Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782

Contents lists available at ScienceDirect

Journal of Cranio-Maxillo-Facial Surgery

journal homepage: www.jcmfs.com

Objective estimation of patient age through a new composite scale for

facial aging assessment: The face e Objective assessment scale
Simone La Padula*, Barbara Hersant, Mounia SidAhmed, Jeremy Niddam,
Jean Paul Meningaud
Department of Plastic and Reconstructive Surgery, Henri Mondor Hospital, UPEC, 51 Avenue du Mar

echal de Lattre de Tassigny, 94010 Cr

eteil, France

a r t i c l e i n f o a b s t r a c t

Article history: Most patients requesting aesthetic rejuvenation treatment expect to look healthier and younger. Some
Paper received 22 October 2015 scales for ageing assessment have been proposed, but none is focused on patient age prediction. The aim
Accepted 27 January 2016 of this study was to develop and validate a new facial rating scale assessing facial ageing sign severity.
Available online 15 February 2016
One thousand Caucasian patients were included and assessed. The Rasch model was used as part of
the validation process. A score was attributed to each patient, based on the scales we developed. The
Keywords:
correlation between the real age and scores obtained, the inter-rater reliability and test-retest reliability
Facial ageing
were analysed. The objective was to develop a tool enabling the assigning of a patient to a specific age
Score
Rejuvenation medicine
range based on the calculated score.
Rejuvenation surgery All scales exceeded criteria for acceptability, reliability and validity. The real age strongly correlated
Ageing with the total facial score in both sex groups.
Facial ageing scale The test-retest reliability confirmed this strong correlation.
We developed a facial ageing scale which could be a useful tool to assess patients before and after
rejuvenation treatment and an important new metrics to be used in facial rejuvenation and regenerative
clinical research.
© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction are supposed to be subjective (Swanson, 2011; Acaster et al., 2012).

Ageing is due to several genetic and environmental factors
resulting in progressive time-related facial and body changes. As
people get older, their concerns about their appearance are
increasingly focused on the face (Honigman and Castle, 2006;
Raschke et al., 2014). Increasing cosmetic surgery acceptance has
resulted in an increased number of patients requesting facial
rejuvenation treatments (Codner et al., 2010; Cula et al., 2013).
Patient satisfaction with their facial appearance should be the most
important outcome to be achieved. Managing patient expectations
is central in clinical assessment. Most patients treated with facial
rejuvenation need to see results such as a reduction in facial ageing
signs, which makes them look younger.
Despite the possibility to assess patient satisfaction, it seems
difficult to quantify someone's apparent age. Indeed, any changes
The objective assessment of age-related signs should be the first
step to closely predict someone's age and invasive and long-lasting
procedures, which are difficult to apply in routine clinical practice
are often required (Waaijer et al., 2012; Miyamoto et al., 2013).
Some scales for facial ageing assessment have been proposed, but
none is focused on patient age prediction (Panchapakesan et al.,
2013; Klassen et al., 2010).
Nowadays, studies objectively assessing ageing-related facial
changes are limited. Therefore, an objective tool allowing assessing
outcomes in patients treated with any type of facial rejuvenation
treatment is needed. The aim of this study was to develop and
validate a new tool, the FACE-Objective Assessment Scale, to
measure ageing sign severity on different facial areas.
2. Materials and methods

This study was a prospective study assessing of the overall face

* Corresponding author. Tel.: þ33 1 49 81 25 31; fax: þ33 1 49 81 25 32. ageing. It was based on 20 scales developed to score important
E-mail address: drsimonelapadula@gmail.com (S. La Padula). facial areas that are commonly subject to aesthetic procedures. The

http://dx.doi.org/10.1016/j.jcms.2016.01.022
1010-5182/© 2016 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.
776 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782

study design was approved by the Ethics Committee of our Table 2

Institution. Correspondence between total face score and patient age.

Age range Age mean ± SD Score range Score mean ± SD

2.1. Development of the FACE-Objective Assessment Scale for 18e22 20.2 ± 1.2 2e6 4 ± 1.6
patient age assessment (Table 1) 23e27 25 ± 1.5 4e10 7.21 ± 1.9
28e32 31 ± 1.1 12e15 13.8 ± 1.6
To assess ageing sign severity, upper, mid and lower face, hair 33e37 35 ± 1.5 22e26 24.1 ± 1.3
38e42 40 ± 0.9 27e29 28 ± 0.8
density and skin quality scales were developed. Each scale severity
43e47 45 ± 1.3 29e33 31.1 ± 1.4
grade was defined to range between 0 (no sign) and 3 (very intense 48e52 50 ± 1.7 32e34 33 ± 0.7
or visible signs). A total of 20 numerical scales were developed. 53e57 55 ± 1.9 32e42 37 ± 4.5
Each scale score was used to obtain a final score ranging between 58e62 60 ± 2.2 33e44 41 ± 3.2
63e67 65 ± 2.6 42e49 44.1 ± 2.8
0 and 60. Twelve different age group series were randomly selected
68e72 70 ± 2.5 51e57 54.2 ± 4.5
from a patient database. For each age group, the mean score and >72 73.5 ± 1.5 >57 57.6 ± 0.6
standard deviation were calculated (Table 2).

2.2. Scale development

included were chosen by four blinded examiners with different
Between January 2013 and January 2015, 1230 subjects were backgrounds: two external board certificated dermatologists, one
enrolled, informed about the study, and assessed. Subjects to be immunologist and one psychologist, based on the severity of their

Table 1
Scale assessment of the facial age.

Upper face

Forehead lines at rest
Forehead lines dynamics
Brow positioning
Glabellar lines at rest
Glabellar lines dynamic
Crow's feet at rest
Crow's feet dynamic
Inferior eyelids dark
circles and bags
Superior eyelid skin elasticity
No lines Mild lines Moderate lines Severe lines
0 1 2 3
No lines Mild lines Moderate lines Severe lines
0 1 2 3
Very high with arch High with arch Medium Low and flat
0 1 2 3
No glabellar lines Mild glabellar lines Moderate glabellar lines Severe glabellar lines
0 1 2 3
No glabellar lines Mild glabellar lines Moderate glabellar lines Severe glabellar lines
0 1 2 3
No wrinkles Mild wrinkles Moderate wrinkles Severe wrinkles
0 1 2 3
No wrinkles Mild wrinkles Moderate wrinkles Severe wrinkles
0 1 2 3
No dark circles and bags Mild dark circles and bags Moderate dark circles and bags Severe dark circles and
0 1 2 bags
3
Eyelid fold well defined Mild loss of skin elasticity Moderate loss of skin elasticity Severe skin redundancy
0 1 2 3

Mid face

Infraorbital hollow No hollowness Mild hollowness Moderate hollowness Severe hollowness

0 1 2 3
Cheek fullness Full cheek Mildly sunken cheek Moderately sunken cheek Severely sunken cheek
0 1 2 3

Lower face

Nasolabial folds No folds Mild folds Moderate folds Severe folds

0 1 2 3
Marionette lines No lines Mild lines Moderate lines Severe lines
0 1 2 3
Lip wrinkles at rest No wrinkles Mild wrinkles Moderate wrinkles Severe wrinkles
0 1 2 3
Lip wrinkles dynamic No wrinkles Mild wrinkles Moderate wrinkles Severe wrinkles
0 1 2 3
Oral commissures No downturn Mild downturn Moderate downturn Severe downturn
0 1 2 3
Jawline No sagging Mild sagging Moderate sagging Severe sagging
0 1 2 3
Neck folds No folds Mild folds Moderate folds Severe folds
0 1 2 3

Hair and skin

Hair High hair density Mild loss of hair density Moderate loss of hair density Severe loss of hair density
0 1 2 or baldness (men)
3
Skin Thick and elastic skin Mild loss of thickness Moderate loss of thickness Severe loss of thickness
0 and elasticity and elasticity and elasticity
1 2 3
 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782
ageing-related facial changes, so that all scale severity grades could
be represented.
One thousand Caucasian patients (500 men and 500 women)
aged 18 to 75, with Fitzpatrick skin types I to IV, were included in
the study. Exclusion criteria were: previous rejuvenation surgery,
botulin toxin or filler treatment, antiretroviral-related facial lipo-
atrophy, temporary or permanent make-up and a disease causing
premature ageing (Lu et al., 2014; Seco-Cervera et al., 2014; Gordon
et al., 2014). Subject two-dimensional photographs were taken
with a high-resolution photography system by two independent
plastic surgeons under the same light conditions and in the same
sitting position: patient facing the surgeon. A digital database
containing the 1000 subject photographs was created. All subjects
were informed about the study purpose and gave their consent for
data analysis and publication. Fifteen raters (6 plastic surgeons, 3
dermatologists, 2 nurses, 2 psychologists, and 2 hospital secre-
taries), who participated in the scale validation process, not aware
of the overall subject selection, were asked to rate photographs. The
scales were printed next to a separate field to enter the ratings for
the 20 aesthetic areas of interest. Photographs were shown at the
same time and in the same office to the raters using 15 identical
computers with the same image setting. The raters were asked to
use four severity items (no, mild, moderate, severe) and to note in
the separate field next to the scales, the ageing sign severity for
each aesthetic area of interest in the 1000 subjects. Each rater
independently made the assessments in the scale validation cycle,
assigning a total score derived from each scale score sum. At the
end of the assessment, the real age was noted. The experts were
instructed to assess patients independently and to return the
printed scales with their ratings. The entire assessment process
lasted two days and was repeated one month later to test the
intrarater reliability. Some cropped images representing different
aesthetic areas were chosen from the 1000 subjects to be coupled
to the scales at the end of the validation process, based on the area
of interest, image quality and clarity. Images from the photograph
database were selected to represent varying degrees of severity of
the ageing processes in the corresponding facial areas. Selected
images were then associated with each numerical grade of the 20
scales (Fig. 1). Photographs were considered eligible to be associ-
ated with the scales if at least seven raters assigned the same rating
for a definite aesthetic area in a given patient. The scales were built
in strict accordance with recommended guidelines to develop a
scientifically credible and clinically meaningful tool (Hays et al.,
1993; Cano and Hobart, 2008; Klassen et al., 2010; Lasch et al.,
2010; Mokkink et al., 2010). Using an inductive methodological
approach, all scale ratings were combined to obtain the score sum
of the different aesthetic areas (upper, mid, lower face, hair and
skin) to calculate a total facial score which was used to holistically
investigate scale validity to predict subject age. Descriptive Statis-
tics (arithmetic mean, standard deviation) were calculated for pa-
tient age and score. The Rasch model was used as part of the
validation process.
The correlation between the real age and scores obtained, the
inter-rater reliability and test-retest reliability were analysed.
2.3. Rasch measurement theory
The Rasch measurement theory was used (RUMM2030 soft-
ware) to analyse the FACE-Objective Assessment Scale (Wright and
Masters, 1982; Andrich et al., 1988a,b; Andrich, 2004). It examines
differences between observed and predicted item responses to
determine the extent to which data for a set of items match a
mathematical model. When the data match the Rasch model, the
measurement theory (i.e., a scale measures a specific construct) is
supported by the data. The Rasch measurement theory analysis
777
examines difference (or match) between the observed scores (rater
responses to items) and the expected values predicted by the Rasch
model, which is assessed using a range of statistical tests to
examine each scale item (Rasch, 1960; Andrich et al., 1988a,b). This
model allows assessing the overall scale quality. Our results were
interpreted as follows:
2.3.1. Item response category
Each item of the FACE-Objective Assessment Scale could belong
to four severity categories (no, mild, moderate, severe), which
reflect an ordered continuum that increases for the construct of
interest. A threshold is the location at which the probability of
responding in adjacent pairs of response options is 50% (Andrich
et al., 1988a,b). When the categories operate as expected, the
thresholds are ordered. “Disordered” thresholds imply that the
response categories for that item are not operating as expected.
They occur when responders show difficulties to consistently
distinguish between the different response options (Zhu et al.,
1997). When the response options operate as expected, the scale
validity is confirmed (Andrich, 1982).
2.3.2. Item matching statistics
The items of a scale must match together as a conformable set
both clinically and statistically. When items do not match together
(mismatch), it would be inappropriate to sum the individual item
responses to obtain a total score. Matching statistics are usually
interpreted together in the context of their clinical usefulness as an
item set, but as a guide, the residual match should range
between 2.5 and þ 2.5, and chi-square values should not be
significant.
2.3.3. Item locations
The scale items define a continuum, and inspecting where items
are located on the continuum shows how well the items map out a
construct. Items should be evenly distributed within a reasonable
range.
2.4. Internal consistency reliability
Internal consistency assesses the extent to which individual
scale items are consistent to each other and reflect an underlying
construct. Internal consistency of the FACE-Objective Assessment
Scale and its dimensions were estimated using the Cronbach's a
coefficient, ranging between 0 (no internal consistency) and 1
(High degree of internal consistency) (Cronbach, 1951). It is
considered a measurement of the scale reliability.
2.5. Person separation index
This reliability statistic is comparable to the Cronbach's a coef-
ficient and quantifies the error associated with subject measure-
ments in a sample. Higher values indicate a greater reliability.
2.6. Reliability and validity of the FACE-Objective assessment scale
Validity of the Facial Score was assessed by investigating the
correlation of the scores obtained for each patient with their age,
using the Pearson test (r) (Alkrisat and Dee, 2014). The inter-rater
reliability was analysed to assess the reliability of aesthetic scales
(Neumann et al., 2000).
The scores following a normal distribution obtained by each
rater were compared using a paired T test. Repeatability or test-
retest reliability was used to observe if the intrarater variability
could be excluded (Rieu et al., 2015).
778 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782

Fig. 1. Representative example of two photonumerical rating scales for the upper and lower face. Forehead lines at rest: no lines (a); mild lines (b); moderate lines (c); severe lines
(d). Nasolabial folds: no folds (e); mild folds (f); moderate folds (g); severe folds (h).

All patients were reassessed one month later by the same raters
to test the score accuracy and possible changes over time. The total
scores obtained one month later and their correlation with patient
real age following a normal distribution were compared to the
initial scores using a paired T test. The same data were analysed
using the Pearson test. A value of p < 0.05 was considered signifi-
cant. Continuous variable normal distribution was analysed using
the KolmogoroveSmirnov test. All analyses were performed using
PRISM, version 5 (Graph Pad, USA). All the authors had full access to
and take full responsibility for the integrity of the data.
 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782 779

Table 3 and men mean age was 45.1 ± 10.4 years. The mean score obtained
Overall fit to the Rasch model and person separation index for each scale. in women and men at the time of the first rating was respectively
Scale Degrees P X2 Person 28.2 ± 11.3 and 28.3 ± 12.3. At the time of the second rating (one
of separation month later), the mean score was respectively 28.2 ± 11.5 and
freedom index 28.4 ± 11.3. Twelve different age group series were randomly
Forehead lines at rest 15 0.16 24.3 0.88 selected from the patient database and the mean score and stan-
Forehead lines dynamics 20 0.56 33.8 0.90 dard deviation were calculated in each age group (Table 2).
Brow positioning 20 0.41 15.3 0.89
Glabellar lines at rest 20 0.15 21.7 0.90
Glabellar lines dynamic 20 0.12 32.4 0.90 3.2. Rasch measurement theory
Crow's feet at rest 16 0.74 41.7 0.90
Crow's feet dynamic 16 0.23 13.3 0.90 The matching statistics for the Rasch model are summarised in
Inferior eyelids dark 20 0.34 34.9 0.90
Table 3 (how closely observed data matched with those expected
circles and bags
Superior eyelid 16 0.15 49.5 0.90
by the model). The targeting was good and all items in each of the
skin elasticity 20 scales showed ordered thresholds, indicating that the raters
Infraorbital hollow 20 0.25 55.8 0.90 were able to distinguish between the four item options (no, mild,
Cheek fullness 20 0.16 14.8 0.90 moderate, severe). A non-significant chi-square value confirmed
Nasolabial folds 20 0.60 33.3 0.90
that the 20 scales matched the Rasch model. All the scale items had
Marionette lines 16 0.21 54.8 0.90
lip wrinkles at rest 15 0.55 31.2 0.88 a residual matching within the recommended range of 2.5
Lip wrinkles dynamic 20 0.45 27.4 0.90 to þ2.5. The Person Separation Index values for each scale were
Oral commissures 20 0.41 20.1 0.90 greater than or equal to 0.8, indicating a good reliability. These
Jawline 20 0.33 61.8 0.90 findings supported the reliability and validity of each of the 20
Neck folds 30 0.45 44.7 0.90
Hair 40 0.67 21.5 0.85
scales for their respective constructs.
Skin 41 0.70 34.8 0.84
3.3. Internal consistency reliability: Cronbach's alpha coefficients
(Table 4)
2.7. Preliminary FACE-Objective Assessment Scale validation in
clinical practice All scales exceeded criteria for acceptability, reliability and val-
idity. In particular, Cronbach's alpha coefficients (0.90) and intra-
To test its efficacy in real-practice conditions, the FACE- class correlation coefficients (0.78) supported scale reliability and
Objective Assessment Scale was used to assess 70 patients (35 validity. These findings indicated that the items of each scale
men and 35 women). They underwent a facelift surgery performed formed a statistically conformable group, and that these scores
by the same surgeon. The ageing facial sign severity was rated by were reliable and valid.
each patient and by the surgeon before surgery and postsurgery
after a 3-month follow-up. 3.4. Validity of the total facial score

The Pearson correlation showed that the real age very strongly
3. Results correlated with the total facial score both in the female and male
groups (Fig. 2a-b). The 12 age group mean scores strongly corre-
3.1. Descriptive statistics lated with the mean age of each group (Fig. 2c). The second vali-
dation cycle (test-retest reliability) confirmed all these strong
Patient mean age was 44.7 ± 14.1 years (range: 18e76). The correlations with almost identical correlation coefficients (Table 5).
men-to-women ratio was 1. Woman mean age was 44.5 ± 11.4 years
3.5. Reliability of the total facial score

Table 4 Inter-rater reliability: No significant difference was observed

Cronbach alpha and intra-class correlation coefficients.
between the scores obtained by the raters in the female (t
Scale Cronbach Mean intraclass test ¼ 1.44; p ¼ 0.15) and male groups (t test ¼ 1.43; p ¼ 0.16).
alpha correlation coefficient Test-retest reliability: All patients were reassessed one month
Forehead lines at rest 0.90 0.78 later by the same raters. No intrarater variability was observed in
Forehead lines dynamics 0.96 0.78 the female (t test ¼ 1.44; p ¼ 0.16) and male groups (t test ¼ 1.43;
Brow positioning 0.97 0.83
p ¼ 0.16).
Glabellar lines at rest 0.92 0.79
Glabellar lines dynamic 0.94 0.80
Crow's feet at rest 0.98 0.88 3.6. Results of the preliminary FACE-Objective Assessment Scale
Crow's feet dynamic 0.94 0.84 validation in clinical practice
Inferior eyelids dark circles and bags 0.95 0.84
Superior eyelid skin elasticity 0.93 0.78
Infraorbital hollow 0.97 0.88
Both the physician and the 70 facelift patients observed a sig-
Cheek fullness 0.93 0.84 nificant reduction in total score after a 3-month follow-up (mean
Nasolabial folds 0.95 0.84 reduction of 9 ± 2.5 points and 10 ± 1.3 points, respectively). The
Marionette lines 0.94 0.84 pre- and postoperative total scores were significantly different
Lip wrinkles at rest 0.93 0.78
(p < 0.05).
Lip wrinkles dynamic 0.96 0.78
Oral commissures 0.97 0.78
Jawline 0.94 0.83 4. Discussion
Neck folds 0.96 0.83
Hair 0.94 0.78 As people get older, significant body changes begin to occur, and
Skin 0.96 0.78
concerns about the appearance are increasingly focused on the face,
780 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782
Fig. 2. Correlation analyses. (a) Correlation analysis of the total facial score with pa-
tient age in women (Rater 1). x: woman age; y: total facial score. (b) Correlation
analysis of the total facial score with patient age in men (Rater 1). x: man age; y: total
facial score. (c) Correlation analysis of the mean total facial score in the 12 age groups
with the mean age of each group. x: mean age; y: mean total facial score.
which sometimes may result in negative psychosocial conse-
quences (Honigman and Castle, 2006; Funk et al., 2012). Anxiety
about ageing and concerns regarding the body image are significant
predictors of social motivations to undergo cosmetic surgery. After
facial rejuvenation treatments, patients often need to appreciate
their apparent age reduction. Several authors have developed some
tools allowing assessing apparent age reduction following aesthetic
treatment (Kosowsky et al., 2009; Chauhan et al., 2012). In partic-
ular, Panchapakesan et al. (2013) have developed the FACE-Q
Ageing Appraisal Scale to provide an overall assessment of pa-
tient perception of their facial ageing. They have also created the
FACE-Q Patient-Perceived Age Visual Analog Scale (VAS), consisting
in a single item questioning patients about their perceived age
compared to their actual age. They have assumed that these scales
allow accurately assessing outcomes in patients who undergo
aesthetic facial procedures. According to us, patient perceived age is
critical to assess satisfaction following an aesthetic procedure but
may not be considered scientifically accepted and clinically
meaningful, since it strictly depends on a single person point of
view. Swanson (2011) has studied the apparent age reduction
following facial rejuvenation procedures. To assess patient age, pre
and post cosmetic surgery photographs were assessed by inde-
pendent members of a public who were asked to rate apparent age.
As stated by the authors, this study was limited by the fact that only
frontal photographs were considered.
In 2012, Rzany et al. (2012) have presented the Merz Rating
Scales for global facial assessment. However, no scale focused on
skin and hair assessment. In our view, the skin quality and hair
density scales we developed could provide additional and impor-
tant information allowing determining whether a global facial
analysis must be performed.
Despite the importance of such measurement tools, a reliable
and valid tool to predict patient age is needed. For this reason, our
team developed a score-based tool that included different scales,
which appeared as a simple, complete and time-sparing method
which could be routinely used in medical practice. The FACE-
Objective Assessment Scale was developed for research and
clinical practice to measure changes after any facial aesthetic
rejuvenation procedure. Our results showed that the inter- and
intrarater reliabilities were good with a substantial or almost
perfect interrater reliability for the total facial score. The high
intrarater reliability showed a high rating stability. The one-
month interval between the two assessments was long enough
to reduce memory effects and reproduced real-practice conditions
when physicians have to reassess patients. The inter-rater reli-
ability showing a high degree of agreement among raters, we
could assume that the FACE-Objective Assessment Scale could be
a good tool for a complete and objective facial age assessment.
Furthermore, the strong correlation between the total facial score
and patient age made it a valid tool for assessing subject apparent
age.
The preliminary FACE-Objective Assessment Scale validation in
clinical practice showed that the more effective a rejuvenation
treatment was the smaller the score was, the less severe ageing
signs were and the younger patients looked like. The physician,
patients themselves and another member of the medical team may
assign a pre and post treatment score to the patient, which could be
transmitted with the patient records and photographs.
In the anti-ageing medicine era, this scale could be used to
investigate the efficacy of a rejuvenation treatment.
It has previously been shown that integrating patient-reported
outcomes into the clinical practice improves patient/clinician
communication and may improve patient care and outcomes
(Marshall et al., 2006; Valderas et al., 2008). Furthermore, the FACE-
Objective Assessment Scale could be an important new metrics to
be used in clinical research. Its use in clinical trials could help to
guide future surgical innovation and to advance effective compar-
ative research on facial rejuvenation treatments, including in
regenerative medicine.
 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782 781

Table 5 Acknowledgements
Correlation of patients age with the total face score at first assessment and one
month later; PCCV (Pearson correlation coefficient value).
The authors declare that all contributors meet the criteria for
Raters PCCV PCCV PCCV PCCV authorship.
females males females males
(test-retest reliability) (test-retest reliability)
References
Rater 1 0.97 0.98 0.97 0.98
Rater 2 0.97 0.98 0.97 0.98 Acaster S, Cimms T, Lloyd A: Design and selection of patient reported outcome
Rater 3 0.97 0.98 0.98 0.98 measures for use in patient centered outcomes research. San Francisco, CA:
Rater 4 0.97 0.97 0.98 0.98 Oxford Outcomes, 2012
Rater 5 0.96 0.98 0.96 0.98 Andrich D: Controversy and the Rasch model: a characteristic of incompatible
Rater 6 0.98 0.98 0.98 0.98 paradigms? Med Care 42(Suppl): 1e16, 2004
Rater 7 0.97 0.99 0.97 0.98 Andrich D: Rasch models for measurement. Newbury Park, Calif: Sage, 1988a
Rater 8 0.98 0.98 0.98 0.98 Andrich D: Rasch models for measurement. Beverley Hills, CA: Sage, 1988b
Rater 9 0.98 0.98 0.98 0.97 Andrich D: An index of person separation in latent trait theory, the traditional
Rater 10 0.97 0.98 0.97 0.98 KR20 index and the Guttman scale response pattern. Educ Psychol Res 9(1): 9,
1982
Rater 11 0.98 0.98 0.98 0.98
Alkrisat M, Dee V: The validation of the coping and adaptation processing scale
Rater 12 0.98 0.97 0.98 0.97
based on the Roy adaptation model. J Nurs Meas 22(3): 368e380, 2014
Rater 13 0.97 0.97 0.98 0.98
Cano SJ, Hobart JC: Watch out, watch out, the FDA are about. Dev Med Child Neurol
Rater 14 0.98 0.98 0.98 0.98 50(6): 408e409, 2008
Rater 15 0.96 0.98 0.97 0.98 Chauhan N, Warner JP, Adamson PA: Perceived age change after aesthetic facial
surgical procedures quantifying outcomes of aging face surgery. Arch Facial
Plast Surg 14: 258e262, 2012
Codner MA, Kikkawa DO, Korn BS, Pacella SJ: Blepharoplasty and brow lift. Plast
Reconstr Surg 126: 1e17, 2010
However, our study has some limitations. First, our sample only Cronbach LJ: Coefficient alpha and the internal structure of tests. Psychometrika 16:
included Caucasian subjects. Future research could investigate the 297e334, 1951
use of our scales in Black and Asian patients. Second, a bias could Cula GO, Bargo PR, Nkengne A, Kollias N: Assessing facial wrinkles: automatic
detection and quantification. Skin Res Technol 19: 243e251, 2013
have been introduced during the patient enrolment process. Funk W, Podmelle F, Guiol C, Metelmann HR: Aesthetic satisfaction scoring e
Further studies are thus needed to confirm our findings and make introducing an aesthetic numeric analogue scale (ANA-scale).
the FACE-Objective Assessment Scale a universally accepted tool for J Craniomaxillofac Surg 40(5): 439e442, 2012
Gordon LB, Massaro J, D'Agostino Sr RB, Campbell SE, Brazier J, Brown WT, et al:
facial ageing assessment.
Impact of farnesylation inhibitors on survival in Hutchinson-Gilford progeria
syndrome. Circulation 1(130): 27e34, 2014
Hays R, Anderson R, Revicki D: Psychometric considerations in evaluating health-
5. Conclusion related quality of life measures. Qual Life Res 2: 441e449, 1993
Honigman R, Castle DJ: Aging and cosmetic enhancement. Clin Interv Aging 1:
115e119, 2006
We suggest using the FACE-Objective Assessment Scale both in Klassen AF, Cano SJ, Scott A, Snell L, Pusic AL: Measuring patient-reported outcomes
clinical research and practice. This is an adjunctive and easy tool to in facial aesthetic patients: development of the FACE-Q. Facial Plast Surg 26:
be used to perform more complete initial and follow-up assess- 303e309, 2010
Kosowski TR, McCarthy C, Reavey PL, Scott AM, Wilkins EG, Cano SJ, et al:
ments in patients undergoing facial rejuvenation treatments.
A systematic review of patient-reported outcome measures after facial cosmetic
surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg 123:
1819e1827, 2009
Ethical approval Lasch K, Marquis P, Vigneuz M, Abetz L, Arnould B, Bayliss M, et al: PRO develop-
All procedures performed in studies involving human partici- ment: rigorous qualitative research as crucial foundation. Qual Life Res 19: 9,
2010
pants were in accordance with the ethical standards of the insti- Lu H, Fang EF, Sykora P, Kulikowicz T, Zhang Y, Becker KG, et al: Senescence induced
tutional and/or national research committee and with the 1964 by RECQL4 dysfunction contributes to RothmundeThomson syndrome features
Helsinki declaration and its later amendments or comparable in mice. Cell Death Dis 15(5): 1226, 2014
Marshall S, Haywood K, Fitzpatrick R: Impact of patient- reported outcome measures
ethical standards.
on routine practice: a structured review. J Eval Clin Pract 12: 559e568, 2006
Miyamoto K, Nagasawa H, Inoue Y, Nakaoka K, Hirano A, Kawada A: Development of
new in vivo imaging methodology and system for the rapid and quantitative
Disclosure evaluation of the visual appearance of facial skin firmness. Skin Res Technol 19:
The authors have no financial interest to declare including any 525e531, 2013
Mokkink L, Terwee C, Patrick D, Alonso J, Stratford PW, Knol DL, et al: The COSMIN
support of grants in relation to the context of this article. checklist for assessing the methodological quality of studies on measurement
properties of health status measurement instruments: an international Delphi
study. Qual Life Res 19(4): 539e549, 2010
Author contribution to the content Neumann L, Press J, Glibitzki M, Bolotin A, Rubinow A, Buskila D: CLINHAQ scale
First author: Study design/writing and data collection. validation of a Hebrew version in patients with fibromyalgia. Clinical Health
Assessment Questionnaire. Clin Rheumatol 19(4): 265e269, 2000
Second author: Statistics. Panchapakesan V, Klassen AF, Cano SJ, Scott AM, Pusic AL: Development and Psy-
Third author: Statistics. chometric evaluation of the FACE-Q aging appraisal scale and patient-perceived
Fourth author: Data collection. age visual analog scale. Aesthet Surg J 33: 1099e1109, 2013
Rasch G: Probabilistic models for some intelligence and attainment tests. Copen-
Last author: Study designer. hagen: Danish Institute for Education Research, 1960
Raschke GF, Rieger UM, Bader RD, Schaefer O, Guentsch A, Gomez Dammeier M,
et al: Perioral aging e an anthropometric appraisal. J Craniomaxillofac Surg
Funding 42(5): 312e317, 2014
None. Rieu I1, Martinez-Martin P, Pereira B, De Chazeron I, Verhagen Metman L,
Jahanshahi M, et al: International validation of a behavioral scale in Parkinson's
disease without dementia. Mov Disord 30(5): 705e713, 2015 Apr 15
Rzany B, Carruthers A, Carruthers J, Flynn TC, Geister TL, Go €rtelmeyer R, et al:
Conflict of interest statement Validated composite assessment scales for the global face. Dermatol Surg 38:
None. 294e308, 2012
782 S. La Padula et al. / Journal of Cranio-Maxillo-Facial Surgery 44 (2016) 775e782
Seco-Cervera M, Spis M, García-Gime
nez JL, Iban ~ ez-Cabellos JS, Vel

azquez-
Ledesma A, Esmorís I, et al: Oxidative stress and antioxidant response in fi-
broblasts from Werner and Atypical Werner Syndromes. Aging. 6: 231e245,
2014
Swanson E: Objective assessment of change in apparent age after facial rejuvena-
tion surgery. J Plast Reconstr Aesthetic Surg 64: 1124e1131, 2011
Valderas JM, Kotzeva A, Espallargues M, Guyatt G, Ferrans CE, Halyard MY, et al: The
impact of measuring patient-reported outcomes in clinical practice: a system-
atic review of the literature. Qual Life Res 17: 179e193, 2008
Waaijer ME, Gunn DA, Catt SD, van Ginkel M, de Craen AJ, Hudson NM, et al:
Morphometric skin characteristics dependent on chronological and biological
age: the Leiden Longevity Study. Age 34: 1543e1552, 2012
Wright BD, Masters G: Rasch measurement. In: Rating scale analysis. Chicago:
Mesa, 1982
Zhu W, Updyke WF, Lewandowski C: Post-hoc Rasch analysis of optimal categori-
zation of an ordered-response scale. J Outcome Meas 1(4): 286e304, 1997