What is the significance of Langerhans lines (also known as cleavage lines or tension lines) in surgical interventions on the face and neck?

Langerhans Lines (Langer's Lines) for Face and Neck Surgery

Direct Recommendation

Incisions on the face and neck should be placed along relaxed skin tension lines (RSTL) or Kraissl's lines—NOT traditional Langer's lines—as these better predict optimal cosmetic outcomes and minimal scarring. 1

Understanding the Different Line Systems

The terminology around skin tension lines is confusing, with multiple competing systems:

• Langer's lines were derived from cadavers in rigor mortis and often run counter to real tension lines in living tissue, making them poor predictors for optimal incision placement 2, 3
• Relaxed skin tension lines (RSTL) follow natural furrows when skin is relaxed and are produced by pinching the skin 2
• Kraissl's lines are oriented perpendicular to underlying muscle action 2
• Main folding lines correspond to the direction of stretch marks (striae distensae) and represent true tension lines 3

For facial incisions, Borges's relaxed skin tension lines are the preferred guide, while Kraissl's lines may be better for the neck and body. 2

Critical Surgical Principles for Face and Neck

Incision Placement Strategy

• Place incisions along natural skin creases and relaxed skin tension lines whenever possible, particularly in the neck or across moving parts 1, 4
• The incision site should be positioned to facilitate excision of the scar should subsequent neck dissection be required 1
• Incisions should be of adequate size to allow proper visualization without creating excessive tension 5

Dynamic Considerations

Langer's lines are NOT static—they rotate up to 90 degrees with facial expressions, which affects scar appearance 6. This dynamic rotation varies by facial location and must be considered when planning incisions 6.

Technical Execution

• Use subcuticular closure technique to optimize cosmetic results and minimize visible scarring 7, 5
• Preserve subcutaneous tissue with separate closure to improve cosmetic outcomes and structural integrity 7, 5
• Meticulous hemostasis is critically important to prevent hematoma formation, which compromises wound healing and complicates postoperative evaluation 1, 7, 5

Common Pitfalls to Avoid

• Do NOT rely solely on classical Langer's lines for facial incision planning, as they poorly predict optimal incision direction in living tissue 2, 3
• Avoid creating tension on closures that appears adequate when the patient is supine but causes distortion when upright 7, 5
• Do not excise skin segments unnecessarily, as this may alter anatomical landmarks and compromise healing 5
• Never sacrifice adequate exposure for cosmesis—the incision must be large enough for proper surgical technique 5

Age-Related Considerations

For young patients, main folding lines (determined by stretch mark direction) should guide incision planning, as these patients are particularly prone to noticeable scarring 3. These lines represent true tension directions and predict minimal scar formation better than traditional Langer's lines 3.

Regional Specificity

The optimal incision orientation varies significantly by facial and neck region due to:

• Underlying muscle action patterns 2
• Dynamic facial expression movements 6
• Gravitational forces over time 8
• Embryological tissue segmentation patterns 8

Each surgical site requires individual assessment of the dominant tension vectors at rest and during movement to determine the optimal incision line 6.