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

The utility of carotid endarterectomy (CEA) in preventing transient ischemic attack (TIA) and stroke has been demonstrated in patients with symptomatic1–3 and asymptomatic4–8 carotid artery stenosis caused by atherosclerosis. Although CEA is very common and has been performed for more than 50 years,9 the specific surgical technique is variable from surgeon to surgeon with respect to the use of general or local anesthesia, eversion or conventional endarterectomy, use of intraoperative shunt and carotid artery patching.10–13 In addition, there is no agreement on the appropriate orientation of the surgical incision. The standard operative approach uses an incision oriented parallel with the anterior border of the sternocleidomastoid muscle. Some surgeons, however, prefer to expose the operative site through an incision that follows the transverse skin creases of the neck. Surgical principles suggest that a transverse incision may provide the patient with a better cosmetic outcome because the scar is oriented along Langer’s lines. The Patient and Observer Scar Assessment Scale (POSAS) was developed and validated in patients with burn scars14 and has demonstrated validity in the assessment of linear surgical scars.15 The POSAS observer score rates the scar on a scale of 1 (normal skin) to 10 (worst scar imaginable) in 5 categories: vascularization, pigmentation, thickness, relief and pliability. Similarly, for the patient component score, the patient self-rates the scar in 6 categories: pain, itching (on a scale of 1 [no complaints] to 10 [worst imaginable]), colour, stiffness, thickness and irregularity (on a scale of 1 [normal skin] to 10 [very different]). The POSAS has previously been used to report on scar outcomes following neck surgery (parathyroidectomy and thyroidectomy),16 but to our knowledge it has not been applied previously to study differences in the outcomes of vertical and transverse incisions for CEA.