Cosmetic Surgery Times / Dr. Behrooz Torkian

Scar Wars: Perception vs Reality

September 20, 2016



Reconstructive surgeons might choose Z-plasty scar revision because of the belief that by breaking a linear scar into multiple parts they can better camouflage it. But a recent studysuggests the lay public prefers the look of linear scars to zigzag scars on the face, researchers report in the July/August issue of JAMA Facial Plastic Surgery.

The authors compared the general public’s perception of the appearance of linear scars versus zigzag scars by asking people to compare and rate a computer-generated scar image, designed in linear and zigzag configurations, and laid over the faces of four Caucasian headshots. Survey respondents rated each scar on a 10-point scale, where a lower score indicated the scar was more similar to surrounding skin and a highest score indicated the worst scar imaginable.

The 810 adult men and women in all age groups who responded gave significantly lower scores and better perceived cosmetic outcomes to the linear scars in every assessed group of pictures, including scars on the temple, cheek and forehead.

Flawed Study?

Dr. LamSamuel M. Lam, M.D., a facial plastic and hair restoration surgeon in Plano, Texas, wrote an accompanying editorial on the study, in which he says, yes, the lay public’s perception is the endgame of any aesthetic surgical endeavor, but he disagrees with the study’s findings and says Z-plasty is but one type of zigzag scar.

“Zigzag lines almost always look better than a linear incision, except if that line is hidden in a rhytid… Even then, a zigzag scar done well should be better… than a straight line closure. The best is the geometric broken line, which truly hides a scar in a way that the one cannot see as clearly,” Dr. Lam says.

Dr. Lam tells Cosmetic Surgery Times that he uses Z-plasty scar revision for only two indications.

“One is, if the scar is contracted, the Z-plasty will make the scar longer (for example, a lip that is contracted). Second, I use it to realign a scar that is not in the natural relaxed skin tension line,” Dr. Lam says. “Those are the only two indications for Z-plasty. It should not be used for any other purpose because it is simply not the best option.”

A linear scar, according to Dr. Lam, could be performed if there’s tension on the wound because there can be slight increase in tension with a geometric closure. It might also make sense to choose linear if the line falls into a wrinkle in someone more mature, and the line would likely hide the scar, he says.

Strategic Incision Placement

Dr. TorkianBeverly Hills-based facial plastic surgeon Behrooz Torkian, M.D., says his use of linear, curved or broken-line (zigzag) scars depends primarily on the scar’s location and purpose.

“In my practice, an incision that is generally placed strategically in a position of anatomic transition, or hidden within a natural anatomic line, is generally designed as a linear or curvilinear incision,” Dr. Torkian tells Cosmetic Surgery Times.

Examples, include incisions used for upper blepharoplasty, which are designed to follow the exact curvilinear shape of the upper eyelid crease; incisions in the neck, used to remove a lesion within the neck, which can be placed within a natural neck crease; incisions used for external approach to placement of a chin implant via submental approach, which is within the submental crease; and for curvilinear incisions, used for alar base reduction in rhinoplasty.

Zigzag, broken-line or geometric incisions are used in locations in which a natural crease, or anatomic transition, does not exist, according to Dr. Torkian.

“This is a means of reducing problems of visibility that may develop with scar contracture, hypertrophy or overall clashing of a wound closure with the anatomic features of the area,” he says.

According to Dr. Torkian, examples of proper uses for broken-line or geometric incision include:

  • A vertical scar from skin cancer removal in the forehead
  • Revision of a scar from traumatic or reconstructive surgery in the cheek
  • Planned open rhinoplasty incision within the narrowest portion of the columella
  • Revision of an incision that has previously healed with contracture, such as an incision or laceration within the epicanthal area causing a distortion of natural anatomic features of the area

“Certain special situations arise in which incisions are closed with specific tissue rearrangement that results in zigzag wound shape, such as use of rhombic or bilobe flaps for closure of tissue defects,” he says. “In these cases, the use of the flap or tissue rearrangement determines the shape of the scar. These are determined, in general on a case-by-case fashion.”

Perception vs Reality

Dr. FreimanMiami, Fla.-based plastic and reconstructive surgeon Jacob J. Freiman, M.D., tells Cosmetic Surgery Times that he agrees the new scar study is flawed.

“When a linear (or straight) scar heals, it contracts. This is called a scar contracture and is unattractive because it pulls in the surrounding tissue. In order to reconstruct this and lengthen the scar, plastic surgeons perform various flaps, the most classic of which is the Z-plasty. Although the Z-plasty leaves a patient with more scars, at least they are not contracted,” Dr. Freiman says. “This study asks patients if they prefer the Z-plasty scar to the linear scar. The conclusion of the study is that patients prefer a linear scar to a Z-plasty scar, which makes sense. The Z-plasty… should be placed in a location where one would expect a contracted scar (like the axilla…). It is usually not employed in cosmetic surgery of the face.”

The two scar types are not interchangeable, he says.

“Linear scars are for closing wounds. Z-plasties are for reconstructing contracted scars. Z-plasties are much more complicated. A linear incision is closed by just closing the wound, while a Z -plasty scar is the result of raising adjacent flaps and changing the direction of pull on the wound,” Dr. Freiman says. “So, if the same patients were asked to evaluate contracted linear wounds to the Z-plasty scar, I would expect they would overwhelmingly prefer the Z-plasty because that is why Z-plasty was created.”

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