Using super tension-relieving suture technique combined with W-plasty for facial scar repair: a retrospective comparative study

Abstract

Purpose

This study aimed to evaluate the efficacy of combining the super tension-relieving suture technique with W-plasty in the repair of facial scars, comparing its outcomes to conventional suture methods.

Method

A retrospective analysis was conducted on 81 patients with facial scars treated at the Department of Plastic and Aesthetic Surgery, Second Affiliated Hospital of Soochow University, between January 2022 and September 2024. Patients were divided into two groups: one received the combined super tension-relieving suture and W-plasty technique, while the other underwent conventional scar excision and linear closure. Scar quality was assessed preoperatively and six months postoperatively using the Patient and Observer Scar Assessment Scale (POSAS) and the Vancouver Scar Scale (VSS).

Result

Postoperative evaluations revealed improvements in scar quality for both groups. However, the combination method group showed a trend toward improved outcomes compared with the control group, including better scores on the VSS scale (pigmentation, P< 0.05 after FDR correction) and POSAS scale (color and pigmentation, P < 0.05 after FDR correction). The total scores in VSS, PSAS and OSAS scale were significantly lower in the combination group (P < 0.05 after FDR correction), indicating enhanced scar appearance and patient satisfaction.

Conclusion

The combination of the super tension-relieving suture technique and W-plasty is an effective approach for facial scar repair, yielding superior aesthetic and functional results compared to conventional methods. This technique addresses mechanical tension and aligns with natural skin lines, making it a promising option for scar revision in plastic and reconstructive surgery.

Introduction

Following surgery, or trauma, wound healing occurs in three distinct and sequential phases: inflammation, proliferation, and remodeling. Under normal conditions, scars gradually mature, reaching maximal tensile strength by approximately six months; however, full maturation may require a year or longer. Upon completion of these phases, the wound typically evolves into a fine-line scar, commonly regarded as a “normal” scar [1]. However, in some cases, scars may become depressed or thin, leading to atrophic scarring, particularly when collagen synthesis is impaired or inflammatory responses are diminished [2]. The pathogenesis of scars is multifactorial, influenced by factors such as age, sex, ethnicity, bariatric surgery [3]. Notably, skin tension plays a critical role in scar formation, with high-tension regions, including the anterior chest and scapula, being particularly susceptible [4]. This phenomenon is associated with mechanical tension-induced activation of integrins and mechanoreceptors, promoting fibroblast-to-myofibroblast differentiation and other processes that contribute to pathological scarring [5, 6].

With the rapid growth of the global economy, aesthetic expectations have increased. The buried vertical mattress suture technique, commonly used in scar excision by plastic surgeons, remains a widely employed method. However, this approach has many limitations, including suboptimal tension reduction and the potential for dead space formation in large or deep incisions. While adjunctive methods such as tension reducers and adhesive tapes can help, patient adherence over prolonged periods is often challenging. To address these limitations, a multidimensional approach aimed at minimizing incision tension, preventing hypertrophic scarring, and improving aesthetic outcomes was explored. Researchers combined the super tension-relieving suture technique with W-plasty [7]. In the early stages of scar healing, absorbable sutures provide effective resistance against tensile forces. The super tension-relieving suture technique modifies suture placement to redistribute tension from the superficial layers to deeper tissues. By shifting the point of tension away from the wound edge, this approach helps prevent pathological scarring associated with mechanical stress at the incision site. W-plasty is a well-established technique for scar revision. Unlike direct excision and linear closure, which result in a straight scar, W-plasty segments the scar into multiple small triangular flaps. This modification alters the scar’s shape and orientation to better align with natural skin tension lines, thereby dispersing mechanical stress and facilitating a more aesthetically favorable healing process [8].

In this research, we evaluated the combination of the super tension-relieving suture technique with W-plasty in scar repair. The surgical outcomes were retrospectively evaluated and compared with those achieved using conventional techniques.

Patients and methods

Patients

This was a retrospective study which included 81 patients diagnosed with either atrophic or hypertrophic scars who underwent surgery at the Department of Plastic and Aesthetic Surgery, Second Affiliated Hospital of Soochow University, between January 2022 and September 2024. Patients were divided into two groups based on the enrollment date: those before April 2023 constituted the conventional method group, and those after constituted the combination method group. Atrophic scars are characterized by a depressed appearance, lying below the surrounding skin and presenting a concave morphology, often with a color that is lighter or distinct from adjacent skin. In contrast, hypertrophic scars typically appear erythematous and edematous, protruding above the skin surface without invading surrounding tissue.

Inclusion criteria were as follows: (1) age between 18 and 65 years; (2) presence of atrophic or hypertrophic scars on the face; and (3) scar length of at least 1 cm. Exclusion criteria included: (1) contraindications for surgical intervention; (2) prior or postoperative treatment with laser therapy or other nonsurgical modalities; (3) pregnancy, lactation, or active menstruation; (4) presence of systemic diseases; and (5) loss to follow-up.

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Soochow University and conducted in accordance with the Declaration of Helsinki. Written and verbal informed consent was obtained from all participants.

Surgical technique

All surgical procedures were performed under local anesthesia. The 81 patients were allocated into two groups. The combination group underwent a combined approach incorporating the super tension-relieving suture technique with continuous W-plasty. Preoperatively, the surgical incision was designed according to the scar morphology and the orientation of the relaxed skin tension lines. The incision was placed either parallel or obliquely relative to these lines. Using methylene blue as a guide, two continuous W-plasty incision lines were marked along both sides of the scar, creating multiple serrated skin flaps. The lengths of the flap edges ranged from 0.5 to 0.8 cm, with an included angle typically set at 60°. When designing triangular skin flaps, symmetry in both angle and size was ensured to facilitate precise suturing. (Fig. 1A)

Fig. 1.

A schema describing this combined technique. A The incision design of “W”-plasty; B “W-“plasty scar excision; C, D Super-tension reduction suturing technique; E Knotting

Following the onset of local infiltration anesthesia, an incision was made along the methylene blue markings, extending through the skin and subcutaneous tissue to the depth of the fat layer, allowing for complete excision of the scar. The subcutaneous tissue was meticulously trimmed, and appropriate tissue undermining was performed. The extent of undermining varied by anatomical region, with a broader separation required in more mobile areas to facilitate super tension-relieving suturing (Fig. 1B). Depending on the skin tension, 4 − 0 or 5 − 0 polydioxanone (PDS) suture were chosen. To achieve uniform wound apposition, consistency in tissue volume and suture placement was maintained, ensuring symmetrical needle entry and exit points (Fig. 1C and D). Previous research suggests that optimal suture spacing ranges from 0.3 to 0.5 cm, depending on wound tension, with higher tension necessitating closer spacing. After intradermal suturing, the epidermis was closed using simple interrupted sutures with 6 − 0 or 7 − 0 nylon thread (Fig. 1E). Precise skin apposition was ensured to maintain adequate perfusion. Additionally, during knot tying, excessive tension was avoided to prevent compromised blood supply. Immediately postoperatively, the incision exhibited a “hillock” appearance, characterized by a raised bulge above the skin surface.

The control group underwent conventional scar excision with tension-relieving sutures and linear wound closure. A fusiform incision was designed along the scar length. Following local infiltration anesthesia, the scar was completely excised along the marked line. Subcutaneous dissection was performed, and meticulous hemostasis was achieved. Closure was performed using a layered approach, with a 4 − 0 or 5 − 0 polydioxanone (PDS) suture for subcutaneous/superficial fascia tension relief and 6 − 0 or 7 − 0 nylon thread for skin closure. Postoperatively, the incision appeared flat. All surgical procedures in both groups were performed by the same surgeon. In both Group 1 and Group 2, erythromycin ointment was applied to the wound postoperatively to prevent infection. Wound dressing changes were performed every two days until the dermal sutures were removed. Patients were instructed to keep the wound dry and avoid strenuous exercise. Based on our experience, the dermal sutures on the face can typically be removed 7 days after surgery.

Outcome assessment

Postoperative follow-up evaluations were conducted monthly to assess incision-related complications, including hematoma formation, infection, dehiscence, and fat liquefaction. Scar morphology was assessed at six months postoperatively, and scar length and width were measured and compared with preoperative dimensions. All assessments were performed by another independent plastic surgeon who was not involved in the surgical procedures.

The Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS) were used preoperatively and at six months postoperatively to evaluate incision recovery and determine the effectiveness of scar repair. The VSS is an internationally recognized scar assessment tool that relies on visual inspection and manual palpation without the need for specialized instruments. It evaluates four parameters: pigmentation, vascularity, pliability, and height, with higher scores indicating more severe hypertrophic scarring [9, 10].

The POSAS consists of two components: the Patient Scar Assessment Scale (PSAS) and the Observer Scar Assessment Scale (OSAS), both used to assess surgical outcomes at the six-month follow-up. The PSAS evaluates six parameters: pain, itch, color, stiffness, thickness, and irregularity, while the OSAS assesses vascularity, thickness, pigmentation, pliability, and relief. Each parameter is scored on a 10-point scale, with 1 representing the best outcome and 10 representing the worst. POSAS thickness score greater than 5 was considered indicative of scar hyperplasia, where increased scores correlated with greater scar hypertrophy [11].

Statistical analysis

Statistical analysis was performed using IBM SPSS Statistics version 27.0 (IBM Corp, Armonk, NY). Prior to comparing quantitative data, normality and homogeneity of variance were assessed. Normality was evaluated through frequency histograms and the Shapiro-Wilk test. If both normality and homogeneity assumptions were met, a paired t-test was used for within-group comparisons of preoperative and postoperative data, while an independent t-test was used for between-group comparisons. If the normality assumption was violated, the Wilcoxon signed-rank test was used for within-group comparisons, and the Mann-Whitney U test was applied for between-group comparisons.

For categorical variables, the Pearson chi-square test, continuity-corrected chi-square test, likelihood ratio chi-square test, or Fisher exact test was used, as appropriate. Quantitative data were reported as mean ± standard deviation (95% CI [lower limit, upper limit]), whereas categorical data were expressed as frequencies and percentages. To account for multiple comparisons, the false discovery rate (FDR) was controlled using the Benjamini-Hochberg procedure for the multiple subscales of the VSS and POSAS. A corrected P value of < 0.05 was considered statistically significant.

Results

Patient characteristics

A total of 81 patients were included in the final analysis. The characteristics of patients in our research are shown in Table 1. There is no significant difference between the two groups of data.

Table 1.

Baseline data of both groups

Characteristics	Total	Conventional method	Combination method	P
	(N = 81)	(N = 36)	(N = 45)	value
Gender (male vs. female)	26:55	14:22	12:33	0.242
Age(years, mean ± SD)	35.86 ± 14.3(32.69,39.04)	35.86 ± 10.6(32.28,39.44)	35.87 ± 16.8(30.79,40.94)	0.999
Scar duration(months, mean ± SD)	33.58 ± 9.6	33.11 ± 8.0	33.96 ± 10.9	0.698
Scar location				0.993
Forehead	5	2	3
Temple	4	2	2
Periocular	10	4	6
Nose	23	10	13
Cheeks	28	14	14
Lip & perioral	6	2	4
Chin & jaw	5	2	3
Scar type				0.619
Atrophic scars	38	18	20
Hypertrophic scar	43	18	25
Etiology				0.968
Acne	35	15	20
Surgery	13	6	7
Trauma	33	15	18

Pearson’s chi-squared test was applied for parameter “Gender, Scar location, Scar type and Etiology”. Independent sample t test was applied for parameter “Age and Scar duration”

Outcome evaluation

All 81 surgical patients did not experience bleeding, hematoma formation, infection, cracking, or fat liquefaction. In the 6-month postoperative evaluation, none of the 81 patients exhibited scar hyperplasia. No significant intergroup differences were observed in preoperative scar length or width measurements. Compared to pre-surgery measurements, scar length increased while width decreased postoperatively. Furthermore, the postoperative scar width for both groups was smaller than their respective preoperative widths, with no significant difference observed in the reduction of scar width between the two groups (Table 2).

Table 2.

Scar parameters before and after operation

	Conventional method			Combination method
Preoperation Postoperation Difference				Preoperation Postoperation Difference			P value
Width(cm)	1.2 ± 0.5[1.0,1.4]	0.9 ± 0.3[0.8,1.0]	0.3 ± 0.4[0.2,0.4]	1.3 ± 0.6[1.1,1.5]	0.9 ± 0.3[0.8,1.0]	0.4 ± 0.4[0.3,0.6]	0.268
Length(cm)	5.3 ± 1.4[4.9,5.8]	6.0 ± 1.4[5.5,6.5]	0.7 ± 0.5[0.5,0.8]	5.5 ± 1.2[5.1,5.9]	6.3 ± 1.2[5.9,6.7]	0.8 ± 0.6[0.2,1.0]	0.461

Mann-Whitney U test was applied

Both groups demonstrated improvements in all VSS parameters from preoperative to postoperative assessments (all P < 0.001). When comparing the outcomes between the two groups, the combination treatment group showed a statistically significant advantage in both the pigmentation score (P = 0.020) and the total VSS score (P < 0.001). Differences in individual parameters such as vascularity and pliability were observed before correction; however, after controlling the false discovery rate, the reduction in the pigmentation score and the total score remained statistically significant (Table 3).

Table 3.

VSS score before and after operation

	Conventional method			Combination method
Preoperation Postoperation Difference				Preoperation Postoperation Difference			P value
Pigmentation	2.5 ± 0.7[2.3,2.7]	1.5 ± 0.7[1.3,1.7]	0.9 ± 0.7[0.6,1.1]	2.5 ± 0.5[2.4,2.7]	1.1 ± 0.6[0.9,1.3]	1.4 ± 0.7[1.1,1.6]	0.020*
Vascularity	2.3 ± 0.8[2.0,2.5]	1.1 ± 0.9[0.8,1.4]	1.1 ± 0.8[0.9,1.4]	2.4 ± 0.7[2.2,2.6]	0.8 ± 0.6[0.7,1.0]	1.5 ± 0.9[1.3,1.8]	0.038
Pliability	2.3 ± 0.7[2.1,2.5]	1.3 ± 0.6[1.1,1.4]	1.0 ± 0.7[0.8,1.3]	2.3 ± 0.7[2.1,2.5]	0.9 ± 0.7[0.7,1.1]	1.4 ± 1.0[1.2,1.7]	0.044
Height	1.0 ± 0.4[0.9,1.2]	0.7 ± 0.4[0.5,0.8]	0.4 ± 0.5[0.2,0.6]	1.0 ± 0.3[1.0,1.2]	0.5 ± 0.5[0.4,0.7]	0.5 ± 0.5[0.4,0.7]	0.124
Total	8.1 ± 1.7[7.5,8.6]	4.5 ± 1.4[4.0,5.0]	3.6 ± 1.8[3.0,4.2]	8.2 ± 1.2[7.9,8.6]	3.3 ± 1.4[2.9,3.7]	4.9 ± 1.5[4.5,5.4]	<0.001*

VSS, Vancouver scar scale. Mann-Whitney U test was applied

* P < 0.05 after FDR correction for multiple comparisons

Similarly, according to the POSAS assessment, both groups showed postoperative improvements in all parameters within their own groups (all P < 0.001). In the between-group comparison, the combination treatment group exhibited greater reductions in multiple parameters. Differences in individual parameters such as PSAS parameters (color, stiffness, and overall patient opinion) and OSAS parameters (vascularity, pigmentation, pliability, relief, and overall observer opinion) were observed. However, after FDR correction for multiple comparisons, the combination treatment group demonstrated statistically superior improvements in color, overall opinion in PSAS, pigmentation and overall opinion in OSAS (P < 0.05, after FDR correction). (Table 4).

Table 4.

POSAS score before and after operation

	Conventional method			Combination method
Preoperation Postoperation Difference				Preoperation Postoperation Difference			P value
PSAS
Color	5.0 ± 1.2[4.6,5.4]	2.6 ± 1.5[2.1,3.1]	2.4 ± 1.3[1.8,2.8]	4.6 ± 1.1[4.3,5.0]	1.3 ± 1.2[0.9,1.6]	3.3 ± 1.6[2.9,3.8]	0.004*
Stiffness	4.5 ± 0.7[4.2,4.7]	2.2 ± 1.4[1.8,2.7]	2.3 ± 1.3[1.8,2.7]	4.6 ± 1.2[4.2,5.1]	1.7 ± 1.0[1.4,2.0]	2.9 ± 1.5[2.5,3.3]	0.041
Thickness	3.9 ± 1.0[3.5,4.1]	1.3 ± 1.0[1.0,1.7]	2.5 ± 1.5[2.0,3.0]	4.0 ± 0.8[3.7,4.2]	1.4 ± 1.1[1.1,1.8]	2.5 ± 1.5[2.1,3.0]	0.959
Irregularity	5.1 ± 1.2[4.7,5.5]	2.8 ± 1.2[2.4,3.2]	2.3 ± 1.3[1.8,2.7]	5.4 ± 1.1[5.1,5.7]	2.6 ± 1.6[2.2,3.1]	2.8 ± 1.4[2.4,3.2]	0.117
Pain	4.4 ± 1.4[4.0,4.9]	3.3 ± 1.5[2.8,3.8]	1.1 ± 1.1[1.0,1.6]	4.6 ± 1.1[4.3,5.0]	3.4 ± 1.2[3.1,3.7]	1.3 ± 1.1[0.8,1.5]	0.495
Itch	3.8 ± 1.6[3.3,4.4]	2.9 ± 1.4[2.4,3.4]	0.9 ± 0.9[0.6,1.2]	3.5 ± 1.3[3.1,3.9]	2.5 ± 0.9[2.2,2.7]	1.0 ± 1.2[0.6,1.4]	0.972
Overall opinion	4.4 ± 1.3[4.2,4.7]	2.5 ± 1.5[2.3,2.8]	1.9 ± 1.4[1.7,2.1]	4.4 ± 1.3[4.3,4.6]	2.2 ± 1.4[2.0,2.3]	2.3 ± 1.6[2.1,2.5]	0.007*
OSAS
Vascularity	4.5 ± 1.4[4.0,5.0]	2.1 ± 1.6[1.6,2.6]	2.4 ± 1.3[2.0,2.9]	4.6 ± 1.3[4.5,5.2]	1.4 ± 1.5[1.0,1.9]	3.1 ± 1.7[2.6,3.6]	0.048
Thickness	3.8 ± 0.9[3.5,4.0]	1.4 ± 1.0[1.1,1.7]	2.3 ± 1.3[1.9,2.8]	3.9 ± 0.9[3.6,4.2]	1.4 ± 1.0[1.0,1.6]	2.5 ± 1.5[2.1,3.0]	0.546
Pigmentation	5.1 ± 1.1[4.8,5.5]	4.3 ± 1.0[3.9,4.2]	0.9 ± 0.7[0.6,1.1]	5.0 ± 0.9[4.7,5.3]	3.6 ± 1.2[3.3,4.0]	1.4 ± 1.0[1.1,1.6]	0.015*
Pliability	4.6 ± 0.9[4.3,4.9]	1.6 ± 1.2[1.2,2.0]	3.0 ± 1.4[2.5,3.5]	4.6 ± 1.0[4.3,4.9]	1.0 ± 1.0[0.7,1.3]	3.6 ± 1.4[3.2,4.0]	0.040
Relief	5.1 ± 1.2[4.7,5.5]	2.3 ± 0.8[2.1,2.6]	2.7 ± 1.3[2.3,3.2]	5.2 ± 1.2[4.9,5.6]	1.9 ± 1.2[1.5,2.2]	3.4 ± 1.5[3.0,3.8]	0.039
Overall opinion	4.6 ± 1.2[4.4,4.8]	2.4 ± 0.5[2.3,2.6]	2.2 ± 0.7[2.0,2.4]	4.6 ± 1.1[4.5,4.8]	2.0 ± 0.6[1.8,2.2]	2.7 ± 0.8[2.4,2.9]	0.003*

POSAS patient and observer scar assessment scale, PASA patient scar assessment scale, OSAS observer scar assessment scale

Independent sample t test was applied

* P < 0.05 after FDR correction for multiple comparisons

Typical cases

Clinical case 1

A 32-year-old woman presented with an atrophic facial scar resulting from an accidental knife injury two years earlier. The scar exhibited significant local depression and was conspicuous at a social distance, prompting the patient to seek surgical excision. A “W”-shaped incision was preoperatively designed to align with the scar’s contour. Intraoperatively, the super tension-relieving suture technique was applied. At the three-month follow-up, the surgical site demonstrated sustained ultra-reduced tension effects. By six months postoperatively, the patient reported high satisfaction with the aesthetic outcome (Fig. 2).

Fig. 2.

A 32-year-old female presented with facial scars. The appearance before and after the application of a super-tension reduction suture technique combined with “W” -plasty surgery was demonstrated. A Before surgery; B Immediately after surgery; C Six months after surgery

Clinical case 2

A 35-year-old man presented with an atrophic facial scar resulting from an accidental laceration caused by an iron roll three years earlier. The scar had an irregular circular shape and significantly affected the patient’s physical and psychological well-being, leading him to seek surgical excision. A “W”-shaped incision was preoperatively designed to conform to the scar’s contour. Intraoperatively, the super tension-relieving suture technique was applied. At six months postoperatively, the patient reported high satisfaction with the aesthetic outcome (Fig. 3).

Fig. 3.

A 35-year-old male with facial scars underwent a super tension-reducing suture technique combined with “W”- plasty surgery. A Before surgery; B During surgery; C Six months after surgery

Discussion

Compared with the low resting mechanical pressure associated with the thin collagen fibers of fetal skin, adult skin contains thick collagen fiber bundles and exhibits significantly higher resting mechanical tension [12]. Mechanical tension plays a critical role in wound healing and scar formation, influencing all three phases of scar repair. During the inflammatory phase, wound apposition primarily relies on sutures to counteract mechanical tension. As the wound transitions into the proliferative phase, its tensile strength increases rapidly but remains below that of normal skin, necessitating continued suture support. In the remodeling phase, scar tissue gradually strengthens and matures [13]. However, even after complete healing, the tensile strength of scarred skin reaches only 75% to 80% of normal skin strength [4, 14]. Throughout the repair process, the ability of the healing tissue to resist mechanical tension remains limited. Under persistent mechanical stress, scar width may double within 3 weeks to 3 months and increase by approximately 50% between 3 and 6 months. In the early stages of healing, the use of absorbable sutures can mitigate tension forces. Polydioxanone (PDS), a monofilament absorbable suture composed of polyester, retains 70% of its tensile strength at 2 weeks, 40% at 4 weeks, and 35% at 6 weeks, with complete hydrolysis and absorption occurring within 180 to 230 days [15, 16]. For nonabsorbable sutures, such as nylon, removal is recommended once the wound has developed sufficient tensile strength, typically within one week postoperatively, to prevent prolonged exposure to suture-related tension.

However, sutures alone cannot provide sustained tension relief beyond three months. Although the continuous tension-reduction (CTR) technique can be employed postoperatively to further minimize tension, patient compliance poses significant challenges to its long-term adherence [8]. The combination of the super tension-relieving suture technique with W-plasty not only counteracts mechanical tension and optimizes scar aesthetics through multidimensional tension reduction, but also does not require strong patient compliance. The researchers investigated the relationship between wound orientation and mechanical stress, demonstrating that the tension of an incision perpendicular to the skin’s relaxation lines is approximately three times greater than that of an incision parallel to these lines [17]. Given that mechanical tension promotes fibrotic tissue proliferation, surgical incisions should be oriented parallel or obliquely to skin relaxation lines whenever possible to mitigate the risk of excessive tension-induced scar hypertrophy [18]. For scars with irregular morphologies, such as arcuate or circular shapes, individualized surgical planning is essential, and in some cases, multiple staged procedures may be required. Additionally, based on clinical experience, aligning incisions with the trajectory of subcutaneous musculature may further enhance outcomes. Adjunctive botulinum toxin injection into the subcutaneous and intramuscular planes postoperatively has demonstrated beneficial effects, including modulation of the inflammatory response and fibroblast activity. This approach results in paler, flatter scars and is particularly effective during the proliferative phase of healing.

The W-plasty technique modifies the incision trajectory to improve scar aesthetics and reduce mechanical tension. The human skin surface exhibits natural textural variations, and while normal skin lines produce characteristic light refraction patterns, scars tend to reflect light more uniformly, resulting in a smoother and flatter appearance. By introducing a “W”-shaped incision, the scar’s orientation is altered, allowing it to blend seamlessly with the surrounding unaffected skin. This modification promotes light scattering, creating a visually more natural appearance. Consistent with this principle, our findings demonstrated a statistically significant improvement in color and pigmentation. Additionally, based on our experience, atrophic scars respond better to the procedure compared to hypertrophic scars.

Additionally, the musculature of the human face is highly complex, and linear scars that align with the direction of facial muscle contraction are subject to increased mechanical tension, leading to more pronounced scar depression. By transforming a linear scar into a sawtooth configuration, W-plasty divides the scar into smaller triangular segments. This redistribution of mechanical forces enables tension to dissipate obliquely in multiple directions during facial muscle movement, thereby mitigating the bowstring effect commonly observed in linear scars and rendering them less noticeable [19].

The super tension-relieving suture technique further mitigates and prevents tension-related effects in wound healing. Following skin injury, the wound edges contract, and conventional transverse and vertical compression sutures are used to approximate the epidermis and dermis. However, upon suture removal, the loss of mechanical support may lead to residual tension, contributing to atrophic scar formation [20]. In contrast, super tension-relieving sutures achieve an optimal redistribution of mechanical forces by incorporating layered tension reduction, dispersing stress across the fascial and subcutaneous fat layers. This approach facilitates dermal and epidermal healing under minimal tension, reducing the likelihood of scar contraction. Facial skin is not a two-dimensional surface; rather, it follows specific curvatures along the cheekbones, forehead, and jawline. Consequently, linear scars in these regions are prone to localized depressions. Immediately postoperatively, compared with the flat incision profile observed with conventional suturing, super tension-relieving sutures create a slight protrusion at the incision site, typically ranging from a few millimeters to approximately 1 cm in height. Over two to three months, progressive skin traction gradually flattens the incision, preventing postoperative scar depression while preserving the natural aesthetic contour of the face [7, 21]. However, this technique requires adequate undermining of skin flaps on both sides of the wound to achieve sufficient tension reduction. This step increases the risk of undermining-related injury and may prolong healing time. Despite this consideration, the combination of super tension-relieving sutures with “W-plasty” effectively minimizes both atrophic and hypertrophic scar formation by addressing mechanical tension at multiple levels. And in our experience, patients whose scars have a length-to-width ratio exceeding 1.5 are more suitable candidates for the combined method. Furthermore, this approach is not limited to scar revision but is also applicable to the excision and reconstruction of superficial tumors, improving postoperative scar morphology and overall aesthetic outcomes [22]. Nowadays, a variety of non-surgical treatment options are available. Emerging therapies such as botulinum toxin A and calcium channel blockers are expanding the therapeutic arsenal for refractory or recurrent cases. We anticipate that combining our surgical approach with other modalities in the future will bring hope for more precise management of keloids [23].

Although the combined approach effectively reduces wound tension and meets aesthetic criteria, it has several limitations. The W-plasty requires the sacrifice of a portion of normal tissue during both the design and operative stages, making it less suitable for areas with minimal skin laxity. Additionally, the immediate postoperative elevation of the incision due to the super tension-relieving suture technique is often misinterpreted by patients, complicating preoperative and postoperative communication. To preserve skin integrity, repeated or excessive trimming of wound edges is contraindicated, necessitating precise execution. This technique requires considerable surgical expertise to ensure complete scar excision is achieved in a single procedure along the predefined “W” incision, and is inherently time-consuming. Furthermore, postoperative adherence to care recommendations varies among patients, potentially affecting long-term outcomes.

This study has several limitations. As a retrospective analysis rather than a fully blinded randomized controlled trial, the study design introduces potential selection bias in patient assignment. Future prospective randomized controlled trials comparing this method with conventional approaches will be important in validating its efficacy. Although widely used, the scar assessment scales remain subjective to some degree, as fully objective scar evaluation methodologies have yet to be established. The 6-month follow-up period has limitations. Future work will include extended follow-up to confirm the persistence of these improved outcomes beyond the scar maturation period of one year.

In conclusion, the combination of super tension-relieving sutures with W-plasty represents an effective technique for facial scar revision. This approach systematically minimizes the impact of mechanical tension, aligns with the natural orientation of skin lines, and yields superior aesthetic outcomes. Given its advantages, this method warrants further clinical application and broader adoption in reconstructive surgery.

Abbreviations

VSS

Vancouver scar scale

POSAS

Patient and Observer Scar Assessment Scale

PSAS

Patient Scar Assessment Scale

OSAS

Observer Scar Assessment Scale

FDR

False Discovery Rate

Authors’ contributions

(I) Conception and design: HT; (II) administrative support: HT and LL; (III) provision of study materials or patients: QL; (IV) collection and assembly of data: ZM and HZ; (V) data analysis and interpretation: all authors; (VI) manuscript writing: all authors; (VII) final approval of manuscript: all authors.

Funding

Not applicable.

Data availability

The data that support the findings of this study are not publicly available due to the privacy of research participants but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was approved by the Ethics Committee of the Second Affiliated Hospital of Soochow University (JD-HG-2025-014). Written and verbal informed consents were obtained from all participants, including those who provided images. In conducting the research, the authors adhered to the principles set forth in the Declaration of Helsinki.

Consent for publication

Written informed consent was obtained from all individual participants included in the study for the publication of their identifiable images and clinical details.

Competing interests

The authors declare no competing interests.