Surgical Skin Incisions Result in Optimal Scars When Made Parallel to Main Folding Lines Surgical Skin Incisions Result in Optimal Scars

Women and young adults often judge the success of an operation based on the condition of the remaining scar. Optimal scars are the hallmark of plastic surgeons, while all other surgical specialties blame scar formation on the patient. If you look at the direction of the collagen fibers in histological images of the dermis, you will see that they adapt parallel to the later skin folds on head, torso and limbs and form wrinkles with age. However, since it is not possible to examine the skin of all areas histologically, we have made use of a little-known fact: the striae distensae of all humans, both women and men, run in the same directions, perpendicular to the main folding lines or tension lines of the skin. On the basis of visible stretchmarks (striae distensae) in the skin, which always appear in the same direction in men and women against skin tension, we demonstrated these Main Folding Lines on other parts of the body of children and young adults which are well-established on face and abdomen. In a former publication, the direction of striae distensae on photographs of 213 individuals were transferred to a human template. This striae-composite was compared with 276 images of incisions in our clinical data base of our scars, scar revisions, and scars from the Internet. They were put in opposition to well-known Langer´s lines along with descriptions of Pinkus’ “main folding lines” and Kraissl’s lines but were running perpendicularly to the direction of the underlying muscles. Langer´s lines are still the recommendation and matrix for surgical incisions in most surgical text books, even if they were never meant as those by their first describer, an anatomist in 1861. In order to achieve minimal scarring, we should look at the direction of collagen fibers within the dermal matrix – and surgeons should attempt to place incisions parallel to skin tension lines, i.e. in in skin folds or skin creases. Main Folding Lines (MFL) should be used in elective incisions in children, adolescents, and young women as guide for the prevention of later visible hypertrophic or hypotrophic wide scars.