title: Digital imaging analysis of scar aesthetics.
abstract: OBJECTIVE
  Aesthetic outcome is an important end point of wound care. The purpose of this study was to compare a wound aesthetic scoring system by emergency physicians, patients, and digital imaging by blinded plastic surgeons. The goal was to see if digital photography could accurately analyze the aesthetics of closed lacerations for future research.
  
  
  METHODS
  This was a subanalysis of a prospective, randomized trial conducted in an urban, academic emergency department. Patients aged 18 to 100 years were included if they had simple, uncomplicated lacerations 8 hours old or less located on the trunk, head or neck (not scalp), or extremities that required repair by sutures. Exclusion criteria included immunocompromised state of health, a complicated laceration, specialty consultant intervention in management of the wound, or current use of or need for antibiotics for wound prophylaxis. Complicated lacerations were defined in the article. Infection outcomes, demographics, and aesthetic outcomes were assessed. Scar appearance was assessed at 3 to 4 months after closure using a previously validated 0-to 100-mm visual analog scale (VAS) score and 6-point wound evaluation score (WES) done by 2 trained emergency physicians (MD1 and MD2). Patients also performed self-VAS (VAS(Pt)), whereas VAS was done using digital imaging by 2 trained plastic surgeons (VAS(Plast1) and VAS(Plast2)). Data were evaluated when both plastic surgeons independently believed that the digital images were able to be adequately scored. Pearson correlation coefficients were performed using mean values.
  
  
  RESULTS
  Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r =0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45). Three- to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45).Three-to 4-month VAS(MD) and WES(MD) follow-up was obtained in 66 of 175 (37.7%), 3- to 4-month VAS(Pt) follow-up was obtained in 70 of 175 (40.0%), and 3- to 4-month digital imaging assessment was obtained in 66 of 175 (37.7%). Digital images were evaluated for VAS(Plast) in 34 of 66 (51.5%). Mean scores for VAS(MD1) and VAS(MD2) were 84.2 (SD, 12.4) mm and 87.8 (SD, 10.5) mm. Mean scores for WES(MD1) and WES(MD2) were 5.5 (SD, 1.0) and 5.4 (SD, 1.0). Mean scores for VAS(Pt) were 86.6 (SD, 16.6) mm. Mean scores for VAS(Plast1) and VAS(Plast2) were 78.7 (SD, 26.6) mm and 66.2 (SD, 30.2) mm. Moderate correlation was noted for VAS(MD1) and VAS(MD2) (r = 0.63; n = 34; P < .001), WES(MD1) and WES(MD2) (r = 0.70; n = 34; P < .001), and VAS(Plast1) and VAS(Plast2) (r = 0.74; n = 34; P < .001). Correlations were also moderate for VAS(MD) and VAS(Plast) (r = 0.56; n = 34; P < .001), VAS(Pt) and WES(MD) (r = 0.60; n = 34; P < .001), and VAS(MD) and WES(MD) (r = 0.64; n = 34; P < .001). However, correlations were weak for VAS(Pt) and VAS(Plast) at r = 0.25 (n = 34; P = .16), VAS(Pt) and VAS(MD) at r = 0.37 (n = 34; P =.03), and WES(MD) and VAS(Plast) at r = 0.13 (n = 34; P =.45).
  
  
  CONCLUSIONS
  Correlations were moderate for VAS(MD) and VAS(Plast); however, correlations were weak for VAS(Pt) and VAS(Plast), VAS(Pt) and VAS(MD), and WES(MD) and VAS(Plast). This small study assessing digital imaging as a tool for evaluating scar aesthetics demonstrated limitations in its use. Future studies with larger populations and improved imaging modalities, such as 3-dimensional cameras and high-dynamic-range imaging, may provide potential for better assessment.
authors.affiliation: The Warren Alpert Medical School of Brown University and Rhode Island Hospital in Providence, Rhode Island, USA.
authors.forename: Jonathan H
authors.initials: JH
authors.lastname: Valente
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Jay
authors.forename: Scott T
authors.initials: ST
authors.lastname: Schmidt
authors.forename: Albert K
authors.initials: AK
authors.lastname: Oh
authors.forename: Steven E
authors.initials: SE
authors.lastname: Reinert
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Zabbo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002921:Cicatrix / Q000473:pathology*; D004954:Esthetics; D005260:Female; D006801:Humans; D022125:Lacerations / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D017060:Patient Satisfaction; D010781:Photography; D012237:Rhode Island; D016037:Single-Blind Method; D014945:Wound Healing