DS10 Use of ‘deckling’ incisions in facial dermatological surgery: a case series

Abstract Relaxed skin tension lines (RSTLs) and aesthetic unit boundaries on the face are not perfectly straight or round, and so irregular incisions producing broken-up scars may give superior aesthetic outcomes. This can be achieved to an extent with carefully designed reconstructions, but some incisions may still be less forgiving – for example across RSTLs and the edge of full-thickness skin grafts (FTSGs). Previously, Aldred, a plastic surgeon, reported the use of a wavy-line incision in facial skin surgery and proposed the term ‘deckling’, which describes the process of creating a rough, feathered edge on paper as an ornamental feature in fine books (Tregaskiss A, Allan J, Gore S, Aldred R. Use of the nasal sidewall island inversion flap for single-stage ala nasi reconstruction: a report of 103 consecutive cases. Plast Reconstr Surg 2014; 133: 377–85). Zig-zag incisions can reduce scar contracture and pin-cushioning deformity. Additionally, new research by Xu et al. suggests that wavy gaps across wound edges heal nearly five times faster than straight-edged ones, due to different cellular movement pathways. (Xu H, Huo Y, Zhou Q et al. Geometry-mediated bridging drives nonadhesive stripe wound healing. Proc Natl Acad Sci USA 2023; 120: e2221040120). Although w-plasty is well recognized in scar modification, little is published on deckling, although it appears to be an evolving theme. To the best of our knowledge, dermatological surgeons are not using wavy or zig-zag-shaped incisions in practice. The aim of this study was to review the literature on the use of deckling and zig-zag incisions and to assess aesthetic outcomes in patients having facial skin surgery using this technique. We present five cases involving facial defects, including one local flap on the forehead, three linear closures (cheek, temple, forehead) and one full-thickness skin graft on the nasal tip. Deckling was performed using a 15° ophthalmic blade to create wavy incisions and a conventional bilayer closure was performed. At 3 months postprocedure, scar appearance was assessed using the Patient and Observer Scar Assessment Scale, with scores ranging from 1 (normal skin appearance) to 10 (worst imaginable scar). Observer assessments were performed by three independent dermatologists. The mean patient score for scar appearance was 2.4, and the mean observer score was 2.6. The deckled wound edges were approximated without any adjustments. The aesthetic outcomes were comparable with standard straight-line incisions. Although deckling requires slightly more tissue removal during primary excision and takes longer to perform, the results are promising and we continue to gather cases. We suggest that deckling incisions may offer aesthetic benefit in some cases, especially when used for unavoidable incisions across facial RSTLs. Future studies are needed to determine whether this technique provides a meaningful and consistent aesthetic benefit.