Aging Mid-Face: Assessment and Proposed Management – …



Aging Mid-Face: Assessment and Proposed Management – Inter-rater reliability and Concordance.

Ali Hazrati, MD, MSc, Daron Geldwert, MD, Khang T. Nguyen, MD, James J Chao, MD, Amanda Gosman, MD, Marek K Dobke, MD, PhD

INTRODUCTION: Differences between professionals assessing the aging mid-face, including proposed management vary. In plastic surgery there is, to some degree, a consensus regarding aesthetic judgment and management guidelines. A professional’s ethnic and cultural background, education and experience, and artistic taste impact one’s opinion. To obtain some insight into the nature and the extent of variable opinions, this study on inter-rater reliability and concordance was designed.

METHOD: Non-digital and non-altered photographic images of forty standardized patients’ faces (front and profile) were presented to 6 senior (over six years in independent practice) board certified plastic surgeons, to 6 junior non-board certified plastic surgeons (less than three years in practice) and to 6 plastic surgery residents (independent program) for their assessment of the mid-face aesthetics and management priorities and recommendations. Surveyed physicians were “blinded” from each other. Assessment included nasolabial fold, cheeks (including skin), perioral area, and jowls characteristics while recommendation options for each anatomical component of the mid-face included: no modification, resurfacing, tissue fillers, liposuction, barbed suture, skin, skin and SMAS, and deep plane lifts.

Interobserver reliability and concordance was assessed by calculating the percentage agreement and kappa statistics. Percentage of agreement was a simple calculation of the fraction of concordant entries in relation to the total.

RESULTS: Total per cent agreement for all “assessment” measures ranged from 62 % in the resident group to 63 % in the junior plastic surgeon group and 90 % in the senior plastic surgeon group, and 73 %, 75 to 95 % on “management” in respective groups. Comparing the agreement between all physicians, the highest agreement was obtained for types of cheek skin rhytids (k = 0.9) (assessment measures by senior plastic surgeons ) and regarding the intervention for nasolabial folds (k = 0.6)(recommendations by senior plastic surgeons) and the lowest agreement for upper lip characteristics (k < 0.2)(assessment by residents) and jowls management (k < 0.2)(recommendations by junior plastic surgeons).

CONCLUSION: Study findings indicate that the most senior plastic surgeons’ assessment and recommendations had the highest level of concordance while the junior

plastic surgeons and the resident group produced variations with less consistency. Subtle details and characteristics of facial anatomy impacting surgical planning and ultimately the outcome, are more likely identified by experienced surgeons who tend to demonstrate a higher convergence of aesthetic opinions than junior colleagues. Discrepancies in judgments between resident colleagues are not surprising. High variability of opinions on specific issues may suggest self-confidence and competence issues regarding assessment and ability to design management. This identification is critical for surgical education.

REFERENCES:

1. Dobke M, Chung C, Takabe K. Facial aesthetic preferences among Asian women: are all Oriental Asians the same ? Aesth Plast Surg 29:1-6, 2006.

2. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 33:159-165, 1977.

3. Tolleth H. Concepts for the plastic surgeon from art and sculpture. Clin Plast Surg 14:585-598,1987.

4. Truong PT, Lee J, Soer B, Gaul CA, Olivotto IA. Reliability and validity testing of the patient and observer scar assessment scale in evaluating linear scars after breast cancer surgery. Plast Reconstr Surg 119:487-494, 2007.

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