ORIGINAL ARTICLE

Utility Assessment of Body Contouring After Massive Weight Loss

Hani Sinno • Stephanie Thibaudeau •

Youssef Tahiri • Elise Mok • George Christodoulou •

Lucie Lessard • Bruce Williams • Samuel J. Lin

Received: 25 November 2010 / Accepted: 31 January 2011 / Published online: 13 April 2011

� Springer Science+Business Media, LLC and International Society of Aesthetic Plastic Surgery 2011

Abstract

Background The number of surgical procedures performed

for obesity and massive weight loss (MWL) is increasing. The

authors set out to quantify the health state utility assessment

of living with MWL that can occur after such procedures.

Methods Utility assessments using the visual analog scale

(VAS), time trade-off (TTO), and standard gamble (SG)

were used to obtain utilities for MWL, monocular blind-

ness, and binocular blindness from a sample of the general

population and medical students.

Results All the measures for MWL of the 100 volunteers

(VAS, 0.79 ± 0.13; TTO, 0.89 ± 0.12; SG, 0.89 ± 0.15)

were significantly different (p \ 0.005) from the corre-

sponding measures for monocular blindness (0.63 ± 0.18,

0.84 ± 0.17, and 0.86 ± 0.16, respectively) and binocular

blindness (0.31 ± 0.17, 0.63 ± 0.28, and 0.66 ± 0.27,

respectively) except for the SG utility measure comparing

monocular blindness with MWL. Age was inversely pro-

portional to the TTO utility scores for MWL (p \ 0.05).

Caucasian race and medical education were independent

predictors of SG utility scores (p \ 0.05).

Conclusion In a sample of the general population and

medical students, SG utility assessments for MWL were

comparable with those for monocular blindness. Utility

assessment of living with MWL varied with race (VAS and

SG) and education (SG). The sample population, if faced

with MWL, would consent to undergo a procedure such as

body contouring with an 11% chance of death and be

willing to trade 4 years of their life.

Keywords Binocular blindness � Body contouring �Massive weight loss � Monocular blindness � Obesity �Quality assessment � Quality adjusted life years � QALY

Introduction

Body contouring for the massive weight loss (MWL) patient

can serve as both aesthetic and functional procedures. These

procedures generally address the stigmata of MWL includ-

ing redundant skin and unwieldy subcutaneous tissue creat-

ing an unattractive appearance, problems of hygiene and skin

irritation, pain, intertrigo, and decreased activity.

Patient satisfaction after body-contouring surgery gen-

erally is high due to improved body image, enhanced

ability to fit clothes, and decreased skin irritation. As with

any procedure, body contouring has its own risks and

complications including infection, hematoma and seroma

formation, deep vein thrombosis, and pulmonary embo-

lism. It still is debated whether the long-term benefit that

patients receive from body-contouring procedures is worth

the increased perioperative risks.

Utility scores ranging from 0 (death) to 1 (perfect

health) are a standardized tool that helps to objectify health

states or disease. These scores allow a comparable quan-

titative value for individual health states that can be used in

health economic decision analysis to determine how health

resources should be allocated for treatment and research.

H. Sinno � S. Thibaudeau � Y. Tahiri � E. Mok � L. Lessard �B. Williams

Division of Plastic Surgery, McGill University, Montreal, QC,

Canada

G. Christodoulou

Faculty of Medicine, McGill University, Montreal, QC, Canada

S. J. Lin (&)

Division of Plastic Surgery, Beth Israel Deaconess Medical

Center, Harvard Medical School, 110 Francis Street Suite 5A,

Boston, MA 02215, USA

e-mail: sjlin@bidmc.harvard.edu

123

Aesth Plast Surg (2011) 35:724–730

DOI 10.1007/s00266-011-9676-1

In this particular setting, utility scores help to objectify

the health burden of living with excess skin and tissue after

MWL. This information can shed some light on the impact

this health state has on patients and thus guide surgical

decision making and influence health insurance coverage

for procedures such as body contouring.

Several validated tools for determining utilities exist

[1–4]. The use of more than one tool minimizes the weak-

nesses of any individual tool such as standard gamble (SG)

[5], time trade-off (TTO) [6], or visual analog scale (VAS)

[7]. Utilities can be measures from a sample of the general

population based on a case presentation of the health state in

question [3, 4]. We used an Internet-based Web site to recruit

a large population-based sample without the need for expert

interviewers, which reduced study expenses considerably [4].

Utilities for the MWL patient objectify this health state

and allow comparison with other diseases. Thus, our pri-

mary objective was to compare the health state utility

assessment of living with MWL and that for monocular and

binocular blindness using three separate tools to measure

utility scores (SG, TTO, and VAS) for a sample of the

general population and medical students. We also aimed to

determine whether the utility assessment of living with

MWL varies with age, race, and education.

Methods

The McGill University Research Ethics Board in accordance

with the Declaration of Helsinki ethical guidelines for human

subject research approved this study. All volunteers signed

an electronic informed consent. The patient whose photo was

used in this study signed a written consent for use of her

photo for publication, presentation, and research purposes.

An open-enrollment, Internet-based utility assessment

Web site was created to extract the utilities for the MWL

patient who may require body contouring. Medical students

at McGill University, Montreal, Quebec, were recruited by

email on a voluntary basis. Recruitment of participants

from the general population was performed by a link to our

Web site through the Web sites of online classified ads

(www.craigslist.org and www.kijiji.com).

The study was open until the sample size reached 100.

Volunteers were asked to complete anonymous demo-

graphic and health state questionnaires as well as utility

assessments for the MWL patients. Single- and double-eye

blindness scenarios were used to assess the comprehension

of the volunteers for the study. Only participants who

correctly rated double-eye blindness with a lower utility

score (i.e., higher morbidity) than single-eye blindness

were included in the study. Figure 1 shows the schematic

of our Web site survey. To minimize multiple entries, a

valid email address was required for participation.

A health state description of post-MWL was constructed

based on both clinical experiences of patients with similar

conditions treated at the McGill University Health Center

and expert opinion:

Imagine yourself like ‘‘Jane’’:

I have lost a lot of weight and as a result was left with

excess skin in my abdominal (tummy) area.

I have no problems walking about.

I have no problems with self-care.

I have some problems performing my usual activities.

I have some pain or discomfort.

I have difficulty finding clothes that fit.

I am moderately depressed or anxious.

Furthermore, a representative photograph of a patient

after MWL was chosen to accompany the description

(Fig. 2).

Fig. 1 Schematic of the online survey. The participants were

introduced to the study and then presented with a consent form to

read and electronically sign. Only if the participants agreed to the

terms and conditions found in the consent would the study begin.

Otherwise, the participants were excluded from the study. To prevent

an anchoring effect, the health states and the utility assessments were

presented in random order [17]

Aesth Plast Surg (2011) 35:724–730 725

123

Three utility measures for assessment of health-related

quality of life were used in this study: VAS, TTO, and SG.

The VAS asked subjects to imagine themselves as the

MWL patient described and then score a value on a slide

bar scale from 0 (death) to 100 (perfect health). The utility

score was calculated from subjects’ ratings using the fol-

lowing formula: utility health state = score 7 100.

The TTO assessment asked volunteers to choose

between living a specified number of years in the described

health state (post-MWL) and ‘‘trading-off’’ some of those

years to live in perfect health. The number of years traded

off in the time trade-off task was sequentially alternated

using a bisecting search routine until the indifference point

was found.

For example, the volunteers were asked to imagine

themselves like the patient in the scenario shown in Fig. 2.

Next, they were given the choice of living in this health

state or having a procedure that would provide them with

perfect health at a price of shortening their life by 35 years.

If the volunteer declined the price of 35 years for perfect

health, they were asked whether they would accept a

shortening of 1 life-year for perfect health. If they agreed,

they then are asked whether they would accept a shortening

of 17.5 life-years. If they declined the 17.5 life-year

reduction, they were asked whether they would accept a

shortening of 8.75 life-years. Six iterations of this bisecting

algorithm were used to find the point of indifference at

which the volunteers would accept the time trade-off to

attain perfect health. The utility value was derived from

this indifference point using the following formula: util-

ity = (number of years specified in the described health

state - number of years traded off at the indifference

point) 7 number of years specified in the described health

state.

In the SG, subjects were asked to choose between two

options: either to remain in a given health state (e.g., post-

MWL) or to take a chance (gamble) with some probability

of success (perfect health) and some probability of failure

(death). Sequentially, percentages of success and failure

were presented until the subject was indifferent whether to

take the gamble or to remain in the described health state.

For example, the volunteers were asked to imagine

themselves like the patient in the Fig. 2 scenario. Next,

they were given the choice of living in this health state or

having a procedure that would provide them with perfect

health with a 50% chance of mortality. If the volunteer

declined the 50% chance of mortality, they were asked

whether they would accept a 1% chance of mortality for

perfect health. If they agreed, they then were asked whether

they would accept a 25% chance of mortality. If they

declined, they are asked whether they would accept a

12.5% chance of mortality. Six iterations of this bisecting

algorithm were used to find the point of indifference at

which the volunteers would accept the gamble (percentage)

of mortality to attain perfect health. The utility score was

derived from this point of indifference by the following

formula: utility health state = (1.00 - risk of death at the

point of indifference) 7 100, as previously done [8, 9].

The survey was completed by asking subjects to rate

their own health state using TTO and EuroQol [9]. A

demographic questionnaire also was included that inquired

about sex, age, education, income, and race of the volun-

teers. Finally, a 5-point Likert scale was presented to assess

the subjects’ understanding of the survey.

Statistical Analysis

The SPSS statistical software for Windows, PASW Sta-

tistics 18, Release 18.0.0 (SPSS, Inc., Chicago, IL, USA)

was used for statistical analysis. Continuous variables

(mean utility scores) were compared using the paired t test

(intragroup comparisons) and the independent t test

(intergroup comparisons). A linear regression was per-

formed using age, race, and education as independent

predictors for each of the utility scores (VAS, TTO, and

SG) for MWL. The chi-square test or Fisher’s exact test

Fig. 2 Anteroposterior photograph of a patient who presented for a

body-contouring consultation accompanied with the clinical descrip-

tion of a massive weight loss scenario

726 Aesth Plast Surg (2011) 35:724–730

123

was used to compare categorical variables. A p value less

than 0.05 was considered statistically significant.

Results

Over a 6-month enrollment period, 114 volunteers partic-

ipated in our survey. Of these volunteers, 14 were excluded

because they rated monocular blindness with a lower utility

score than binocular blindness. This occurrence was likely

due to the participants’ misunderstanding of the survey or

‘‘invalid’’ preference [10, 11]. As a result, 100 of the 114

unique responses (88%) were used for the utility assess-

ment. The excluded participants did not differ from the

study subjects in terms of age (33.6 ± 14.9 vs.

27.86 ± 9.8 years; p = 0.067) or sex (87% [68/78] of the

women vs. 90% [28/31] of the men were included;

p = 0.755). Five participants did not enter their gender.

The predominant race of volunteers was Caucasian (75%)

(Table 1).

All the measures for MWL (VAS, 0.79 ± 0.13; TTO,

0.89 ± 0.12; SG, 0.89 ± 0.15) were significantly different

(p \ 0.005) from the corresponding ones for monocular

blindness (0.63 ± 0.18, 0.84 ± 0.17, and 0.86 ± 0.16,

respectively) and binocular blindness (0.31 ± 0.17,

0.63 ± 0.28, and 0.66 ± 0.27, respectively) except for the

SG utility measure comparing monocular blindness with

MWL (p = 0.072) (Table 2).

The TTO utility scores for MWL of 0.89 ± 0.12 and the

SG utility scores of 0.89 ± 0.15 translate to a willingness

to sacrifice 4 years of their life and to undergo a procedure

with an 11% chance of death to attain perfect health,

respectively.

The MWL utility scores extracted from the VAS did not

differ between the medical students (n = 40; VAS,

0.80 ± 0.12) and the general public (n = 42; VAS,

0.79 ± 0.13) (p = 0.82). The utility scores of the MWL

patient were significantly higher for the medical students

(TTO, 0.91 ± 0.10; SG, 0.93 ± 0.01) than for the general

public (TTO, 0.85 ± 0.14; SG, 0.84 ± 0.19) (p \ 0.05)

(Table 3). No comment was made by 18 participants on

their education. The utility scores for the female partici-

pants did not differ significantly from those for the male

participants.

Linear regression analyses using age, race, and educa-

tion as predictors of each of the utility scores for MWL

showed that age was inversely proportional to the TTO

utility score (p \ 0.05), decreasing a utility score of 0.003

for every increase of 1 year of life. Race was a significant

predictor of VAS utility scores, with Caucasians scoring

0.1 points higher on the VAS than the other races

(p \ 0.01). Both race and education were significant pre-

dictors of SG utility scores (p \ 0.05). Specifically, the

Caucasians scored 0.1 points higher on SG than the other

races, and the medical students scored 0.1 points higher on

SG than the general population.

The respondents rated their own quality of life signifi-

cantly higher than the MWL patients (TTO, 0.93 vs. 0.89;

p \ 0.0001). The Likert scale (Table 4) shows that the

most challenging part of the questionnaire was to imagine

being the person described in the case example. Ten sub-

jects did not complete the scale.

Discussion

Body contouring after MWL addresses aesthetic, func-

tional, and emotional concerns. These procedures not only

allow for the excision of excess skin and fat but also

enhance a patient’s body image and self-confidence,

improve ability to fit clothes, and decrease skin irritation.

However, the associated perioperative risks including

bleeding, infection, and deep vein thrombosis are

Table 1 Demographics of the respondents to the online survey

including age, sex, race, education, and income

n (%)

Mean age (years) 27.89 ± 9.70

Gender

Females 68 (71)

Males 28 (29)

Race

African-American 1 (1)

Asian 7 (7)

Caucasian 57 (57)

Hispanic 3 (3)

Other 8 (8)

Prefer not to answer 24 (24)

Education

Some college 8 (10)

College graduate 18 (22)

Graduate or professional degree 16 (20)

1st year medical student 17 (21)

2nd year medical student 13 (16)

3rd year medical student 8 (10)

4th year medical student 2 (2)

Income

\$10,000 33 (33)

$10,000–25,000 7 (7)

$25,000–50,000 11 (11)

$50,000–100,000 5 (5)

[$100,000 1 (1)

Prefer not to answer 43 (43)

Aesth Plast Surg (2011) 35:724–730 727

123

significant and of concern to the treating plastic surgeon.

There still is no consensus as to whether body-contouring

surgery is a purely aesthetic or functional procedure and

thus whether it should be covered by select health insur-

ance plans. Nonetheless, certain insurance plans more

frequently cover certain procedures (e.g., panniculectomy)

than others (e.g., brachioplasty, lower body lift). Further-

more, it is uncertain whether the potential complications

associated with this procedure outweigh the benefits of

surgical treatment for the stigmata associated with MWL.

Findings have shown that bariatric surgery is a clinically

valuable and cost-effective intervention for morbidly obese

patients [12]. It has been shown that bariatric procedures

effectively decrease body weight and related medical risks

such as diabetes mellitus type 2 and cardiovascular disease.

The incidence of obesity and the number of bariatric pro-

cedures are significantly rising in the developed world.

However, little is known regarding patient quality of life

after MWL compared with that after body-contouring

surgery. Moreover, the literature lacks an objective mea-

sure for quality of life experienced by those living with the

stigmata after MWL who may benefit from body-con-

touring surgery.

We established a measure for the quality of life expe-

rienced after MWL by an Internet population and medical

students. The two sample populations did not differ in

their VAS utility score assessment. The nondiffering VAS

utility scores between the two populations can be

explained by the similar perception of living with the

stigmata of MWL.

The medical students and the sample from the general

population did, however, differ significantly in their TTO

and SG utility score assessments. The medical students

were less likely to trade 2 years of life or risk less than 9%

chance of death for a body-contouring procedure if faced

with MWL stigmata. This finding may be explained by

their higher awareness of the increased risks associated

with such surgery, including death.

Regression analyses using age, race, and education as

independent predictors of MWL utility scores showed that

age was inversely proportional to the TTO utility scores,

decreasing a utility score of 0.003 for every increase of

1 year in age. In other words, the older the volunteers were,

the less likely they were to sacrifice years of life for a

procedure such as body contouring if faced with MWL.

Another independent predictor of the VAS and SG

utility scores for MWL was being Caucasian. Caucasian

participants were less likely to risk a chance of death for

body-contouring procedures. The data suggest that Asians,

Hispanics, and other ethnic groups more negatively per-

ceived the stigmata of MWL because they were willing to

risk a greater chance of death for procedures such as body

contouring. In addition to race, education was an inde-

pendent predictor of the SG utility score, with medical

students scoring 0.1 points higher on SG than the general

population. Thus, medical students were less likely to risk

the chance of death for body-contouring procedures.

In a sample of the general population and medical stu-

dents, although utility scores (VAS, TTO, and SG) for

Table 2 Mean utility score for all the participants using the visual analog scale (VAS), time trade-off (TTO), and standard gamble (SG) to assess

living with the health burden of monocular blindness, binocular blindness, and massive weight loss (MWL)

Method Monocular blindness Binocular blindness MWL Self

VAS 0.63 ± 0.18a 0.31 ± 0.17a 0.79 ± 0.13

TTO 0.84 ± 0.17b 0.63 ± 0.28a 0.89 ± 0.12 0.93 ± 0.11a

SG 0.86 ± 0.16 0.66 ± 0.27a 0.89 ± 0.15

a p \ 0.0001 versus MWL (paired t test)b p \ 0.01 versus MWL (paired t test)

Table 3 Mean utility scores of massive weight loss (MWL) for the

medical students and the sample from the general populationa

Methods Medical students General public p Value

VAS 0.80 ± 0.12 0.79 ± 0.13 0.82

TTO 0.91 ± 0.10 0.85 ± 0.14 \0.05

SG 0.93 ± 0.01 0.84 ± 0.19 \0.05

VAS visual analog scale, TTO time trade-off, SG standard gamblea Comparison between the medical students and the general public

(t test)

Table 4 Likert scale for understanding the survey (5 = strongly

agree)

Item Likert scale

This survey was easy to understand 4.63 ± 0.14

This was not a confusing exercise 4.53 ± 0.15

I understood all the questions above 4.66 ± 0.14

I understood all the cases presented 4.69 ± 0.13

It was easy to imagine myself being the person in the

cases described

3.78 ± 0.21

Values are presented as mean ± standard deviation

728 Aesth Plast Surg (2011) 35:724–730

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MWL were higher than the respective utility scores for

blindness, the utility scores for MWL patients were rela-

tively low (VAS, 0.79 ± 0.13; TTO, 0.89 ± 0.12; and SG,

0.89 ± 0.15). In fact, the SG utility scores comparing

monocular blindness with MWL were similar. This finding

shows that our volunteers were willing to take the same

chance of death for a body-contouring surgery for MWL as

they were for treatment of monocular blindness. Our

sample, if faced with MWL, would have consented to

undergo a procedure such as body contouring with an 11%

chance of death and to trade 4 years of their life.

Living with the stigmata of MWL can now be objecti-

fied with utility scores. In fact, the MWL utility scores

were comparable with the utility scores of other health

states associated with a relatively poor quality of life (e.g.,

erectile dysfunction TTO of 0.89 [13]; monocular blind-

ness TTO of 0.83 and SG of 0.82 [8]; and severe breast

hypertrophy TTO of 0.85 and SG of 0.88 [3]).

A weakness of such surveys is the extent to which the

studied sample population is representative of society as a

whole. This sample bias may limit the applicability of our

data to cost-effectiveness studies. Other issues that arise in

such studies are whether to measure the utilities of patients

who suffer from a given health state or the utilities of a

group of subjects representative of the general population

who are asked to imagine that they suffer from a given

health state. At least one expert panel concluded that utility

assessment should be performed on the latter group [14].

Other studies and reviews have validated the method of

utility assessment of healthy volunteers as opposed to

patients with the disease state [3, 15, 16]. Furthermore, the

method used in this study has been recommended as an

accurate and cost-effective alternative for measuring

quality of life [3]. The large population size of 100 par-

ticipants is however a strength in this study. Furthermore,

we have shown with subgroup analysis that our participants

understood the study and rated utility scores of MWL

despite education level. Moreover, the utility scores for

MWL generated from this study are valid and provide a

cost-effective means that can be appropriately extrapolated

for further understanding of this health state. Further

studies measuring utility scores from patients who have

undergone MWL can be useful, but these studies are sub-

ject to higher costs and the difficulty of volunteer recruit-

ment [3].

Conclusions

We have shown that the quality of life of living with the

stigmata after MWL requiring body contouring is compa-

rable with that of living with monocular blindness, erectile

dysfunction [13], or severe breast hypertrophy [3]. We

have objectified this with a measure of utility scores for

MWL (VAS, 0.79 ± 0.13; TTO, 0.89 ± 0.12; and SG,

0.89 ± 0.12) that can be used for cost-effectiveness anal-

yses and comparison with other disease states. Our sample

population, if faced with MWL, would have undergone a

body-contouring procedure with an 11% chance of mor-

tality and would have been willing to trade 4 years of their

life to attain this procedure. Further ethical and psycho-

logical studies are warranted.

Acknowledgments There was no external financial support for this

study.

Conflict of interest None of the authors have a financial interest in

any of the products, devices, drugs or procedures mentioned in this

manuscript.

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