Incisions in the scalp run the risk of creating visible scars. Such visible scalp scars are almost always due the lack of hair with it. As a matter of fact scalp scars can be very narrow, but if hair is lost along the edges the scar will appear much bigger than the actual scarred skin itself. Thus maintaining follicle viability is of critical importance in making scalp incisions for elective surgery.
One other cause of wide scalp scars are incisions that are performed at a very young age. Due to the growth of the skull and the subsequent expansion of the overlying scalp, incisions in infants and children can stretch over time increasing the width of the scar. This is most manifest in the temporal scalp areas. Why scalp scars become wider on the sides of the head rather than across the top is not clear but it is a consistent finding on my experience. As a result coronal scalp scars made early in life often lead to wide temporal scars later.
Temporal scar revisions, in particular, must be done in a unique fashion. Simply cutting out the scar and closing it in a straight line rarely results in an improved scar appearance. The scar quickly expands and becomes a visible non-hair bearing line again. To avoid this problem the scar edges must be cut so they interdigitate like connecting fingers. Using a running w-plasty excision pattern the temporal scar is removed and put back together in an interdigitating fashion. This allows the tension of the closure pattern to be better distributed with a far greater chance of a less visible scar.
Temporal scars become visible from the anterior temporal line of the skull down to the ear. A ‘pinking shear’ pattern of excision and closure in a meticulous manner puts hair follicles closer together with less chance of widening again.
Dr. Barry Eppley