Quality of life, well-being and aesthetics

Dr Michèle Verschoore

Dermatologist, Sabouraud Center Paris,
Medical Director L'Oréal Research and Innovation.

Clara Gicquel

Sci. Master, L'Oréal Research and Innovation.

 

SUMMARY

Whatever the region of the world, and from all times, aesthetic practices have been a constant for humanity.

This phenomenon generally concerns women more, but men too, depending on the period and the culture.

The following terms are used "Aesthetic practices cosmetic treatments, aesthetic medicine, aesthetic dermatology, and other treatments plastic and aesthetic surgery, to correct, to camouflage a disorder of appearance, a disgrace. 

  • These acts allow everyone to feel aesthetically more pleasing and socially accepted. It is noted that these practices exist in all societies and this whatever the social level.

  • Taking charge of one's appearance contributes to well-being and self-esteem.

  • In recent years, the development of validated scales has made it possible to quantify these benefits through evidence-based studies.

  • We thus demonstrate that good appearance, beauty and health are linked, and we also understand more precisely the variations according to cultural and societal criteria.

Key words: aesthetic practices, cosmetic care, aesthetic medicine, aesthetic dermatology, plastic surgery, hyaluronic acid, botulinum toxin, peeling, mammoplasty, rhinoplastylaser, abdominoplasty, facelift, liposuction, dermatoses, melasma, vitiligo, cancer, measurement scales, aesthetic well-being, quality of life, self-esteem.

AESTHETICS AND WELL-BEING ARE ASSOCIATED WITH GOOD HEALTH

The importance of skin care is not new: Women and men have always given particular importance to their beauty to magnify or even transform their appearance. This phenomenon is found throughout the history of civilizations.

During the period of ancient Egypt, the ideal of beauty for women was already a clear, smooth, hairless and soft skin.

Later, during the ancient Greece, we witness the emergence of skin care, for women but especially for men who practiced cold and hot water baths, followed by massages, scrubs and applications of aromatic perfumes all over the body.

This ritual was the inspiration for the first thermal baths, which developed intensively during the Roman period ; These public relaxation centers combine philosophical discussion, pleasure, health and body hygiene. This link between skin health and well-being is observed.

In the first century A.D., Crito, a Greek physician considered the father of cosmetic medicine was one of the first to integrate the notion of aesthetics into the teaching of medicine.

A century later, Galen will continue this work, integrating the quality of the formulas, the pleasure of the galenic of topical care in a therapeutic goal.

 It is these aspects, enlightened by modern works, which have led to the World Health Organization (WHO) to be modified the definition of good health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

This definition confirms the notion of well-being in human health and in this context we understand better the role of cosmetic products on the well-being as well as that of aesthetic procedures and plastic surgery.

 

 

DERMATOSES: BENIGN BUT CHRONIC

 

THEIR IMPACT ON WELL-BEING AND QUALITY OF LIFE

Skin diseases are rarely life-threatening but they are visible, both to oneself and to others. It is this Their particularity and frequent chronicity alter the quality of life, and make their management essential.

Skin color pathologies, such as hyper or hypopigmentation are two frequent examples, they are not well experienced by the majority of patients.

 

THE VITILIGO

This common skin pigmentation disease manifests itself as white patches that can affect the entire body, and affects approximately 1% of the population, both women and men.

The impact on the quality of life of patients, with loss of self-confidence, social isolation and a feeling of shame about exposing one's skin, are frequently found. 

  • The VitiQOL is a vitiligo-specific scale validated by Lilly et al in 2013 to specifically assess the impact of this dermatosis on quality of life. A study on 198 patients with vitiligo measured the significant alteration in quality of life according to the severity of the disease: the more extensive the skin damage, the more altered the self-esteem.

  • The VitiQOL assesses stigma, social embarrassment and behavioral impact of the disease. Women, young adults, and those with more than 5-10 years of disease had significantly impaired quality of life (p = 0.02). It has been shown that these impairments in self-esteem are an aggravating factor in the prognosis of the disease and are associated with a greater risk of recurrence.

  • It is thanks to these specific standardized scalesThe link between psychology, social relations and skin diseases has been clarified.

  • The oldest and most used because it applies to all dermatoses is le DLQIdeveloped and validated by Finlay in 1994.

  • This Dermatology Life Quality Index (DLQI) consists of ten questions that can be easily used in clinical practice. Not only can the negative impact of a dermatosis be measured, but also the improvement when skin lesions are made less visible with appropriate cosmetic measures. In one study, not only quality of life was assessed with the DLQI but also psychological distress with the validated GHQ-28 scalein 300 patients with vitiligo and 300 controls.

  • This General Health Questionnaire-28, contains 28 questions measuring severe depression, anxiety, social dysfunction and somatic symptoms. Psychiatric disorders were more common in young, unmarried women with a duration of illness greater than 5 years. The mean global DLQI score was 6.71 indicating a moderate grade impact on average but in 65 patients (21.7 %) the impairment was severe. The quality of life was more degraded in single, young people with a disease duration of more than 5 years.

These two scales confirm that the impact is not only emotional and social but also psychiatric.

Thanks to adapted make-up techniques, we can cover vitiligo lesions that allow for immediate satisfaction as demonstrated in numerous studies.

Levy et al collated these studies in 2012 on a total of 544 patients [7], demonstrating the indispensable role of these camouflage techniques, a true therapeutic weapon for vitiligo, regardless of country and skin color [8].

 

 AND ALSO DURING MELASMA

Melasma, is a frequent dermatosis too, it is characterized by yourhyper-pigmented skin generally on the photo-exposed areas of the skin: the face, neck, décolleté and sometimes the arms.

This heterogeneous pigmentation Melasma is not well received, with a perception of dirty skin, and consistently affects well-being and self-esteem. In India melasma is the leading cause of facial melanosis.

A study of 104 patients demonstrated the correlation between the severity of melasma and the impact on self-esteem: mild to moderate damage (0-8) is associated with a low score DLQI (9,34). Conversely, significant melasma extension (> 16-24) is associated with a score DLQI high (15.33).

Thanks to a clinical severity scale for melasma, M-MASI (Modified Melasma Area and Severity Index),  it was concluded that women (score 10.19) are more affected than men (score 9.27), as well as young people (score 10.52) are more impacted than the elderly (score 7.44). But here, it is when the disease is recent that the DLQI is the highest (score 11). In patients who have been affected for more than five years, a form of tolerance to the discomfort seems to develop (score 7.71).

A simple measure to prevent and reverse melasma consists of the daily use of a broad band" filtration sunscreen i.e. broad spectrum, effectively filtering in UVA, thus limiting induced UV pigmentation.

In a recent study in India [10], the 100 patients only applied a broad spectrum sunscreen (SPF 19, PA +++) three times a day to the affected areas (Garnier White Complete R) for 12 weeks, their MASI (Melasma Area Severity Score) decreased on average from 12.38 to 9.15 and quality of life (Hi-MELASQoL, specific scale validated in India) fell from 47.2 to 38.1. These results confirm the link between melasma and quality of life and demonstrate the positive impact on quality of life with only appropriate cosmetic photo-protection.

With another cosmetic-specific quality of life scale, the BeautyQoL, A study was conducted on 88 women, phototype III and IV, with facial aesthetic imperfections (acne scars, chicken pox, melasma, etc.).

Thanks to the daily use of a covering cream and a loose powder that camouflages the lesions, a significant improvement (p < 0.05) in quality of life was observed after 3 weeks, particularly in the "self-confidence" dimension, and this from the first week.

These benefits induced by cosmetics could depend on social, cultural and geographical factors, which is why it is interesting to quote the review of 18 studies, carried out in eleven different countries: France, Taiwan, Australia, Japan, Belgium, Canada, etc... including a total of 912 patients with vitiligo, melasma or acne scars.

For seven of these studies, the DLQI decreased significantly after the first application.

This review shows that, whatever the type of skin: fair, intermediate or dark, and whatever the culture, we confirm the improvement of the quality of life thanks to cosmetics which significantly decrease the display character of these dermatoses.

 

BEAUTY, WELL-BEING AND CANCER

and cosmetic care

During serious pathologies such as cancer, quality of life is altered by the disease itself and its symptoms, but also by the often severe cutaneous effects of anti-cancer treatments, leading to aesthetic and functional problems.

A 2014 study of 73 women with breast cancer quantifies the impact of these side effects on Quality of Life (p = 0.005) [13].

In this particular context, the use of adapted cosmetics is essential. 

High tolerance emollients (Lipikar Balm APÒ) after 6 weeks of twice-daily application, a significant improvement in Quality of Life measured by the DLQI (score 2 for standard care and score 1.3 for cosmetic care).

The "symptoms and feelings" domain is significantly improved by facials from the fourth week compared to standard care (p = 0.006.)

This cosmetic treatment not only allows patients to find comfort during their treatment but also better adherence to cancer treatments by reducing the discomfort of their cutaneous side effects.

Taking care of one's skin and appearance allows women to regain their self-confidence and to better apprehend the disease and maintain a sense of well-being. 

 

AESTHETIC PROCEDURES 

FOR THE IMPROVEMENT OF SELF-ESTEEM

Rejuvenation procedures such as hyaluronic acid, botulinum toxin or peelings are very frequently practiced and have one thing in common: they have immediate effects on well-being and quality of life.

First of all, botulinum toxin, used in aesthetic medicine since 1997 in France, introduced later in 2003 in the USA.

This toxin, administered in the form of injections, reduces the signs of skin aging, particularly facial wrinkles (frown lines, crow's feet) and smoothes the neck by relaxing the unsightly contractions of the platysmal bands.

A 2010 American study shows that botulinum toxin type A improves quality of life and self-esteem in 100 patients aged 25 to 73 years.

Thanks to a methodology randomized, double-blind, placebo-controlledA significant difference between the treated group and the placebo group is demonstrated.

To measure quality of life and self-esteem, the following two questionnaires were used before the injections, then two weeks, and three months after the procedure:

  1. "Quality of Life Enjoyment and Satisfaction Questionnaire - Short Form. (QLESQ-SF)

  2.  "Heatherton and Polivy State Self-Esteem. (HPSS)

The group treated with botulinum toxin A showed a significant improvement (p < 0.05) on the following criteria: global self-esteem, self-esteem related to appearance, self-esteem related to social life and performance.

This study clearly demonstrates the positive impact on quality of life and well-being of wrinkle treatments with botulinum toxin injections. Patients gain in appearance, social life and performance, particularly through the erasing of facial wrinkles, especially those of the glabella.

Other anti-aging procedures that are very frequently used, called fillers, are injections most often based on hyaluronic acid.

Introduced in Europe in the early 2000s, These injections fill in wrinkles, correct loss of facial volume, smooth the skin surface and improve skin hydration. Many publications report not only the immediate quantifiable effect of these injections on the erasing of wrinkles but also the repercussions on the quality of life and the well-being of the treated patients.

  1. In a study conducted in 2020, it was estimated that the positive impact of hyaluronic acid injections on the subjective perception by the patients themselves, thanks to at My Skin" questionnaire specifically developed. In these 57 women (age 35-55 years), treated for facial wrinkles, skin improvement was positively correlated with a greater sense of autonomy (p = 0.028) et of well-being (p = 0,008). The most significant improvements in well-being are found in older women, menopausal or not.

  2. We should also mention the very interesting prospective study done in Germany on 145 patients, average age 50, who received botulinum toxin and/or hyaluronic acid injections compared to a database control group (BGR 2013). In the group of women who have their wrinkles treated, they are less overweight, more often single, have a higher level of education, and their quality of life evaluated by WhoQOL and BFI-10 is superior. These women do not show more signs of dysmorphic disorders than the control group who do not have their wrinkles treated.

In other situations such as facial lipo-atrophies of patients treated for HIV, social stigma can be extreme.

And there too, correct the appearance with fillers, hyaluronic acid or autologous fat grafting, allows a significant improvement not only of the atrophy of the cheeks, but at the same time will have a positive psychological impact, well demonstrated in many studies, on the well-being and quality of life.

Combination treatments have also been evaluated and reported to improve quality of life during wrinkle treatments combining botulinum toxin and hyaluronic acid.

During 6 months, the 60 patients (50 women, 10 men) aged 18 to 64 years (phototypes II to V) had a improvement of their well-being (World Health Organization -Five Well-Being Index, WHO-5) and their self-esteem (Heatherton & Polivy State Self-Esteem Scale, HPSS). 

These improvements in well-being were significant as early as the third week (p = 0.008) and persisted at 6 months (p = 0.037). Similarly, for self-esteem, the improvement was significant at 3 weeks (p < .001), and persisted 4 months later (p = .002) as well as at 6 months (p = .006).

These methodologies have also been used to evaluate the impact on well-being of peels that have long been used in aesthetics.

This procedure of smoothing the skin surface allows a more or less deep exfoliation of the skin thanks to active ingredients such as TCA, AHA, often associated with vitamin complexes, depigmenting agents, etc... They reduce superficial fine lines, treat hyperpigmentation spots, acne scars, and improve the surface appearance of the skin.

Thanks to these multiple properties, peels have a significant effect on the quality of life. 

A study conducted in the USA showed that DLQI improved the quality of life of patients treated with salicylic acid peel to reduce post-inflammatory hyperpigmentation lesions [20].

In these dark phototype patients (IV-VI), on the side of the face, treatment of the spots significantly reduced them and the quality of life measured by DLQI was significantly improved (8.4 before the peel, 6.7 two weeks after treatment).

This improvement in self-esteem is also observed in adolescents, a critical period of life when body image is very emotionally charged, and acne lesions and their scars clearly worsen self-esteem.

Peelings used for therapeutic purposes in 67 adolescents for their acne, scars etc.... and 59 others for purely aesthetic reasons, clarity of complexion, imperfections, resulted in a significant improvement in quality of life scores measured by the RSES (Rosenberg Self-Esteem Scale) regardless of the reason for requesting the peels.

Thanks to these numerous validated scales, these studies confirm the beneficial influence on well-being of peeling procedures, a procedure that has certainly been used for a long time, but which is still relevant today, as patient satisfaction is well demonstrated.

 

AND PLASTIC SURGERY?

For the sustainability of satisfaction and the long-term effect on body image.

If there is one area in which facial surgery is unquestionable, it is post-traumatic facial reconstruction. On the other hand, what have we not heard about the motivations of facial plastic surgery and their protagonists.

If indeed, the more emotional characteristics of women who have a facelift are real, the beneficial consequences on well-being are no longer disputable and thanks to validated Quality of Life scales, the quantification of these benefits is now widely demonstrated.

In a 2014 Indian study, The authors have shown that cosmetic and reconstructive surgery has an impact on the quality of life of patients. 

In this study, 91 patients, 43 of whom had surgery for cosmetic reasons and 48 had reconstructive surgery. Quality of life before and then 3 months after surgery was measured by two different scales: Short Form (SF)-36 and BCS. 

  1. The SF-36 is a scale for assessing mental health, vitality and general social role, while the BCS(Body Cathexis) assesses the level of satisfaction with body image.

  2. The BCS shows that body image was worse before the intervention and that alterations in body image perception were almost constant.

After surgery, the scores were significantly improved: 148.38 to 168.38 for reconstructive surgery and of course to a lesser extent, 153.44 to 166.81, for cosmetic surgery.

With regard to SF-36 scale, the average scores show that before surgery well-being, especially its emotional dimension is, as expected, much lower before reconstructive surgery (11.81) than before cosmetic surgery (44.96).

After surgery, both scores increased to 80.56 and 86.05, respectively.

The gain is dramatic after reconstructive surgery. Interestingly, after the surgery, the levels of well-being are similar for both groups.

A 3-year study conducted in Canada, on 93 patients, including 82 women, operated for a rhinoplasty (49%) or a anti-aging surgery (51%) was used to assess quality of life by the scale DAS-59 (59-item Derriford Appearance Scale) [23]. This validated scale assesses psychological distress associated with self-confidence and facial appearance.  

DAS-59 is comprised of 57 self-assessment items that are divided into six areas:

  1. general awareness of appearance,
  2. social awareness of appearance,
  3. self-awareness of sexual and body appearance,
  4. negative self-image,
  5. self-consciousness of the facial appearance,
  6. physical distress and dysfunction.

After rhinoplasty, overall scores for general self-awareness and negative self-image were significantly improved.

For anti-aging surgery, DAS-59 has been improved for the facial and body appearance satisfaction domain.

Cosmetic surgery has a positive effect on quality of life by enriching overall well-being, sense of satisfaction and confidence.  

We can see that cosmetic surgery is not just a futile "desire" but a social concern, a reinforcement of self-confidence.

Given the multiplicity of scales for assessing well-being and quality of life, it was useful to bring all these studies together in a meta-analysis. 

In 2016, Dreher R et al. pooled 20 qualitative and 16 quantitative studies published in PUBMED or LILACS. 

These studies, which involve a total of 1614 patients, have shown and confirmed that cosmetic surgery improves quality of life.

This is the mammoplasty which is the most practiced aesthetic operation (12 studies) and which most intensely improves well-being compared to other aesthetic procedures.

Body contouring also called "Body Contouring uses surgical techniques.  Either they are normal weight patients, called "aesthetic" patients, or most often following a massive weight loss after bariatric surgery, when the weight loss is at least 50% of the excess compared to a normal Body Mass Index (BMI) of 25kg/m2.

In fact, in these patients who gradually regain a weight in almost normal values, the dissatisfaction of body image persists because of an unsightly and often functionally embarrassing excess of skin, especially on the abdominal wall.

It is precisely for these situations that the Body-QOL has been developed, it measures different areas:

  1. body satisfaction

  2. self-esteem and social performance

  3. sex life

  4. physical symptoms.

The Body-QOL was used to compare the consequences of body contouring surgery on self-esteem and well-being in patients who had undergone massive weight loss or in control patients who had undergone cosmetic abdominal surgery outside the context of massive weight loss (20 and 92 patients respectively).

The surgical procedures performed consisted of:

  1. abdominoplasty

  2. liposuction

  3. lipo-abdominoplasty,

  4. and/or lower body lift.

If preoperatively, Body-QOL scores were lower for the massive weight loss cohort (33.9) than the cosmetic surgery cohort (46.1); postoperatively, the scores of the two cohorts were not significantly different (P = 0.223 at 9 months and P = 0.1133 at 2.7 years).

It is interesting to note a plateau effect at 3 months and maintained throughout the observation period, meaning sustainability of satisfaction and the long term effect on body imageincluding for so-called "aesthetic" patients. 

THE FACE-Q 

Featured for the first time, personal satisfaction of patients 

regarding the clinical outcome of the aesthetic procedure is an essential measure.

Their quality of life was measured using the FACE-Q in a study of 31 patients. 

The FACE-Q is a  validated scale that takes into account the results reported by the patient on their satisfaction with the appearance of their face, the appearance of their skin and also their evaluation of the improvement of their wrinkles, after treatment with laser, filler injections: hyaluronic acid or botulinum toxin.

The results show an improvement in all three measured parameters:

        1. From 48.4 to 73.4 for facial appearance

        2. From 43.7 to 66.9 for the appearance of the skin,

        3. And from 55.2 to 66.8 for the wrinkle assessment.

This study using the FACE-Q scale demonstrates the importance of the patient's perspective in the success of cosmetic procedures and the positive impact of cosmetic procedures on quality of life. 

This approach complements the many studies that have proven significant impact aesthetic procedures and interventions on quality of life and self-esteem, by linking it to the change in clinical signs observed by the patients.

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[19] Molina B, David M, Jain R, et al. Patient Satisfaction and Efficacy of Full-Facial Rejuvenation Using a Combination of Botulinum Toxin Type A and Hyaluronic Acid Filler. Dermatol Surg. 2015;41 Suppl 1: S325-S332. doi:10.1097/DSS.0000000000000548

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Dr Michèle Verschoore
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