirectional conversation between surgeons and patients. In contrast, shared decision-making (SDM) is a collaborative dialog that elicits patient preferences. Despite emerging interest in SDM, there is a paucity of literature on its application to ventral incisional hernia repair (VIHR). The various surgical techniques and mesh types available, the potential impact on functional outcomes and quality of life, the largely elective nature of the operation, and the significant risk of perioperative patient complications render VIHR an ideal field for SDM implementation.

METHODS

The authors reviewed the current literature and drew on their own practice experience to describe evidence-based practical guidelines for implementing the SDM into VIHR care.

RESULTS

We summarized the evidence basis for SDM in surgery and discussed how this model can be applied to VIHR given the multiple, complex factors that influence surgical decision-making. We outlined an example of using an SDM framework, "SHARE," with a patient with a large, recurrent ventral hernia.

CONCLUSIONS

SDM has the potential to improve patient-centered and preference-concordant care among individuals being considered for VIHR to ensure that treatment interventions meet a patient's goals, rather than solely treating the underlying disease process.

WUWHS 2020 Global Healing Changing Lives, Abu Dhabi, UAE March 8-12

The abstract book contains the abstracts of keynote lectures, global gelebration, focus sessions, symposia, regional view, workshops, sponsored symposia, oral presentations, posters and the index.

Attitudes, Beliefs, and Practices of Aesthetic Plastic Surgeons Regarding Informed Consent

BACKGROUND

Best practice for informed consent in aesthetic plastic surgery is a process of shared decision-making, yet evidence strongly suggests this is not commonly reflected in practice nor is it supported by traditional informed consent documents (ICD). Falsely held beliefs by clinicians about shared decision-making may contribute to its lack of adoption.

OBJECTIVE

The authors sought to understand the baseline attitudes, beliefs, and practices of informed consent among board-certified plastic surgeons with a primarily aesthetics practice.

METHODS

A 15-question online survey was emailed to active members of the American Society for Aesthetic Plastic Surgery. Items included demographics, Likert scales, free-text, acceptability, and 1 question seeking consensus on general information all patients must understand before any surgery.

RESULTS

This survey yielded a 13% response rate with a 52% completion rate across 10 countries and 31 US states. A total of 69% were very or extremely confident that ICD contain evidence-based information, but 63% were not at all or not so confident in ICD effectiveness of prompting patients to teach-back essential information. A total of 50% believed surgical ICD should be reviewed annually. Eighty-six percent reported assistance with patient education during informed consent. Members of professional plastic surgery societies should be a source of evidence for content (free-text). A total of 64% were somewhat to very satisfied with the survey and 84% will probably to definitely participate in future related surveys.

CONCLUSIONS

The findings echo concerns in the literature that ICD are focused on disclosure instead of patient understanding. There is notable concern regarding information overload and retention but less regarding the quality and completeness of information. Current culture suggests key clinician stakeholders are amenable to change.

Perioperative Management of the Facelift Patient

In this article, the authors set out to lay a foundation for successful perioperative management of the facelift patient. They describe the changes of normal facial aging in an attempt to help one recognize the universal way the face is affected by aging. Having a clear understanding of these factors may help to guide the physician with procedures necessary to offer the patient for a desired outcome. Also, the authors emphasize the preoperative assessment and postoperative care necessary to ensure a successful, low-risk operation with minimal downtime and beautiful results, meeting the patient's expectations.

Botulinum Toxin Type A Overdoses: Analysis of the FDA Adverse Event Reporting System Database

INTRODUCTION

Published literature on overdoses related to botulinum toxin A (BtxA) agents is scarce.

OBJECTIVE

The aim of this study was to assess the BtxA drug class' respective agents for associations with overdose.

METHODS

United States Food and Drug Administration (FDA) adverse event reporting system (FAERS) database was utilized to search for overdoses. The analysis was conducted on data between second quarter 2014 and third quarter 2017. BtxA cases were included when they were considered the "Primary Suspect" drug. Overdose was defined as presence of 'overdose' being reported as an adverse event. Primary outcome was incidence of 'overdose' compared within the respective agents. Additionally, a disproportionality analysis was conducted utilizing reporting odds ratio (ROR) versus onabotulinumtoxinA as a referent while controlling for confounding variables.

RESULTS

A total of 3,837,406 unique adverse events were reported during the study period for all drugs in the FAERS database. Of which, 13,078 were BtxA cases. The rate of adverse events involving overdose for abobotulinumtoxinA (20.2%; 215/1065) was significantly higher than both onabotulinumtoxinA (0.4%; 48/11,323; p < 0.0001) and incobotulinumtoxinA (0.1%; 1/690; p < 0.0001). In the regression analysis, abobotulinumtoxinA (ROR 73.26; 95% CI 51.17-104.90) had a significant association with overdose, whereas incobotulinumtoxinA (ROR 0.73; 95% CI 0.10-5.36) did not, versus the referent onabotulinumtoxinA.

CONCLUSION

The present analysis showed adverse events of abobotulinumtoxinA were significantly associated with overdose versus the other two BtxA agents. Overdose can be difficult to research, particularly for in-clinic administered drugs. Future studies should venture to confirm these results in new and novel ways.

Facilitating shared decision-making with breast augmentation patients: Acceptability of the PEGASUS intervention

BACKGROUND

PEGASUS is an intervention to facilitate shared decision-making by helping prospective patients consider their expectations of surgery, so that surgeons have a clear understanding of their individual goals. To date, shared decision-making interventions within aesthetic surgery are lacking. The present mixed methods study therefore explored the acceptability of implementing PEGASUS into routine private practice with breast augmentation patients and aesthetic providers.

METHOD

Seventeen women presenting for breast augmentation surgery from three practices received the PEGASUS intervention pre-operatively and completed a process evaluation post-operatively. Semi-structured interviews exploring 3 aesthetic providers' experiences of using PEGASUS were subjected to a thematic analysis, whilst a content analysis was conducted on the 77 goals identified by patients.

RESULTS

The majority of patients reported that the PEGASUS intervention was relevant, helpful and useful, and they felt comfortable during it. Qualitatively, patients and aesthetic providers found that PEGASUS enabled them to reflect on and discuss about their expectations from surgery. Aesthetic providers discussed some of the issues and barriers associated with implementing PEGASUS in routine private practice, factors that must be considered prior to further evaluation.

CONCLUSION

This study provides preliminary support for the acceptability of PEGASUS to breast augmentation patients and to aesthetic providers working in the private sector.