British Journal of Plastic Surgery (2001), 54, The British Association of Plastic Surgeons doi: /bjps

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1 British Journal of Plastic Surgery (2001), 54, The British Association of Plastic Surgeons doi: /bjps The Derriford Appearance Scale (DAS59): a new psychometric scale for the evaluation of patients with disfigurements and aesthetic problems of appearance D. L. Harris and A. T. Carr* Department of Reconstructive Plastic Surgery, Derriford Hospital, Plymouth, UK and *Clinical Teaching Unit, Department of Psychology, University of Plymouth, Plymouth, UK SUMMARY. The DAS59 has been designed and developed to meet the need for an objective measure of the spectrum of psychological distress and dysfunction that is characteristic of disfigurements, deformities and aesthetic problems of appearance. Content validity has been assured by basing the scale s items on a detailed autobiographical study of representative patients. Internal consistency is high (0.98) and test retest reliabilities are good (general population: 0.75; clinical population: 0.86). Correlations with other appropriate standardised tests show good criterion validity and good construct validity. Factor analysis of 2741 data sets (general population and clinical population) identified three factors that are not feature specific and two that are (bodily and sexual features, facial features). The DAS59 thus generates a full-scale score and five factorial sub-scale scores. The DAS59 has been standardised on the clinical population across a range of patient groups and on the general population subdivided into those concerned and those not concerned about appearance. The DAS59 is highly sensitive as a measure of change following treatment with large and significant preoperative postoperative reductions in full-scale and factorial scores of patients treated for facial features or bodily/sexual features. The DAS59 offers benefits for patient selection in both cosmetic and reconstructive plastic surgery and in the evaluation of outcome. It provides valid and reliable data for clinical audit and governance and for evaluating the merits of one treatment protocol against another The British Association of Plastic Surgeons Keywords: plastic surgery, measurement, governance, audit, psychological scale. Much of the art and craft of plastic surgery is directed towards normalisation of appearance, be it the aesthetic harmonisation of features by cosmetic surgery or the approximation of normal appearance in the treatment of disfigurements and deformities by reconstructive surgery. The benefits of these interventions for the patients concerned are psychological: relief of psychological distress and improvement in social and psychological functioning. 1 Objective evaluation of clinical need for these treatments and measurement of their therapeutic effectiveness therefore require a psychometric instrument that validly and reliably assesses the specific problems of the clinical population. The need for such an instrument has been highlighted by contemporary issues such as risk benefit analysis of breast augmentation using silicone breast implants 2 and the inclusion of some cosmetic surgical procedures within policies of state-funded healthcare systems such as the National Health Service of the UK. 3,4 Historically, psychological evaluation of plastic surgery patients, particularly those requesting cosmetic surgery, has centred on the search for personality types that might predict the dissatisfied postoperative patient Stages in the development of the Derriford Appearance Scale have been presented at the following meetings: the British Association of Aesthetic Plastic Surgeons, Plymouth, 1990; the British Psychological Society, Scarborough, 1991; the British Association of Plastic Surgeons, Glasgow, 1992, Swansea, 1994 and London, and on measures of psychopathology. Most such studies have been conducted by psychiatrists using the clinical interview and/or standardised tests of mental health (e.g. Beck Depression Inventory, 5,6 Brief Symptom Inventory, 7 General Health Questionnaire, 8 Rosenberg s Self-esteem Scale, 8 Crown Crisp Experiential Index 9 ) or personality (e.g. Eysenck Personality Questionnaire, 10 Minnesota Multiphasic Personality Inventory 11,12 ). Their results have generated confusion rather than clarification. 13 Cosmetic surgery patients do not demonstrate a specific personality type, they do not uniformly meet the diagnostic criteria of body dysmorphic disorder (Diagnostic and Statistical Manual of Mental Disorders: DSM IV) and only some have levels of anxiety and depression that are clinically significant. 13 More focused and appropriate measures of the effects of living with an aesthetic problem of appearance, such as the Appearance Schemas Inventory, 14 the Body Image Avoidance Questionnaire 15 and the Body Dysmorphic Disorder Examination, 16 suffer from low content validity, restricted range of applicability, impracticability or limited psychometric development. 17,18 Recently, measures of quality of life (Short Form 36, Health Measurement Questionnaire) have shown preoperative levels of psychological distress and dysfunction in plastic surgery patients that are significantly higher than in the general population in some of the dimensions measured 4,8,19 and one study using these measures has shown 216

2 The Derriford Appearance Scale (DAS59) 217 significant benefits of cosmetic surgery in a sample of 105 patients up to 6 months postoperatively. 19 None of these measures were designed specifically to assess the spectrum of symptomatology that is relevant to the wide range of difficulties experienced by patients living with problems of appearance; therefore, the scales lack sensitivity to the nature of the dysfunctions and the severity of the distress that these patients experience. Consequently, they are insensitive to therapeutic change and their item contents are less acceptable to plastic surgery patients. The potential for a specific instrument was suggested by an autobiographical study of representative patients. 20 This sampled 54 reconstructive and cosmetic plastic surgery patients postoperatively and asked them to describe, as if explaining to someone else, what life had been like for them living with their particular problem of appearance. A key finding was a remarkable consistency in their symptomatologies regardless of whether the problem of appearance was severe or minor and whatever its cause; cosmetic surgery patients had suffered as much distress and disruption to their lifestyles as had reconstructive surgery patients. Levels of distress and dysfunction, particularly among cosmetic surgery patients, were also much higher than expected. These findings highlighted the need to develop a valid and reliable self-report questionnaire that would measure the specific emotional and behavioural problems of cosmetic and reconstructive surgery patients whose primary concern is appearance. Design, development and psychometric evaluation of the Derriford Appearance Scale A detailed and technical description has been published elsewhere. 18 In brief, an experimental scale was designed initially consisting of 136 items based on data from the autobiographical study and respondents phraseology. Following an initial pilot study (n 72), a longitudinal clinical study was undertaken of plastic surgery patients (n 50) and non-self-conscious surgical controls (n 41), which confirmed the validity of the new scale by correlating its data with those of established psychological tests. Then, a large clinical database comprising scores of preoperative plastic surgery patients (n 606) was generated and used to refine the experimental scale into two final versions: a short form of 24 items, the Derriford Appearance Scale 24 (DAS24), that is intended for use as a routine instrument in day-to-day clinical practice; and a longer, factorial scale of 59 items, the Derriford Appearance Scale 59 (DAS59), that is intended for use in research as well as in clinical practice. The DAS24 generates a single score and will be the subject of a separate publication. The DAS59 generates five factorial scores in addition to a total score and is the subject of this paper. The Derriford Appearance Scale (DAS59) The DAS59 is presented as a series of 59 statements and questions with response categories in a Likert format to measure frequency of symptomatology ( almost never almost always ) and levels of associated distress ( not at all distressed extremely distressed ). It is intended for use in the adult population (16 years of age and over). An introductory section gathers relevant demographic information and identifies the aspect of appearance that is of greatest concern to the respondent. This is referred to as the respondent s feature in the body of the scale. It also identifies any other aspects of appearance about which the respondent may also be concerned. Fifty-seven items (Table 1) assess relevant psychological distress and dysfunction, and two items assess physical distress and physical dysfunction. The format of the introductory section and a not applicable response category for most items make the scale acceptable to respondents who are not concerned about appearance such as those in the general population and patients following treatment. Feedback from respondents who are concerned about their appearance has been consistently positive: they are grateful to know that their problems are recognised by the profession. Respondents who are not concerned report that the content of the scale is irrelevant but not disturbing. Administration and scoring Clear and simple instructions are given on how to complete the scale, which is designed as a self-report questionnaire to be completed without supervision. The DAS59 generates six measures of psychological distress and dysfunction (an overall, fullscale score and five factorial scores) as well as a measure of physical distress and dysfunction (items 25 and 26). The higher the score, the greater is the respondent s level of distress and dysfunction. Full-scale and factorial sub-scale scores are obtained by adding the scores of individual items according to instructions given in a manual that accompanies the DAS59. A patient s scores can be compared with normative values for the clinical and/or general populations as given in standardisation tables (Table 2). Validity and reliability of the DAS59 Technical details of the scale s psychometric development and evaluation have been published elsewhere. 18 The DAS59 correlates strongly with the original experimental scale (0.99) and appropriately with a range of other established psychological tests, including the Social Anxiety and Distress Scale, 21 the Beck Depression Inventory, 22 the State and Trait Anxiety Inventory 23 and the Eysenck Personality Questionnaire. 24 It has good internal consistency (0.98) and good test retest reliability (3 month interval: full-scale 0.86), which means that, in addition to the scale s sensitivity, the scores are stable over time and the DAS59 can be used with confidence to measure changes in a condition. Standardisation of the DAS59 For a psychometric scale to be of value in clinical practice, the score of a patient needs to be placed in context with scores of others in comparable populations. For these purposes, normative DAS59 full-scale data have been analysed for three principal groups: 1. A sample from the clinical population aged 18 years and over composed of preoperative (n 1474) and postoperative (n 266) plastic surgery patients (NHS: n 1253; private: n 487) with problems of appearance ranging from minor to severe and caused by congenital malformation (cleft lip, birth marks, naevi), trauma (scars, burns), disease (facial palsy, acne, mastectomy), pregnancy (abdominal striae, breast ptosis), facial ageing and disproportionate or asymmetrical growth of features (breasts, nose, ears, lipotrophies). 18 All preoperative respondents completed the scales after the decision to undergo plastic surgery had been taken. 2. The general population who are concerned about appearance (n 473). 3. The general population who are not concerned about appearance (n 528).

3 218 British Journal of Plastic Surgery Table 1 The Derriford Appearance Scale (DAS59): reliabilities and item content by factorial sub-scales and mean item scores preoperatively and postoperatively and percentage changes Mean Mean Percentage preoperative postoperative change score score General self-consciousness of appearance (GSC) (variance: 20.05%; reliabilities: alpha 0.96, test retest 0.79) 1. self-consciousness of feature taking a special interest in others features avoiding photography being hurt by others comments raising subject of the feature in conversation before others do 17. being irritable at home feel unattractive feel unlovable feel embarrassed feel inferior distress when others make remarks distress when others stare distress when others ask about the feature distress when seen in a particular view distress when feature seen in a mirror/window distress when meeting strangers how hurt do you feel? Social self-consciousness of appearance (SSC) (variance: 18.47%; reliabilities: alpha 0.95, test retest 0.70) 2. avoiding children in the street difficulty making friends avoiding school/college/work avoiding pubs/restaurants avoiding parties/discos avoiding department stores avoid leaving the house closing into a shell being misjudged previous avoidance of school/college/work feeling an embarrassment to friends feeling a freak worrying about sanity feel isolated feel rejected feel useless distress when going to school/college/work distress when on public transport distress when not being able to go to social events distress when not being able to go to pubs/restaurants Sexual and bodily self-consciousness of appearance (SBSC) (variance: 12.26%; reliabilities: alpha 0.90, test retest 0.73) 4. avoiding undressing in front of partner avoiding communal changing rooms adverse effect on sex life adverse effect on marriage distress when going to the beach distress from being unable to wear favourite clothes distress from being unable to go swimming distress from being unable to play games distress from being unable to look in the mirror Negative self-concept (NSC) (items are reverse scored) (variance: 7.14%; reliabilities: alpha 0.89, test retest 0.70) 52. how confident do you feel? how secure do you feel? how cheerful do you feel? how normal do you feel? how masculine/feminine do you feel? Facial self-consciousness of appearance (FSC) (variance: 5.61%; reliabilities: alpha 0.74, test retest 0.51) 11. avoid getting the hair wet distress from being unable to change hairstyle distress from being unable to answer the front door distress from being unable to go out in windy weather Not loading on a specific factor 53. how irritable do you feel? how hostile do you feel?

4 The Derriford Appearance Scale (DAS59) 219 Table 2 Mean preoperative DAS59 scores (full-scale and factorial sub-scales) of patients in a range of treatment-defined sub-groups of plastic surgery Operation n Full-scale GSC SSC NSC SBSC FSC abdominoplasty breast reduction breast augmentation otoplasty, men gynaecomastia mastopexy rhinoplasty, women breast asymmetry otoplasty, women breast reconstruction rhinoplasty, men facelift, women cosmetic, women cosmetic, men reconstructive, women reconstructive, men GSC: general self-consciousness of appearance; SSC: social self-consciousness of appearance; NSC: negative self-concept; SBSC: sexual and bodily self-consciousness of appearance; FSC: facial self-consciousness of appearance. Table 3 DAS59 full-scale normative data for general and clinical populations by gender and by age bands (18 30 years, years and 61 years and over): minimum, maximum and quartile (Q1, Q2 and Q3) values, means and standard deviations General population: not concerned General population: concerned Clinical population Age (year) Men minimum Q Q Q maximum * mean ( s.d.) (18.5) (22.0) (20.7) (34.2) (33.3) (42.3) (38.1) (44.4) (34.8) n Women minimum Q Q Q maximum * mean) ( s.d.) (26.2) (16.9) (16.3) (37.1) (39.2) (25.6) (38.4) (43.4) (36.8) n * Excludes outliers: value mean 2 s.d. The general-population database was constructed from respondents to a postal study that involved 2700 residents of southwest Devon aged 18 years and over who were randomly selected from a total population of with constraints for sex, socio-economic status, urban/rural residence and age. 25 Table 3 lists the DAS59 full-scale scores that subdivide these populations into quartiles (minimum Q1, Q1 Q2, Q2 Q3 and Q3 maximum) together with the mean scores and standard deviations. As the DAS59 discriminates significant differences in levels of distress and dysfunction between men and women and between different times of life, normative data for each sex are tabulated for early adulthood (age: years), mid-adulthood (age: years) and late adulthood (age: 61 years and over). For all age groups, all scores for the clinical population exceed the scores for the general population concerned about appearance, and both are substantially higher than the scores for the general population not concerned about appearance. In the general population concerned about appearance and in the clinical population, the mean scores for women are consistently higher than those for men and in the clinical population the difference is significant (P ). In both populations there is a serial reduction in the mean DAS59 scores with increasing age. Among women in the clinical population, the reduction is significant from early to mid-adulthood (P 0.001) and from mid- to late adulthood (P 0.001). For men, the reduction is significant from mid- to late adulthood (P 0.01). Factorial sub-scales of the DAS59 Factor analysis groups together scale-items that score in similar ways. This helps in the selection of items during the refinement of a scale and contributes to an understanding of what a scale is measuring. Factor analysis (Principal components and Varimax

5 220 British Journal of Plastic Surgery Table 4 Preoperative to postoperative changes in mean DAS59 full-scale and factorial sub-scale scores (with standard deviations in parentheses) of patients treated for abnormalities of bodily features and facial features compared with the general-population values n full-scale GSC SSC NSC SBSC FSC Bodily features preoperative (38.1) 43.3 (13.6) 24.8 (15.6) 16.0 (4.1) 24.8 (15.6) 1.5 (2.0) postoperative (31.2) 14.2 (11.9) 12.3 (10.9) 9.7 (3.5) 7.3 (6.3) 1.3 (1.6) significance t 10.3, t 12.2, t 5.4, t 9.0, t 11.1, ns * P P P P P percentage change Facial features preoperative (36.0) 35.9 (13.9) 20.1 (13.6) 13.8 (4.0) 7.9 (6.4) 3.1 (3.6) postoperative (25.0) 15.8 (11.1) 11.0 (8.9) 9.6 (3.5) 5.5 (5.4) 1.6 (1.9) significance t 6.8, t 9.2, t 3.7, t 6.2, ns * t 2.6, P P P P P 0.01 percentage change General population total (38.9) 17.9 (16.9) 20.3 (21.5) 6.9 (7.9) 11.7 (4.2) 1.9 (2.6) unconcerned (20.9) 5.8 (6.8) 9.1 (13.1) 2.9 (4.1) 10.0 (3.7) 1.3 (2.0) GSC: general self-consciousness of appearance; SSC: social self-consciousness of appearance; NSC: negative self-concept; SBSC: sexual and bodily self-consciousness of appearance; FSC: facial self-consciousness of appearance; * ns: P 0.1. rotation) of the combined general population and clinical population databases indicated an optimum five-factor solution comprising three factors that are not feature specific and two that are: 18 general self-consciousness of appearance (GSC); social self-consciousness of appearance (SSC); negative self-concept (NSC); sexual and bodily self-consciousness of appearance (SBSC); and facial self-consciousness of appearance (FSC). The item contents of these sub-scales are given in Table 1, which reveals the extent of symptomatology covered by each of these factors. Table 2 gives mean preoperative DAS59 scores (full-scale and factorial sub-scales) for a number of treatmentdefined sub-groups of plastic surgery patients together with scores for men and women undergoing cosmetic or reconstructive surgery for comparison. Data for the treatment-defined subgroups are ranked according to mean full-scale scores, revealing abdominoplasty patients to have the highest levels of measured distress and dysfunction, and male rhinoplasty and female facelift patients to have the lowest levels. Mean scores for the SBSC factor are highest in patients undergoing breast surgery, abdominoplasty and excision of gynaecomastia, whilst mean scores for the FSC factor are highest in men and women having prominent-ear correction and in women having rhinoplasty. These data illustrate the appropriateness of the featurespecific factors. Mean full-scale and factorial sub-scale scores for women undergoing reconstructive surgery are consistently lower than the scores for women undergoing cosmetic surgery. Out of the sub-groups of breast surgery, mean scores were lowest among patients having reconstructive surgery after mastectomy or for congenital asymmetry and highest among patients having breast reduction. These findings reflect clinical experience. Although fewer data are available for men, those undergoing otoplasty and excision of gynaecomastia tend to have higher scores. Physical distress and dysfunction Included in the DAS59 are two items that assess how often the feature causes pain or discomfort and how often the feature physically limits the respondent s ability to do things. The mean of these totals for patients undergoing breast reduction (6.1) was significantly higher than the mean for patients undergoing breast augmentation (3.9) (t 7.3, P ). Sensitivity of the DAS59 to change in condition after treatment Table 4 gives the mean DAS59 full-scale and factorial sub-scale scores for patients undergoing cosmetic surgery of bodily features (mainly breast and abdomen, n 59) and facial features (n 63) who were tested preoperatively and 3 months postoperatively. For both groups, there were large and significant preoperative to postoperative reductions in full-scale scores and in the scores on the factorial sub-scales that are not feature specific (GSC, SSC, NSC). Percentage changes were greatest for patients treated for bodily features in whom preoperative scores were highest. Data for the feature-specific sub-scales showed a significant reduction in the mean SBSC scores of patients treated for bodily features and a significant reduction in the mean FSC scores of patients undergoing facial surgery. The mean postoperative scores of both groups were closely similar and fell between the mean scores of the total general population and the mean scores of the general population unconcerned about appearance. Preoperative to postoperative changes in item scores are given in Table 1. Discussion The DAS59 (and its parallel short form, the DAS24) provides, for the first time, a self-report questionnaire that generates a series of valid and reliable measures of the specific psychological distress and disruption to everyday life that are associated with self-consciousness of appearance. By basing its item content on autobiographical data from a representative sample of the clinical population, we have ensured that the DAS59 is fully descriptive of the condition measured, both for people who are self-conscious of visible disfigurements and deformities, and for people who are self-conscious of aesthetic problems of appearance. During the scale s development, an open comments

6 The Derriford Appearance Scale (DAS59) 221 section was provided for respondents to add information that the scale might not cover but the overwhelming opinion was that the scale was comprehensive enough as it was. Considerable care has been taken to preserve the breadth of symptomatology during the refinement of the DAS59. Clinicians can be reassured that the problem focus of many items, whilst highly appropriate for respondents who are self-conscious of appearance, is of no concern to non-self-conscious respondents, who use the not applicable option. The DAS59 is user-friendly, simple to administer and easy to score. The factorial structure enhances its sensitivity to change in condition after surgical and/or psychological treatment. It is now available for use in the adult clinical population (aged 16 years and over). It is not appropriate for children, who have unique requirements for self-report questionnaires in terms of item content, language and standardisation. The idea of using a psychometric scale in routine clinical practice is novel to most plastic surgeons. However, the benefits of doing so can be considerable 17 in terms of patient selection in both aesthetic plastic surgery and reconstructive plastic surgery and for the evaluation of outcome following treatment and in research. Patient selection in cosmetic surgery has traditionally centred upon surgical judgement of what can be done to enhance a given aspect of appearance together with an explanation to the patient of the limitations, consequences and risks of the operation proposed. If the patient consents, the surgeon usually agrees to carry out the surgery provided that he or she has no anxieties about the patient s psychological health. An alternative approach would be to use the DAS59 as an adjunct to the routine clinical interview to assess, objectively, the need for cosmetic surgery based on measured levels of psychological distress and dysfunction. From tables of normative data (e.g. Table 2, 3) the patient s DAS59 score(s) can be placed within the distributions of scores of other relevant groups such as those undergoing the same procedure. In general, the higher the score, the stronger the indication for treatment but, as paired preoperative and postoperative data accumulate, it should become possible to predict the odds for outcome based on preoperative scores. The DAS59 can be administered at any stage before, during or after consultation. The scale s high face validity reassures patients that their problems are understood, which helps to alleviate feelings of guilt. During consultation the scale s items can also be a useful aide-mémoire for the clinician of the range of symptomatology. As with cosmetic surgery, current practice in patient selection for reconstructive plastic surgery tends to be centred on surgical assessment of the disfigurement or deformity with a recommendation to the patient as to what can be done and what ought to be done. In this process, the surgeon is intuitively influenced by the severity of the abnormality as he or she sees it rather than by the severity of the patient s psychological reaction to that abnormality. The latter, which clearly is the more important, is measured by the DAS59. The scale s introductory section will also identify which aspect of the patient s abnormality causes most concern, thereby enabling the surgeon to focus on planning an operation that will give maximum relief from self-consciousness of appearance. Using the DAS59, the progress of patients undergoing multistage reconstructive surgery can be assessed, and treatments planned, with greater objectivity. The DAS59 is a highly sensitive instrument with which to measure the effectiveness of reconstructive and cosmetic surgical interventions for appearance. It offers the potential to generate valid and reliable data for clinical audit and governance and to compare one operation or protocol for treatment against another: for example, to answer questions such as which is the better method of breast reduction or how effective is cognitive therapy in improving life for patients with residual scarring. As an objective measure of outcome, the DAS59 can highlight those patients for whom treatment has been ineffective and, in reconstructive surgery, those patients who become psychologically distressed and dysfunctional in response to iatrogenic disfigurements (e.g. donor-site scarring and deformity). In the latter patients, the privacy of a self-report questionnaire can overcome the natural reservations of some patients to complain for fear of upsetting or offending their surgeons. In research, the DAS59 will be highly valuable as an instrument with which to investigate new treatment protocols that combine plastic surgical interventions and psychological interventions such as cognitive behavioural therapies. It may help to answer questions of theoretical interest in psychological aspects of problems to do with appearance. For example, the development of the scale has revealed the possibility that self-consciousness of appearance is a psychological dimension distributed throughout the general population, from which the clinical population self-selects, at least in part, by virtue of the high levels of psychological distress and dysfunction that are associated with their self-consciousness of appearance. 18 Clarification of the importance of appearance to successful psychological functioning and wellbeing is necessary if politicians, managers and others who influence the allocation of resources for plastic surgical and psychological services are to recognise the full clinical needs of patients who are self-conscious of disfigurements and aesthetic problems of appearance. 25 Acknowledgements We thank the British Association of Plastic Surgeons, the Polytechnics and Colleges Funding Council, the Department of Health, the South West Regional Health Authority, the South and West Devon Health Authority, the Head and Neck Directorate, Plymouth Hospitals NHS Trust and the Torbay Research and Education Fund for funding various parts of the work upon which this paper is based. We also thank Jan Collis, Stella Barton, Rona Slator, Tim Moss and Christine James for their assistance at different stages of the project. References 1. Macgregor FC. Social, psychological and cultural dimensions of cosmetic and reconstructive plastic surgery. Aesthetic Plast Surg 1989; 13: Fee-Fulkerson K, Conaway MR, Winer EP, Fulkerson CC, Rimer BK, Georgiade G. Factors contributing to patient satisfaction with breast reconstruction using silicone gel implants. Plast Reconstr Surg 1996; 97: Ward CM. Rationing and resource management. Br J Plast Surg 1994; 47:

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