Comparison of W-Plasty and Straight-Line Trichophytic Closure on Aesthetic Outcomes of Occipital Hairline Scars in Rhytidectomy

Key Points

Question

Does W-plasty closure result in better aesthetic outcomes for scars along the posterior occipital hairline in rhytidectomy than the more traditional straight-line trichophytic closure technique?

Findings

In this cohort study of 46 patients who underwent rhytidectomy, W-plasty and straight-line closures along the posterior occipital hairline had equivalent cosmesis ratings under objective blinded evaluation.

Meaning

Both W-plasty and straight-line closure techniques along the posterior occipital hairline resulted in highly acceptable cosmetic outcomes, with no one technique being superior to the other.

Abstract

Importance

Incision placement and design in rhytidectomy is critical for patient satisfaction.

Objective

To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) trichophytic closure techniques on posterior occipital hairline scars in rhytidectomy.

Design, Setting, and Participants

A retrospective cohort study was conducted at the Buckingham Center for Facial Plastic Surgery. Clinical history and operative reports were reviewed for 46 patients who underwent rhytidectomy (23 using W-plasty and 23 using SL technique) between June 1, 2014 and August 31, 2015. Blinded photographic analysis of 1-year postoperative photographs was performed.

Interventions

The posterior occipital hairline incision was primarily closed with either a W-plasty or SL trichophytic technique.

Main Outcomes and Measures

Standard photographs of the posterior occipital incision site obtained after the 1-year postoperative mark were reviewed and scored in a blinded fashion by 3 nonphysician medical staff members using a modified Manchester Scar Scale (MSS: from 0 [best possible outcome] to 24 [worst possible outcome]). Interrater reliability was assessed via Cronbach α testing.

Results

There were 23 patients in each group. The W-plasty and SL groups were similar in terms of age (mean [SD] age, 59.6 [6.3] years and 64.1 [7.3] years, respectively), sex (21 [91%] and 21 [91%] women, respectively), race-ethnicity, and absence of risk factors (smoking and diabetes) predisposing to poor wound healing (0 and 0 smoking/diabetes, respectively). Mean (SD) follow-up times for the W-plasty and SL groups were 388 (38.8) and 475 (100.1) days, respectively. No statistical difference was demonstrated in the mean aggregate MSS scores from all evaluators between the W-plasty group and the SL group (reviewer 1: 5.69 vs 5.86, P = .60; reviewer 2: 10.09 vs 9.56, P = .65; and reviewer 3: 5.30 vs 6.17, P = .08). Overall interrater reliability for the MSS scores was 0.56.

Conclusion and Relevance

Primary W-plasty and SL trichophytic closures in the posterior occipital hairline appear to yield highly acceptable and similar cosmetic outcomes under objective blinded evaluation. These techniques can be used with success to help minimize conspicuous scarring after rhytidectomy.

Level of Evidence

3.

This cohort study of rhytidectomy compares W-plasty and the more traditional straight-line trichophytic closure techniques for aesthetic outcomes for scars along the posterior occipital hairline.

Introduction

Patients seeking rhytidectomy aspire to reverse the effects of aging on their face and classically desire an improved jawline, reduced jowling, and a tighter neck. This is rarely at the cost of grossly visible incisions or distortions of their native hairline, telltale signs of a poor-quality face-lift. Anecdotal experience among facial plastic surgeons who commonly manage patients seeking revision face-lift suggests a pervasive intolerance among patients for rhytidectomy scar outcomes.

Efforts to improve incision design and placement in rhytidectomy are evident in the literature and in cosmetic surgery training programs across the country. These efforts focus on allowing an appropriate vector for the surgical lift while rendering any evidence of an operation inconspicuous to the passive observer. The use of W-plasty and geometric broken-line closure techniques for further improvement in rhytidectomy incision outcomes in both primary and secondary settings has been observed in clinical practice among cosmetic surgeons around the country; however, to our knowledge, it has not been specifically studied or commented on. Introduced to break up a linear scar into smaller, more camouflageable segments that essentially trick the mind of the observer to the presence of a scar, these techniques have become an integral component of the surgical algorithm when dealing with wound closures and scar revision. Only a few studies have actually compared the cosmetic outcomes of these techniques to more traditional straight-line (SL) closures, and the conclusions are mixed.

A randomized study of temporoparietal facial flaps in 30 patients showed that zigzag incisions resulted in a more conspicuous scar than a linear technique in patients younger than 65 years. Jáuregui et al recently demonstrated that donor-site closure on the forehead using a primary W-plasty technique resulted in better scar appearance than SL closure after paramedian forehead flap elevation in 31 patients. In contrast, a national survey of 810 layman participants of the public perceived linear scars as more cosmetically favorable than zigzag scars in 3 facial locations (temple, cheek, and forehead). Undoubtedly, the location of the scar, closure technique, technical expertise of the surgeon, and various patient factors influence the overall cosmetic result of any surgical closure. However, with these parameters kept constant, further studies are needed to elucidate the role of W-plasty or geometric broken-line techniques in cosmetic facial surgery, where inconspicuous scarring is of paramount importance.

Herein, we present a comparative study of aesthetic outcomes using W-plasty and SL closure techniques for occipital hairline scars in rhytidectomy.

Methods

Study Design

A retrospective cohort study was designed to compare postsurgical scar results of rhytidectomy in patients who underwent either an SL or W-plasty trichophytic incision and closure along the occipital hairline component of the rhytidectomy skin incision (Figure 1). The W-plasty technique was adopted by the primary surgeon (E.D.B.) for all patients after January 20, 2015, in an effort to further improve postsurgical cosmesis for his patients, especially for patients who customarily wear their hair up in a ponytail. All patients who underwent rhytidectomy by the primary investigator (E.D.B.) from June 1, 2014, to August 31, 2015, and were at least 1 year out from surgery were eligible for enrollment in the study (n = 147). Surgical procedures were performed in the office under oral and local sedation or at an outpatient ambulatory surgical center under moderate, intravenous sedation (for patients who needed adjunctive procedures such as autologous fat transfer and/or submental liposuction and platysmaplasty).

Figure 1. W-Plasty Incision Along Posterior Occipital Hairline.

Twenty-three patients with SL closure (surgery before January 20, 2015) and 23 with W-plasty closure (surgery after January 20, 2015) who were available for follow-up after the 1-year mark and during the data collection phase of this study were consecutively enrolled (n = 46; 31% of all eligible patients). The study was reviewed by an independent institutional review board (IntegReview IRB, Austin, Texas) and granted an official waiver; no patient written informed consent was required. Standardized photographs of the occipital hairline were taken using a Canon EOS Rebel T2i SLR camera with 60-mm Canon EFS Ultrasonic Macro lens with dual box flashes (Canon USA Inc) in addition to routine postoperative views. After deidentification, the pictures were compiled in a Microsoft PowerPoint document with each slide containing a single patient’s left and right occipital hairline pictures (Figure 2). Independent, blinded photographic analysis was then conducted by 3 nonphysician medical staff members using a printed handout (to scale) of a modified Manchester Scar Scale (MSS), a validated scar evaluation tool that includes a visual analog scale (VAS) (0-10 cm; 0 = best, 10 = worst) and 4 ordinal items in a Likert-type scale (color [1-4], surface appearance [1-2], contour [1-4], and distortion [1-4]), resulting in a score between 4 (best) and 24 (worst). Bilateral photographs were used for a single assessment on each patient. Evaluators were asked to mark their scores on the handout, and scores were subsequently summed, compiled, and analyzed. Statistical analysis to determine the significance of the findings was performed to compare both groups.

Figure 2. Evaluation of Posterior Occipital Hairline Scars.

Clinical images depicting posterior occipital hairline scars evaluated by reviewers.

Surgical Technique

We performed a standardized extended high-SMAS (superficial muscular aponeurotic system) rhytidectomy technique on all patients in the study. All procedures were performed by the primary investigator (E.D.B.). Incisions are routinely designed to preserve the native position of both temporal hair tuft and occipital hairlines with standard periauricular components (eFigure in the Supplement). Skin flap elevation proceeds in a subcutaneous plane to widely expose the SMAS layer, after which a sub-SMAS flap is created over the parotid, and if indicated over the masseteric fascia and releasing the zygomatic-cutaneous ligament. Horizontal and vertical strips of redundant SMAS are then excised at the level of the zygoma and in the preauricular region, respectively, and the remaining SMAS layer is secured to the temporalis fascia superiorly and mastoid periosteum posteriorly. Skin flaps are then redraped passively and trimmed to appropriate contour. For the W-plasty closure, the occipital hairline component of the skin flap is cut to match the W-plasty design of the recipient skin edge. This segment of the skin incision (SL or W-plasty) is then closed with a running, locking 5-0 nylon suture. Skin sutures are removed in 7 days, and standardized wound care instructions are provided to all patients.

Statistical Analysis

Power calculation based on a priori studies using VAS, a component of the MSS, suggested a sample size of 32 patients (16 in each group) to detect a minimally clinically important difference of 1.5 cm between the 2 groups (SD = 1.5 cm, α = 0.05, and β = 0.20). We were able to enroll 46 patients (23 in each group). A 2-tailed, unpaired t test was used to analyze the mean aggregate MSS scores as previously described. For additional statistical validation, VAS and Likert-type scales were separated and analyzed independently using a 2-tailed Mann-Whitney test for independent, nonparametric data. Differences at P < .05 were considered to be statistically significant. Cronbach α testing was used to determine interrater score reliability, a score greater than 0.4 being considered good.

Results

Demographic characteristics of the 23 patients enrolled in each group are summarized in Table 1. There were no associated intraoperative complications or major postoperative complications reported for any of the patients (including but not limited to clinically significant hematoma formation needing to be surgically evacuated, incisional breakdown, or skin flap compromise or necrosis). Four patients had minor fluid accumulations (≤5 cc) noted the day after surgery that required needle aspiration: 3 in the W-plasty group and 1 in the SL group. No patient in either group had complaints regarding their occipital hairline scar, and no scar revisions had to be performed.

Table 1. Patient Demographics.

Characteristic	Patients, No. (%)
	W-Plasty (n = 23)	SL Incision (n = 23)
Female sex	21 (91)	21 (91)
White race/ethnicity	23 (100)	23 (100)
Age, mean (SD), y	59.6 (6.3)	64.1 (7.3)
Smoker at DOS	0	0
Diabetes mellitus	0	0

Abbreviations: DOS, date of surgery; SL, straight-line.

Mean (SD) follow-up time for postoperative pictures in the W-plasty and SL groups was 388 (38.8) days vs 475 (100.1) days, respectively. No statistical difference was demonstrated in the mean (SD) aggregate MSS scores from all evaluators between the postoperative W-plasty and SL groups, respectively: reviewer 1, 5.69 (1.18) vs 5.86 (1.10); 95% CI, −0.85 to 0.51 (P = .60); reviewer 2, 10.09 (4.31) vs 9.56 (3.37); 95% CI, −1.78 to 2.82 (P = .65); reviewer 3, 5.30 (1.29) vs 6.17 (1.97); 95% CI, −1.86 to 0.12 (P = .08) (Table 2). Looking at each component of the MSS independently, we found no statistical difference in the mean (SD) VAS scores between the W-plasty and SL groups, respectively: reviewer 1, 4.91 (0.67) vs 4.96 (0.56) (P = .83); reviewer 2, 6.43 (1.65) vs 6.43 (1.38) (P = .98); and reviewer 3, 4.69 (0.63) vs 5 (0.90) (P = .34). We also found no statistical difference in the mean (SD) Likert-type scale scores between the W-plasty and SL groups, respectively: reviewer 1, 0.78 (0.60) vs 0.91 (0.67) (P = .57); reviewer 2, 3.65 (2.82) vs 3.13 (2.20) (P = .53); and reviewer 3, 0.61 (0.72) vs 1.17 (1.11) (P = .10). Biostatistical interrater reliability analysis of the MSS data revealed an overall Cronbach α value of 0.56, with 0.57 for the W-plasty group and 0.57 for the SL group.

Table 2. Comparison of W-Plasty and SL Closures With the Modified Manchester Scar Scale.

Reviewer	MSS Scores, Mean (SD)		Significance, P Value
	W-Plasty Group (n = 23)	SL Group (n = 23)
1	5.69 (1.18)	5.86 (1.10)	.61
2	10.09 (4.32)	9.56 (3.37)	.65
3	5.30 (1.29)	6.17 (1.97)	.08

Abbreviation: MSS, Manchester Scar Scale; SL, straight-line.

Discussion

Attention to appropriate incision design and placement is critical in achieving success with rhytidectomy. Kridel and Liu brought specific attention to this issue when pointing out the multifaceted effects, both physical and emotional, of poorly placed incisions on recipients of rhytidectomy, coining the terms face-lift cripples and hairline cripples to describe patients with permanent disfigurement from a poorly performed face-lift. Clearly, several options exist to ensure inconspicuous scarring after rhytidectomy. We have found that with regard to the occipital incision, a trichophytic technique along the posterior occipital hairline itself results in the best lifting outcome with little to no derangements of the hairline. This has been well received by our patients, especially those who have a tendency to wear their hair up year-round.

Although we believe that the W-plasty closure achieves a better cosmetic outcome along the posterior occipital hairline because of its regularly irregular pattern going in and out of hair-bearing skin, the results of our study suggest that a well-placed trichophytic incision and meticulous technique ensuring a tension-free closure results in a cosmetically favorable scar regardless of whether an SL or W-plasty technique is used. This may be the effect of hairline concealment or simply that the scars in this area were overall below the threshold of visible derangement for the individuals rating them. We chose nonphysician medical personnel to evaluate the scars because we wanted reviewers to have some experience looking at scars and dealing with scar-related issues among practice patients while not being biased by predetermined notions of alternative approaches to incisional closure such as with W-plasty or geometric broken-line patterns.

Scar perception is evidently a complicated phenomenon to explain because it combines several objective and subjective parameters that vary in different individuals and that ultimately influence how tolerant and accepting we are to any distortions in the “norm.” As surgeons, we are acutely aware of several factors influencing the cosmetic appearance of our work, and that of others, including texture, color match, topography, width, light reflection, and distortion of native anatomy, among others. Those with limited medical expertise do not analyze a scar in as much detail or in as many categories, but are still innately capable of determining an inconspicuous, cosmetically acceptable result from one that draws negative attention. No doubt, the threshold for detection of subtle derangements in soft-tissue anatomy related to a scar is variable among patients seeking cosmetic surgery, but it is likely higher overall (excluding those with perceptive disorders) than that of most cosmetic surgeons.

There is certainly a role for W-plasty and geometric broken-line closure techniques to reorient, irregularize, and camouflage grossly visible linear scars. Use of these techniques should be determined by the surgeon based on where the incision is, how long the incision will be, and what anatomic structures lie nearby. Increased operative time associated with these techniques is another consideration, though we did not specifically measure this.

Limitations

The study has several limitations. The first is that despite using a validated scar evaluation tool (which is photograph-based, psychometrically studied, and specifically designed to assess surgical incision healing), the aesthetic outcomes were still based on a subjective assessment by individuals with varying degrees of medical expertise related to scar appearance and characterization. By not incorporating texture, we also left out a potentially informative feature from scoring. Follow-up time was not exactly the same between groups, with patients in the SL group presenting on average approximately 3 months later than the patients in the W-plasty group, possibly allowing for increased scar maturation and a better cosmetic appearance. There may also have been a selection bias as far as which patients agreed to come in for follow-up after 1 year, although this would have been similar for each group. Finally, the homogeneity of our population sample presents definite advantages and disadvantages. Benefits include the ability to control for any discrepancies in wound healing among patients of different ethnicities or sexes. Limitations include the inability to make broader conclusions regarding the role of these surgical techniques on aesthetic outcomes after rhytidectomy in a heterogeneous population of patients seeking face-lift surgery.

Conclusions

Primary W-plasty and SL trichophytic closures in the posterior occipital hairline in rhytidectomy appear to yield highly acceptable cosmetic outcomes that did not differ under objective blinded evaluation. These techniques can be used with success to help minimize conspicuous scarring after rhytidectomy.

Supplement.

eFigure. Standard rhytidectomy incision