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Original Investigation |

Perceptions of Aesthetic Outcome of Linear vs Multiple Z-Plasty Scars in a National Survey

Mondhipa Ratnarathorn, MD1,2; Tatyana A. Petukhova, MD, MS3; April W. Armstrong, MD, MPH4; Audrey S. Wang, MD5; Thomas H. King, MD4; Daniel B. Eisen, MD4
[+] Author Affiliations
1Department of Dermatology, Kaiser Permanente, Vacaville, California
2currently with Sutter Medical Group of the Redwoods, Santa Rosa, California
3Department of Dermatology, University of California, Davis, Sacramento
4Department of Dermatology, University of Southern California, Los Angeles
5Department of Dermatology, Rady Children’s Hospital, University of California, San Diego, Health System
JAMA Facial Plast Surg. 2016;18(4):263-267. doi:10.1001/jamafacial.2016.0107.
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Importance  The process of Z-plasty scar revision breaks up a linear scar into multiple parts with the purpose of camouflage and improvement of the cosmetic appearance of surgical scars. Although this postulation guides the practices of many reconstructive surgeons, few studies support improved aesthetic outcomes.

Objective  To compare the perceived cosmetic appearance of linear scars vs zigzag scars by the general public.

Design, Setting, and Participants  A computer-generated image of a mature scar was designed in linear and zigzag configurations and overlaid on the faces of standardized headshots of 4 white individuals. Twelve sets of images of linear vs zigzag scars were arranged in side-by-side comparisons in an Internet-based national survey. Respondents rated each scar on the 10-point Patient and Observer Scar Assessment Scale, where a lower score indicated likeness with normal skin and a higher score, the worst scar imaginable. Data were collected from May 1 through June 30, 2013, and analyzed from July 31 to September 1, 2013.

Main Outcomes and Measures  Aesthetic rating of scars by the survey respondents.

Results  Eight hundred seventy-six participants responded to the survey (24.5% response rate); of these, 810 completed the survey (379 men [46.1%] and 443 women [53.9%]; 148 [18.0%] were 18 to 29 years, 171 [20.8%] were 30 to 44 years, 290 [35.3%] were 45 to 60 years, and 213 [25.9%] were older than 60 years). Significantly lower scores and better perceived cosmetic outcomes were found for linear scars compared with zigzag scars in every assessed group of images on the Patient and Observer Scar Assessment Scale (mean [SD] scores, 2.9 [1.6] vs 4.5 [2.2], respectively; P < .001).

Conclusions and Relevance  The lay public has a significantly better perception of the appearance of linear scars compared with zigzag scars in 3 facial locations (temple, cheek, and forehead) of white patients in various age groups.

Level of Evidence  NA.

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Figure 1.
Study Design

Images of an identical mature scar were generated in linear and zigzag configurations using computer software. These scars were placed on the forehead (flat surface), cheek (convex surface), and temple (concave surface) of 4 volunteers (a white man and woman older than 50 years and a white man and woman younger than 50 years).

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Figure 2.
Example of an Image Used in the Survey

The side-by-side scar comparison and 10-point Patient and Observer Scar Assessment Scale are shown.

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