LAUSR

as scar pliability and relief. Second, the POSAS is a composite scale with equal weightings for a range of measures, some of which are important in reconstructive surgery (surface area) and some of which are less useful (pliability); thus, it does not differentially weight those areas of greatest concern to surgeons and patients. Other shortcomings of the POSAS, including item redundancy, central tendency bias, and concerns regarding feasibility, have also been highlighted in the past. Despite the authors’ rigorous methodology and execution, there are 3 additional limitations to using the POSAS with photographs. First, removing pliability from the POSAS (because it cannot be assessed photographically) potentially changes the psychometric properties of the scale, shifting not only mean/median values but also its dimensionality, validity, and reliability. Second, the authors’ reliability testing included predominantly centrofacial scars in patients with fair skin; because their goal was to evaluate the scale’s use with postsurgical scar photographs in general, a broader range of images may have been helpful. Third, the 2-week lag between in-person and photographic assessments may mean that scar evolution could have occurred in this time frame, particularly for the 25% of patients whose scars were assessed less than 1 month after surgery; in these cases, intrarater reliability results may have been potentially underestimated. Many of the limitations inherent in the POSAS were addressed in the Scar Cosmesis Assessment and Rating (SCAR) scale (seeTable S1, SupplementalDigitalContent 1, http://links. lww.com/DSS/A377) that was developed, validated, and reliability tested expressly for postoperative scarring and specifically for use with photographic images—and was found to be psychometrically superior to existing scales, including the POSAS. For clinicians and researchers, it represents a potentially better option than the modified OSAS, given its feasibility (,20 seconds to perform), reliance on objective measures (rather than 0–10 ranges), high generalizability (developed on a wide range of skin types and scar locations), clinical meaningfulness (items are weighted based on level of impact on appearance), involvement of patients (patient priorities are reflected in the weightings), and clear terminology (avoiding references to measures, such as “pliability” and “relief”). Given these benefits, the SCAR scale may be preferable to the modified POSAS with photographic images, particularly when used for reconstructive surgery assessments.