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Incision placement and design in rhytidectomy is critical for patient satisfaction.To evaluate the aesthetic outcome of W-plasty vs traditional straight-line (SL) trichophytic closure techniques on posterior occipital hairline scars in rhytidectomy.A retrospective cohort study was conducted at the Buckingham Center for Facial Plastic Surgery. Clinical history and operative reports were reviewed for 46 patients who underwent rhytidectomy (23 using W-plasty and 23 using SL technique) between June 1, 2014 and August 31, 2015. Blinded photographic analysis of 1-year postoperative photographs was performed.The posterior occipital hairline incision was primarily closed with either a W-plasty or SL trichophytic technique.Standard photographs of the posterior occipital incision site obtained after the 1-year postoperative mark were reviewed and scored in a blinded fashion by 3 nonphysician medical staff members using a modified Manchester Scar Scale (MSS: from 0 [best possible outcome] to 24 [worst possible outcome]). Interrater reliability was assessed via Cronbach α testing.There were 23 patients in each group. The W-plasty and SL groups were similar in terms of age (mean [SD] age, 59.6 [6.3] years and 64.1 [7.3] years, respectively), sex (21 [91%] and 21 [91%] women, respectively), race-ethnicity, and absence of risk factors (smoking and diabetes) predisposing to poor wound healing (0 and 0 smoking/diabetes, respectively). Mean (SD) follow-up times for the W-plasty and SL groups were 388 (38.8) and 475 (100.1) days, respectively. No statistical difference was demonstrated in the mean aggregate MSS scores from all evaluators between the W-plasty group and the SL group (reviewer 1: 5.69 vs 5.86, P = .60; reviewer 2: 10.09 vs 9.56, P = .65; and reviewer 3: 5.30 vs 6.17, P = .08). Overall interrater reliability for the MSS scores was 0.56.Primary W-plasty and SL trichophytic closures in the posterior occipital hairline appear to yield highly acceptable and similar cosmetic outcomes under objective blinded evaluation. These techniques can be used with success to help minimize conspicuous scarring after rhytidectomy.3.