A systematic review of direct preference measurements in health states treated with plastic surgery

Figures & data

Figure 1. PRISMA flow diagram.

Table 1. Preferences for health states treated with plastic surgery.

First author, year, country	Whose references (perspective)	Health state^a pre-treatment	Preferences before surgery mean (SD)	Health state post treatment	Preferences after surgery mean (SD)	Risk of bias
Yeung, 2011, USA [56]	Med stud (n = 171)	General principles and procedures Flap surgery/microsurgery		Scar donor site from free flap harvest -anterolateral thigh	VAS: 0.82 (0.19)	Serious
				-proximal lateral calf	VAS: 0.50 (0.20)
				-lateral arm	VAS: 0.22 (0.16)
		Burns
Chuback, 2015, Canada [29]		Severe face and neck burn and composite tissue allotransplantation after facial burn		Composite tissue allotransplantation after facial burn		Serious
	Gen pop (n = 25)		TTO: 0.68		TTO: 0.82
			SG: 0.54		SG: 0.78
	Med exp (n = 25)		TTO: 0.42		TTO: 0.63
			SG: 0.40		SG: 0.63
	Pat (n = 25)		TTO: 0.57		TTO: 0.67
			SG: 0.54		SG: 0.64
Hulktman, 2015, USA [46]	Pat (n = 20)	Burn scars, non-specified location		Burn scar dyschromia treated with intense pulsed light	WTP-C: 1200 (2664)	Serious
		Head and neck
		Congenital
Sinno, 2012, Canada, USA [16]	Gen pop (n = 104) Med stud (n = 6)	Cleft lip and palate	VAS: 0.69 (0.18)			Serious
			TTO: 0.85 (0.16)
			SG: 0.84 (0.18)
Byun, 2016, Canada [17]	Gen pop (n = 104)	Microtia without deafness	VAS: 0.90 (0.85–0.95)*			Serious
			TTO: 0.91 (0.87–0.95)*
			SG: 0.95 (0.91–0.97)*
		Microtia with deafness	VAS: 0.90 (0.72–0.85)*
			TTO: 0.88 (0.77–0.91)*
			SG 0.91 (0.84–0.97)*
Kuta, 2017, Canada [30]	Gen pop (n = 75) Med stud (n = 43)	Scaphocephaly due to sagittal craniosynostosis	VAS: 0.85 (0.76–0.95)*			Serious
			TTO: 0.91 (0.84–0.95)*
			SG: 0.92 (0.85–0.98)*
		Traumatic and neoplastic
Chuback, 2015, Canada [29]		Severe face and neck burn and composite tissue allotransplantation after facial burn		Composite tissue allotransplantation after facial burn		Serious
Sinno, 2010, Canada, USA [18]	Gen pop (n = 142) Med stud (n = 114)	Facial disfigurement requiring facial transplantation	VAS: 0.46 (0.02)			Serious
			TTO: 0.68 (0.03)
			SG: 0.66 (0.03)
Dey, 2016, USA [15]	Gen pop (n = 200)	Facial deformity, without surgery		Facial deformity, after surgery		Moderate
		Small peripheral	VAS: 0.76 (0.25)	Small peripheral	VAS: 0.95 (0.15)
			SG: 0.94 (0.14)		SG: 1.0 (0.01)
			WTP-C: $1170 (4082)		WTP-C: $50 (288)
			WTP-I: $1213 (1580)		WTP-I: $7 (54)
		Small central	VAS: 0.56 (0.26)	Small central	VAS: 0.94 (0.16)
			SG: 0.83 (0.22)		SG: 0.99 (0.06)
			WTP-C: $3240 (4653)		WTP-C: $88 (350)
			WTP-I: $4089 (3247)		WTP-I: $35 (120)
		Large peripheral	VAS: 0.52 (0.27)	Large peripheral	VAS: 0.96 (0.12)
			SG: 0.81 (0.24)		SG: 1.0 (0.01)
			WTP-C: $5125 (10 088)		WTP-C: $116 (1152)
			WTP-I: $4572 (3595)		WTP-I: $11 (69)
		Large central	VAS: 0.38 (0.26)	Large central	VAS: 0.81 (0.26)
			SG: 0.72 (0.26)		SG: 0.94 (0.15)
			WTP-C: $7875 (15 892)		WTP-C: $1785 (5265)
			WTP-I: $9446 (6338)		WTP-I: $1330 (2745)
		Facial palsy
Sinno, 2012, Canada, USA [40]	Gen pop (n = 96) Med stud (n = 5)	Unilateral facial paralysis	VAS: 0.56 (0.18)			Serious
			TTO: 0.78 (0.21)
			SG: 0.79 (0.21)
Su, 2017, USA [26]	Gen pop (n = 384)	Facial paralysis, grade				Moderate
		Normal	VAS: 0.99 (0.18)
			TTO: 1.00 (0.03)
			SG: 1.00 (0.19)
			WTP-C**: $1980 (1233–3014)
		Low	VAS: 0.92 (0.18)
			TTO: 0.98 (0.11)
			SG: 0.98 (0.09)
			WTP-C**: $3487 (2363–4961)
		Medium	VAS: 0.76 (0.21)
			TTO: 0.92 (0.21)
			SG: 0.93 (0.15)
			WTP-C**: $8571 (6401–11 234)
		High	VAS: 0.43 (0.21)
			TTO: 0.74 (0.30)
			SG: 0.77 (0.25) WTP-C**: $20 431
			(16 273–25 317)
Farris, 2018, USA [34]	Gen pop (n = 298)	Facial paralysis without surgery		Facial paralysis post-facial reanimation		Serious
		Flaccid unilateral	VAS: 0.60 (0.21)	All types	VAS: 0.74 (0.19)
			TTO: 0.72 (0.25)		TTO: 0.84 (0.19)
			SG: 0.71 (0.24)		SG: 0.83 (0.21)
		Unilateral moderate to severe post-paralytic facial nerve syndrome	VAS: 0.63 (0.21)
			TTO: 0.74 (0.25)
			SG: 0.75 (0.24)
		Orthognathic surgery
Almadani, 2020, Canada [23]	Gen pop (n = 463)	Mandibular hypoplasia	VAS: 0.48 (0.24)	Mandibular hypoplasia post	VAS: 0.63 (0.20)	Serious
				distraction osteogenesis	TTO: 0.83 (0.13)
	Gen pop (n = 463)	Maxillary hypoplasia	VAS: 0.56 (0.23)	Maxillary hypoplasia after	VAS: 0.73 (0.22)	Serious
				Le Fort I distraction	TTO: 0.83 (0.14)
		Chest and breast
		Neoplastic
Sinno, 2012, Canada, USA [37]	Gen pop (n = 116) Med stud (n = 4)	Bilateral mastectomy defect	VAS: 0.70 (0.18)			Serious
			TTO: 0.85 (0.16)
			SG: 0.86 (0.17)
Sinno, 2014, Canada, USA [39]	Gen pop (n = 149) Med stud (n = 5)^b	Unilateral mastectomy defect	VAS: 0.75 (0.17)			Serious
			TTO: 0.87 (0.14)
			SG: 0.86 (0.18)
Ibrahim, 2015, Canada [21]	Gen pop (n = 97) Med stud (n = 6)	Nipple-areolar-complex deformity	VAS: 0.84 (0.18)			Serious
			TTO: 0.92 (0.11)
			SG: 0.92 (0.11)
Thoma, 2003, Canada [45]	Med experts (n = 33)			Breast reconstruction with free TRAM flap- no complications	VAS: 0.87	Serious
Thoma, 2004, Canada [43]	Med exp (n = 32)			Breast reconstruction with free TRAM/DIEP-no complications	VAS: 0.87	Serious
		Other
Kerrigan, 2000, USA [27]	Female gen pop (n = 34) Med stud (n = 13)	Breast hypertrophy	SG: 0.94			Serious
			VAS: 0.85
			SG: 0.96
			VAS: 0.75
Chang, 2001, USA [14]	Gen pop (n = 355)	Breast hypertrophy				Serious
		Mild	VAS: 0.93 (0.081)
			TTO: 1.0 (0.089)
			SG: 0.98 (0.11)
		Severe	VAS: 0.70 (0.17)
			TTO: 0.85 (0.24)
			SG: 0.88 (0.19)
Ibrahim, 2015, Canada [20]	Gen pop (n = 97) Med stud (n = 10)	Breast ptosis	VAS: 0.80 (0.14)			Serious
			TTO: 0.87 (0.18)
			SG: 0.90 (0.14)
		Trunk and abdomen
Mercili, 2019, USA [57]	Med exp (n = 20)			Reconstruction of oncologic spinal wound, no complications	VAS: 0.92	Serious
		Lower extremity
Sinno, 2014, Canada, USA [36]	Gen pop (n = 111) Med stud (n = 3)	Lower extremity lymphoedema	VAS: 0.50 (0.18)			Serious
			TTO: 0.76 (0.22)
			SG: 0.76 (0.21)
Chung, 2011, USA [58]	Med exp (n = 65)			Lower limb salvage and reconstruction after open tibia fracture, no complications	SG: 0.98
	Pat (n = 18)				SG: 0.83
		Skin and adnexa
Heiser, 2020, USA [31]	Gen pop (n = 262)	Facial hypertrophic capillary malformation	VAS: 0.71 (0.24)	Laser treated	VAS: 0.87 (0.16)	Serious
			TTO: 0.83 (0.21)	facial hypertrophy capillary	TTO: 0.92 (0.16)
			SG: 0.83 (0.23)	malformation	SG: 0.91 (0.18)
		Aesthetic surgery
		Head and neck
Sinno, 2012, Canada, USA [38]	Gen pop (n = 8) Med stud (n = 120)	Nasal deformity after primary rhinoplasty	VAS: 0.80 (0.14)			Serious
			TTO: 0.91 (0.12)
			SG: 0.91 (0.13)
Aldihan, 2019, Saudi Arabia [28]		Unattractive nose with functional problem				Serious
	Gen pop (n = 161)		VAS: 0.77 (0.13)
			TTO: 0.87 (0.16)
			SG: 0.91 (0.17)
	Med stud (n = 129)		VAS: 0.81 (0.13)
			TTO: 0.89 (0.15)
			SG: 0.96 (37)
	Pat (n = 117)		VAS: 0.71 (0.12)
			TTO: 0.83 (0.08)
			SG: 0.86 (0.16)
Kumar, 2020, USA [24]	Gen pop (n = 161)	Unattractive nose	VAS: 0.68 (0.21)	Cosmetic rhinoplasty	VAS: 0.36 (0.31)^****	Moderate
					SG: 0.90 (0.21)
					WTP***: $15 681 (13426.09)
Chen, 2019, USA [25]	Gen pop (n = 228)	Unattractive nose		Cosmetic rhinoplasty	WTP: 2254-6949	Moderate
Faris, 2019, USA [32]	Gen pop (n = 273)	Post-rhinectomy nasal defect, untreated	VAS: 0.59 (0.24)	Post-nasal surgical	VAS: 0.88 (0.16)	Serious
			TTO: 0.74 (0.24)	reconstruction	TTO: 0.89 (0.13)
			SG: 0.74 (0.24)		SG: 0.9 (0.18)
				Post-nasal prosthetic rehabilitation	VAS: 0.67 (0.22)
					TTO: 0.82 (0.2)
					SG: 0.80 (0.2)
Abt, 2018, USA [33]	Harvard stud (n = 308)	Hair loss without surgery		Hair loss after transplantation		Serious
		Female	VAS: 0.83 (0.19)	Both sexes	VAS: 0.93 (0.11)
			TTO: 0.91 (0.18)		TTO: 0.95 (0.16)
			SG: 0.92 (0.17)		SG: 0.95 (0.15)
		Male	VAS: 0.85 (0.18)
			TTO: 0.93 (0.17)
			SG: 0.93 (0.17)
		Postbariatric surgery
Sinno, 2011, Canada, USA [41]	Gen pop (n = 42) Med stud (n = 40)^c	Massive weight loss requiring body contouring	VAS: 0.79 (0.13)			Serious
			TTO: 0.89 (0.12)
			SG: 0.89 (0.15)
Sinno, 2012, Canada, USA [42]	Gen pop (n = 88) Med stud (n = 14)	Aging neck following massive weight loss	VAS: 0.89 (0.07)			Serious
			TTO: 0.94 (0.08) SG: 0.95 (0.10)
Izadpanah, 2013, Canada, USA [22]	Gen pop (n = 103) Med stud (n = 9)	Thigh laxity after massive weight loss	VAS: 0.77 (0.15)			Serious
			TTO: 0.90 (0.11)
			SG: 0.89 (0.14)
Ibrahim,2014, Canada, USA [19]	Gen pop (n = 97) Med stud (n = 10)	Arm laxity after massive weight loss	VAS: 0.80 (0.14)			Serious
			TTO: 0.91 (0.12)
			SG: 0.94 (0.10)

*Median (interquartile range).

**Mean (95%, CI).

***Willingness to pay for the reconstruction depicted in the study.

****Change after surgery.

^aDivided into domains according to the European Training Requirements for the Specialty of Plastic, Reconstructive, and Aesthetic Surgery [9].

^bdemography is given for 154 participants, even though only 140 unique answers were analysed.

^ceducation is only given for 82 participants.

DIEP: Deep inferior epigastric perforator flap; Gen pop: General public; Med exp: Medical expert; Med stud: Medical student; Pat: Patients with the condition in question; SG: Standard gamble; TRAM: Transverse rectus abdominis myocutaneous flap; TTO: Time trade-off; VAS: Visual analogue scale; WTP: Willingness to pay; WTP-C: Willingness to pay determined by the standard contingent valuation method; WTP-I: Willingness to pay derived from the iterative bidding method.

Figure 2. Preference measurements according to TTO as stated by the general public. Red: Excess skin after MWL (massive weight loss), Blue: Acquired facial deformities, Green: Congenital facial malformations, Purple: Breast deformities, Black: Lower extremity, Grey: Aesthetic defects. In cases where several scores exist for the same condition, the lowest score was used.

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