Postoperative scar can affect a patient's health-related quality of life after surgery, and scar assessment is an integral part of assessing the cosmetic outcome of cardiac surgery, especially in Asian populations, which are at a higher risk of developing unsightly scars13–14. Study shows that patients often develop keloid scar at the incision site after median sternotomy15. The Vasudev's opinion is that large and multiple keloids are difficult to treat completely and can currently only be treated with multiple modal therapies that aim to relieve the symptoms of keloid16. The incidence of scar hypertrophy, and scar stretch in the anterior sternal region of individuals with fair skin after open heart surgery via median sternotomy incision was studied by Elliot. Study demonstrates scar hypertrophy and stretching often occur. And its occurrence is not related to different types of subcutaneous suture materials17.
Totally thoracoscopic cardiac surgery, which is commonly used in our institution, does not damage the sternum or break the ribs, does not harm the aesthetics of the breast, and is more invisible. Many people believe that totally thoracoscopic cardiac surgery has cosmetic advantages. However, there are few studies in the relevant fields that provide detailed data. Standardized scar assessment in totally thoracoscopic cardiac surgery was conducted and evaluated in this study for the first time.
There are a number of scar scales that have been used to evaluate the condition of scars, including the Vancouver Scar Scale (VSS) 18, the Patient and Observer Scar Assessment Scale (POSAS) 19, the Manchester Scar Scale (MSS) 20, the Stony Brook Scar Evaluation Scale21, and the Scars Cosmetic Assessment and Rating (SCAR) Scale. Each scale has advantages and disadvantages for estimating different characteristics of scars. However, there is currently no valid and reliable scar scale to effectively assess the quality of postsurgical scars. The VSS and the POSAS were originally developed to assess burn scars and are not suitable for assessing post-surgical linear scars. Although the applicability of these scales in post-surgical linear scars was later tested, the clinical considerations of these scales at their inception were very different. Therefore, a new evaluation tool is needed that provides a reliable outcome measure for post-surgical scars. Jonathan Kantor introduced the Scar Cosmesis Assessment and Rating (SCAR) scale, which is an outcome measure for assessing linear postsurgical scars in a clinical and research context. The SCAR scale was tested for convergent validity, inter-rater reliability and intra-rater reliability, and the results showed that the SCAR scale is outstandingly combination of the scale in terms of feasibility, validity and reliability of postoperative scar assessment outcome measures7. The Cronbach's alpha value of the SCAR scale in this study was 0.81. The SCAR scale and the NRS scores were convincingly reliable and valid, suggesting that the combination of the SCAR scale and NRS scores is a valid and reliable method for estimating scars after cardiac surgery. By briefly training the raters, the SCAR scale can be quickly and reliably applied during the clinical follow-up process. There is an advantage to choosing this scale, it can be assessed by photographs, a patient included in this study lived on a sea island, but scars can be assessed by uploading photographs via mobile phone social software9.
Evaluation of the long-term cosmetic effects of post-operative scars is quite meaningful. Post-operative scars have a variety of final appearance, which are related to the incision site, the skin types, the suture tension, the suturing method, the wound closure technique, and the surgeon's technical ability and other factors22. There was no significant difference (P༞0.05) between the two groups of patients in terms of poor wound healing and subcutaneous emphysema in our study(P༞0.05). However, there were significant differences between the two groups in “Overall impression” and “Patient questions” scores. Scars in the TA group seemed less impressed, less painful and itchy compared to the SA group. The reason for the difference is unknown and may be related to median sternotomy, destruction of the periosteum, placement of a wire foreign body, additional tension caused by wire sutures to the sternum, etc23–24.
The average score of the NRS for aesthetics was quite low in both the TA and SA groups. On the other hand, the TA group had more incisions than the SA group. The application of extracorporeal circulation and the application of thoracoscopy in totally thoracoscopic cardiac surgery can explain the large number of incisions and their dispersion. But the scar length is apparently shorter in TA group. In our study, we observed that a susceptible patient who underwent thyroid surgery had scar hypertrophy in neck, so she was more willing to request minimally invasive cardiac surgery and postoperative scar hypertrophy occurred in her incision site. If a median sternotomy incision was made, it was estimated that the scar hypertrophy can seriously affect the quality of life (Fig. 3).
In general, the median sternotomy is the most straightforward and simplest approach, as it is easy for the surgeon to operate, but the totally thoracoscopic incision is less painful and the recovery period is shorter25. The TA approach with the aid of thoracoscopy has little tissue trauma, less pain and short recovery period4. The results of our study showed that there were differences in the “Overall impression” and “Patient questions” between the two groups, and there were significant differences in the overall SCAR scores and the NRS scores for scar appearance. Our study suggested that the combination of the SCAR scale and NRS scores is a valid and reliable tool for estimating scars after cardiac surgery. Our findings may provide new evidence and ideas for the selection of surgical approach in clinical practice. Patients with appropriate indications can undergo cardiac surgery through totally thoracoscopic approach with a satisfactory scar appearance.