Minimal Scar Formation After Orthopaedic Skin Incisions Along Main Folding Lines

Abstract

Background: Patients, particularly those who are young, often develop noticeable orthopaedic scars. In order to achieve minimal scarring, surgeons should attempt to place incisions in skinfolds or skin creases. Methods: Optimal incision lines can be determined from the direction of stretch marks (striae distensae), which develop perpendicular to lines of tension or main folding lines. A composite diagram of photographs of 213 individuals with striae distensae was created and compared with 276 images of incisions and scars derived from the Internet. Results: Classically described Langer cleavage lines often run counter to real tension lines and poorly predict the optimal direction for skin incisions. Conclusions: Whenever possible, main folding lines should be utilized as a guide in planning surgical incisions for young patients as well as for correction of problem scars.

Facial Scars: Do Position and Orientation Matter?

“…The recommendation to place incisions in line with resting tension lines and on the border of anatomical subunits of the face has been recommended since at least the 1950s and is still recommended today. [7][8][9][10][11][12][13][14][15][16][17][18][19]38,39 The effects of scar orientation and position relative to anatomical subunits on attractiveness have not, to the authors' knowledge, been studied rigorously. Scar healing in reference to skin tension lines has been explored, with wounds or incisions parallel to resting tension lines noted to heal better.…”

“…6 The fundamental teachings of facial incisional design dictate that surgeons should make incisions away from highly viewed structures of Plastic and Reconstructive Surgery • December 2022 the face, in line with resting facial tension lines, and position scars at borders of anatomical subunits of the face to reduce appearance-related burden. [7][8][9][10][11][12][13][14][15][16][17][18][19] The purpose of this study was to challenge these core tenets of facial scar design by characterizing layperson response to faces with well-healed scars and identify scar factors that may warrant scar revision. Specifically, we examined whether judgments of attractiveness and character inferences depend on facial scar placement and orientation.…”

Classification of Distinct Endotypes in Human Skin Scarring: S.C.A.R.—A Novel Perspective on Dermal Fibrosis

“…1,29 With regards to response to treatment, flat scar endotypes tend to respond well to surgical treatment if required, exception are those not in parallel to Langer's lines. 35 Environmental factors influencing the formation of stretched scars include tension or stretch to the wound site or improper (loose) suturing and in situ foreign body whilst the wound is healing. 16 The genetic aspect of acquiring a flat or stretched scar endotype is unknown but there seems to be no genetic susceptibility.…”

Clinical and Histological Proof that Surgical Incisions along Skin Folding Lines Result in Optimal Scars

“…In an early publication [1], we could show that striae distensae always develop perpendicular to the skin tension lines. In another article [2], we demonstrated that virtual skin tension lines are identical to the obvious Main Folding Lines; we recommended their use as optimal directions for orthopedic incisions, when inconspicuous scar formation is a prerequisite, as in children, younger adults, and women.…”

“…Skin incisions should always be as deep as needed in order to avoid disruption of collagen fibers in wound edges, which will stimulate fibroblasts and cause more scar production (Figures 2a and 2b). More examples and illustrations are provided in a small booklet on optimal surgical incisions [5]. Interestingly, the stripes of tigers and zebras follow similar lines, transverse at the torso and extremities, and concentric towards the inner side of the large joints.…”