After healing, minor facial scars have little or no effect on ratings of attractiveness – while some scars are even linked to more favorable ratings, suggests a survey study in the December issue of Plastic and Reconstructive Surgery.
“Contrary to our predictions, we found that a single well-healed scar generally does not affect individuals’ first impressions of perceived attractiveness or confidence negatively and may even increase perceived friendliness,” according to the report by ASPS Member Surgeon Jesse A. Taylor, MD, and colleagues of University of Pennsylvania, Philadelphia.
The researchers designed an online survey to test the “core tenets” of facial scar design, with the goal of identifying potentially modifiable factors that improve how facial scars are perceived. Dr. Taylor and colleagues digitally altered facial photographs by adding 14 unique scars in various locations and orientations.
Online participants rated 50 different faces in terms of confidence, friendliness, and attractiveness. Data analysis included nearly 89,000 ratings by 1,800 respondents.
On initial analysis, “the presence of a facial scar did not have a significant impact on attractiveness,” Dr. Taylor and coauthors write. Average ratings for attractiveness (on a 0-to-5 scale) were 4.25 for scarred faces and 4.26 for unscarred faces.
In a further analysis, the researchers looked for possible interactions between key factors considered by plastic surgeons in evaluating facial scars.
“We predicted that scars closer to highly viewed structures of the face (i.e., upper lip and lower lid), scars aligned against resting facial tension lines, and scars in the middle of anatomic subunits of the face would be rated less favorably,” Dr. Taylor and colleagues write.
The results suggested some subtle interactions: for example, faces with scars located at the mid-lower eyelid were rated lower for attractiveness, confidence, and friendliness – but only if oriented perpendicular to facial tension lines.
The researchers note that the effects on ratings were small – at most equal to “roughly two percent of the overall rating value.”
Research is positive news to patients concerned with facial scars
Minimizing the severity of scars, particularly on the face, is an important objective for plastic surgeons. Dr. Taylor and colleagues note the large industry for scar care is expected to surpass $34 billion in revenue by 2023.
“Our faces are vital to our identities and bear a significant portion of the burden for self-expression,” Dr. Taylor and colleagues write.
“Yet the social consequences of well-healed facial scars are poorly understood.” The findings may be “surprising and perhaps welcome news” to patients concerned that facial scars or incisions may negatively affect their appearance or how others perceive them.
The study is the first systematic, large-scale investigation of several techniques surgeons may be able to use to hide facial scars.
The researchers note that the findings don’t alter the long-held fundamental principles of facial scar design, based on location, position in anatomic subunit, or orientation along facial tension lines.
However, Dr. Taylor and coauthors add, “Well-healed scars that even violate all three principles have minimal effects and likely would not benefit from scar revision.”
As evidence for the “anomalous-is-bad” stereotype mounts, it is important for surgeons to understand how scars from elective operations affect the social perceptions of their patients. In this study, we present the first large-scale systematic investigation of several techniques that surgeons may be able to use to hide elective facial scars, including positioning scars away from highly viewed structures of the face, placing scars on the borders of anatomical subunits, and orienting scars with resting facial tension lines. Contrary to our predictions, we found that a single well-healed scar generally does not affect individuals’ first impressions of perceived attractiveness or confidence negatively and may even increase perceived fr
iendliness. These data are surprising, and perhaps welcome news for plastic surgeons who regularly counsel anxious patients who present with conditions that mandate a surgical incision be made on the face. The origin of the scar does not have to be surgical; it could come as a result of trauma or other mechanisms. Provided that the scar heals reasonably well, these data from scars rated one of 13 on the Vancouver Scar Scale suggest that the patient’s face will not necessarily be subject to an anomalous-is-bad stereotype.
When isolating the effects of location alone, there were no effects on attractiveness, but scars on the forehead were rated friendlier and more confident compared to the cheek reference group. Neither subunit position nor scar orientation to resting facial tension lines had a significant effect in isolation. We identified one scar—lower lid, mid subunit, perpendicular to resting facial tension lines—that negatively affected attractiveness, friendliness, and confidence ratings. The effect sizes observed for this scar were small, however, with the largest effect equating roughly 2 percent of the overall rating value.
On the surface, the lack of effects we report may appear unexpected. Similar results were observed by Burriss et al., who found that raters prompted to rate attractiveness in the context of a long-term relationship showed no difference for scarred relative to typical faces.31 When female respondents were prompted to rate attractiveness in a short-term relationship, they rated men with scars as more attractive than their nonscarred counterparts.
A review of facial anomalies as represented in classic movies offers a potential explanation. Villains are often portrayed with significant deformities, and in the case of facial scars, they are not well-healed, deform anatomical structures such as eyelids, and are usually numerous.32
Characters who play heroes are also sometimes depicted with facial scars, but that are subtler, do not cause anatomical deformation, and are less numerous. The depiction of well-healed facial scars on heroes, which could be perceived to have resulted from noble conquest, may have downstream consequences for public perceptions and could account for the lack of significant adverse effects detected in our study.
Eye-tracking studies demonstrate that the eyes and perioral region are the most viewed structures, followed by the cheeks.33–37 Consequently, we predicted that scars close to highly viewed structures of the face (i.e., the upper lip and lower lid) would be rated unfavorably. In our study, we predicted that scars on the lower lid and upper lip would be rated most unfavorably. In our cohort, we did not observe a clear negative pattern for the lower lid and upper lip locations.
However, the forehead was the only location that had a significant effect, having been rated more confident and friendlier compared to the check location. The forehead result is consistent with visual gaze preferences. Previous work demonstrated that individuals with gross defects centrally located on the face experienced greater social penalties and were rated less attractive than people with defects in the periphery.6
The scars presented in this study were considerably less severe than the anomalies in Dey et al.6 We believe a severity threshold exists for observing a consistent location effect, with a single well-healed facial scar remaining below this threshold.
The recommendation to place incisions in line with resting tension lines and on the border of anatomical subunits of the face has been recommended since at least the 1950s and is still recommended today.7–19,38,39 The effects of scar orientation and position relative to anatomical subunits on attractiveness have not, to the authors’ knowledge, been studied rigorously.
Scar healing in reference to skin tension lines has been explored, with wounds or incisions parallel to resting tension lines noted to heal better.13,40 Incisions under tension can induce a wider or hypertrophic scar,41–43 which can to some degree be improved by postoperative taping.44
Although perpendicular scars were not wider in this study, we hypothesized that the perpendicular orientation violates normal lines of the face and contributes to the teaching that a scar in the middle of anatomical subunits of the face will be more visible. Consequently, we predicted that scars perpendicular to resting tension lines and in the middle of anatomical subunits, a so-called “two-hit” hypothesis, would be rated harsher. However, no consistent pattern emerged in our cohort.
Notably, the worst scar in our study (lower lid, middle subunit, perpendicular), three “hits,” violated all the core tenets tested, and indeed was judged to have a negative effect on appearance. Wherever possible, during an elective lesion excision for instance, a surgeon should avoid placing scars in the lower lid, mid subunit, perpendicular to facial tension lines The general public is likely not as discerning as plastic surgeons about the finer details of scars.
That said, although they may be insensitive to minor changes that would be notable to those with years of training and practice, they represent the true audience for scars. Notwithstanding the data presented in this article, the authors still agree with the fundamental principles of facial scar design and recommend their continued use.
In settings where this is not possible, surgeons can still report to patients that a facial scar that heals well is likely to have little impact on perceived attractiveness, friendliness, and confidence. Well-healed scars that even violate all three principles have minimal effects and likely would not benefit from scar revision.
This study is not without limitations. Previous literature used various scar stimuli design methods, including scarring generated by professional makeup artists,45,46 digitally altered grayscale images,31 and digitally altered full-color images.47–49 Given the study design, we needed over 700 unique photographs. The only reasonable solution was to digitally alter images of typical faces. The decision to use full-color images made generating the stimuli considerably more challenging.
Scars could not simply be moved to different locations and orientations, as lighting, color, texture, and contour were different. To balance scar contrast and create realistic images, detailed edits included color correction, brightness alterations, and blending. These edits may have created minor imbalances, even though scars were screened and flagged for further editing before approval for final use. Stimuli were standardized on features such as scar length, scar width, scar characteristics, numbers of scars, facial expression, age, and others.
Adding additional factors such as racial differences or hypertrophic scar would dramatically increase the number of digitally altered images needed to maintain adequate statistical power and reliability for the face ratings. Participants saw both scarred and unscarred faces, which could allow raters to identify the study’s purpose and cause them to respond unnaturally.
This concern was raised in Burriss et al.31 We doubt the general public has explicit knowledge of facial tension lines and anatomical subunits of the face required to modulate responses to specific scars. We limited our stimuli, to White, Black, Asian, and Hispanic faces. Other racial and ethnic groups may be affected differently.
Notably, the scars presented in this study are mild, with a rating of one of 13 on the Vancouver Scar Scale, and may represent a better postoperative outcome than some patients attain. We cannot generalize the effects reported here to other types and quantities of facial scars.
Future research will be directed toward identifying characteristics of unfavorable scars that warrant scar revision. Furthermore, future work should examine how the characteristics of respondents (e.g., race, sex, gender identity, age, disgust sensitivity) influence attitudes toward individuals with facial scars.
Original Research: Open access.
“Facial Scars: Do Position and Orientation Matter?” by Jesse A. Taylor et al. Plastic and Reconstructive Surgery