Aesthetic Outcomes of Transverse Versus Longitudinal Incision Techniques in Occipital Nerve Decompression Surgery

Surgical treatment of occipital headaches involves the decompression of the peripheral occipital nerves. While the literature extensively describes the longitudinal midline incision approach, our group initially used the longitudinal approach and switched to the transverse approach. The aesthetic outcomes of both incision techniques remain unexplored.

Patients undergoing surgical decompression for occipital headaches were instructed to provide images of their exposed occipital scalp scar. Evaluation was conducted using the Stony Brook Scar Evaluation Scale (SBSES) and the Scar Cosmesis Assessment and Rating (SCAR) scale by 3 independent plastic surgeons. SBSES scores range from 0 to 5 (higher indicating better outcomes), while SCAR scores range from 0 to 15 (higher indicating worse outcomes). Comparisons were made between transverse and longitudinal scars, with factors influencing scores identified.

Forty patients (average age: 47; 73% female) participated, with 28% having longitudinal midline scars and 72% having transverse scars. Patients with transverse scars exhibited higher SBSES scores (4.2 vs. 3.6; P = 0.044) and lower SCAR scores (3.0 vs. 4.6; P = 0.016). Longitudinal scar patients displayed more suture marks (SBSES: P =0.018; SCAR P = 0.003) and wider scar spread (SBSES: P = 0.013; SCAR: P = 0.038) compared with transverse scar patients. On regression analysis, higher BMI was associated with worse SCAR scores ( P =0.015), and a transverse scar was associated with improved SCAR scores ( P =0.008).

Our study reveals superior aesthetic outcomes with the transverse incision approach for occipital nerve decompression surgery compared with the longitudinal midline technique. Transverse scars exhibited higher SBSES scores and lower SCAR scores, indicating better cosmesis. Notably, longitudinal scars were associated with more prominent suture marks and wider scar spread.