Disability and Rehabilitation, 2009; 31(25): 2055–2063

REVIEW

How to assess postsurgical scars: A review of outcome measures

STEFANO VERCELLI1, GIORGIO FERRIERO1, FRANCESCO SARTORIO1,

VALERIA STISSI2 & FRANCO FRANCHIGNONI1
1
Fondazione ‘‘Salvatore Maugeri’’, Unit of Occupational Rehabilitation and Ergonomics, Via per Revislate 13, Veruno, Italy,
and 2Private Practise, Via Correggio, 1, Busto Arsizio, Italy
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Accepted March 2009

Abstract
Purpose. Complications of surgical incision include pathological scars with functional, cosmetic or psychological
consequences. Postsurgical scar assessment is fundamental for a complete functional evaluation and as an outcome
measure. Scar assessment scales are here reviewed and discussed from a clinical and psychometric point of view, with a clear
definition of different scar parameters.
Method. An extensive review of the English-language literature was conducted using the Medline database.
For personal use only.

Results. Four scales that satisfy psychometrical criteria were identified: Vancouver Scar Scale (VSS), Patient and Observer
Scar Assessment Scale (POSAS), Manchester Scar Scale (MSS) and Stony Brook Scar Evaluation Scale (SBSES).
Conclusions. To date, VSS is the most widely used rating scale for scars but POSAS appears the most comprehensive, taking
into account the important aspect of patient’s perspective. The MSS has been never used for research, while SBSES has only
been very recently proposed.

Keywords: Scars, outcome measures

Introduction most important parameters to analyse. At the 2nd

month, changes in width, height and colour are more
Skin tissue repair after surgical intervention can evident, while at the 3rd month possible hypertrophy
result in a broad spectrum of scar types, ranging from is visible, and it is possible to observe trouble in
a fine line to a variety of abnormal and pathologic pliability and texture.
scars, which can have functional, cosmetic and In the literature, scar assessment has mainly been
psychological consequences. focused on burn scars, but interest in postsurgical
Early diagnosis of a pathologic scar can have a scars is increasing [4]. Often the same evaluating
considerable impact on the final outcome, because it instruments are used in both conditions, even if the
is easier to prevent pathologic scars than to treat two kinds of scar frequently present different
them [1]. Assessment is fundamental for monitoring features. For example, although burn scars may
scar evolution and treatment efficacy, and quantify- occupy larger surface areas with more variations
ing its importance in clinical and forensic settings present over the area, postsurgical scars are mostly
[2,3]. Scars usually develop in 6–8 weeks after re- linear or round-shaped and well-defined [6]. How-
epithelialisation, and a period of at least 6–18 months ever, the psychometric properties of an assessment
is required for their maturation [4]. The European tool are not an inherent part of the instrument but
Tissue Repair Society recommends performing three must be evaluated within the context of the test’s
different assessments at the end of the 1st, 2nd and intended use and the specific target population.
3rd month after wound closure [5]. The first clinical Thus, the appropriateness of these tools for post-
assessment determines the general features of the surgical scars must be always specifically demon-
scar: at this stage, colour and vascularity seems the strated. The ideal scar assessment scale should: (i) be

Correspondence: Stefano Vercelli, Fondazione ‘‘Salvatore Maugeri’’, Unit of Occupational Rehabilitation and Ergonomics, Via per Revislate 13, Veruno
I-28010, Italy. E-mail: [email protected]
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2009 Informa UK Ltd.
DOI: 10.3109/09638280902874196
 2056 S. Vercelli et al.

easy to complete and replicate, (ii) reliably quantify Relief/irregularity. Relief signifies the extent of surface
the magnitude of pathologic complications, monitor irregularities (uneven parts, bumpiness or rough-
the effects of prevention or treatment interventions ness) when compared with adjacent normal skin
(e.g. massage therapy, cryotherapy, silicone gel [12]. The degree of irregularity can be reliably
sheets) [1], and analyse the impact of the scar on evaluated with subjective scales [15,16]; devices to
the patient’s activities, social participation and establish the irregularity of skin surfaces (profil-
quality of life and (iii) integrate clinician observations ometer) were designed only for use in the cosmetic
with patient-based symptoms [6–8]. industry, and have not been studied in the evaluation
To date, there is no standardised and universally of scars [13].
accepted method to assess postsurgical scars, and
although various treatments have been described as Surface area. This parameter defines the surface area
clinically effective, controlled trials have been limited of the scar, decreased or increased in relation to the
by the difficulty to objectively measure scar proper- original wound area [12]. The term used for
ties [9]. Another factor that has hampered advances measuring surface area is planimetry, and tracing of
in scar assessment is the confusing terminology used scar margins on clear plastic film and planimetry by
in the medical literature [10]. photography are the most common methods [13].
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To discuss the state of the art in postsurgical scar

assessment and to guide clinicians and inexpert Pliability/texture/stiffness. Pliability can be defined as
researchers in the choice of the best tool, we propose the mechanical property of the skin’s firmness and
in this review to: (1) define the dimensions included extensibility that reflects both the morphological and
in scar assessment scales; (2) illustrate the assess- physiological properties of the scar [17]. Pliability is
ment scales validated for postsurgical scars and (3) also referred to as ‘texture’, ‘elasticity’, ‘stiffness’,
compare them in an attempt to arrive at recommen- ‘scar compliance’, ‘suppleness’ and ‘pressure
dations that will help clinicians and researchers to required to deform the skin’ [11].
select the most appropriate scale. Lack of pliability can contribute to loss of motion,
For personal use only.

particularly when crossing a joint. In this case, range

of motion is one of the simplest indirect methods for
What should be measured? measuring pliability, even if it may not be sensitive
enough to detect smaller changes occurring in
Comprehensive scar assessment must include three response to scar maturation or treatment. Pliability
different dimensions: (a) physical characteristics; (b) can be tested also by wrinkling the scar between the
cosmetic appearance; (c) patient’s symptoms. Here we thumb and index finger [12] or stretching it with the
present a brief list of their definitions and the common fingers (Figure 1). Otherwise, objective evaluation is
methods utilised for their measurement. possible by means of suction, pressure, torsion and
tension principles. The instruments suggested for
this purpose are not yet widely applied in clinical
Physical characteristics settings due to a number of drawbacks (e.g. invasive
nature, high cost, operator and equipment depen-
The physical characteristics of skin are crucial for the dence, unproved/low reliability, limited appropriate-
maintenance of mechanical and physiological func- ness) [11,13].
tions. Excess of thickness or relief, contraction or
expansion of the surface area, and lack of pliability
can contribute to disabling and dysfunctional pro-
blems like scar contractures, loss of motion or
muscle weakness. Hence, the measure of these
parameters is a good predictor of scar functional
outcome [11].

Thickness/height/contour. Scar thickness is related to

hypertrophy, and it is defined as the average distance
between the subcutical-dermal border and the
epidermal surface of the scar itself [12]. It is known
also as height or contour. Ultrasonography is the
most accurate and reproducible method used to
measure the overall thickness above and below the
skin surface [13,14], while the protruding part can be
measured with a ruler [13]. Figure 1. Pliability evaluation by scar stretching with fingers.
 Outcome measures for postsurgical scars 2057

Appearance sutures or staples. Cosmetic defects are usually

evaluated with ordinal scales by visual inspection.
Scars can be disfiguring and aesthetically unpleasant,
and the final scar appearance is what matters most to
patients [18]. Poor restoration of colour and other Patient’s symptoms
cosmetic defects can lead to unpleasant appearance
and cause psychosocial sequelae including anxiety, Pain and itching are the most common symptoms of scar
depression, post-traumatic stress reactions, loss of healing. However, there are no long-term prospective
self esteem and stigmatisation [2]. studies that document their course and extent. The most
common scar-related pain descriptor is ‘tender’. Sensa-
Colour. Scar colour is determined by the vascularity tions of ‘shooting’, ‘sharp’, ‘aching’ and ‘heavy’ pain are
and pigmentation of the skin, and may be influenced additional terms commonly reported by patients
by the time elapsed from surgery. [12,21]. Individuals who underwent surgical procedures
Vascularity is defined as the amount of skin redness and who experienced early post-traumatic distress are
and can be reliably assessed by the vasocompression more likely to suffer from long-term and persistent
test: the time to recolouration after application of itching, that can last up to 2 years [22].
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digital pressure (or a piece of plexiglass) on the scar is Assessment of these symptoms is usually per-
measured and compared with previous measures or formed by visual analogue scales, numerical rating
the contralateral side [12]. A red colouration is linked scales, or Likert-type scales.
to scar hypervascularisation: this colour becomes a
good indicator of pathologic scarring 8 weeks after
complete healing [19]. Rating scales for scar assessment
Pigmentation is the brownish colouration of the
scar by pigment (melanin), and during clinical A comprehensive review of the English-language
evaluation it is recommended to apply a moderate literature was conducted using the Medline database.
For personal use only.

pressure with plexiglass to eliminate the effect of To date, only four scales [23,24] have been psychome-
vascularity [20]. Scar colour is usually evaluated by trically studied: the Vancouver Scar Scale (VSS), the
subjective assessment (according to a numerical Patient and Observer Scar Assessment Scale (POSAS),
rating scale or Likert-type scale) but it can be the Manchester Scar Scale (MSS) and the Stony Brook
performed also with portable instruments such as Scar Evaluation Scale (SBSES) (Table I). The VSS and
the tristimulus colorimeter (Minolta Chroma- POSAS were originally designed to rate burn scars, and
meter1) or narrow-band simple reflectance meter successively validated also for postsurgical scars; the
(DermaSpectometer1). The DermaSpectometer1 MSS and SBSES were developed to assess scars from
was recently judged to be the best choice because surgical incisions and focus only on the cosmetic scar
of its smaller dimension and easy-to-interpret indices appearance. Each scale has advantages and disadvan-
[20]. tages, and at present there is no general agreement on
which is the most appropriate [7,12].
Cosmetic Defects. Cosmetic defects can be both phy-
sically and psychologically disturbing for patients.
Scar distortion is one of the most disfiguring Vancouver Scar Scale
sequelae, particularly in exposed skin like hands or
face. Other factors to be considered are the presence The VSS (also known as Burn Scar Index) was
of shiny surface and/or hatch marks from previous created in 1990 and is the most widely used rating

Table I. Rating scales for postsurgical scar assessment.

Scale Year Score Internal consistency Inter-rater reliability (for total score) Validity

VSS 1990 0–13 Acceptable [6,21] Poor to moderate [6,21] Correlation with OSAS [6]
MSS 1998 5–28 / Good (multiple observers) [29] Correlation with histologic assessment of scar
specimen [29]
OSAS 2004 0–60 Acceptable [6,12] Good [12] Correlation with VSS [6]
Poor to moderate [6]
PSAS 2004 0–60 Acceptable [12] / /
SBSES 2007 0–5 / Good [31] Correlation with VAS for cosmetic appearance [31]

Internal consistency is considered to be acceptable with Cronbach’s alpha values greater than or equal to 0.70 [37]. The Intraclass
Correlation Coefficient (ICC), with its 95% confidence interval, can be applied to data on interval/ratio scales and to ordinal scales when
intervals are equivalent to calculating the interrater reliability; ICC values above .75 are indicative of good reliability, those below .75 of poor-
to-moderate reliability [32].
 2058 S. Vercelli et al.

scale for scars [25]. Four physical characteristics are Manchester Scar Scale
scored: height, pliability, vascularity and pigmenta-
tion, and each variable include ranked subscales that The MSS includes six items: contour, texture, colour,
are summed to obtain a total score ranging from 0 to distortion, shiny surface and overall patient’s opinion
13, with 0 representing normal skin (Table II). Each (Table III) [29]. Each of the first four parameters is
subscale is defined not only by a numerical score but given a score between 1 and 4. Whether a scar is matte
also by descriptors to increase the potential for or shiny is recorded (1 and 2 points, respectively), and
objective rating and facilitate the training process for the patient’s overall opinion is measured on a 0–10
observers [6]. The subscale descriptors and score VAS. The total score is obtained by summing the six
distribution have been slightly modified by other items; higher values indicate worse scars.
authors [26–28], often without providing an expla- Inter-rater reliability for total score was good
nation for the changes or reassessing the scale’s (Spearman’s correlation coefficient 0.87), but data
psychometric characteristics. Although the literature were calculated excluding the texture parameter and
on VSS has been predominantly focused on burn VAS scores [29]. A high correlation was found
scars, the scale was recently validated to rate between MSS and overall histological assessment of
postsurgical scars and gave comparable results. In scar specimens [29]. Some limitations of this scale
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two cohorts of women who presented linear scars are: the overall score results from different level
due to breast cancer surgery, results showed its scales (quantitative, semi-quantitative and qualita-
acceptable internal consistency (Cronbach’s alpha tive) and different raters (observer and patient).
0.71–0.79) but a poor-to-moderate inter-rater relia-
bility (Intraclass Correlation Coefficient, ICC, 0.03–
0.64) [6,21]. Moreover, it was found that the scale Patient and Observer Scar Assessment Scale
did not give clinically useful information on the
patient’s symptoms and perspective [6]. To over- The POSAS is a recent and promising scar assess-
come this last problem, Nedelec et al. [27] added ment tool incorporating both observer and patient
For personal use only.

two visual analogue scales (0–10 points) to rate scar ratings (Table IV). It consists of two distinct
itching and pain, but this adjunct has not been scales: the OSAS and the PSAS [28].
validated. The five variables rated by the original version of the
OSAS were: thickness, relief, pliability, vascularity and
pigmentation. Another item (surface area) was then
Table II. The Vancouver Scar Scale.*
added in a modified version, after linear regression
Scar characteristic Score Description analysis had shown that the opinion of the observer is
most influenced by the dimension of the scar area. In
Pigmentation 0 Normal colour that closely resembles
the colour over the rest of
one’s body
Table III. The Manchester Scar Scale.*
1 Hypopigmentation
2 Hyperpigmentation Visual analogue scale: excellent ! poor
Vascularity 0 Normal colour that closely resembles
the colour over the rest of Lighter or darker A Colour
one’s body Perfect 1
1 Pink Slight mismatch 2
2 Red Obvious mismatch 3
3 Purple Gross mismatch 4
Pliability 0 Normal B Matte (1) Shiny (2)
1 Supple: flexible with minimal C Contour
resistance Flush with surrounding skin 1
2 Yielding: giving way to pressure Slightly proud/Indented 2
3 Firm: inflexible, not easily moved, Hypertrophic 3
resistant to manual pressure Keloid 4
4 Banding: rope-like tissue that D Distorsion
blanches with extension of None 1
the scar Mild 2
5 Contracture: permanent shortening Moderate 3
of scar producing deformity or Severe 4
distortion E Texture
Height 0 Normal: flat Normal 1
1 52 mm Just palpable 2
2 55 mm Firm 3
3 45 mm Hard 4

*Data from [23]. *Data from [23].

 Outcome measures for postsurgical scars 2059

Table IV. The Patient and Observer Scar Assessment Scale.*

Observer Scar Assessment Scale (OSAS)

Normal skin 1 2 3 4 5 6 7 8 9 10 Worst scar imaginable

Vascularity o o o o o o o o o o
Pale
Pink
Red
Purple
Mix
Pigmentation o o o o o o o o o o
Hypo
Hyper
Mix
Thickness o o o o o o o o o o
Thicker
Thinner
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Relief o o o o o o o o o o
More relief
Less relief
Mix
Pliability o o o o o o o o o o
Supple
Stiff
Mix
Surface area o o o o o o o o o o
Expansion
Contraction
Mix
For personal use only.

Overall opinion o o o o o o o o o o

Patient Scar Assessment Scale (PSAS)

No, not at all 1 2 3 4 5 6 7 8 9 10 Yes, very much
Has the scar been painful the past few weeks? o o o o o o o o o o
Has the scar been itching the past few weeks? o o o o o o o o o o
No, as normal skin 1 2 3 4 5 6 7 8 9 10 Yes, very different
Is the scar colour different from the colour of o o o o o o o o o o
your normal skin at present?
Is the stiffness of the scar different from your o o o o o o o o o o
normal skin at present?
Is the thickness of the scar different from o o o o o o o o o o
your normal skin at present?
Is the scar more irregular than your o o o o o o o o o o
normal skin at present?
As normal skin 1 2 3 4 5 6 7 8 9 10 Very different
What is your overall opinion of the scar o o o o o o o o o o
compared to normal skin?

*Data from [12].

addition, alongside the scoring system adjectives were both OSAS and PSAS have good internal consis-
inserted to better describe each item [12]. tency (Cronbach’s alpha 0.74–0.90) [6,12]. They
The PSAS consists of six items: scar-related pain, found also a significant correlation (convergent
itchiness, colour, stiffness, thickness and irregularity. validity) between VSS and OSAS (all p va-
Each POSAS item has a 10-point scoring system, lues 5 0.001). The stiffness score of PSAS correlated
with 1 representing normal skin and 10 the worst well with VSS pliability item (p ¼ 0.02), but there
imaginable scar or sensation: these items are summed was no other significant correlation between PSAS
to obtain a total score ranging from 6 to 60 for each and VSS [6]. The intra-rater reliability of PSAS total
scale. In addition to the POSAS score, both observer score was good (ICC range for single parameters:
and patient give their own overall opinion on the 0.89–0.96) [12]. The results on OSAS inter-rater
appearance of the scar using a 10-point scale. reliability showed some discrepancy: ICC values for
Both versions of POSAS (original and modified) the total score were good in the first study (ICC
have been recently validated for application on linear range for single parameters: 0.65–0.83) [12], but not
postsurgical scars [6,12]. The two studies found that in the second (ICC range for single parameters:
 2060 S. Vercelli et al.

0.18–0.56) [6]. The numerical 10-point rating is defined as the ability to identify changes or differences
system of POSAS seems to allow a very flexible that are clinically or individually meaningful.
assessment, but alternative scoring systems have
never been comparatively analysed [30].
Reliability

Stony Brook Scar Evaluation Scale Reliability is the capacity of a measurement to reflect
mostly true scores. It comprises the internal con-
The SBSES is a new scale composed of five dichot- sistency (i.e. the homogeneity of all items in
omous, evenly weighted categories [31]. Scars are measuring the same attribute), and the stability (i.e.
assigned 0–1 point for the presence or absence of the the reproducibility of a measure administered by
following: a width greater than 2 mm at any point of the different raters or by the same rater at different
scar, a raised (or depressed) scar, a darker colouration times) [32]. High internal consistency was found for
than surrounding skin, any hatch or staple marks, an both VSS and POSAS, but it has never been
overall poor appearance (Table V). The total score is calculated for MSS and SBSES.
then derived by adding the scores on the individual Inter-rater reliability was found to be moderate to
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items of the scale ranging from 0 (worst) to 5 (best). good for the overall score of each of the four scales,
Inter-rater agreements between observers was good with better values recorded with multiple observers.
for the total score (Spearman’s correlation coefficients Two studies [6,12] on the inter-rater reliability of
ranging from 0.73 to 0.85); moderate to substantial for OSAS gave significantly different results: potential
overall appearance; substantial for width, elevation factors contributing to these variations may include
and discolouration; substantial to excellent for hatch inherent differences in the types of scar being
marks (kappa statistic). The SBSES showed a high evaluated, in the number of observers performing
correlation with a visual analogue scale measuring the assessment and their level of training as regards
overall cosmetic appearance [31]. use of the scale. In all scales, thickness and pliability
For personal use only.

were the items with lowest reliability, and for

pliability none of the studies was able to report good
Which scale is best? [32] intra-class correlation coefficient values. This
implies that future research should focus on inves-
Any assessment method should show evidence of tigating more reliable methods to assess scar
acceptable levels of scale reliability, validity and respon- pliability in a busy clinical setting.
siveness to change. The first two characteristics sum- Intra-rater reliability was good for all items of
marise if the measure is reproducible and internally PSAS (ICC 4 0.89) [12], and for MSS the range of
consistent (reliability) and its ability to measure what it is observer variation was between 7.8% and 14.8%,
intended to measure (validity), whereas responsiveness with the largest variability seen for scars with mid-
range clinical scores [29].

Table V. The Stony Brook Scar Evaluation Scale.*

Validity
Scar category Points

Width There are three main types of validity: content,

42 mm 0 construct and criterion-related validity. Content
2 mm 1 and construct validity are usually considered as
Height separate categories, but part of construct validity is
Elevated or depressed in 0
based on the content validity. In fact, an instrument
relation to surrounding skin
Flat 1 must be able to define the content universe that the
Colour construct represents in order to develop a test to
Darker than surrounding 0 measure it [32].
skin (red, purple, brown or black) Among the four scales, the POSAS seems to be the
Same colour or lighter than 1
most comprehensive scale (Table VI).
surrounding skin
Hatch marks or suture marks First, the patient’s portion of the POSAS allows
Present 0 for a more complete evaluation, while other scales
Absent 1 fail to provide clinically useful information on the
Overall appearance patient’s symptoms and perspective. The overall
Poor 0
patient’s opinion score included in MSS reflects
Good 1
only the cosmetic aspect of the scar and is not
*Data from [31]. sensitive to other characteristics or symptoms.
 Outcome measures for postsurgical scars 2061

Table VI. Items measured by: Vancouver Scar Scale (VSS); (a criterion measure that is already established or
Manchester Scar Scale (MSS); Observer Scar Assessment Scale assumed to be valid) [32]. VSS and OSAS were
(OSAS) and Patient Scar Assessment Scale (PSAS); and Stony
Brook Scar Evaluation Scale (SBSES).
analysed and found to have similar structure and
significant convergent validity, whereas no significant
Items VSS MSS OSAS PSAS SBSES correlation was found between PSAS and VSS
(except for the items stiffness and pliability, respec-
Physical characteristics
Thickness, height, X X X X X tively) [6,12]. This is understandable because PSAS
contour measures patient’s symptoms and shows the general
Relief, irregularity X X worse opinion patients have of their scars with
Surface area X X respect to observers [12]. The high correlation
Pliability, texture, X X X
exhibited by MSS with histologic scar specimen
stiffness
Appearance would indicate that the macroscopic scar appearance
Colour X X X may be a reflection of the histologic abnormalities.
Vascularity X X
Pigmentation X X
Distortion X
Responsiveness to change
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Shiny surface X
Hatch marks X
Patient’s symptoms To compare various scar treatments (including
Pain X surgical techniques, pharmacologic agents or physi-
Itching X cal therapies) an assessment scale also needs to be
Patient’s opinion
responsive enough to capture the real modifications
Overall opinion X X
in the scar and the effects of the scar over time [7].
The level of change (or percentage change) of the
score obviously must reflect a true change in the
Comparing the scores usually assigned to the scar by condition and not test–retest errors. Unfortunately,
For personal use only.

patients and observers, it can be said that patients at present such information is not available for any
think worse of their scars. This could be partially scale. Moreover, there is a lack of information on
attributed to pain or itching, which are invisible to reference values regarding the physiological healing
the observers and are considered as good predictors process over time (see later).
of pathologic scars [12]. However, the frequency of
pain or itching is probably higher in burns than
postsurgical scars, where these symptoms are re- Discussion
ported only by 13% of patients [6]. Thus, as must be
done with all other parameters, their correct weight In our view, each of the scar assessment scales lacks
in the overall score must be adequately calculated. some useful information.
Second, POSAS incorporates two items that are Surprisingly, no scale includes the measurement of
not present in other scales: scar relief and pigment scar adhesion except for a modified version of the
type. Longer linear surgical scars may demonstrate VSS, in which this parameter was taken into account
features of both hypopigmentation and hyperpig- as part of the worst pliability score [27]. However,
mentation, and thus require an adequate scoring adhesion could be defined as the obstacle to mobility
system. The VSS assigns a higher score for hyper- between skin and underlying soft tissues and is
pigmentation than hypopigmentation, but this is an different from pliability. The outcome of scar
assumption that has been challenged [6,27]. Further- adhesion is not necessarily related to other para-
more, the categorical level of this type of classifica- meters, e.g. a scar might be aesthetically acceptable,
tion (rated on a nominal scale) does not allow to sum asymptomatic, flat and with supple or yielding
the pigmentation score with other ordinal items of pliability, but nevertheless lead to functional limita-
the scale. The modified version of the VSS [27], tions during muscular contraction or active joint
where pigmentation was measured on an ordinal motion due to adhesion (Figure 2). The reduced
scale, has yet to be validated for postsurgical scar. shifting movements of the scarred tissue with respect
The MSS and SBSES encloses vascularisation and to underlying layers may limit range of motion,
pigmentation in one item, losing useful information decrease muscular strength and alter the proprio-
about each single feature. The advantage of these two ceptive input of the region as a result of compro-
scales, strictly related to cosmetic outcome, is their mised tissue tensioning, leading to a variety of
validity in scoring scars from photographs in a complications such a protective postural patterns,
different place or at a different time. increased neurovascular activity and pain syndromes
Criterion-related validity is based on the ability of [33]. We believe that impairment and disability
one test to predict results obtained on another test caused by scar adhesion needs to be adequately
 2062 S. Vercelli et al.

effectiveness of therapeutic interventions or to

validate new instruments. The MSS could be used
when direct assessment is not possible and a good
image capture system is available.
To promote the measures in clinical practice and
decision-making, future research should focus on the
following needs: (1) to design a new scale for
postsurgical scars, analysing further relevant aspects
Figure 2. With the wrist in resting position (left), the scar appears
like scar adhesion, patients’ overall satisfaction
to be well healed and not pathologic. When active wrist extension
occurs (right), the scar adhesion becomes evident. and impact on social participation and quality
of life; (2) to achieve more reliable methods to
measure scar pliability and thickness; (3) to provide
measured with an objective method and included in normative values and responsiveness of these scales
the total scar assessment score. early after wound closure and at follow-up (at least 1
Another useful clinical item not gathered by the year); and (4) to use more powerful approaches
scales is the alignment of scar with respect to for measurement validation (e.g. Rasch analysis).
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cutaneous creases. Scars parallel to cutaneous

creases develop less tension, while perpendicular Declaration of interest: The authors report no
angles create more tension, with possible diastasis conflicts of interest. The authors alone are respon-
and hypertrophy. This was confirmed by two studies sible for the content and writing of the paper.
examining cosmesis in women treated with breast
surgery, which showed that patient satisfaction
significantly decreased with improperly oriented References
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