Patient and observer scar assessment scores favour the late appearance of a transverse cervical incision over a vertical incision in patients undergoing carotid endarterectomy for stroke risk reduction

Abstract

Background: Carotid endarterectomy (CEA) is a very common operation, but there is no agreement on the appropriate orientation of the surgical incision. Methods:We retrospectively reviewed the charts of patients who had undergone CEA between Jul. 1, 2010, and Dec. 31, 2013. We contacted patients identified in the review to solicit participation in a clinical follow-up examination, during which the esthetic outcome of the scar was evaluated using the Patient and Observer Scar Assessment Scale (POSAS).Results: During the study period 237 CEAs were performed. Nine patients refused the use of their personal health information in this study. There were no significant differences in the neurologic outcomes of patients based on the incision orientation (perioperative stroke and death 1.4% with transverse incision v. 0% with a vertical incision, p = 0.44). Fifty-two patients presented for follow-up examination. Thirty-three had a transverse incision and 19 had a vertical incision. Results of the POSAS significantly favoured the transverse incision (p = 0.03). Vertical incisions were more often associated with persistent, mild marginal mandibular nerve dysfunction (p = 0.04). Conclusion:Carotid endarterectomy performed through a transverse skin incision compared with a vertically oriented skin incision is associated with improved esthetic outcome, as measured by the POSAS, without an observed statistically significant difference in the risk of perioperative stroke or death between the 2 techniques.Contexte : L'endartériectomie de la carotide est une intervention chirurgicale très courante. Toutefois, il n'existe aucun consensus sur l'orientation de l'incision.Méthodes : Nous avons analysé rétrospectivement les dossiers de patients ayant subi une endartériectomie de la carotide entre le 1 er juillet 2010 et le 31 décembre 2013. Nous avions communiqué au préalable avec les patients concernés pour solliciter leur participation à un examen de suivi clinique au cours duquel le résultat esthétique de leur cicatrice serait évalué au moyen de l'échelle d'évaluation des cicatrices par les patients et les observateurs (POSAS).Résultats : Au cours de la période visée, 237 endartériectomies de la carotide ont été pratiquées. Neuf patients ont refusé qu'on utilise leurs renseignements médicaux personnels dans le cadre de l'étude. Aucune différence significative n'a été observée quant aux capacités neurologiques des patients selon l'orientation de leur incision chirurgicale (décès et accident vasculaire cérébral périopératoires : 1,4 % avec incision transversale contre 0 % avec incision verticale, p = 0,44). Au total, 52 patients se sont présentés pour un examen de suivi : 33 avaient eu une incision transversale et 19, une incision verticale. Les résultats à la POSAS étaient nettement meilleurs pour les incisions transversales (p = 0,03). Les incisions verticales étaient plus souvent associées à un dysfonctionnement léger, mais persistant de la branche marginale de la mandibule du nerf facial (p = 0,04). Conclusion :Notre étude indique...

Cosmetic effects of skin-crease camouflage incision versus longitudinal incision following carotid endarterectomy.

“…POSAS is recommended by plastic surgeons and was successfully used in CEA scar assessment [ 14 , 19 , 20 ]. Our results are similar to the data already reported in the literature [ 17 ].…”

“…This is a well-established method used at a variety of sites on a regular basis. However, worldwide, such a technique is undoubtedly less popular even with the available results of comparisons between oblique and transversal incisions [ 1 – 5 , 17 ]. Furthermore, minimally invasive CEA has been suggested to be technically more difficult [ 5 , 18 ].…”

Outcomes after Transverse-Incision ‘Mini’ Carotid Endarterectomy and Patch-Plasty

“…In an attempt to shorten the length of the incision, re-orientation of the incision in a transverse or oblique direction in line with the skin creases of the neck (and therefore Langer’s lines) has further improved cosmesis [5,9,12,14–17]. Concerns with transversely oriented incisions in CEA were related to the lack of enhanced exposure through the incision extension in instances wherein either the location of the carotid bifurcation or the extent of disease is misjudged preoperatively and to increased difficulty with shunt deployment compared to that through longitudinally oriented incisions [3,13].…”

“…Concerns with transversely oriented incisions in CEA were related to the lack of enhanced exposure through the incision extension in instances wherein either the location of the carotid bifurcation or the extent of disease is misjudged preoperatively and to increased difficulty with shunt deployment compared to that through longitudinally oriented incisions [3,13]. Proponents of the technique advice that with the increase in the subplatysmal flap, the use of self-retaining retractors as well as natural laxity of the neck skin is generally possible to gain additional cephalad or caudal exposure as needed [12,14,18]. Recent reports describe the use of specialized ring retractor systems in enabling mini-incision CEA [19,20].…”

Surgical Technique for Carotid Endarterectomy: Current Methods and Problems

“…3B ). 11 , 13) Kazimierczak et al 14) reported a randomized study of camouflage (transverse) incision versus longitudinal incision. Although no significant difference in mortality or morbidity was seen between groups, scar assessment scale score was significantly better in patients with camouflage incision than in patients with longitudinal incision.…”