Exploring Patient Motivations and Impact of Asian Blepharoplasty.

To date, patient motivations for Asian blepharoplasty and the surgery's impact on quality of life have not been quantified. Here, we employed structured interviews and a web-based survey to better characterize patient motivations for Asian blepharoplasty and the impact of Asian blepharoplasty on self-reported domains of happiness, self-esteem, attractiveness, social life, and professional life. Structured interviews were conducted to inform a web-based survey regarding Asian blepharoplasty. Survey respondents used visual analog scales to rate their satisfaction with their eye shape, motivations for undergoing Asian blepharoplasty, and perceived outcomes after surgery. A total of 315 participants (mean 25.7 [18-58] years) of East or Southeast Asian descent were included. 185 participants expressed no desire for Asian blepharoplasty, 76 expressed some desire, and 54 had already undergone surgery. There were statistically significant differences regarding baseline satisfaction, perceived social limitation, and perceived professional limitations regarding eye shape (p < 0.0001). The Looking Glass Self index (comprised of media exposure, low self-esteem, and negative stereotypes related to eye shape) is negatively associated with preoperative satisfaction with eye shape (rho = -0.29, p < 0.01). The desire for social-professional advancement and the Looking Glass Self index significantly predict self-reported improvements in professional and social life, respectively (both p < 0.01). Asian blepharoplasty may be driven by functional, social, or economic patient motivations. Some patients may see Asian blepharoplasty as a potential solution for sociological concerns. These expectations should be further explored in physician-patient discussions regarding candidacy for surgery and establishing expectations for postoperative outcomes.

Association Between the Use of Social Media and Photograph Editing Applications, Self-esteem, and Cosmetic Surgery Acceptance.

IMPORTANCE: Social media platforms and photograph (photo) editing applications are increasingly popular sources of inspiration for individuals interested in cosmetic surgery. However, the specific associations between social media and photo editing application use and perceptions of cosmetic surgery remain unknown. OBJECTIVE: To assess whether self-esteem and the use of social media and photo editing applications are associated with cosmetic surgery attitudes. DESIGN, SETTING, AND PARTICIPANTS: A population-based survey study was conducted from July 1 to September 19, 2018. The web-based survey was administered through online platforms to 252 participants. MAIN OUTCOMES AND MEASURES: Each participant's self-esteem was measured using the Rosenberg Self-esteem Scale (scores range from 0-30; higher scores indicate higher self-esteem) and the Contingencies of Self-worth Scale (scores range from 1-7; higher scores indicate higher self-worth). Cosmetic surgery attitude was measured using the Acceptance of Cosmetic Surgery Scale (scores range from 1-7; higher scores indicate higher acceptance of cosmetic surgery). Unpaired, 2-tailed t tests were used to assess the significance of self-esteem and cosmetic surgery attitude score differences among users of various social media and photo editing applications. Structural equation modeling was used to assess the association between social media investment and cosmetic surgery attitudes. RESULTS: Of the 252 participants, 184 (73.0%) were women, 134 (53.2%) reported themselves to be white, and the mean age was 24.7 (range, 18-55) years. Scores on the Rosenberg Self-esteem Scale from users and nonusers across applications were compared, with lower self-esteem scores noted in participants who reported using YouTube (difference in scores, -1.56; 95% CI, -3.01 to -0.10), WhatsApp (difference in scores, -1.47; 95% CI, -2.78 to -0.17), VSCO (difference in scores, -3.20; 95% CI, -4.98 to -1.42), and Photoshop (difference in scores, -2.92; 95% CI, -5.65 to -0.19). Comparison of self-esteem scores for participants who reported using other social media and photo editing applications yielded no significant differences. Social media investment had a positive association with consideration of cosmetic surgery (R, 0.35; 95% CI, 0.04-0.66). A higher overall score on the Acceptance of Cosmetic Surgery Scale was noted in users of Tinder (difference in means, 0.79; 95% CI, 0.34-1.23), Snapchat (difference in means, 0.39; 95% CI, 0.07 to 0.71), and/or Snapchat photo filters (difference in means, 0.44; 95% CI, 0.16-0.72). Increased consideration of cosmetic surgery but not overall acceptance of surgery was noted in users of VSCO (difference in means, 0.84; 95% CI, 0.32-1.35) and Instagram photo filters (difference in means, 0.38; 95% CI, 0.01-0.76) compared with nonusers. CONCLUSIONS AND RELEVANCE: This study's findings suggest that the use of certain social media and photo editing applications may be associated with increased acceptance of cosmetic surgery. These findings can help guide future patient-physician discussions regarding cosmetic surgery perceptions, which vary by social media or photo editing application use. LEVEL OF EVIDENCE: NA.

Stretched Earlobe Piercings Negatively Impact Casual Observer Perceptions.

Patients with stretched earlobes seek reconstruction to mitigate social stigma. To date, there have been no studies measuring the impact of stretched earlobe piercings on casual observer perceptions. One-hundred seventy-three casual observers were enrolled via public-access web sites. Participants were randomly shown frontal and profile views of six subjects with stretched earlobe piercings and four controls. Participants evaluated photos for first impressions using a survey containing choices regarding personal attributes. Latent class analysis was performed to categorize observer ratings. Analysis of variance (ANOVA), bootstrap analysis, and permutations testing were used to evaluate the relationship between perceived attractiveness, success, and approachability scoring and stretched earlobe status. Latent class analysis categorized responses into three classes: positive, negative, and neutral. Patients with stretched earlobe piercings were significantly less likely to be classified as positive by observers without body modifications (i.e., tattoos and piercings) in comparison to control photos (30.9 and 40.1%, p = 0.007) and more likely to be classified as negative (38.5 and 28.1%, p = 0.002). These changes were abolished when photos were evaluated by observers with body modifications (p > 0.05). ANOVA revealed that stretched earlobe piercings and observer body modification status have a significant effect on rated approachability (F [1,1726] = 4.08, p = 0.04) and successfulness (F[1,1726] = 9.67, p = 0.002; F [1,1726] = 70.33, p < 0.0005). No significance was found for rated attractiveness (p > 0.05). Patients with stretched earlobe piercings were more likely to be classified as having negative affect display and being less approachable and successful compared with controls when evaluated by observers without body modifications. This effect was abolished when photos were evaluated by observers with body modifications. These findings validate patient motivations for seeking stretched earlobe repair.

Objectively measuring social attention of thyroid neck scars and transoral surgery using eye tracking.

OBJECTIVE: Measure the social attention of thyroid neck scars and transoral surgery using eye tracking. METHODS: Observers viewed images of patients with thyroid neck scars, control patients with no scars, and patients who underwent transoral thyroidectomy as an eye-tracking monitor recorded their eye movements. Hotelling's multivariate analysis, followed by planned posthypothesis testing, were used to compare fixation times for the central triangle (CT), peripheral face, and neck between the three groups. To assess if these gaze patterns would normalize with transoral surgery, a two-sample t test was done to assess for differences in neck fixations between control and transoral patients and between transoral and traditional thyroidectomy. RESULTS: One hundred and thirty participants completed the eye-tracking experiment (mean age 24.3 years, 65 females). Observers directed the majority of their attention to the CT in both control and scar patients. Observers paid more attention to the neck (103.72 ms, P < .0001, 95% confidence interval [CI] [55, 152] ms) and less to the peripheral face (115.50 ms, P = .01, 95% CI [19, 211] ms) in patients with neck scars than in control patients. Furthermore, transoral surgery eliminated this attentional distraction wherein there was no difference in the fixation time to the neck (-39.198 ms P = .16, 95% CI [-93.978, 15.5816] ms) between controls and those who underwent transoral surgery. CONCLUSION: Observers directed their gaze away from the face and toward the neck in patients with thyroid neck scars. Furthermore, this distraction was eliminated with tranoral surgery. These findings shed light onto the altered observer perceptions of patients with thyroid neck scars. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2789-2794, 2019.

Assessment of the Influence of "Other-Race Effect" on Visual Attention and Perception of Attractiveness Before and After Rhinoplasty.

IMPORTANCE: The "other-race effect" describes the phenomenon in which individuals demonstrate greatest recognition ability among faces of their own race. Thus, in our multicultural world, it follows that race influences social interactions. However, the association of race with perception of plastic surgery outcomes has not been studied. OBJECTIVE: To objectively measure how the other-race effect influences perception of white and Latin American patients undergoing rhinoplasty by using eye-tracking technology and survey methodology. DESIGN, SETTING, AND PARTICIPANTS: In the first part of the study, 134 participants viewed 32 paired facial images of white and Latin American patients, either prerhinoplasty or postrhinoplasty, on an eye-tracking system that recorded observer scan paths. In the second part of this study, the same patient images were individually graded by a separate group of 134 participants for degree of racial identification and perceived attractiveness. MAIN OUTCOMES AND MEASURES: The primary outcome was to measure the influence of patient and observer race on perception of rhinoplasty outcomes. For the eye-tracking part, planned hypothesis testing was conducted using an analysis of variance to compare patient race, rhinoplasty status, and attractiveness with respect to visual fixation time. RESULTS: Of the 134 eye-tracking participants, 68 (51%) were women and the mean (SD) age was 26.4 (7.7) years; of the 134 graders, 64 (48%) were women and the mean (SD) age was 25.0 (6.9) years. Rhinoplasty did not affect racial identity scores among either same-race or other-race evaluators. Visual fixation times for white faces were significantly increased compared with Latin American faces among all casual observer groups (white observers mean change, -20.14 milliseconds; 95% CI, -29.65 to -10.62 milliseconds; P < .001; Asian observers mean change, -39.04 milliseconds; 95% CI, -48.95 to -29.15 milliseconds; P < .001; and African American observers mean change, -20.73 milliseconds; 95% CI, -37.78 to -3.69 milliseconds; P < .02), with the exception of Latin American observers (mean change, -7.8 milliseconds; 95% CI, -29.15 to 14.39 milliseconds; P < .51). With respect to attractiveness, white graders reported a significant postrhinoplasty increase across both races (white patients mean change, 8.07 points; 95% CI, 5.01-11.12 points; P < .001; and Latin American patients mean change, 3.69 points; 95% CI, 0.87-6.49 points; P = .01), whereas Latin American graders only observed a significant attractiveness increase in their own race (Latin American patients mean change, 10.50 points; 95% CI, 1.70-19.32 points; P = .02). Neither perceived attractiveness nor rhinoplasty status influenced fixation times. CONCLUSIONS AND RELEVANCE: Both patient and observer race influence visual attention and perception of attractiveness before and after rhinoplasty. These findings underscore the importance of counseling patients that the influence of rhinoplasty, as perceived by the casual observer, may vary by race or ethnicity of the observer group. LEVEL OF EVIDENCE: NA.

Objectively Measuring Observer Attention in Severe Thyroid-Associated Orbitopathy: A 3D Study.

OBJECTIVE: Measure the attentional distraction of facial deformity related to severe thyroid-associated orbitopathy using three-dimensional (3D) images and eye-tracking technology. METHODS: Observers recruited at an academic tertiary referral center viewed 3D facial images of patients with severe thyroid-associated orbitopathy (TAO) and controls without TAO. An infrared eye-tracking monitor recorded their eye movements and fixations in real time. Multivariate Hotelling's analysis, followed by planned posthypothesis testing, was used to compare fixation durations for predefined regions of interest, including the eyes, nose, mouth, central triangle, and remaining face without the central triangle between severe TAO patients and controls. RESULTS: One hundred sixteen observers (mean age 26.4 years, 51% female) successfully completed the eye-tracking experiment. The majority of their attention was directed toward the central triangle (eyes, nose, mouth). On multivariate analysis, there were significant differences in the distribution of attention between control and severe TAO faces (T2 = 49.37; F(5,922) = 9.8314, P < 0.0001). On planned posthypothesis testing, observers attended significantly more to the eyes (0.77 seconds, P < 0.0001, 95% confidence interval [CI], 0.51, 1.03 seconds) and less to the nose (-0.42 seconds, P < 0.0001, 95% CI, -0.23, -0.62 seconds) in severe TAO patients. There was no significant difference in time spent on the mouth, the total time spent on the central triangle, or time spent in the remaining face between the two groups. CONCLUSION: Severe TAO distracted observer attention toward the eyes compared to control patients. These data lend insight into how TAO may alter observers' perceptions of these patients. Future studies should investigate how these changes in observer gaze patterns may reflect the social perception of TAO patients. LEVEL OF EVIDENCE: NA Laryngoscope, 129:1250-1254, 2019.

Assessment of Casual Observers' Willingness to Pay for Increased Attractiveness Through Rhinoplasty.

IMPORTANCE: Contingent valuation, or willingness to pay, is an established economic concept that has been applied in other areas of medicine and may be useful for understanding the economic forces that determine the cost of cosmetic procedures. OBJECTIVE: To determine the monetary value of changes in attractiveness achieved through rhinoplasty, as perceived by society. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional survey administered via public online forums to 228 casual observers. MAIN OUTCOMES AND MEASURES: Participants were shown preoperative and postoperative photographs of 12 patients who underwent cosmetic rhinoplasty and 4 patients who did not undergo any surgery. They were asked to rate (1) the change in overall attractiveness of the patients, and (2) the monetary value they would associate with these changes. RESULTS: Completed surveys were obtained from 228 casual observers; 144 were female (63.2%); median age, 25 years (median income bracket, $50 000-$75 000). Multilevel, mixed-effects, linear regression was used to characterize the association between monetary value and change in attractiveness. There was a significant association between the change in attractiveness from a rhinoplasty and its monetary value as perceived by society. The baseline value of a rhinoplasty without any change in attractiveness was $3769.98 (95% CI, $3541.59-$4007.10; P < .001). To increase 1 standard deviation in attractiveness was worth an additional $2353.77 (95% CI, $2197.57-$2512.81; P < .001), while increasing 2 standard deviations in attractiveness was worth an additional $5453.07 (95% CI, $5052.57-$5865.51; P < .001). CONCLUSIONS AND RELEVANCE: There is a significant association between the societally perceived value of cosmetic rhinoplasty and the change in attractiveness after surgery. The average value of a rhinoplasty in our study approximates the actual average cost of cosmetic rhinoplasty, suggesting that willingness to pay may be a useful concept for studying the value of cosmetic procedures. LEVEL OF EVIDENCE: NA.

Over-the-Counter Hair Loss Treatments: Help or Hype?

Introduction: A limited number of treatments have been approved for androgenetic alopecia, however, myriad over-the-counter products for hair loss are available and readily purchased by consumers. This study aims to provide an overview of popular over-the-counter hair loss products and to review the available evidence regarding their use. Methods: Top-selling hair loss products were identified using sales data from the online retailer Amazon.com. The active ingredients, consumer ratings, quantity, and price were collected for each product. A search of the literature was conducted for ingredients that frequently appeared on the top-seller list. Results: Forty-two of the top 50 products met inclusion criteria, including orals (21.4%), topicals (35.7%), or shampoos/conditioners (42.9%). Common active ingredients included minoxidil, nutrients (ie, vitamins, minerals, proteins), and plant-based botanicals. 23.8% of products were FDA-approved treatments for androgenetic alopecia. Evidence for non-approved treatments is limited to small studies without generalizability. Discussion: While some over-the-counter treatments may be efficacious, more rigorous study is required. Dermatologists should be equipped to discuss the efficacy of these therapies as well as the risks and benefits associated with their use with patients. J Drugs Dermatol. 2018;17(12):1317-1321.

Societal Identification of Facial Paralysis and Paralysis Location.

IMPORTANCE: When able to identify facial paralysis, members of society regard individuals with facial paralysis differently. They perceive a decrease in attractiveness, more negative affect, and lower quality of life. However, the ability of lay people in society to accurately identify the presence of facial paralysis has not yet been defined. OBJECTIVE: To determine societal members' ability to (1) identify paralysis in varying degrees of paralysis severity and (2) localize the defect on the face. DESIGN, SETTING, AND PARTICIPANTS: A prospective observational study conducted in an academic tertiary referral center using a group of 380 casual observers was carried out. MAIN OUTCOMES AND MEASURES: Surveys were designed containing smiling and repose images of normal faces and faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) as categorized by House-Brackmann (HB) grade. The photographs were then shown to casual observers in a web-based survey. After reviewing both normal faces and faces with varying degrees of paralysis, they then indicated (1) whether paralysis was present and (2) if so, where the paralysis was on the face. RESULTS: A total of 380 participants (267 [70.3%] women and 113 [29.7%] men with a mean [SD] age of 29 [12] years) successfully completed the survey, viewing 2860 facial photographs in aggregate. The accuracy rate of identifying paralysis increased from low-grade through high-grade paralysis. Facial paralysis was identified in 249 (34.6%) of 719 facial photographs with low-grade paralysis, 448 (63.2%) of 709 with medium-grade paralysis, and 696 (96.7%) of 720 with high-grade paralysis (χ2 = 912.6, P < .001); 6.2% (44/731) of normal faces were incorrectly identified as having paralysis (χ2 = 912.6, P < .001). Participants correctly localized paralysis in 157 (63.0%) of 249 low-grade photographs, 307 (68.5%) of 448 medium-grade photographs, and 554 (79.6%) of 696 high-grade photographs (χ2 = 32.5, P < .001). In general, participants tended to identify facial paralysis more accurately in smiling vs repose faces (48.6% vs 20.6%, 92.4% vs 33.7%, and 96.7% vs 96.6% in low-, medium-, and high-grade paralysis, respectively) (χ2 = 62.2, P < .001; χ2 = 262.6, P < .001; χ2 = 0.0, P = .96, respectively). CONCLUSIONS AND RELEVANCE: The ability of individuals to identify the presence of facial paralysis increased as paralysis severity increased. Further, smiling increased accurate identification. However, even when individuals can identify paralysis, they are not necessarily able to accurately localize the paralysis on a face. This may speak to a phenomenon in which perception of a facial defect comes from a holistic interpretation of a face, rather than a clinically accurate specification of the defect location. These findings are important in the future counseling of patients. 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 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.

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.

Association of Face-lift Surgery With Social Perception, Age, Attractiveness, Health, and Success.

IMPORTANCE: Evidence quantifying the influence of face-lift surgery on societal perceptions is lacking. OBJECTIVE: To measure the association of face-lift surgery with observer-graded perceived age, attractiveness, success, and overall health. DESIGN, SETTING, AND PARTICIPANTS: In a web-based survey, 526 casual observers naive to the purpose of the study viewed independent images of 13 unique female patient faces before or after face-lift surgery from January 1, 2016, through June 30, 2016. The Delphi method was used to select standardized patient images confirming appropriate patient candidacy and overall surgical effect. Observers estimated age and 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, with higher scores corresponding to more positive responses. To evaluate the accuracy of observer age estimation, the patients' preoperative estimated mean age was compared with the patients' actual mean age. A multivariate mixed-effects regression model was used to determine the effect of face-lift surgery. To further characterize the effect of face-lift surgery, estimated ordinal-rank change was calculated for each domain. MAIN OUTCOMES AND MEASURES: Blinded casual observer ratings of patients estimated age, attractiveness, perceived success, and perceived overall health. RESULTS: A total of 483 observers (mean [SD] age, 29 [8.6] years; 382 women [79.4%]) successfully completed the survey. Comparing patients' preoperative estimated mean (SD) age (59.6 [9.0] years) and patients' actual mean (SD) age (58.4 [6.9] years) revealed no significant difference (t2662 = -0.47; 95% CI, -6.07 to 3.72; P = .64). On multivariate regression, patients after face-lift surgery were rated as significantly younger (coefficient, -3.69; 95% CI -4.15 to -3.23; P < .001), more attractive (coefficient, 8.21; 95% CI, 7.41-9.02; P < .001), more successful (coefficient, 5.82; 95% CI, 5.05 to 6.59; P < .001), and overall healthier (coefficient, 8.72; 95% CI, 7.88-9.56; P < .001). The ordinal rank changes for an average individual were -21 for perceived age, 21 for attractiveness, 16 for success, and 21 for overall health. CONCLUSIONS AND RELEVANCE: In this study, observer perceptions of face-lift surgery were associated with views that patients appeared younger, more attractive, healthier, and more successful. These findings highlight observer perceptions of face-lift surgery that could positively influence social interactions. LEVEL OF EVIDENCE: NA.

Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics.

IMPORTANCE: Body dysmorphic disorder (BDD) is a relative contraindication for facial plastic surgery, but formal screening is not common in practice. The prevalence of BDD in patients seeking facial plastic surgery is not well documented. OBJECTIVE: To establish the prevalence of BDD across facial plastic and oculoplastic surgery practice settings, and estimate the ability of surgeons to screen for BDD. DESIGN, SETTING, AND PARTICIPANTS: This multicenter prospective study recruited a cohort of 597 patients who presented to academic and private facial plastic and oculoplastic surgery practices from March 2015 to February 2016. METHODS: All patients were screened for BDD using the Body Dysmorphic Disorder Questionnaire (BDDQ). After each clinical encounter, surgeons independently evaluated the likelihood that a participating patient had BDD. Validated instruments were used to assess satisfaction with facial appearance including the FACE-Q, Blepharoplasty Outcomes Evaluation (BOE), Facelift Outcomes Evaluation (FOE), Rhinoplasty Outcomes Evaluation (ROE), and Skin Rejuvenation Outcomes Evaluation (SROE). RESULTS: Across participating practices (9 surgeons, 3 sites), a total of 597 patients were screened for BDD: 342 patients from site 1 (mean [SD] age, 44.2 [16.5] years); 158 patients, site 2 (mean [SD] age, 46.0 [16.2] years), site 3, 97 patients (mean [SD] age, 56.3 [15.5] years). Overall, 58 patients [9.7%] screened positive for BDD by the BDDQ instrument, while only 16 of 402 patients [4.0%] were clinically suspected of BDD by surgeons. A higher percentage of patients presenting for cosmetic surgery (37 of 283 patients [13.1%]) compared with those presenting for reconstructive surgery (21 of 314 patients [6.7%]) screened positive on the BDDQ (odds ratio, 2.10; 95% CI, 1.20-3.68; P = .01). Surgeons were only able to correctly identify 2 of 43 patients (4.7%) who screened positive for BDD on the BDDQ, and the positive likelihood ratio was only 1.19 (95% CI, 0.28-5.07). Patients screening positive for BDD by the BDDQ had lower satisfaction with their appearance as measured by the FACE-Q, ROE, BOE, SROE, and FOE. CONCLUSIONS AND RELEVANCE: Body dysmorphic disorder is a relatively common condition across facial plastic and oculoplastic surgery practice settings. Patients who screen positive on the BDDQ have lower satisfaction with their facial appearance at baseline. Surgeons have a poor ability to screen for patients with BDD when compared with validated screening instruments such as the BDDQ. Routine implementation of validated BDD screening instruments may improve patient care. LEVEL OF EVIDENCE: NA.

Societal Value of Surgery for Facial Reanimation.

IMPORTANCE: Patients with facial paralysis are perceived negatively by society in a number of domains. Society's perception of the health utility of varying degrees of facial paralysis and the value society places on reconstructive surgery for facial reanimation need to be quantified. OBJECTIVE: To measure health state utility of varying degrees of facial paralysis, willingness to pay (WTP) for a repair, and the subsequent value of facial reanimation surgery as perceived by society. DESIGN, SETTING, AND PARTICIPANTS: This prospective observational study conducted in an academic tertiary referral center evaluated a group of 348 casual observers who viewed images of faces with unilateral facial paralysis of 3 severity levels (low, medium, and high) categorized by House-Brackmann grade. Structural equation modeling was performed to understand associations among health utility metrics, WTP, and facial perception domains. Data were collected from July 16 to September 26, 2015. MAIN OUTCOMES AND MEASURES: Observer-rated (1) quality of life (QOL) using established health utility metrics (standard gamble, time trade-off, and a visual analog scale) and (2) their WTP for surgical repair. RESULTS: Among the 348 observers (248 women [71.3%]; 100 men [28.7%]; mean [SD] age, 29.3 [11.6] years), mixed-effects linear regression showed that WTP increased nonlinearly with increasing severity of paralysis. Participants were willing to pay $3487 (95% CI, $2362-$4961) to repair low-grade paralysis, $8571 (95% CI, $6401-$11 234) for medium-grade paralysis, and $20 431 (95% CI, $16 273-$25 317) for high-grade paralysis. The dominant factor affecting the participants' WTP was perceived QOL. Modeling showed that perceived QOL decreased with paralysis severity (regression coefficient, -0.004; 95% CI, -0.005 to -0.004; P < .001) and increased with attractiveness (regression coefficient, 0.002; 95% CI, 0.002 to 0.003; P < .001). Mean (SD) health utility scores calculated by the standard gamble metric for low- and high-grade paralysis were 0.98 (0.09) and 0.77 (0.25), respectively. Time trade-off and visual analog scale measures were highly correlated. We calculated mean (SD) WTP per quality-adjusted life-year, which ranged from $10 167 ($14 565) to $17 008 ($38 288) for low- to high-grade paralysis, respectively. CONCLUSIONS AND RELEVANCE: Society perceives the repair of facial paralysis to be a high-value intervention. Societal WTP increases and perceived health state utility decreases with increasing House-Brackmann grade. This study demonstrates the usefulness of WTP as an objective measure to inform dimensions of disease severity and signal the value society places on proper facial function. LEVEL OF EVIDENCE: NA.

Perception of Hair Transplant for Androgenetic Alopecia.

IMPORTANCE: Hair transplant is among the most common cosmetic services sought by men, with more than 11 000 procedures performed in 2014. Despite its growing popularity, the effect of hair transplant on societal perceptions of youth, attractiveness, or facets of workplace and social success is unknown. OBJECTIVES: To determine whether hair transplant improves observer ratings of age, attractiveness, successfulness, and approachability in men treated for androgenetic alopecia and to quantify the effect of hair transplant on each of these domains. DESIGN, SETTING, AND PARTICIPANTS: A randomized controlled experiment was conducted from November 10 to December 6, 2015, using web-based surveys featuring photographs of men before and after hair transplant. One hundred twenty-two participants recruited through various social media platforms successfully completed the survey. Observers were shown 2 side-by-side images of each man and asked to compare the image on the left with the one on the right. Of 13 pairs of images displayed, 7 men had undergone a hair transplant procedure and 6 had served as controls. Observers evaluated each photograph using various metrics, including age, attractiveness, successfulness, and approachability. A multivariate analysis of variance was performed to understand the effect of hair transplant on observer perceptions. Planned posthypothesis testing was used to identify which variables changed significantly as a result of the transplant. MAIN OUTCOMES AND MEASURES: Observer ratings of age (in number of years younger) and attractiveness, successfulness, and approachability (on a scale of 0 to 100; scores higher than 50 indicate a positive change). RESULTS: Of the 122 participants in the survey, 58 were men (47.5%); mean (range) age was 27.1 (18-52) years. The initial multivariate analysis of variance revealed a statistically significant multivariate effect for transplant (Wilks λ = 0.9646; P < .001). Planned posthypothesis analyses were performed to examine individual differences across the 4 domains. Findings determined with t tests showed a significant positive effect of hair transplant on observers' perceptions of age (mean [SD] number of years younger, 3.6 [2.9] years; P < .001), attractiveness (mean [SD] score, 58.5 [17.5]; P < .001), successfulness (mean [SD] score, 57.1 [17.1]; P = .008), and approachability (mean [SD] score, 59.2 [18.1]; P = .02). CONCLUSIONS AND RELEVANCE: Men were perceived as being younger and more attractive by casual observers after undergoing hair transplant. Participants also rated posttransplant faces as appearing more successful and approachable relative to their pretransplant counterparts. These aspects have been shown to play a substantial role in both workplace and social success, and these data demonstrate that hair transplant can improve ratings universally across all 4 domains. LEVEL OF EVIDENCE: NA.