The research team, led by Emma Hansson with Catrin Wessman and Anna Paganini, recruited 276 women who were referred for breast reduction within Sweden’s publicly financed health care system. All participants met the Swedish national guidelines for the procedure, which specify criteria such as a body mass index under 30 and a minimum breast volume of more than 800 millilitres per breast, adjusted upward for higher BMI ranges. Each woman completed the HADS questionnaire before surgery, and a subset of 52 patients filled it in a second time two weeks later to test how stable the scores were over time. Another 52 patients completed the questionnaire again twelve months after their operation, allowing the researchers to see whether the instrument could detect the change in psychological symptoms that surgery is expected to produce.

The choice of HADS was deliberate and scientifically motivated. Many familiar depression measures, including the Beck Depression Inventory and the Hamilton rating scales, were originally developed for psychiatric populations. Women seeking breast reduction, by contrast, typically do not have primary psychiatric disorders; their distress is linked to a somatic condition. HADS was designed precisely for medically ill patients. Its fourteen items, split evenly between an anxiety subscale and a depression subscale, deliberately exclude symptoms that could be confused with physical illness, such as fatigue and dizziness, and it omits items on suicidal ideation. Each item is scored on a four-point scale, giving subscale scores from 0 to 21, where 0 to 7 suggests no significant symptoms, 8 to 10 indicates possible cases, and above 10 suggests probable cases. Despite its validation for breast cancer reconstruction, HADS had never been validated for benign breast conditions such as macromastia, a distinction the authors argued warrants separate testing.

The technical heart of the study was a battery of psychometric analyses reported according to the COSMIN checklist, an international standard for studies of patient-reported outcome measures. Confirmatory factor analysis was used to test whether the questionnaire’s underlying structure held up in this specific population. The researchers compared the classic two-factor model, with separate anxiety and depression factors, against a three-factor model that adds a dimension of negative affectivity, reflecting the theoretical overlap between anxiety and depression. Both models showed satisfactory or near-acceptable fit across standard indices, including the comparative fit index, the nonnormal fit index, the root mean square error of approximation and the standardised root mean squared residual. All factor loadings were statistically significant and above 0.30. Because both structures fit comparably well, the team judged the models using the Akaike information criterion and, weighing clinical usefulness and comparability with prior research, proceeded with the original two-factor structure.

The reliability results were reassuring. Internal consistency, measured by Cronbach’s alpha, came out at 0.85 for the anxiety subscale and 0.87 for the depression subscale, comfortably within the accepted range of 0.70 to 0.95 and short of the level that would suggest redundant items. Every item correlated sufficiently with the total score of its subscale, with corrected item-total correlations ranging from 0.45 to 0.73, all above the recommended threshold of 0.3. Inter-item correlations fell between 0.2 and 0.8 for both subscales, indicating that the questions hang together without duplicating one another. In plain terms, the questionnaire measures what it claims to measure consistently, without wasted or contradictory questions.

Stability over time, known as test-retest reliability, was assessed in the 52 women who repeated the questionnaire after two weeks. The intraclass correlation coefficient was 0.81 for anxiety and 0.75 for depression, values classified as good reliability under widely used benchmarks. Bland-Altman plots showed mean differences between the two time points close to zero, and the limits of agreement stayed within the seven-point margin the researchers had prespecified, corresponding to the clinical cut-off between non-cases and probable cases. This matters because a screening tool that gives wildly different answers on consecutive occasions cannot be trusted to guide individual treatment decisions.

Construct validity was tested by comparing HADS against instruments that should, in theory, produce related results. The depression subscale correlated strongly with the Beck Depression Inventory and the anxiety subscale correlated strongly with the Beck Anxiety Inventory, both at a Spearman coefficient of about 0.7, exactly matching the researchers’ pre-registered hypotheses. The team also compared HADS with the psychosocial well-being domain of the BREAST-Q, the most widely used quality-of-life instrument in breast surgery, which asks about feelings such as self-confidence and happiness with one’s body. Here the correlation was moderate and negative, around minus 0.5, meaning that higher breast-related psychosocial well-being goes hand in hand with fewer symptoms of anxiety and depression. Importantly, the authors note, this moderate relationship shows that the two instruments capture related but distinct constructs, supporting the case for measuring depression and anxiety separately rather than assuming a breast-specific quality-of-life questionnaire covers them adequately.

The questionnaire also proved responsive, meaning it could detect real change over time. Twelve months after surgery, patients reported significantly fewer symptoms on both subscales, with mean decreases of 1.1 points for anxiety and 1.2 points for depression, each statistically significant. No floor or ceiling effects were observed, so the scale retains its ability to distinguish between patients at both the healthy and severely symptomatic ends of the spectrum. Together, these findings paint a picture of an instrument that is valid, reliable and sensitive enough to serve both halves of the clinical workflow: pre-operative evaluation and post-operative outcome assessment.

The authors are candid about the limits of generalisability. Their sample comprised women treated in the Swedish public system, excluding patients with a BMI over 30, a group that is operated on in some countries, particularly the United States, and one in which obesity and comorbidity are known to influence HADS scores. The post-operative sample was relatively small, and cultural factors can affect questionnaire scores, although the authors argue this matters most when creating norm data rather than when validating an instrument for a specific condition. They also caution that because both the two-factor and three-factor structures fit the data acceptably, and because anxiety and depression symptoms clinically overlap, HADS should be used carefully when attempting to differentiate the two conditions in individual patients.

Even with those caveats, the study delivers something the field has lacked: a validated, reliability-tested standard for measuring depression and anxiety in women with breast hypertrophy undergoing reduction. Because different clinics and countries have historically used a patchwork of unvalidated instruments, comparisons between studies and meta-analyses have been difficult, slowing the accumulation of evidence about the psychological benefits of the surgery. A common, psychometrically sound yardstick changes that. It gives clinicians a defensible tool for documenting the emotional indications for surgery and for demonstrating, with patient-reported data, that the operation relieved psychological as well as physical suffering. For a procedure that has often had to justify itself against perceptions of being cosmetic, that standard may prove as consequential as any surgical technique.

Subject of Research: Validation of the Hospital Anxiety and Depression Scale for assessing depression and anxiety symptoms in women undergoing breast reduction surgery

Article Title: Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS

Article References: Hansson, E., Wessman, C., & Paganini, A. (2025). Creating a standard for evaluation of symptoms of depression and anxiety in women undergoing reduction mammaplasty: validation and reliability of HADS. BMC Plastic and Reconstructive Surgery, 1(1), Article 2. https://doi.org/10.1186/s44452-025-00001-9

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00001-9

Keywords: breast reduction, breast hypertrophy, HADS, depression, anxiety, patient-reported outcomes, psychometric validation, plastic surgery, macromastia, questionnaire reliability, BREAST-Q, Sweden

The problem the editorial describes is one that has shaped surgical research for decades. Historically, outcomes in plastic and reconstructive surgery were evaluated through surgeon-reported assessments, non-standardized rating scales, or questionnaires designed in-house by individual institutions. A surgeon might declare a result excellent based on visual inspection and personal judgment, while the patient, whose expectations and daily experience were never formally recorded, might feel very differently. Because every center used its own criteria, results from different hospitals and countries could not be meaningfully compared. Systematic reviews and meta-analyses, the backbone of evidence-based medicine, were crippled by this heterogeneity. The editorial notes that this fragmentation limited both reproducibility and comparability, two qualities that modern science considers non-negotiable.

The turning point came with the recognition that the patient’s voice is not a soft, anecdotal supplement to hard clinical data but a rigorous measurement domain in its own right. This insight gave rise to a family of instruments developed with psychometric discipline rather than ad hoc questionnaire writing. The most celebrated examples are the BREAST-Q, the FACE-Q, the BODY-Q, and the CLEFT-Q, each targeting a specific anatomical region or patient population. These tools marked what the editorial calls a pivotal shift toward standardized outcome measurement, and their development methodology is worth understanding because it explains why they work where older scales failed.

The Q-family instruments were built using rigorous mixed-methods approaches grounded in Rasch Measurement Theory, a mathematical framework from psychometrics, the science of measuring latent traits such as satisfaction, well-being, or perceived function. Rasch analysis converts ordinal questionnaire responses, such as ratings on a Likert scale, into interval-level measurements, allowing researchers to say not just that one patient scored higher than another but by how much, on a scale with equal intervals. The development process typically begins with qualitative interviews with patients to identify which aspects of their condition and treatment actually matter to them, ensuring content validity, meaning the instrument measures what patients consider important rather than what clinicians assume matters. Statistical validation then confirms that the items behave consistently across diverse populations, that the scale measures a single coherent construct, and that scores remain stable when the underlying condition has not changed yet respond sensitively when it has.

The practical payoff of this rigor is enormous. Validated PROMs quantify domains that cannot be reliably defined by subjective assessment alone: appearance-related feedback, physical symptoms and how patients perceive them, psychosocial impact, and overall quality of life. In breast surgery, for example, the BREAST-Q captures satisfaction with breasts, psychosocial well-being, physical well-being of the chest and torso, and sexual well-being, producing profiles that reveal trade-offs invisible to a clinical photograph. In facial aesthetic and reconstructive practice, the FACE-Q measures how patients feel about their appearance and the social consequences they experience. The BODY-Q serves patients undergoing weight loss and body contouring, while the CLEFT-Q gives children and young people with cleft lip and palate a validated way to report on their own appearance, speech, and psychosocial functioning. Region-specific instruments like these are commonly used alongside generic tools that evaluate overall patient condition and treatment effectiveness, giving researchers both a wide-angle and a close-up view of outcomes.

The editorial also highlights instruments designed for specific disease states, including the LYMQOL quality-of-life measure for limb lymphedema and the ULL-27 questionnaire for upper limb lymphedema, both cited in the article’s reference list. Lymphedema, a chronic swelling condition that frequently follows cancer surgery involving lymph node removal, illustrates why standardized measurement matters so much. Limb circumference measurements tell clinicians about volume, but they say nothing about the heaviness, tightness, pain, and functional limitation that define the patient’s daily reality. Questionnaires such as the ULL-27 translate that lived experience into numbers that can be tracked over time, compared across treatments, and pooled across studies, which is precisely what the field needs as lymphedema research expands.

Standardization also attacks one of the most insidious problems in surgical literature: outcome reporting bias. When researchers choose which outcomes to report, and how, after seeing their results, the published record becomes selectively flattering. Pre-specified, validated instruments make it much harder to cherry-pick, because the domains of interest are defined in advance and measured with tools whose properties are known. The editorial states that the routine use of validated outcome measures directly aligns with the journal’s principles by reducing outcome reporting bias, improving reproducibility, and facilitating secondary analyses. In an era when the volume of plastic surgery research output continues to grow, this infrastructure is what allows individual studies to aggregate into genuine knowledge rather than a pile of incomparable anecdotes.

There is, however, a practical wrinkle that the editorial is careful to flag: licensing. Many of the best-known instruments are copyrighted, and using them, even in academic publications, requires obtaining a license. The good news, according to the editorial, is that most instruments available for outcome measurement offer a free license for use and publication, but a license must still be formally acquired. This step is easy to overlook in the rush to launch a study, and overlooking it can create legal complications that delay publication. For research teams, the message is to plan instrument licensing at the protocol stage, alongside ethics approval and sample size calculations, rather than treating it as an afterthought.

For patients, the broader significance of this shift is that their subjective experience is finally being treated as primary evidence. A reconstruction that looks flawless to the surgical team but leaves the patient in chronic pain, or a contouring procedure with technically excellent measurements but devastating psychological side effects, will now register in the data. Conversely, interventions that produce modest anatomical change but transform quality of life can finally demonstrate their true value, which matters enormously for reimbursement decisions, health technology assessments, and priority-setting in public health systems. Patient-centered measurement changes not only how studies are scored but which questions get asked and funded in the first place.

The editorial closes on a forward-looking note: as plastic and reconstructive surgery research continues to expand in volume, standardized outcome measurement will remain central to generating reproducible, transparent, and accessible publications. In a field where success is measured in confidence restored, function regained, and identities rebuilt, the instruments described in this overview are more than statistical conveniences. They are the mechanism by which the most human dimensions of surgical care earn a rigorous, comparable, and permanent place in the scientific record, ensuring that the next generation of surgical evidence speaks both the language of the operating room and the language of the people it serves.

Subject of Research: Standardized patient-reported outcome measures and assessment tools in plastic and reconstructive surgery research

Article Title: Standardized outcome assessment tools in plastic and reconstructive surgery: an overview

Article References: Sinelnikov, M. Y. (2025). Standardized outcome assessment tools in plastic and reconstructive surgery: an overview. BMC Plastic and Reconstructive Surgery, 1(1), Article 12. https://doi.org/10.1186/s44452-025-00012-6

Image Credits: AI Generated

DOI: 10.1186/s44452-025-00012-6

Keywords: plastic surgery, reconstructive surgery, patient-reported outcome measures, PROMs, BREAST-Q, FACE-Q, BODY-Q, CLEFT-Q, psychometrics, Rasch Measurement Theory, outcome reporting bias, lymphedema