Development of a scale for evaluating the severity of disfigurements caused by injuries disease or surgery

Background/Aim. Medico-legal aspect of physical disfigurements has been subject of few scientific researches. The aim of this study was to establish a standardized instrument for forensic evaluation of all kinds of physical disfigurements, which has not existed until now. Methods. The research was conducted in 3 phases: the first one – drafting a list of disfigurements; the second phase – evaluation of the draft of the disfigurement list provided by 11 experts (plastic surgery lecturers) by the use of the Delphy method; the third one during which 51 medical doctors, members of Serbian Association of Plastic, Reconstructive and Aesthetic Surgery were evaluating the list of disfigurements. Results. Totally 176 individual physical disfigurements were described in the first phase of research. In the second phase, 217 disfigurements were established which were classified into 5 degrees of severity 0 – none/very small, 1 – small, 2 – medium, 3 – large, 4 – very large disfigurements. In the third phase, 217 disfigurements were evaluated. Conclusion. The first 4-point ordinal scale was established, rating 217 disfigurements, which showed high level of compatibility in practice and which can be used as an instrument for standardization of disfigurements in giving of forensic expertise.


Introduction
The term disfigurement is defined as an impairment of previous external appearance or body harmony, i.e. the harmony of a body part of an individual or as an impairment of any body function which is reflected in physical appearance 1 .In legal terminology, disfigurement refers to any damage suffered by a patient.It represents the link between medical and legal science, both in practical and theoretical terms 1 .Living with a disfigurement represents an emotional, social and cultural challenge, since physical appearance is, after all, important in relations with other people 2 .The damaged ones often claim financial compensation for mental anguish suffered because of disfigurement 1 .It is believed that mental anguish here arises from the uncomfortable feeling of inferiority and suffering of disfigured individuals, which are particularly caused by reactions and behavior of their social environment (pitiful, repulsive, contemptuous attitude) 3 .The mission of experts is to evaluate disfigurements, in the most objective manner possible.The expert report submitted to the Court of Law is compiled based on a detailed clinical examination and it includes expert opinion -expertise 1 .Although disfigurements are often clear and obvious, it is difficult to establish objective criteria for disfigurement description and evaluation, due to a wide range of existing situations referring to such individuals 1 .Therefore, disfigurement and disfigurement expertise remain an inadequately resolved problem.
Previous studies have shown that just few papers on medico-legal aspect of scars and disfigurements in general, have been published 4 .Several scales for scar evaluation and evaluation of the effects of therapy are in use, but these scales do not contribute to the medico-legal evaluation of scars [Vancouver Scar Scale (VSS) and Manchester Scar Scale (MSS)] [5][6][7][8] .
The aim of this study is to provide description and classification for all types of disfigurements according to their severity, all for the purpose of medico-legal expertise in disfigurements.

Methods
The research was conducted in 4 successive phases: the first one -drafting a list of disfigurements occurring as a result of injuries, surgery, illness and treatment; the second phase -evaluation of the draft of the disfigurement list provided by 11 experts (plastic surgery lecturers) using the Delphi method (in 3 iterations); the third one during which 51 medical doctors, members of Serbian Association of Plastic, Reconstructive and Aesthetic Surgery (SRBPRAS) participated in evaluating previously formed list of disfigurements; and the fourth phase during which the list, i.e. scale of disfigurements, formed in the previous, third phase, was applied to actual cases taken from the case-law.
In the process of preparing the questionnaire, 3 groups of disfigurements were hypothetically determined first, according to their exposure to view, i.e. according to the visibility of zones, regions or body parts where disfigurements could be identified.According to this criterion the first group includes disfigurements of body parts which are always exposed to view (disfigurements of the face, neck, scalp, and hands).The second group includes disfigurements identified on the body parts which are frequently exposed to view (forearms, lower legs, feet) and the third group includes disfigurements of the body parts which are rarely exposed to view (upper arms, thighs, torso, genitals).
After defining these groups, 176 individual disfigurements in total were hypothetically determined within each one of them according to the method of their quantitative and/or qualitative descriptions.Hence, 117 disfigurements were determined within the first group, 15 within the second one and 44 disfigurements within the third group.The following measurement units were used for the purpose of providing quantitative descriptions of disfigurements: 1) percentage (%) of the body surface area covered by disfigurement with respect to the total body surface area (TBSA); 2) the length of linear (expressed in cm) and surface spatial disfigurements (expressed in cm² or mm²); 3) lack (amputation) of the whole organ or a part thereof, expressed in natural numbers (for example: one limb, 2 teeth, 3 fingers) or as a ratio (for example: 1/2 lip, 1/3 earlobe) according to the criterion of functional reconstruction of organs.Specific characteristics of disfigurements were used for the purpose of providing their qualitative descriptions (for example: relief, elevation, depression etc.) 2 .
The questionnaire was completed by determining 4 possible degrees for classifying each of 176 individually described disfigurements according to the severity criterion.Each of 176 individually determined disfigurements was classified under one of these degrees (degree I -small; degree II -medium; degree III -large and degree IV -very large disfigurements).The questionnaire designed in this way, represented the basis for the application of the Delphi method in the following phase of research.Within the received questionnaire, the experts were provided with the descriptions of individual disfigurements and 4 possible degrees for their classification according to the severity criterion, but they could not see their hypothetical classification under these degrees, nor did they know the individual opinions of other experts.
The first phase included using the method of content analysis and using personal expert experience of the candidates.The findings of research published in the available literature and electronic databases which defined the key concepts (scale, disfigurement, scar/scars, medicolegal evaluation, damage compensation) were used during the content analysis.
Delphi method implies that experts should provide their opinions, without any group discussions, by answering the questions given in the questionnaire in several phases.In each successive stage these experts again answer the questions on which no consensus was reached in the previous phase and they are able to confirm, modify or completely change their answers after analyzing answers of other experts given in the first phase.At the same time, none of the experts knows the identity of other participants nor their individual answers to the questions asked 9 .
For the purpose of this research, the Delphi method was applied by obtaining expert opinions on each proposed disfigurement in the first iteration, whereby experts submitted their opinions individually and anonymously, which referred to the following: a) description, whereby the experts could accept, dismiss, correct or propose a completely new description; b) degree, whereby the experts could classify each proposed disfigurement under one of four offered degrees, according to their severity (I -small; II -medium; II -large and IV -very large disfigurements) provided that each of the proposed disfigurements was observed and evaluated from the distance of 50 cm from an unclothed patient 1 .
All disfigurements that most of the experts (more than 50% or at least 6 out of 11) accepted in terms of their description and classified under the same degree, were considered accepted in terms of the description and degree and they were not included in the following iteration.Data on the expert opinions on disfigurements that, in terms of their descriptions, some of the experts dismissed or proposed their corrections, newly proposed disfigurements or disfigurements classified under different degrees, were presented in the following (second) iteration to all experts for another round of decision-making.
This procedure was repeated in the third iteration, during which the consensus was reached among the experts as regards the acceptance, dismissal or correction of each description and degree of disfigurement on which the consensus was not reached in the previous iteration.Up until this iteration, the experts did not know the identity of other participants in the survey, nor did they know who gave what answer in the previous iteration.A selection criterion for qualifying individual descriptions and degrees of disfigurements for the following iteration step was the consensus among the experts (at least 6 out of 11 experts, or more than 50%).
The first 3 phases of the research were conducted in the period between 2013 and 2015, at the Department of Surgery, i.e. the Department of Plastic Surgery, at the School of Medicine, the Universities of Belgrade, Novi Sad and Kosovska Mitrovica.Experts from these scientific areas, medical specialists in plastic and reconstructive surgery, engaged in teaching, participated in this research.The fourth phase research was conducted in April, 2016 in the Third Basic Court in Belgrade.We reviewed the total number of 75 different types of disfigurements that were subjected to forensic expertise in the period between 2005 and 2015.These cases included the evaluation of the severity of disfigurements by authorized forensic experts, who are specialists in forensic medicine, orthopaedics, physical medicine and plastic surgery.In providing their expertise on particular disfigurement, or very small forensic experts could declare that there was no disfigurement -0, or that the disfigurement is small -1, medium -2, large -3 or very large -4.
The following statistical methods were used for processing these data: descriptive and inferential statistical analysis and non-parametric statistical method for testing the significance and strength of concordance (Kendall's W-coefficient of concordance).The first method was used to present individual descriptions of disfigurements in the form of a central tendency measure -the median, as well as the measure of dispersion, presented by the interquartile range.These parameters were complemented by the presentation of the number and percentage of experts who had a consistent position in determining the degree of individual disfigurements.The second method, i.e. testing the significance and strength of concordance was applied at the probability level of p < 0.05.

Results
The result of the first phase was a draft of a hypothetical model -a list of disfigurements occurring as a result of injuries, surgery, illness and treatment; the second phase -evaluation of the draft of the disfigurement list provided using the Delphi method.In the first iteration of the Delphi method experts accepted descriptions of all 176 proposed disfigurements.Ninety three out of 176 disfigurements were rated in the same manner as in the hypothetical model draft, whereas 49 disfigurements were rated differently, while consensus was not reached in the first iteration regarding 34 descriptions.
In the second iteration of the Delphi method, the consensus in terms of the evaluation was reached for 30 disfigurements.Kendall's coefficient of concordance (W) (Table 1) was obtained and it represented the level of consensus reached among experts in assessing the degree of disfigurement.In addition, majority of experts agreed that it was necessary to add a new group including 30 descriptions of very small disfigurements.Furthermore, a new description of a small disfigurement was added.The number of disfigurements in the end of this iteration reached 207.
In the third iteration, 4 disfigurements on which no consensus had been reached in two previous iterations, were evaluated.Based on the consensus of the experts involved, 12 descriptions of individual disfigurements were included, whereas 22 descriptions of disfigurements were rephrased and reevaluated in order to achieve greater accuracy of the disfigurement description.Therefore, the total number of descriptions of disfigurements increased from the initial 207 to 217 (Appendix).

Discussion
This final ordinal scale of disfigurements confirms that its draft established in the first phase of research, represented a good foundation for the implementation of the following 3 phases of research.In the second and the third phase, it was adjusted and qualitatively improved in a methodologically adequate scientific procedure, particularly with regard to.
The number of descriptions of individual disfigurements and the number of disfigurement severity degrees.
So far, just a few descriptions of disfigurement have appeared in relevant literature (elevated scar, depressed scar, hipertrophyc scar etc 7 .We provided disfigurement description and evaluation in terms of describing a linear scar, a relief scar, a scar with or without contracture, facial or body asymmetry, amputation, etc.
Several scales that provide rating from 1-13 or 1-100 are currently in use exclusively to evaluate scars as a disfigurement.Through a scientific procedure we obtained a scale which enables rating from 0-4 which is more practical.Until now it was not possible evaluate disfigurements by using score of 0-4 according to the research that we reviewed.
Such results of the fourth phase of research confirmed the existence of good judicial practice, i.e. practice of forensic expert witnesses that turned out to be consistent with the findings of the conducted scientific research to a greater extent.In addition, results of the research may be of use in future forensic expertise, due to the possibility of using the scale of disfigurements as an instrument of expertise.

Conclusion
Through 3 phases of research and with the participation of 62 specialists in plastic and reconstructive surgery, a 5degree ordinal scale was established, rating the total of 217 disfigurements according to the severity criterion as none/very small (0), small (1), medium (2), large (3) and very large (4) disfigurements.
Such ordinal scale of disfigurements is a result of a scientific process and may be used for uniform assessment of disfigurement severity in giving forensic expertise.
The results of this study indicate the need for their verification in practice and the need for possible adjustment of degrees of disfigurement, the number of individual descriptions of disfigurements, establishing new disfigurements or additionally, more precise definition of existing disfigurements.

*
Interquartile range of 25th and 75th percentile.**Code of disfigurement: eache disfigurement had a designed code which remained the same throughout the whole study in order to track accurately any potential change in the description of relevant disfigurement.
/or forehead scar (at the level of the surrounding skin or not), overall length 10-15 cm 2e Linear face and/or forehead scar (at the level of the surrounding skin or not), overall length more than 15 cm 3c Multiple benign lesions present on the face and/or forehead (acne scars and/or smallpox scars and/or skin diseases and/or tumors) 16 cm 2 -2% TBSA 3d Multiple benign lesions present on the face and/or forehead (acne scars and/or smallpox scars and/or skin diseases and/or tumors) 2% TBSA or more 4c Elevated and/or depressed and/or relief face and/or forehead scar (without contracture) 16 cm 2 -2% TBSA 5c A distinct facial asymmetry (due to scarring and/or desmogenous contracture and/or paralysis, e.g.central facial palsy) and/or distinct ectropion; altered facial expression of feelings 7d Deficiency of all or certain eyelid tissues, more than 1/2 8b Elevated and/or depressed nose scar, covering up to ¼ of nasal dorsum and sidewalls 8c Elevated and/or depressed nose scar, covering 1/4 -1/2 of nasal dorsum and sidewalls 8d Elevated and/or depressed nose scar or amputation of the whole nasal dorsum and sidewalls 8e Nasal tip amputation and/or ala of the nose and/or columella 9c Lack of a part or the entire lip fullness 1/3 -1/2 9d Lack of more than ½ of lip fullness 11c Elevated and/or depressed and/or relief scalp and/or scar (with or without alopecia or contracture) 1 -2% TBSA 11d Elevated and/or depressed and/or relief scalp and/or scar (with or without alopecia or contracture) 2% -3% 12d Linear scalp scar (at the level of the surrounding skin or not), overall length 20-30cm 12e Linear scalp and ear scar (at the level of the surrounding skin or not), overall length more than 30cm 13c Elevated and/or depressed and/or relief hand scar (with or without contracture) 1% -2% TBSA.13d Elevated and/or depressed and/or relief hand scar (with or without contracture) more than 2% TBSA.14d Multiple benign lesions present on hands (acne/smallpox scars, skin diseases and tumors) 1% -2% TBSA 14e Multiple benign lesions present on hands (acne/smallpox scars, skin diseases and tumors) more than 2% TBSA 15h Elevated and/or depressed and/or relief neck scar without contracture, total coverage 1%-2% TBSA 15j Elevated and/or depressed and/or relief neck scar with contracture, total coverage 4cm 2 -0.5% TBSA 15k Elevated and/or depressed and/or relief neck scar with contracture, total coverage 0.5-1% TBSA 16c Multiple benign lesions present on the neck (acne/smallpox scars, skin diseases and tumors) 0.5%-1%TBSA 16d Multiple benign lesions present on the neck (acne/smallpox scars, skin diseases and tumors) 1-2%TBSA 17d Linear neck scar (at the level of the surrounding skin or not), overall length 20-30 cm 17e Linear neck scar (at the level of the surrounding skin or not), overall length more than 30cm 18d Linear scar of one or both hands (at the level of the surrounding skin or not), overall length 20-30cm 18e Linear scar of both hands (at the level of the surrounding skin or not), overall length more than 30cm 19d Asymmetry of the body, large gait and posture deviation due to contractures in large joints, limping, involuntary movements or palsy, aids mandatory

Appendix SMALL DISFUGUREMENT (1); n = 45 Code Degree Description of disfigurement 1a Very mild strabismus, hardly visible 2a Linear face and/or forehead scar (at the level of the surrounding skin or not), overall length 1-2cm 2b Linear face and/or forehead scar (at the level of the surrounding skin or not), overall length2-5 cm 3a Multiple benign lesions present on the face and/or forehead (acne scars and/or smallpox scars and/or skin diseases and/or tumors) 1-2cm 2 4a Elevated and/or depressed and/or relief face and/or forehead scar (without contracture)1-2cm 2 5a Slightly visible facial asymmetry (due to scarring and/or desmogenous contracture and/or paralysis); facial expression of feelings is not altered 6b Absence or dental caries of up to two teeth (from one to four) 7a Deficiency of all or certain eyelid tissues, barely visible 10a Deficiency of all or certain earlobe tissues from 1cm 2 to 1/4 of helix 10b Partial loss of the lobule 11a Elevated and/or depressed and/or relief scalp scar (with or without alopecia or contracture) 2-4cm 2 12a Linear scalp and/or ear scar (at the level of the surrounding skin or not), overall length 2-4cm 12b Linear scalp and/or ear scar (at the level of the surrounding skin or not), overall length4cm-10cm 13a Elevated and/or depressed and/or relief hand scar (with or without contracture) 1/4-1/2 TBSA 14a Multiple benign lesions present on a hand (acne/smallpox scars, skin diseases and tumors) 2cm 2 -1/4TBSA 15e Elevated and/or depressed and/or relief neck scar without contracture, total coverage 2-4cm 2 16a Multiple benign lesions present on the neck (acne/smallpox scars, skin diseases and tumors) 2-4cm 2 17a Linear neck scar (at the level of the surrounding skin or not), overall length 2-4cm 18a Linear hand scar (at the level of the surrounding skin or not), overall length 2-4 cm 18b Linear scar on both hands (lateral, at the level of the surrounding skin or not), overall length4-10 cm VERY SMALL DISFUGUREMENT (0); n = 32 Code Description of disfigurement 6a Absence or dental caries of on tooth (from one to four) 19a Slight gait and posture deviation, barely visible (due to contractures in large joints, limping, involuntary movements or palsy) 32a Asymmetry of male and female genital organs -hardly visible 35e Amblyopia, poor eyesight 36a Very small disfigurement of sclera or iris -barely visible 36b Linear face and/or forehead scar (at the level of the surrounding skin or not), overall length up to 1cm 36c Multiple benign lesions present on the face and/or forehead (acne scars) up to 1cm 2 36d Elevated/depressed and/or relief face and/or forehead scar (without contracture) up to 1cm 2 36e Facial asymmetry, hardly visible at first sight 36f Minimum eyelid deficiency, hardly visible at first sight 36i Lack of any part of the earlobe up to 1cm 2 36j Elevated and/or depressed and/or relief scalp scar up to 2cm 2 36k Linear scalp scar (at the level of the surrounding skin or not), overall length up to 2cm 36l Elevated and/or depressed and/or relief hand scar (with or without contracture) up to 2cm 2 36m Multiple benign lesions present on a hand up to 2cm 2 36n Elevated / depressed and/or relief neck scar without contracture, up to 2cm 2 36o Coverage of neck benign lesions (acne scars) up to 2cm 2 36p Linear neck scar (at the level of the surrounding skin or not), overall length up to 2cm 36q Linear scar on both hands (at the level of the surrounding skin or not), overall length up to 2cm 36r Loss of a part of a fingertip and/or finger nail plate 36s Elevated/depressed/relief forearm and/or lower leg and/or foot scar with or without contracture, up to 8cm 2 36t Multiple benign lesions present on a forearm and/or lower leg and/or foot (scars), up to 8cm 2 36u Linear forearm and/or lower leg and/or foot scar (at the level of the surrounding skin or not), overall length up to 4cm 36v Elevated/depressed/relief torso and/or upper arm and/or upper leg scar, up to 2.5% 36w Multiple benign lesions present on the torso and/or upper arm and/or upper leg (smallpox scars), up to 2.5% 36x Linear torso and/or upper arm and/or upper leg scar (at the level of the surrounding skin or not), overall length up to 8 cm 36y Hardly visible breast asymmetry, imperceivable at first sight 36z Breast scar, imperceivable at first sight 37a Asymmetry of genital organs, imperceivable at first sight 37b Loss of up to ½ of glanspenis 37c Lack of up to 2cm 2 of vulva 37d Relief scar of female or male genital organs, imperceivable at first sight, up to 2cm 2 19b Slight gait and posture deviation due to contractures in large joints, limping, involuntary movements or palsy 20f Amputation of one (any) hand phalanx, thumb excluded 21a Amputation of one (any) foot phalanx 21b Amputation of one toe, big toe excluded 23a Elevated and/or depressed and/or relief forearm and/or lower leg and/or foot scar with or without contracture8-16 cm 2 24a Multiple benign lesions present on a forearm and/or lower leg and/or foot (acne scars, smallpox scars, skin diseases and tumors)8-16 cm 2 25a Linear forearm and/or lower leg and/or foot scar (at the level of the surrounding skin or not), overall length 4-8 cm 26a Elevated/depressed/relief torso and/or upper arm and/or upper leg scar (with or without contracture) 2.5- 5 % TBSA 27a Multiple benign lesions present on the torso and/or upper arm and/or upper leg (acne/smallpox scars, skin diseases and tumors) 2.5-5 % TBSA 28a Linear torso and/or upper arm and/or upper leg scar (at the level of the surrounding skin or not
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and female genital organs, clearly visible 32c Distinct asymmetry of male and female genital organs 32d Striking asymmetry of male and female genital organs 34a Lack, loss of 2cm 2 -¼ of vulva 35a Elevated and/or depressed, relief scar of female or male genital covering the surface area of 2 cm²-¼ of genital organs 35b Elevated and/or depressed, relief scar of female or male genital covering the surface area of ¼ -½ of genital organs 35c Elevated and/or depressed, relief scar of female or male genital covering the surface area of more than ½ of genital organs 35d Elevated and/or depressed and/or relief hand scar (with or without contracture)2 cm 2 -¼TBSA 37g Elevated and/or depressed scar of nasal dorsum and sidewalls covering the surface area of 0-3mm 2 37e Lack of a part of the lip 0-3mm 2 MEDIUM DISFUGUREMENT (2); n = 56 Code Description of disfigurement 1c Blindness (referring to the appearance of a blind person, to the eye function) 2c Linear face and/or forehead scar (at the level of the surrounding skin or not), overall length 5-10 cm 3b Multiple benign lesions present on the face and/or forehead (acne/smallpox scars and/or skin diseases and/or tumors) 2- 16 cm 2 4b Elevated and/or depressed and/or relief face and/or forehead scar (without contracture) 1-16 cm 2 5b Clearly visible facial asymmetry (due to scarring and/or desmogenous contracture and/or paralysis) and/or slightly distinct ectropion; facial expression of feelings is not altered 6c Absence or dental caries of on up to three teeth (from one to four) 6d Absence or dental caries of on six to eight front teeth 6e Absence or dental caries of on more than eight front teeth 7b Deficiency of all or certain eyelid tissues, up to 1/3 of a lid 7c Deficiency of all or certain eyelid tissues, 1/3-1/2 of a lid 8a Elevated and/or depressed nose scar, covering 0.5-1cm 2 of nasal dorsum and sidewalls 9a Lack of a part or the entire lip fullness 5 mm 2 -1/4usne 9b Lack of a part or the entire lip fullness 1/4 -1/3 10c Deficiency of all or certain earlobe tissues 1/4 -1/3 10d Loss of the lobule, more than½ 10e Deficiency of all or certain earlobe tissues 1/3-1/2 11b Elevated and/or depressed and/or relief scalp and/or ear scar (with or without alopecia or contracture)od 4 cm 2 -1% TBSA 12c Linear scalp scar (at the level of the surrounding skin or not), overall length 10-20cm 13b Elevated and/or depressed and/or relief hand scar (with or without contracture) 1/2% -1% TBSA. 14b Multiple benign lesions present on hands (acne/smallpox scars, skin diseases and tumors) 1/4-1/2 TBSA 14c Multiple benign lesions present on hands (acne/smallpox scars, skin diseases and tumors) 1/2% -1% TBSA 15f Elevated and/or depressed and/or relief neck scar without contracture, total coverage 4cm 2 -0.5% TBSA 15g Elevated and/or depressed and/or relief neck scar without contracture, total coverage 0.5-1% TBSA 15i Elevated and/or depressed and/or relief neck scar with contracture, total coverage 2-4cm 2 16b Multiple benign lesions present on the neck (e.g. acne/smallpox scars, skin diseases and tumors) 4cm 2 -0.5% TBSA 17b Linear neck scar (at the level of the surrounding skin or not), overall length 4-10 cm 17c Linear neck scar (at the level of the surrounding skin or not), overall length 10-20 cm 18c Linear scar of both hands (lateral, at the level of the surrounding skin or not), overall length 10-20 cm 19c Obvious gait and posture deviation due to contractures in large joints, limping, involuntary movements or palsy 20g Amputation of two (any) hand phalanges, thumb excluded 20h Loss of one finger, thumb excluded 20k Lossof one thumb phalanx
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