The effects of surgical scars can be far-reaching and life-changing for many women. Understanding and quantifying the impact of scars is an important aspect of patient management, however, scar size or placement is not routinely considered as a prominent outcome for anterior lumbar spine surgery, writes Jennie Walker.
Surgical scars are viewed by some women as a necessary blemish following surgery, or evidence of the challenges that have been overcome. Others, however, may view their scars as an imperfection that is associated with decreased self-esteem and self-confidence. The emphasis placed on physical perfection by modern society means that scars can have a significant psychosocial impact (Brown, 2010). While surgical scars are a small price to pay for successful spinal surgery they can have a substantial effect on the psychological well-being of women by causing anxiety, social avoidance, and impaired quality of life.
The size and location of scars on the abdomen may not only affect women’s confidence to wear clothes that reveal the midriff, but can result in women choosing to wear loose fitting garments to conceal any change in contour due to the size and location of surgical scars. Although these changes may seem insignificant to some, they are life changing for those affected, in some cases shifting the lived experience of women from feeling sensual to frumpy or aberrant. These changes to body image can have long-lasting effects on daily activities as well as sexual intimacy and sexual relations. Holistic discussions are needed during pre- and postoperative consultations to ascertain women’s ideas, concerns and expectations regarding surgical scars as well as to establish the actual and potential impact of surgical scars.
Preliminary evaluations performed at our centre of women who have had elective anterior lumbar spine surgery have highlighted the varied impact that scars can have. The Patient Scar Assessment Questionnaire (PSAQ) (Durani et al, 2009) was used to assess the characteristics of the scar, symptoms, awareness and satisfaction. Reported difficulties relating to surgical scars largely focused on aesthetics and the impact on quality of life rather than actual scar symptoms.
Interim data from 113 patient surveys identified that only 20% of women had no preference of scar orientation. A horizontal scar would be preferred by the majority group of women (44%), compared to 36% who would prefer a vertical scar. Respondents conversely reported receiving a vertical scar in 73% of cases and a horizontal scar in only 25%. Additional comments predominantly focused around the ease or ability to hide scars as well as the impact of the scar on body image and on sexual relations.
Despite 87% of women rating the overall appearance of the scar as ‘excellent’, good’ or ‘okay’, the majority considered their scars to be long (54%) or very long (16%), and a minority considered their scar to be wide (13%) or very wide (2%). Many women reported that their scars were very or fairly noticeable to others (41%), with 18% of women stating that they are were very self-conscious of their scar.
Annotated comments provided insight to both positive and negative experiences. While some women were not concerned about their scar:
“The scar was the least of my concerns and still is…I am just thankful I was allowed the surgery…”
other women reported considerable dissatisfaction:
“My scar is 10 inches—I find the size of it upsetting”
“I have a big scar which dips in and out. This affects my body image and sexual relations.”
Further research is required to establish prospective quantitative data as well as qualitative perspectives on surgical scars and outcomes specific to body image following lumbar spinal surgery via an anterior approach. Further work is also required to ensure that a network of resources is established which can support spinal patients who have dysfunctional changes to body image, or sexual relations following spinal surgery.
Brown, B et al. Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010; 63 (6): 1022-1029.
Durani P, et al.Plastic and Reconstructive Surgery, 2009; 123 (5): 1481-1489.
Jennie Walker is a nurse and clinical educator based at Nottingham University Hospitals National Health Services Trust, Nottingham, UK