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Latest JAMA FPS study findings about facial rejuvenation surgery are flawed and prejudiced

Updated on August 7, 2013
Facial surgery results , Study 1
Facial surgery results , Study 1 | Source
Face surgery results, Study  2
Face surgery results, Study 2 | Source
Face- and neck- lift surgery, before and after
Face- and neck- lift surgery, before and after | Source

Dr K M Kapoor*, MS, MCh (Plastic Surgery), DNB (Plastic Surgery), MBA

*Senior Consultant, Plastic Surgery, Fortis Hospital, Mohali, India.

*Director, AntiClock- Age Reversal Clinic & Medispa, Chandigarh, India.

Email: kmkapoor@gmail.com

Recently published study in JAMA Facial Plastic Surgery journal, titled ‘Objective assessment of perceived age reversal and improvement in attractiveness after aging face surgery’ by Zimm et al has concluded that mean perceived improvement in age after surgical facial rejuvenation procedures is only 3.1 years with no significant improvement in the attractiveness after surgery. However, looking closely at the study and comparing it with a similar study in the same journal & from the same practice, we have found that study is biased due to inclusion of larger number of less extensive facial surgical procedures in sample. This sample selection has lead to lower number of ‘years saved after surgery’ in the current study. This bias against surgical facial procedures could be due to the fact that the lead investigator has a major interest in promoting non-surgical facial rejuvenation procedure over surgical facial rejuvenation procedures.

The biggest flaw of this study is its wide variation from a similar study that came out from the same surgical practice, titled Perceived age change after aesthetic facial surgical procedures quantifying outcomes of aging face surgery’. This was published in JAMA FPS (earlier called Arch Facial Plastic Surgery) in 2012 with Dr P Adamson as co-author. The study, which had analyzed 60 patients operated by Dr Adamson, had concluded that patient ages were estimated to be 7.2 years younger than their chronological age after facial rejuvenation surgery. In contrast within one year of publication of this study, the newer study published in JAMA again with Dr P Adamson as a co-author, has brought down the ‘years saved’ from facial rejuvenation surgeries by nearly 60% to 3.1 years.

Part I. The study design is flawed and sample selection is biased: In the previous 2012 study (henceforth mentioned as Study 1), 60 patients operated by Dr P Adamson from January 2005 to December 2008, were selected. While in the current 2013 study (henceforth mentioned as Study 2), 49 consecutive patients operated by Dr P Adamson from July 2006 to July 2010 were selected. Despite using an overlapping set of patients operated by single surgeon in both the studies, there is such a wide variation in the ‘ years saved’ after facial rejuvenation surgery in them (7.2 years in study 1 versus 3.1 years in study 2).

  1. A major flaw of Study 2 is that the duration between pre operative pictures taken at the time of surgery and postoperative picture during follow-up was not same for all the patients, the time range for taking post op pictures varied from 6 to 36 months. While in Study 1, all the post op pictures used were take 6 months after surgery. Results in 36-month post surgery picture cannot ideally be considered same as those seen in a 6 months postoperative picture. The possible explanation could be that the patient at 36 months postoperative point has further aged chronologically by 3 years and also the effect of surgery has decreased to some extent due to factors like aging/ gravity, during this period. It is a normal practice in clinics to photograph patients during subsequent follow-up visits but it was intriguing why even 3 years post surgery photos were included in the sample when the aim of the study was to objectively assess ‘ number of years saved’.
  2. Another discrepancy seems to be that in Study 1, patients who had undergone face- and neck-lift surgery, ‘number of years saved’ were 5.74 years after surgery while for the same patients in Study 2 number of years saved were only 3.2 years. With the same surgeon operating patients in same clinic during overlapping time period in both studies, such a big difference in results is inexplicable.
  3. In Study 1, there were three groups of patients, with Group 1 having 22 patients (face- and neck-lift); group 2 had 17 patients (face-and neck-lift & upper AND lower Blepharoplasty) while group 3 had 21 patients (face- and neck-lift + upper and lower blepharoplasty, and forehead lift). All 60 patients in the three groups had face-and neck-lift procedure as a common factor, which is considered synonymous with facial rejuvenation surgery. On the other hand in Study 2, out of 49 patients, 46 patients had Upper face rejuvenation (upper and /or lower blepharoplasty and /or brow lift; note the word OR here, which was not there in sample of Study 1) as a common factor which, as a well known fact, contributes much less to age reversal compared to a more major procedure of face- and neck-lift surgery. In study 2, out of total 49 patients, only 3 were patients of face- and neck-lift, 28 patients had face- and neck-lift + upper and /or lower blepharoplasty and/or brow lift, while 18 patients had only upper face surgical procedures (upper and /or lower blepharoplasty and /or brow lift). The sample selected in study 2 is grossly biased towards less extensive and lesser number of procedures to deliberately get a lower ‘years saved after surgery’ score.
  4. Another point to be noted in Study 2 is that out of total 21 patients in sub group ‘upper facial rejuvenation or lower facial rejuvenation’, only 3 patients were of face- and neck-lift procedure which had a significant 3.2 ‘years saved by surgery’. This subgroup in comparison had 18 patients with upper face rejuvenation, which had a mean ‘years saved’ of only 1.3 years. This combination of 3 lower face surgery patients and 18 upper face surgery patients gave a mean improvement of 3.1 years to the whole group of 49 patients. However in a hypothetical reversal of the ratio i.e. had the research team picked up 18 patients with lower face rejuvenation and 3 patients with upper face rejuvenation in this subgroup, the average ‘years saved’ for the full group of 49 patients would have risen dramatically to 3.7 from 3.1, an improvement of nearly 20%. The selection of more number of upper face surgery cases in the sample was done to keep the overall improvement i.e. ‘years saved’ down by a whopping 20%.
  5. Although the mean ‘years saved’ after aesthetic facial surgery in Study 2 was 3.1 years , the maximum value in this range was 9.4 years. This point has not been highlighted much as this piece of data clearly shows that in some patients, surgery is capable of shaving off nearly 10 years from a patient’s age and such patients, if carefully selected, could achieve to look almost 10 years younger after surgery. The reason for this vast variation in results could be attributed to many factors including patient’s age at the time of surgery, patient selection, technique of surgery.
  6. The method to calculate ‘Attractiveness’ in study 2 is also not very convincing with raters not getting any guidelines by the authors to judge and categorize the patients. The raters were asked to categorize patients between 1 (most unattractive) & 10 (most attractive). This led to confusion in rater’s mind; with 75% of all attractiveness scores chosen by raters were between ‘score 4-7’ range. This shows that though the statistical analysis of ‘Attractiveness score’ was objective in nature, the data collected was only subjective. For raters, it is much easier to objectively define age of a person that has always been calculated in numbers compared to a more difficult task of measuring ‘Attractiveness’ in numbers for the first time.

II. The study is motivated to disparage surgical procedures for facial rejuvenation: This study, by making surgical facial rejuvenation procedures look frivolous in terms of lesser ‘years gained after surgery’, has actually created an ideal marketing situation for companies dealing with non-surgical skin tightening equipment. There are clear pointers that the lead investigator has steered study in such a manner so as to prove that surgical facelift is less useful. This situation is likely to push more prospective clients to non-surgical options available in the market including the ultrasound skin tightening.

As per ASPS statistics for year 2012, in US 204015 persons underwent eyelid surgery (3rd most popular surgical procedure) and 126320 persons underwent Facelift surgery (5th most popular surgical procedure). On the other hand, same report shows that amongst non-surgical procedures, non-surgical skin tightening does not feature in even in top 10 procedures as yet. The publicity around this study seems intended to reverse the scenario. The specific pointers, which suggest that this study is biased against surgical facial rejuvenation surgeries, are:

  1. In ‘conflict of interest disclosures’ declaration at the end of paper, it is written ‘None reported’. The lead investigator, Dr Zimm has not mentioned about his stakes in non surgical ultrasonic skin tightening business which he has aggressively pushed in last 3 months on Facebook, Twitter, his personal website and through lucky draw. He is even featured, along with his clinic address, on ‘Find a doctor’ section of the website of a leading ultrasound skin tightening machine marketing company.
  2. On the personal website of the lead investigator, Dr Joshua Zimm, the procedure which has been highlighted most is not any surgical one but the non surgical ultrasound based skin tightening from a leading brand. This is the one procedure which has been most prominently displayed on the home page of his website.
  3. Dr Zimm is even offering a free ultrasound based neck rejuvenation treatment to one winner through a lucky draw on his website. For this he has asked prospective clients to send in their old scarves in order to enter the contest.
  4. In a YouTube video on Dr Zimm’s website, dedicated to promote U**hera treatment in his clinic, the interviewer introduces Dr Zimm and says that U**hera treatment is “going to wipe out facelifts.” https://www.youtube.com/watch?v=Eq8lTELUXOw
  5. The article advertising U**hera treatment at Dr Zimm’s office has been posted on web as under, http://fabatanyage.com/2013/05/lift-tighten-your-face-without-surgery/
  6. On his twitter account, started on 17th April 2013, the initial 4 tweets are dedicated to Dr Zimm’s new equipment i.e. U**hera. In a tweet on 18th June, 2013, Dr Zimm has appealed “ Please help support U**herapy.” On the same day, he has mentioned suggested people to check his Facebook page for a chance to win a U**hera treatment. https://twitter.com/ZimmFPlastics

All these facts tend to suggest that there are some extraneous influences/ considerations, which could have affected the design as well as outcome of this study. Such studies need to be designed in a more objective manner with careful selection of data to reflect the true outcome. Although the role of non-surgical facial rejuvenation techniques is quite exciting especially in early cases of aging, it is too premature to junk the surgical facial rejuvenation treatments as the authors of this study have tried to make us believe.


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