Impact of Surgical Technique and Nuance vs Choice of Scar Shape.

Abstract

Perception of a cosmetic result by a lay bystander should be the endgameof any aesthetic surgical endeavor. Toooften,we judge aesthetic results by our own academic, esteemed criteria without regard to how that person is perceived by the public at large. Simply put, does the individual appear to be more attractive or less deformed by the lay public?1 Ratnarathorn and colleagues2 take on this very daunting task by constructing a large-scale, prospective analysis on the appearance of scars as perceived by the public. The 2key referenced studies that have foundaworse outcome with a zigzag scar or no difference between types of scars3,4 are flawed in my opinion. The study of temporoparietal flaps3 might reasonably show a worse outcome because zigzagscars inhair-bearing tissuewouldmost likelycausemore hair transections and thereby a worse scar. As a hairtransplant surgeon, I always discourage complex scar revisions in the hair-bearing scalp because the outcome generally is the same or worse.5 Furthermore, the study on hysterectomyscars4 isa flawedcomparisonbecausebodyscars heal poorly compared with facial scars, and I would surmise that a complex zigzag scar would not heal on the body compared with the face. I also believe that Z-plasties are not themost ideal way to performascar revisionunless thewound ismisdirectedagainst a relaxed skin tension line or is contracted, because the Zplastywould lengthenthescar, asRatnarathornetal2 cite.Even aW-plasty does not sufficiently irregularize a scar, compared with my preferred choice of a geometric broken line repair. When Iperformageometricbroken line repair, I usevery small limbs of about 2mmbecause even that slight irregularity can make the scar harder to visualize. Thepoint of a scar revision is tomake the scar veryhard to seeonsocial inspection. Ibelieve that thegeometricbroken line repair accomplishes that objective in most cases, especially whencombined judiciouslywith scar creams, lasers, andpostoperativemechanicaldermabrasion to finesse the result. If you comparemacroscopically a linewith a zigzag, I would understandwhy the zigzagwould lookworse.As stated, themethod withwhich Iwouldundertakemyscar revisionwouldusevery small limbs that would not substantially increase the visible width of the scar. Further, I believemany of the photographs in this study show that the straight lines fall in natural rhytids in relativelymature individuals.Accordingly, the straight lines would be less obviously obtrusive to a viewer because they wouldresemblewrinkles,whereasazigzaglineinthatsamearea wouldcatchone’sattentionmorereadily. I suggest that tomake a truecomparisonof2 typesof scars, bothscars should fall outside awrinkle or appear in a younger patientwithout rhytids. Even then, theproblemremains that anobvious zigzagwould most likelybeworse inappearance thanastraight line,because a true scar revision shouldhave small zigzag limbs that remain relatively undetectable to the human eye at a social distance. If a patient came tomewith a linear scar, Iwouldnot trade that scar for another linear scar, despite the findings in this study. I would still perform a scar revision using techniques to visually break up the scar; whether themethodwould be a Z-plastyor ageometricbroken line repairwoulddependon the clinical circumstance. I would caution any surgeon to glean from reading the conclusion of this study that a linear scar trumps a nonlinear scar in all cases. Nevertheless, constructing a study that justifiably quantifiesperception isdifficult. This interesting studyoffers avery large step forward to fulfill this objectiveof examining theoutcomes of classic scar revision techniques. Related article page 263 Aesthetic Outcome of Linear vs Multiple Z-Plasty Scars Original Investigation Research