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

Paul, Sharad P.

doi:10.17554/j.issn.2413-8223.2017.02.19

Cited by 21 publications

(25 citation statements)

References 102 publications

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“… 15 One of the other problems has been that different textbooks have marked out Langer’s lines on the lower limb differently, adding to the confusion during planning excisions. 7 …”

Section: Discussionmentioning

confidence: 99%

“…We used Borges method of determining RSTL, that is, pinching skin and noting both furrows and ridges—because when contour lines are produced by muscle of joint action, one only notes furrows 7 and therefore this may be confusing. Using this technique, RSTL and wrinkle lines, that is, skin lines that we observe on our legs at rest seem to lie in the same oblique–horizontal plane (Fig.…”

Section: Discussionmentioning

confidence: 99%

“…Although closure of wounds under least tension is well known to result in best outcomes to do with both wound healing and scar formation, the lines of excision that result in least tension have often been contentious. It has been noted that many textbooks depict skin tension lines such as Langer’s lines differently, and there may be a “lack of science behind skin lines currently used for surgical excisions.” 7 …”

Section: Introductionmentioning

confidence: 99%

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Biodynamic Excisional Skin Tension Lines for Excisional Surgery of the Lower Limb and the Technique of Using Parallel Relaxing Incisions to Further Reduce Wound Tension

Paul

2017

Plastic and Reconstructive Surgery - Global Open

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Background:Closing of defects of the lower limb after skin cancer excision poses a challenge in lower limb skin. Although the concept of relaxed skin tension lines has been established as ideal on the face, on the lower limb there remains confusion between Langer’s lines and wrinkle lines, and this study was done with the task of identifying and mapping biodynamic excisional skin tension (BEST) lines on the lower limb.Methods:Following studies on BEST lines elsewhere on the body, the author investigated BEST lines on the lower limb. Using a specially designed tensiometer, inherent skin tension (pretension) and wound-closing tension were studied along with the force needed to bring the wound edges together after excision of a lesion in 23 cases with defects ranging from 1.5 to 4.5 cm in diameter. Skin tension measurements of skin lines (relaxed skin tension lines (RSTL) versus BEST) and vertical closure (BEST) versus vertical closure with a parallel relaxing incision were undertaken and followed by statistical analyses utilizing the paired t test and the unpaired Student’s t tests.Results:BEST lines run in the vertical direction on the lower limb, that is, closure in a vertical direction resulted in a statistically significant reduction in closing tension when compared with other directions. Using a parallel relaxing incision can offer further reduction in tension, if needed.Conclusion:BEST lines of the lower limb are discussed, and a new technique of using parallel relaxing incisions to achieve closure of larger defects is also presented as an alternative to cutaneous flaps or grafts in the lower limb.

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“… 15 One of the other problems has been that different textbooks have marked out Langer’s lines on the lower limb differently, adding to the confusion during planning excisions. 7 …”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Biodynamic Excisional Skin Tension Lines for Excisional Surgery of the Lower Limb and the Technique of Using Parallel Relaxing Incisions to Further Reduce Wound Tension

Paul

2017

Plastic and Reconstructive Surgery - Global Open

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“…7 How did cleavage lines, often marked differently, end up as lines for surgical excision? 9 Skin may be anisotropic, but is does exhibit orthotropy (i.e. a degree of symmetry with respect to two normal planes), which is due to the preferential orientation of collagen fibres, 9 which explains the clear pattern that emerged in this study.…”

Section: Discussionmentioning

confidence: 65%

Biodynamic excisional skin tension lines for surgical excisions: untangling the science

Paul

2018

annals

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Objective There remains confusion between Langer's lines and wrinkle lines with respect to the optimal orientation of elliptical excisions on the trunk. This study sought to determine the directions of wound closure that would result in least wound tension after skin lesion excisions. Materials and methods Some 1181 consecutive skin lesion excisions were investigated (age range 13-95 years, median 64 years) using a tensiometer to determine directions of least wound tension. These lines were mapped. Skin tension measurements were taken during the procedure and analysed. The clear majority of excisions were for skin cancer and the others were for cysts or dysplastic naevi. Lesions such as lipomas, which entail incisional rather than excisional surgery (i.e. where overlying skin was not excised) were excluded. All lesions were cut out in a circular fashion following tension measurements. Closure was undertaken in the direction of least tension (biodynamic excisional skin tension line) and this was illustrated. This process was repeated in all cases where body site and direction of closure was mapped. Statistical analyses were undertaken on a series on the scalp and lower limb. Results Biodynamic excisional skin tension lines have a clear directional preference: scalp-coronal direction, limbs--vertical orientation of ellipses and trunk - mostly horizontal except oblique at the shoulder and scapular regions. Discussion Skin cancer excisions often end up with poor cosmetic results, owing to inconsistency in identifying the correct excisional wound closure lines. This has not been helped by the (hitherto) lack of large in vivo biomechanical studies, and because incisional lines and excisional lines have not been considered separately in surgical practice. Orientating ellipses or wound closures using biodynamic excisional skin tension lines offers a guide to reducing wound tension and minimising wound complications or scarring after cutaneous surgery.

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“…To solve this problem, the surgeon can use different incisions that can be closed in a more expedite way and with better cosmetic results. Another alternative would be a split-thickness skin graft, which sometimes would not match the color or texture of the recipient area [1][2][3].…”

Section: Introductionmentioning

confidence: 99%

Designing Flaps for Closure of a Variety of Skin Defects

A¹

2021

Trauma and Emergency Surgery - The Role of Damage Control Surgery

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In this article, I am presenting a variety of working models for closure of skin defects of different shapes along with their corresponding indications and mode of use. These working models can be enlarged or reduced in size using a regular copying machine in order to evaluate the best possibilities related to the position of the incision. The great advantage of this method is that the geometric results are always predictable. Furthermore, this method will improve the survival of the flaps and the cosmetic results. In summary, the surgeon can use a variety of skin incisions taking advantage of the minimal tension lines of the skin and also taking into consideration the anatomical characteristics of the region involved. In this article, I have used the minimal tension lines of the skin, because they are easy to demonstrate by simple measures, such as pinching of the skin in different directions. In addition, the surgeon can assess the mobility and the elasticity of the skin on an individual basis.

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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

Cited by 21 publications

References 102 publications

Biodynamic Excisional Skin Tension Lines for Excisional Surgery of the Lower Limb and the Technique of Using Parallel Relaxing Incisions to Further Reduce Wound Tension

Biodynamic Excisional Skin Tension Lines for Excisional Surgery of the Lower Limb and the Technique of Using Parallel Relaxing Incisions to Further Reduce Wound Tension

Biodynamic excisional skin tension lines for surgical excisions: untangling the science

Designing Flaps for Closure of a Variety of Skin Defects

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