AB: One thing we do is try to place scars in the shadows. In a facial reconstruction, for example, we’ll hide them in the mouth or under the jawline. In hand surgery, we routinely use zigzag (or z-plasty) incisions because we want to reduce the risk of scar contractures, which is when skin scars pull the fingers into suboptimal or functionally limiting positions. In plastic surgery in general, z-plasty incisions are used to lengthen tight scars in many parts of the body, but often from burn scars affecting the joint creases, like the neck, elbow, wrist, fingers, knee. The purpose in these situations is not just cosmetic, but more importantly, functional. From the cosmetic perspective, the z-plasty can be used to try to align scars with a natural skin fold. For example, if I align the scar along a joint crease, like the flexor creases of your fingers, not only does it create improved function, but also, improved cosmetics, because the scar is less visible in the crease.
MN: You’re creating a longer scar, but because of its placement, it follows contours of the body more naturally.
AB: Sometimes a longer scar is preferable to a scar with an abnormal contour. For instance, we routinely excise circular lesions in an ellipse to provide a scar with a flatter, more linear contour.
MN: Meaning the scar becomes a line instead of a circle?
AB: Actually, the scar ends up with a more regular contour, instead of bunched up edges, and may align with natural wrinkles within the skin.
MN: That’s really fascinating. Aesthetically, do we prefer lines to circles—at least in terms of marks on our bodies?
AB: A thin line will cover more length, but it may be less visible than a scar that forms more of a solid shape. It’s interesting, the psychology of it. Say a 12 year old has a circular lesion on his chin. His friends might point it out or make fun of him and he’ll feel self-conscious about it. If we turn that into a line, it’s still a mark, but it hopefully becomes thinner, takes up a lower profile on his face; maybe even lines up with the some of the natural lines of his face. Some kids actually enjoy their scars and are more confident in describing a scar to their friends and classmates than a congenital difference.
MN: Drawing has always had a relationship to magic—to draw is to conjure an image where there previously was none. But your magic trick seems to be of the opposite kind: a disappearing act. Your craft is one of concealment—to literally place the scars in the shadows. Do you ever think about your work as an act of erasure?
AB: That’s an interesting point. I think what I do, as a surgeon, involves both kinds of magic: creation and erasure. I think it depends on the kind of case I’m performing. For instance, my favorite procedure, pollicization, involves the “creation” of a thumb in patients who have lost their thumb from congenital or traumatic causes. Although it involves repositioning the next finger—usually the index finger—into a new position, the appearance and function of the hand are completely changed. Despite the fact that the patient still has a four-fingered hand, at first glance, the deformity becomes almost imperceptible after the thumb has been “created”. In fact, many cartoon characters—Mickey Mouse, The Simpsons, Family Guy—have four-fingered hands. Speaking of magic, Walt Disney is credited with this development; it made Mickey’s animators 20% faster, and they felt his hands looked strange with five fingers.