INTRODUCTION
The search for greater objectivity in evaluating treatment results is necessary to
improve the levels of evidence, especially in plastic surgery, whose main objective
is subjective, to improve quality of life (QoL)1.
In the literature, it is clear that the mechanisms for objective measurement of results
in cosmetic procedures are still in their infancy, but they point to a tendency to
use tools to measure results reported by patients themselves (PROM or PRO) through
questionnaires2. Fortunately, there are already great advances in this area, with the publication
of several articles proposing questionnaire models3,4.
The Breast-Q, Face-Q and Satisfaction with Facial Appearance Scale and Skindex tools,
for example, have gone through a rigorous validation process and are fully compliant
with US Department of Drug Control (FDA) acceptance requirements, and they stand out,
together with Skindex, concerning the other PROMs, according to Morley et al.2,3.
Kosowski et al.4 found 442 articles evaluating results in aesthetic, surgical or non-surgical procedures.
Among these, 47 were specific for facial appearance, but only 9 met the study’s inclusion
and exclusion criteria. None of them satisfied all the guidelines. All tools proved
to be limited, either by their development, validation, or content. In the same study,
only the Blepharoplasty Outcomes Evaluation (BOE) was specific for blepharoplasty4.
The BOE was described by Alsarraf et al., along with other questionnaires in English
specific to skin rejuvenation and facial procedures (Skin Rejuvenation Outcome Evaluation
- SROE), rhinoplasty (Rhinoplasty Outcome Evaluation or ROE) and rhytidectomy (Facelift
Outcome Evaluation - FOE). )5,6.
Such questionnaires address the physical, mental and social aspects necessary for
a good evaluation.3.4. The BOE questionnaire was tested regarding its validity, reliability and responsiveness
presented as a reliable quantitative tool for measuring results2,5,7.
The internationalization of these questionnaires, in turn, allows the comparison of
treatment results between different populations. However, some care must be taken
so that there are no distortions due to failures in translation or cultural differences
that alter the results of the questions, per se. This would decrease the interpopulation
comparative value8,9. Of the four Alsarraf questionnaires, the ROE (Rhinoplasty Outcome Evaluation), the
FOE (Facelift Outcome Evaluation), and the SROE (Skin Rejuvenation Outcome Evaluation)10 had already been translated into Portuguese, leaving only the BOE (Blepharoplasty
Outcome Evaluation) to which this study refers11.
The BOE is composed of six questions (Annex 1). Each answer can be graded from 0 (least satisfied possible) to 4 (most satisfied
possible). The marked values must be added, divided by 24 and multiplied by 100, to
obtain a score from 0 to 100, with 0 being the least satisfied possible and 100 being
the most satisfied possible6.
Such an instrument can be very useful for developing scientific studies and for the
follow-up of results by plastic surgeons.
Thus, the objective of the present study is to translate and culturally adapt the
BOE questionnaire into Brazilian Portuguese.
OBJECTIVE
Translate and culturally adapt the Blepharoplasty Outcome Evaluation (BOE) questionnaire
to Brazilian Portuguese.
METHODS
The study was authorized by the Research Ethics Committee of the Federal University
of Ceará, under protocol number 33290513.8.0000.5589, and performed in a private clinic
in 2019.
The BOE questionnaire was translated and culturally adapted to Brazilian Portuguese
according to the methodology proposed by Guillemin et al.12. This methodology consists of five stages (Figure 2) and is accepted in the literature for translating several other instruments8.
Figure 1 - Flowchart of the translation and cultural adaptation methodology proposed by Beaton
el al.8.
Figure 1 - Flowchart of the translation and cultural adaptation methodology proposed by Beaton
el al.8.
Translation
Stage 1 the questionnaire was submitted to two translations (T1 & T2) from English to Portuguese.
One of them was performed by a lay translator and the other by a plastic surgeon translator,
with experience in the procedure, as recommended in the literature.
Stage 2 (Synthesis): The T1 and T2 Portuguese versions of the questionnaires were evaluated
by both Stage 1 translators. The translators discussed the differences between their
versions and developed a consensual version called T-12.
Stage 3 (Reverse translation): the T-12 questionnaire was submitted to two lay translators
unaware of each other or the current study, whose native language was English.
Stage 4 (Submission to an expert committee): a medical board with knowledge in the area was
asked to monitor the process, evaluate the versions, pointing out inconsistencies
and deviations. This board was composed of a dermatologist, a general surgeon and
an orthopedist.
There was pacification, through discussions, on four points:
Semantic equivalence. The translations were evaluated regarding the preservation of their meaning, the
possibility of multiple meanings, and the existence of grammatical difficulties.
Idiomatic equivalence. Expressions or colloquialisms are difficult to translate. The committee sought the
presence of these expressions and equivalents in Portuguese.
Experimental equivalence. The questioned experiences were evaluated as to their existence in the Portuguese
language.
Conceptual equivalence. The expressions must contain the same concept. For example, when talking about family,
in some cultures, it means the closest small family nucleus, and others include all
relatives.
Cultural adaptation
Stage 5 - (Pre-final version testing). A pre-test with the final T-12 version was
carried out with a sample of 20 people. This group was composed of dermatofunctional
physiotherapy graduate students. Each participant completed the questionnaire and
was interviewed by the researcher to point out possible inconsistencies and difficulties
in understanding.
Stage 6 - Submission of documentation to the expert committee to verify the translation
process.
RESULTS
The BOE questionnaire was translated into T1 and T2 versions. There were some points
of divergence between the two versions, but a consensus was reached with the T-12
version.
This version was subjected to two reverse translations, B1 and B2, which presented
some divergences without changing the original meaning.
Versions B1 and B2 were analyzed by the author of the original questionnaires, contacted
by email, who did not identify any change in meaning or inconsistency between the
questionnaire translated from Portuguese into English and its original version.
There were no difficulties concerning filling in and understanding the questionnaires.
The committee evaluated all translation process steps and contributed with suggestions
for changes, which were accepted. As a result, the final result of the translation
was as shown in Annex 2.
DISCUSSION
There were no major difficulties translating the questionnaires due to the small number
of expressions with no known translation into Portuguese.
We believe that quality of life questionnaires are important to make some subjective
parameters more objective and comparable. This allows results to be compared, providing
better levels of evidence in an area of knowledge that lacks it. However, there is
still no perfect questionnaire.
Comparing tools is outside the scope of this study. However, although the BOE questionnaire
has statistically shown its validity, reliability and responsiveness, its design does
not seem to be as well-founded as that of the Face-Q, which provides a significant
interval level. This allows the construction of defined units with a uniform distance
between them. This means, for example, that if a person progressed from a score of
100 to a score of 120, there was an increase similar to that of another person who
progressed from a score of 120 to a score of 140, which is not true for most other
instruments13.
On the other hand, unlike the Face-Q, the BOE is a specific questionnaire for blepharoplasty,
publicly and freely available, which facilitated its translation. Its application
takes less than 1 minute.
Other shortcomings of the BOE are that there are still no cut-off points and levels
of normality, even in its original language, which we suggest for future studies.
CONCLUSION
Considering the methodology applied, we concluded that the translation of the BOE
questionnaire (Figure 3) is suitable for use in Brazilian Portuguese.
REFERENCES
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Annex 1 - BOE Questionnaire (Blepharoplasty Outcomes Evaluation) original in the English language.
Source: Alsarraf6.
Annex 1 - BOE Questionnaire (Blepharoplasty Outcomes Evaluation) original in the English language.
Source: Alsarraf6.
Annex 2 - BOE Questionnaire (Blepharoplasty Outcomes Evaluation) translated by the authors.
Annex 2 - BOE Questionnaire (Blepharoplasty Outcomes Evaluation) translated by the authors.
1. Eduardo Furlani Clinic, Fortaleza, CE, Brazil.
Corresponding author: Eduardo Antonio Torres Furlani, Rua Barbosa de Freitas, 1990, Aldeota Fortaleza, CE, Brazil, Zip Code 60170-021,
E-mail: eduardo@eduardofurlani.com.br
Article received: March 16, 2021.
Article accepted: July 14, 2021.
Conflicts of interest: none.
