DAS59 - Derriford Appearance Scales

British Journal of Plastic Surgery (2001), 54, 216–222
© 2001 The British Association of Plastic Surgeons
doi:10.1054/bjps.2001.3559
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. © 2001 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, 1998.
216
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

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 Inventory23 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).

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’ 3.3 1.7 �48
8. taking a special interest in others’ ‘features’ 2.3 1.8 �21
10. avoiding photography 2.1 1.4 �34
12. being hurt by others’ comments 2.1 1.4 �35
15. raising subject of the ‘feature’ in conversation
before others do
1.8 1.3 �25
17. being irritable at home 1.8 1.2 �34
27. feel unattractive 2.9 1.6 �45
28. feel unlovable 1.8 1.2 �35
30. feel embarrassed 2.9 1.5 �46
31. feel inferior 2.0 1.2 �40
35. distress when others make remarks 2.7 1.2 �55
34. distress when others stare 2.6 1.2 �54
36. distress when others ask about the ‘feature’ 2.2 1.2 �47
38. distress when seen in a particular view 2.2 1.1 �51
41. distress when ‘feature’ seen in a mirror/window 2.8 1.4 �46
42. distress when meeting strangers 2.0 1.1 �46
58. how hurt do you feel? 2.7 1.8 �34
Social self-consciousness of appearance (SSC) (variance: 18.47%; reliabilities: alpha�0.95, test–retest�0.70)
2. avoiding children in the street 1.0 0.9 �9
3. difficulty making friends 1.4 1.1 �22
5. avoiding school/college/work 1.0 0.9 �7
6. avoiding pubs/restaurants 1.3 1.0 �24
7. avoiding parties/discos 1.5 1.1 �26
13. avoiding department stores 1.1 0.9 �14
14. avoid leaving the house 1.0 0.9 �9
16. closing into a shell 1.8 1.2 �30
18. being misjudged 1.5 1.1 �24
19. previous avoidance of school/college/work 1.1 1.0 �15
20. feeling an embarrassment to friends 1.4 1.0 �28
21. feeling a freak 1.6 1.1 �32
22. worrying about sanity 1.2 1.0 �15
29. feel isolated 1.7 1.1 �33
32. feel rejected 1.6 1.1 �30
33. feel useless 1.4 1.1 �24
39. distress when going to school/college/work 1.0 0.7 �34
40. distress when on public transport 0.9 0.7 �30
47. distress when not being able to go to social events 1.2 0.6 �46
50. distress when not being able to go to pubs/restaurants 1.0 0.6 �37
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 1.6 1.1 �31
9. avoiding communal changing rooms 2.3 1.5 �33
23. adverse effect on sex life 1.8 1.2 �34
24. adverse effect on marriage 1.4 1.3 �9
37. distress when going to the beach 2.1 1.2 �44
43. distress from being unable to wear favourite clothes 2.2 1.0 �54
45. distress from being unable to go swimming 1.8 0.9 �52
46. distress from being unable to play games 1.4 0.6 �56
49. distress from being unable to look in the mirror 1.8 0.9 �50
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? 3.6 2.6 �26
54. how secure do you feel? 3.3 2.5 �22
55. how cheerful do you feel? 3.1 2.4 �23
56. how normal do you feel? 3.4 2.3 �31
57. how masculine/feminine do you feel? 3.2 2.3 �28
Facial self-consciousness of appearance (FSC) (variance: 5.61%; reliabilities: alpha�0.74, test–retest�0.51)
11. avoid getting the hair wet 1.2 1.0 �16
44. distress from being unable to change hairstyle 0.7 0.5 �39
48. distress from being unable to answer the front door 0.4 0.4 �5
51. distress from being unable to go out in windy weather
Not loading on a specific factor
0.5 0.4 �24
53. how irritable do you feel? 2.7 1.8 �34
59. how hostile do you feel? 2.0 1.5 �24

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 123 124.2 48.2 28.5 14.9 27.3 1.8
breast reduction 125 123.6 44.4 32.8 15.7 24.8 1.8
breast augmentation 49 119.7 46.1 27.1 17.2 24.7 1.6
otoplasty, men 31 113.8 42.3 29.5 16.6 13.6 6.3
gynaecomastia 34 110.6 42.2 28.5 13.1 20.9 2.2
mastopexy 20 107.4 38.4 23.6 16.3 22.1 2.7
rhinoplasty, women 128 103.2 42.6 25.9 14.5 11.1 4.4
breast asymmetry 13 102.5 34.1 26.7 15.1 21.2 2.5
otoplasty, women 47 101.1 35.7 24.1 15.5 14.8 7.5
breast reconstruction 11 95.1 32.7 21.3 15.8 21.6 1.2
rhinoplasty, men 80 83.2 30.5 22.2 14.9 8.7 2.6
facelift, women 32 77.6 32.2 16.7 13.8 8.7 2.4
cosmetic, women 698 112.1 43.4 26.7 15.2 20.4 2.5
cosmetic, men 116 89.4 32.9 23.7 14.4 11.6 2.5
reconstructive, women 287 103.6 40.8 24.1 14.7 15.3 4.2
reconstructive, men 147 96.8 37.1 24.4 15.4 10.9 3.7
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, 31–60
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) 18–30 31–60 61� 18–30 31–60 61� 18–30 31–60 61�
Men
minimum 8 8 8 30 8 9 26 10 10
Q1 17 13 12 66 57 24 73 58 29
Q2 28 21 19 83 77 35 93 85 64
Q3 46 51 46 107 97 74 124 118 76
maximum * 70 76 71 153 143 137 174 179 130
mean 33.3 32.0 29.3 85.5 76.7 52.6 98.3 89.8 60.6
(�s.d.) (18.5) (22.0) (20.7) (34.2) (33.3) (42.3) (38.1) (44.4) (34.8)
n 50 156 80 60 80 16 146 121 27
Women
minimum 8 8 8 21 13 17 17 11 12
Q1 15 12 12 63 55 44 88 71 53
Q2 37 17 19 83 77 60 110 102 76
Q3 59 23 28 102 104 80 144 131 109
maximum * 92 56 57 160 161 114 172 191 155
mean) 40.0 22.0 24.0 86.1 82.2 62.6 115.3 103.9 81.4
(�s.d.) (26.2) (16.9) (16.3) (37.1) (39.2) (25.6) (38.4) (43.4) (36.8)
n 57 123 61 102 188 27 400 637 67
* 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 583 000 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: 18–30 years), mid-adulthood
(age: 31–60 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�0.0001). 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

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 59 112.3 (38.1) 43.3 (13.6) 24.8 (15.6) 16.0 (4.1) 24.8 (15.6) 1.5 (2.0)
postoperative 59 46.2 (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�0.0001 P�0.0001 P�0.0001 P�0.0001 P�0.0001
percentage change
Facial features
�59 �67 �50 �39 �71 �13
preoperative 63 83.0 (36.0) 35.9 (13.9) 20.1 (13.6) 13.8 (4.0) 7.9 (6.4) 3.1 (3.6)
postoperative 63 45.0 (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�0.0001 P�0.0001 P�0.001 P�0.0001 P�0.01
percentage change
General population
�46 �56 �45 �30 �30 �48
total 1001 53.1 (38.9) 17.9 (16.9) 20.3 (21.5) 6.9 (7.9) 11.7 (4.2) 1.9 (2.6)
unconcerned 529 29.3 (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�0.0001).
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’

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.
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The Authors
David L. Harris MS, FRCS, Honorary Consultant in Plastic Surgery
Department of Reconstructive Plastic Surgery, Plymouth Hospitals
NHS Trust, Derriford Hospital, Plymouth, Devon PL6 8DH, UK.
Anthony T. Carr BSc, PhD, DipClinPsychol, CClinPsychol, Head of
Clinical Psychology
Clinical Teaching Unit, Department of Psychology, University of
Plymouth, Plymouth, Devon PL4 8AA, UK.
Correspondence to Mr David Harris MS FRCS, The Consulting Rooms,
Nuffield Hospital, Derriford Road, Plymouth PL6 8BG, UK.
Paper received 23 May 2000.
Accepted 21 November 2000, after revision.