Keywords rhytidectomy scar - facelift scar - hypopigmented scar - incision placement
Patients typically undergo rhytidectomy to improve age-related changes as viewed by
themselves and others. The patient's perception of their surgical outcome determines
the success of this procedure, and it is important to understand how a cosmetic patient
conceptualizes the effects of rhytidectomy. Studies have shown that the cosmetic patient
associates the physical changes of rhytidectomy with youth, attractiveness, and increased
health.[1 ] Perceptions of rhytidectomy even affect the cosmetic patient's willingness to pay
for the procedure across different economic markets.[2 ] However, there is a dearth of prior research on the cosmetic patient's perception
specifically regarding variations on rhytidectomy incisions and resulting surgical
scars. Previous research on skin scars demonstrated that patient-rated scar severity,
but not physician-rated scar severity, correlated with psychosocial distress.[3 ] This suggests not only the psychosocial impact of scar visibility but also the importance
of capturing the patient perspective given the potential disparity with the physician
perspective. Studies have shown that understanding and incorporating the patient perspective
provide more clinical data to guide treatment and improve the patient–physician relationship.[4 ]
In this study, the authors seek to analyze the cosmetic patient's assessment of the
rhytidectomy scar and compare it to the perception of the rhytidectomy scar by facial
plastic and reconstructive surgeons.
Methods
Participants
In-person surveys were administered to a sample of voluntary patients presenting for
cosmetic consultation in the senior author's (T.C.K.) facial plastic and reconstructive
surgery private practice population. Patients presenting with reconstructive issues
were excluded. The survey for facial plastic surgeons was distributed online through
the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS). Completed
surveys were collected from 69 cosmetic patients, 18 years of age or older, and from
120 surgeons from March to April 2019 and October to November 2019, respectively.
Survey Instrument
Participants were presented with standardized lateral view photographs of 10 patients
at least 12 months post rhytidectomy procedure. A variety of rhytidectomy incisions
were chosen to include pre- versus post-tragal incisions, blunted hair tuft, hypopigmentation,
narrow versus wide scar healing. All patients consented to have photos used in research
studies, and photos were standardized for facial expression and lighting. For the
cosmetic patients, one standardized set of printed photographs were used for all patients
and surveys were printed out on paper for response. For the surgeons, Google Forms
were used to electronically deliver the same patient photographs. Both sets of participants
were asked to rate the outcome of the rhytidectomy scar using the Likert scale from
1 to 10, where 10 was the most favorable outcome. For each patient photograph, all
participants were also asked the following question allowing for free-form response:
“What characteristic influenced your choice?”
The cosmetic patients were asked demographic data including age, sex, and whether
they or acquaintances had undergone or were considering cosmetic surgery. Facial plastic
surgeons were asked demographic data including age, sex, number of years in practice,
location of practice, completion of an AAFPRS fellowship, and number of rhytidectomy
performed per year.
Data Analysis
All statistical analyses were conducted using R (Vienna, Austria: R Foundation for
Statistical Computing). Prior to analysis, patient photographs were subdivided based
on similar characteristics including pigmentation of scar, relation of incision to
tragus, and blunting of hair tuft. Primary univariate measures were conducted with
responses from cosmetic patients and responses from surgeons to characterize overall
ratings within each of the aforementioned photo characteristic subgroups. Subsequent
intragroup rating differences were evaluated utilizing Welch's two sample t -test for unequal variances and Kruskal–Wallis rank sum test with Dunn's multiple
comparison test. Additional comparisons were made between ratings of cosmetic patients
and surgeons using Welch's t -test. Furthermore, the free-form responses were used in qualitative analysis using
anthropologic frameworks.
Results
Demographic data for the cosmetic patients and surgeons is provided in [Tables 1 ] and [2 ]. Characteristics of the patient photographs are provided in [Table 3 ].
Table 1
Patient demographic characteristics
Characteristics
N (%)
Age, mean (SD), y
53.77 (14.69)
Gender
Female
65 (95.59)
Male
3 (4.41)
Prior facial cosmetic surgery
Yes
14 (21.54)
No
51 (78.46)
Considering cosmetic surgery
Yes
5 (7.69)
No
23 (35.38)
Undecided
37 (56.92)
Table 2
Surgeon demographic characteristics
Characteristics
N (%)
Gender
Female
107 (89.17)
Male
13 (10.83)
Years in facial plastics practice
< 5
28 (23.33)
5–10
20 (16.67)
11–15
8 (6.67)
16–20
17 (14.17)
21–25
14 (11.67)
> 25
33 (27.50)
Facial plastic surgery fellowship
Yes
92 (77.31)
No
27 (22.69)
Facelift procedures performed per year
< 5
19 (15.83)
5–10
14 (11.67)
11–15
14 (11.67)
16–20
8 (6.67)
21–25
14 (11.67)
> 25
51 (42.50)
Table 3
Characteristics of patient photographs
Gender
Relationship to tragus
Blunted hair tuft
Pigmentation
Scar width
Extension into neck
Photo 1
Male
Pre-tragal
No
Normal
Narrow
No
Photo 2
Female
Post-tragal
No
Normal
Narrow
No
Photo 3
Female
Pre-tragal
Yes
Hypo-pigmented
Wide
No
Photo 4
Female
Pre-tragal
No
Hypo-pigmented
Narrow
No
Photo 5
Female
Pre-tragal
Yes
Hypo-pigmented
Narrow
Yes
Photo 6
Female
Post-tragal
No
Normal
Narrow
No
Photo 7
Female
Post-tragal
No
Normal
Narrow
No
Photo 8
Female
Post-tragal
Yes
Hypo-pigmented
Narrow
No
Photo 9
Female
Post-tragal
Yes
Hypo-pigmented
Wide
Yes
Photo 10
Male
Post-tragal
Yes
Normal
Narrow
No
Perception of Cosmetic Patients
Cosmetic patients perceived non-hypopigmented scars more favorably than hypopigmented
scars [p <0.001 with 95% CI (−1.52e−08, −0.73e−08)]. Similarly, cosmetic patients rated narrow
scars more favorably than wider ones [p <0.001 with 95% CI (−1.87e−07, −0.82e−07)]. However, there was neither any significant
difference valuation of pre-tragal compared with post-tragal incisions nor any significant
difference if blunted hair tuft was present.
Within the cohort of cosmetic patients, participant age or personal history of rhytidectomy
was not a confounding factor. Compared with female participants, male participants
rated non-hypopigmented scars and post-tragal incisions more favorably with statistical
significance [p = 0.04 with 95% CI (0.16, 2.67) and p = 0.014 with 95% CI (0.60, 2.84)].
Perception of Surgeons
Similar to the cosmetic patient cohort, surgeons view non-hypopigmented scars more
favorably than they do hypopigmented scars [p <0.001, 95% CI (−2.16e−16, −1.69e−16)] and narrow scars more favorably than wide
scars [p <0.001, 95% CI (−2.18e−16, −1.62e−16)]. In contrast to the cosmetic patient cohort,
surgeons rated post-tragal incisions more favorably than pre-tragal incisions [p <0.001, 95% CI (−2.16e−05, −1.69e−05)]. Furthermore, surgeon's preference regarding
blunted hair tufts was statistically significant, with less favorable ratings.
When comparing ratings within the surgeon's cohort, there are statistically significant
differences in how wide and hypopigmented scars, pre-tragal incision, and blunted
hair tufts were rated based on number of rhytidectomies performed by surgeons. With
pre-tragal incisions, there is no clear trend of the number of rhytidectomies performed;
however, lower ratings of wide scars, hypopigmented scars, and blunted hair tufts
correlated with higher number of rhytidectomies performed by surgeons ([Figs. 1 ]
[2 ]
[3 ]). Furthermore, there are statistically significant differences in how incisions
that did not blunt the hair tuft were rated based on surgeons' number of years in
practice, but there are no discernable trends in the correlations.
Fig. 1 Rating of hypopigmented scars decreases with surgeon rhytidectomy volume. Box and
whisker plot of the effect of rhytidectomy volume on surgeon ratings of hypopigmented
scars. Overall Kruskal-Wallis chi-squared = 15.33, p = 0.01.
Fig. 2 Rating of wide scars decreases with surgeon rhytidectomy volume. Box and whisker
plot of the effect of rhytidectomy volume on surgeon ratings of wide scars. Overall
Kruskal-Wallis chi-squared = 16.72, p = 0.005.
Fig. 3 Rating of blunted hair tuft decreases with surgeon rhytidectomy volume. Box and whisker
plot of the effect of rhytidectomy volume on surgeon ratings of images with a blunted
hair tuft. Overall Kruskal-Wallis chi-squared = 13.97, p = 0.02.
Comparison of Observer and Surgeon
When directly comparing the surgeon and cosmetic patient cohorts, surgeons rate hypopigmented
scars significantly lower than that of observers [p <0.01, 95% CI (−0.61e−7, −1.33e−7)], but there was no difference in valuation of
the non-hypopigmented scar. Additionally, surgeons rate pre-tragal incisions and blunted
hair tuft significantly lower than observers [p <0.001, 95% CI (−0.54e−0.6, −1.28e−0.6) and p <0.001, 95% CI (−0.43e−0.6, −1.1e−0.6), respectively]. Surgeons also rated both wide
[p <0.001, 95% CI (−0.38e−04, −1.46e−04)] and narrow scars [p < 0.001, 95% CI (−0.12e−03, −0.62e−03)] significantly lower than do observers, with
an appreciably greater discrepancy in ratings for wide scars.
Qualitative Analysis
The free responses from cosmetic patients and surgeons were used for qualitative analysis.
In the responses of 69 cosmetic patients, the word “noticeable” was used 35 times
while it was used 21 times in the responses of 120 surgeons. The repetition of words
such as “noticeable,” as well as “visible” and “natural” in the cosmetic patients'
comments suggests the importance of maintaining a sense of “normalcy” as well. In
contrast, the surgeons' comments are most frequently about the relationship between
the scar and surrounding anatomical structures, such as relationship to tragus and
to hair tuft. In the responses of 120 surgeons, the word “placement” was used 58 times
while it was used one time in the responses of 69 cosmetic patients. This discrepancy
in language suggests a focus on the technicality of scar placement and subsequent
anatomical result in comparison to the global perspective of the scar relative to
the person's overall appearance, which is more aligned with the cosmetic patients'
comments.
Discussion
Commonality in Valuation
In analyzing the perceptions of rhytidectomy scar by cosmetic patients and facial
plastic surgeons, certain aspects of the scar were valued similarly. Scars that were
not hypopigmented and scars that were post-tragal were rated significantly favorably
by both cohorts, though hypopigmented scars would also be less visible when placed
post-tragal. Within the surgeon's cohort, as the number of rhytidectomies performed
increased, hypopigmented scars and blunted hair tufts were increasingly perceived
more negatively.
Surgical Techniques
This study's findings provide insight into surgical incision placement of the pre-auricular
rhytidectomy incision. Given the importance of avoiding scar widening and hypopigmentation
for both patients and surgeons, surgical techniques such as multilayer wound closure
and minimal tension on the skin re-approximation are of paramount importance.[5 ] Patient factors such as skin type, sun exposure, tobacco use, vascular diseases,
and medications also affect wound healing. For unfavorable scar healing, treatment
options such as dermabrasion, laser, interlesional injections, and surgical scar revisions
can be performed at a later time. While this study does not analyze the post-auricular
incision, there are recommended techniques on incision placement to maximize aesthetic
outcomes and minimize wound tension, such as but not limited to using W-plasty along
the occipital hairline[6 ] and avoiding incision placement within the post-auricular sulcus.[7 ]
Differences in Language
Observers and surgeons differed in the overall language used in analyzing rhytidectomy
scars. While surgeons predominantly used technical terms and noted anatomical descriptions
in the free-text responses, the narrative responses of the cosmetic patients focused
on the desire to maintain looking “natural” after rhytidectomy. In the context of
rhytidectomy scars, we interpret “normal” and “natural” as referring to scars that
minimize the suggestion of surgical intervention. These scars tend to be not widened,
not hypopigmented, and well-hidden in natural creases. These types of scars would
also maintain preoperative anatomical appearances, such as preserving the patients'
hair tufts.
Analysis of the concept of “normality” and its connotations extends to the 1930s in
the work of anthropologist Ruth Benedict. Describing “normal” and “abnormal” as socially
constructed frameworks, Benedict argues that the inability to function socially is
tied to the concept of “abnormal.”[8 ] This theory suggests that conforming to a society's concept of normal gives an individual
more societal agency. Thus, it is understandable why patients use language to emphasize
the “natural look,” or maintaining appearances that minimize the suggestion of having
undergone physically altering procedures. Therefore, the qualitative responses from
patients are congruent with the quantitative analysis of their evaluation of rhytidectomy
scars.
Nonetheless, this study findings do not imply that surgeons do not care about the
“natural look,” and while the results may not change how surgeons design the placement
of rhytidectomy scars; this study demonstrates that it is worth examining how language
and perspective are important considerations even when discussing surgeries or goals
with patients.
Study Limitations
The study utilized the distribution of the survey at a facial plastic surgeon's office
and via communication through the World Wide Web, there is invariably selection bias
in the participant cohort. Based on the demographic profile, while only 35% of the
patient participants pursued surgical options for themselves, all patient participants
have some degree of experience with the appearance of their faces either with surgical
or non-surgical interventions. Furthermore, the gender distribution in our study demographics
is heavily skewed toward female participants and surgeons compared with that of the
general population.[9 ] We also focus on assessing preauricular variations of rhytidectomy scars and do
not include post-auricular scar appearance and other surgical outcomes such as improvement
in facial contour. We were specifically analyzing the perception of scars that are
not typically visible on frontal view, and we did not want the results of the rhytidectomy
itself to influence rating of the perceived scar; therefore, only lateral views of
the scar were provided in the survey. Additionally, preoperative photographs were
not included for comparison in analyzing the scars.
Conclusion
In this study, we analyzed perceptions of rhytidectomy scars from the perspectives
of cosmetic patients, representing the general population and facial plastic surgeons.
The ratings from cosmetic patients were centered on general scar morphology, notably
scar width and pigmentation, and concerns about maintaining natural-looking appearance
post-procedure. Surgeons were more critical of the nuances of the incision placement;
this technical orientation of evaluating scar outcomes is likely influenced by their
surgical practice. Ultimately, an understanding of nuances in language and observer
preference is vital for surgeons to create outcomes that align with the goals of patients
undergoing cosmetic surgery.
