Prevention of hyper- and hypotrophic scars through surgical incisions in the direction of the “main folding lines” of the skin

Abstract

Langer’s lines are still the recommendation and matrix for surgical incisions in most surgical textbooks, even if they were never meant to be by their first describer in 1861. To achieve minimal scarring, surgeons should attempt to make incisions parallel to skin tension lines, i.e., in skin folds or skin creases. On the basis of visible stretch marks (striae distensae) in the skin, which always appear in the same direction against skin tension in men and women, the direction of skin tension lines can be manifested also in the skin of children and young patients. These invisible or virtual tension lines are the same as the main folding lines (MFL) in adults and run perpendicular to the stretch marks. While well-established on the face and abdomen, these folding lines may not be obvious on other parts of the body. On chest, back and extremities, optimal direction of surgical skin incisions should take into account the patterns of striae distensae, which develop perpendicular to skin tension lines. MFL should be used in elective incisions in children, adolescents, and young women as a guide for the prevention of later visible hyper- or hypotrophic scars.

Keywords

Surgical incisions / folding lines / skin tension lines / Langer’s lines / striae distensae / stretch marks / hypertrophic scar

References

[1] Langer K.On the anatomy and physiology of the skin. I. The cleavability of the cutis. (Translation from German in 1861)..Br J Plast Surg1978;31:3-8

[2] Kocher T.Textbook of operative surgery.1911;3rd English ed.LondonAdam and Charles Black30

[3] Pinkus F.Pinkus F.Die Faltung der Haut..Die normale Anatomie der Haut. Jadassohn’s Handbuch der Haut und Geschlechtskrankheiten, Vol 1.1927;BerlinSpringer4-76

[4] Kraissl CJ.Excision of small tumours of the skin of the face with special reference to the wrinkle lines..Surgery1949;4:592-600

[5] Kraissl CJ.The selection of appropriate lines for elective surgical incisions..Plast Reconstr Surg1951;8:1-28

[6] Borges AF.Relaxed skin tension lines, z-plasties on scars, and fusiform excision of lesions..Brit J Plast Surg1962;15:242-54

[7] Borges AF.Elective incisions and scar revision.1973;BostonLittle, Brown5-10

[8] Borges AF.Relaxed skin tension lines (RSTL) versus other skin lines..Plast Reconstr Surg1984;73:144-50

[9] von Torklus D.Atlas orthopädisch-chirurgischer Zugangswege.2002;4th ed.Auflage MunichUrban & Fischer Verlag

[10] Miller MD.2010;BaltimoreLippincott Williams & Wilkins

[11] Lemperle G,Dieter Knapp D.The direction of optimal skin incisions derived from striae distensae..Plast Reconstr Surg2014;134:1424-34

[12] Wilhelmi BJ,Phillips LG.Langer’s lines: to use or not to use..Plast Reconstr Surg1999;104:208-14

[13] Carmichael SW.The tangled web of Langer’s lines..Clin Anat2014;27:162-8

[14] Russell CJ,Russell GW,McGrouther DA.Dynamic skin tension in the forearm: effects of pronation and supination..J Hand Surg Am2009;34:423-31

[15] Courtiss EH,deStefano GA,Holmstrand K.The Placement of elective skin incisions..Plast Reconstr Surg1963;31:31-44

[16] Barile L.Incisioni chirurgiche in ortopedia e linee di tensione cutanea..Arch Putti Chir Organi Mov1976;27:127-36

[17] Paul SP,Charlton N.A new skin tensiometer device: computational analyses to understand biodynamic excisional skin tension lines..Sci Rep2016;6:301 PMCID:PMC4958993

[18] Paul SP.Biodynamic excisional skin tension (BEST) lines: revisiting Langer’s lines, skin biomechanics, current concepts in cutaneous surgery, and the (lack of) science behind skin lines used for surgical excisions..J Dermatol Res2017;2:77-87

[19] Piérard GE.Microanatomy of the dermis in relation to relaxed skin tension lines and Langer’s lines..Am J Dermatopathol1987;9:219-24

[20] Viennet C,Armbruster V,Gabiot AC.Contractile forces generated by striae distensae fibroblasts embedded in collagen lattices..Arch Dermatol Res2005;297:10-7

[21] Arem AJ.Analysis of striae..Plast Reconstr Surg1980;65:22-9

[22] Alshaiji JM,Schwartzfarb E,Schachner LA.Unilateral striae distensae affecting the right axilla in a 16-year-old boy: brief report..Pediatr Dermatol2014;31:617-8

[23] Cho S,Lee DH,Chung JH.Clinical features and risk factors for striae distensae in Korean adolescents..J Eur Acad Dermatol Venereol2006;20:1108-13

[24] Basile FP,Basile AR.Striae distensae after breast augmentation..Aesth Plast Surg2012;36:894-900

[25] Sorensen GW.Axillary and inguinal striae induced by systemic absorption of a topical corticosteroid..Cutis1976;17:355-7

[26] Rotsztejn H,Nadolski M,Kamer B.The unusually large striae distensae all over the body..Adv Med Sci2010;55:343-5

[27] Salter SA,Rohrer TE,Kimball AB.Striae and pelvic relaxation: two disorders of connective tissue with a strong association..J Invest Dermatol2006;126:1745-48

[28] Watson REB.Stretching the point: an association between the occurrence of striae and pelvic relaxation?.J Invest Dermatol2006;126:1688-9

[29] Ashcroft GS,Lei K,Jeong MJ.Estrogen modulates cutaneous wound healing by downregulating macrophage migration inhibitory factor..J Clin Invest2003;111:1309-18 PMCID:PMC154440

[30] Cordeiro RC,de Moraes AM.Expression of estrogen, androgen, and glucocorticoid receptors in recent striae distensae..Int J Dermatol2010;49:30-2

[31] Elsaie ML,Elsaaiee LT.Striae distensae (stretch marks) and different modalities of therapy: an update..Dermatol Surg2009;35:563-73

[32] Whalen JG.Case study on linear focal elastosis..Dermatol Nurs2006;18:469-71

[33] Jeong JS,Kim MK.Linear focal elastosis following striae distensae: further evidence of keloidal repair process in the pathogenesis of linear focal elastosis..Ann Dermatol2011;23:S141-3 PMCID:PMC3229050

[34] Spitz JL.Genodermatoses: a full color clinical guide to genetic skin disorders.2005;2nd ed.BaltimoreLippincott, Williams & Wilkins

[35] Lemperle G,Cohen SR.A classification of facial wrinkles..Plast Reconstr Surg2001;108:1735-50

[36] Lim SY,Kim Y,Park JS.Comparison of outcomes between vertical and transverse skin incisions in percutaneous tracheostomy for critically ill patients: a retrospective cohort study..Crit Care2018;22:246 PMCID:PMC6164179

[37] Bedard P,Brais MP.Submammary skin incision as a cosmetic approach to median sternotomy..Ann Thoracic Surg1986;41:339-41

[38] Shrotria S.The peri-areolar incision - gateway to the breast!.Eur J Surg Oncol2001;27:601-3

[39] Halm JA,Schmitz PI.Incisional hernia after upper abdominal surgery: a randomised controlled trial of midline versus transverse incision..Hernia2009;13:275-80 PMCID:PMC2690844

[40] Bickenbach KA,Ammori JB,Winter JM.Up and down or side to side? A systematic review and meta-analysis examining the impact of incision on outcomes after abdominal surgery..Am J Surg2013;206:400-9

[41] Heller L,Xue AS.Abdominal wall reconstruction with mesh and components separation..Semin Plast Surg2012;26:29-35 PMCID:PMC3348745

[42] Leunig M,Ricciardi BF,Rüdiger HA.Skin crease ‘bikini’ incision for the direct anterior approach in total hip arthroplasty: a two- to four-year comparative study in 964 patients..Bone Joint J2018;100-B:853-61

[43] Andermahr J,Elsner A,Schiffer G.Die Hautspaltlinien und die Schnittführung bei Fußoperationen..Orthopäde2007;36:265-72

[44] Pérez-Bustillo A,Rodríguez-Prieto MA.Surgical principles for achieving a functional and cosmetically acceptable scar..Actas Dermosifiliogr2013;104:17-28

[45] Ismail A,Elmaraezy A,Menshawy E.Cutting electrocautery versus scalpel for surgical incisions: a systematic review and meta-analysis..J Surg Res2017;220:147-63