INTRODUCTION
Unlike other fields of medicine that use mortality and morbidity rates as a basis for evaluation, patient satisfaction is an important factor in plastic surgery, one that affects quality of life [
1,
2]. Therefore, it is important to understand the factors that affect the level of patient satisfaction. Understanding these factors may give doctors an opportunity to implement changes to reduce the conditions that adversely influence patient satisfaction.
In plastic surgery, some patients show dissatisfaction despite good aesthetic results. Some patients are dissatisfied due to psychiatric problems, but in most cases, the correlation between patient dissatisfaction and mental condition has not been understood clearly [
3]. The authors have experienced low patient satisfaction with esthetic suture in thyroidectomy through transverse cervical incision, even though they were objectively assessed as having had good esthetic results. The authors believed other factors could have influenced patient satisfaction with cosmetic surgery. According to a literature review on patient satisfaction [
4], a total of 122 studies on functional and cosmetic aspects as well as all other issues have been reported. Most of the studies were on patients' feelings of satisfaction; however, there were no studies on patients' preoperative levels of familiarity with wound healing factors and patient expectations that influence on the patient satisfaction.
In this study, personal factors that affected the satisfaction levels of patients who underwent esthetic suture in the course of a thyroidectomy through a transverse cervical incision were investigated. The purpose of this study was to identify personal factors that influence patient satisfaction and to provide patients with an appropriate explanation and education before their surgery in an attempt to enhance the level of patient satisfaction.
DISCUSSION
According to Ware et al. [
6], the factors that affect patient satisfaction include interpersonal manner, technical quality, accessibility/convenience, finances, efficacy/outcomes, continuity of care, physical environment, and availability of care and resources. Clapham et al. [
4] modified Ware's taxonomy to make it applicable to the field of plastic surgery; they classified the factors that affect patient satisfaction after cosmetic surgery into three groups: provider-related issues, efficacy/outcome, and all other issues. The efficacy/outcomes were classified into three factors: the aesthetic outcomes, the functional outcomes, and the psychological outcomes. In addition, they conducted a literature review on 178 studies with regard to the factors that affect the patient satisfaction level after plastic surgery. They found that most studies were about cosmetic and functional factors, with the remainder focusing on the general feeling of satisfaction.
In conceiving this study, the authors suspected that, other than the aforementioned factors, there might be personal factors that affect the satisfaction level. In particular, in this study, not only the preoperative familiarity level with wound healing factors, the level of expectation regarding the surgery results, and the reasons for deciding to undergo esthetic suture were investigated, but also demographic factors such as age and education level, in order to evaluate the influences on the satisfaction level. In this study, age did not affect satisfaction. Chung et al. [
7] conducted a study on the prognosis of plastic surgery outpatients and reported that the patient age did not significantly affect satisfaction level. This conclusion coincides with that of this study. In this study, most of the subjects were high school graduates, followed by college graduates and middle school or lower school graduates. According to a study that reported on the expectations of patients regarding orthognathic surgery [
8], the satisfaction level did not show differences according to education level; and in the aforementioned studies, the education level likewise did not affect the satisfaction level. The perceived sufficiency of the doctor's explanation did not significantly affect the satisfaction level. This might have been because the explanation was repeated by the same doctor in all cases and the satisfaction level was evaluated six months postoperatively.
The correlation analysis in this study showed that the level of familiarity with factors affecting wound healing; the expectation level of the results; pain; itching sensation; and the observer scale were significantly correlated with the satisfaction level. The multiple regression analysis showed that the level of familiarity with factors influencing the healing process, the itching sensation, and the observer scale independently affected the satisfaction level. The independent evaluation of the expectation regarding the results in relation to the other factors showed that they did not significantly affect the satisfaction level. In clinical situations, the functional and aesthetic results are important factors that affect the level of satisfaction with cosmetic surgery. The satisfaction level seriously deteriorates when a hypertrophic scar develops, and the aesthetic and functional results are significantly worse than compared with those of normal scars [
4,
9]. Therefore, the authors thought that the factors that affect the satisfaction levels of hypertrophic scar patients might differ from the factors that affect the satisfaction levels of patients with flat and linear scars but without hypertrophic scars. To investigate the factors that affect the satisfaction levels of patients without hypertrophic scars, ten hypertrophic scar patients were excluded from the multiple regression analysis. Only the familiarity level with wound healing factors and the expectation level of the results were confirmed to have affected the satisfaction level. In this study, the functional and aesthetic results, such as the itching sensation and the observer scale, significantly affected only ten hypertrophic scar patients. Therefore, the satisfaction levels of most of the patients may not have depended only on cosmetic and functional factors. This is considered an important fact that plastic surgeons, who tend to concentrate on the aesthetic results of cosmetic surgery, should keep in mind. According to the studies on patient satisfaction conducted by Olson and Laskin [
8] and Mira et al. [
10], doctors' explanations of the anticipated surgical process, the completed surgical process, and the follow-up management significantly affected the level of satisfaction. Therefore, detailed preoperative explanations of the wound healing process may enhance the familiarity with factors that affect the process, and adjusting any unreasonable expectation levels may enhance patient satisfaction. This result is considered to apply not only to patients who undergo esthetic suture after typical thyroidectomy, but also to general cosmetic surgery patients. As for other types of cosmetic surgery, recognition of the factors that affect the results of the surgery may need to be enhanced.
In multiple regression analysis, to determine the factor that most affected the satisfaction among 4 factors (familiarity with wound healing factors, expectations, observer scale, itching), standardized coefficients were used because standardized coefficients represent the relative influence among the 4 factors that explain satisfaction. That the standardized coefficients were differentiated according to the 4 factors means that when the 4 factors had a simultaneous effect, the factor that had the highest standardized coefficient influenced satisfaction the most.
For this study on the factors that affect the patient satisfaction level after cosmetic surgery, patients who underwent esthetic suture after typical thyroidectomy through transverse cervical incision were selected. This is because, unlike other cancer patients, most thyroid cancer patients are young, the majority of the patients are female, the postoperative incision site is not covered with clothing [
11], and the patients and their families are very sensitive to scars because thyroidectomy is not life-threatening despite being a cancer surgery [
12-
14]. In the authors' hospital, more and more patients, especially young female patients, elect to undergo esthetic suture after thyroidectomy. In this study, the general factors, including the surgeons, and the cosmetic, functional, and mental factors that can affect the satisfaction level, were better-controlled for than those in other types of cosmetic surgery. Accordingly, it is believed that the influence of personal factors, such as the patient's preoperative expectations of the postoperative satisfaction level were well investigated in this study.
The items in the preoperative survey were devised to evaluate the personal factors that we hypothesized would have an effect on patient satisfaction (demographics, level of familiarity with factors affecting the wound healing process, reason for choosing aesthetic closure, expectation level of the result, level of preoperative explanation). Among those factors, factors that would affect wound healing were designed to include both local factors and systemic obstacles [
5]. The items in the postoperative survey were designed to evaluate cosmetic and functional results as well as the level of patient satisfaction. Since the cosmetic and functional results significantly affect the satisfaction level, an exact evaluation of the factors is important. In this study, the POSAS was used to evaluate the cosmetic and functional results. This method is deemed useful for linear scar evaluation and burn scar evaluation [
15,
16]. Patients may have more diverse problems than observers recognize, and their own perspectives can influence their quality of life [
17]. Functional factors, such as itching sensation and pain, have usually not been evaluated by observers, but they were evaluated in this study using a patient scale, along with the effects of the functional factors on the satisfaction level.
The limitation of this study was that not all the factors that affect the satisfaction level were considered. In an attempt to include as many factors that affect the satisfaction level as possible, cosmetic and functional factors were evaluated. In the multiple regression analysis where the familiarity with factors affecting the wound healing process, the expectation of the results, itching sensation, and the observer scale were independent variables and the satisfaction level was a dependent variable, the adjusted coefficient of determination was calculated to be 0.242. Accordingly, the integrated effect of the independent variables on the satisfaction level was 24.2%. In the analysis without the hypertrophic scar patients, the effect of the independent variables on the satisfaction level was only 27.2%. This implies that there may be items that significantly influence the satisfaction level other than those that were used in this study. In future studies, these factors may need to be added and evaluated to enhance the satisfaction level.
In conclusion, when the hypertrophic scar patients were excluded, the functional and esthetic results did not affect the satisfaction level; and with an increase in the familiarity with the factors that affect wound healing and decrease in the level of expectation regarding the results, the postoperative satisfaction level improved. Therefore, regardless of the cosmetic and functional results (except with respect to hypertrophic scar patients), sufficient preoperative explanation of the results of cosmetic surgeries and adjustment of the expectation level may contribute to enhanced postoperative patient satisfaction.