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Lemperle Plast Aesthet Res 2020;7:40 Plastic and
DOI: 10.20517/2347-9264.2020.14 Aesthetic Research

Review Open Access

Prevention of hyper- and hypotrophic scars through
surgical incisions in the direction of the “main

folding lines” of the skin

Gottfried Lemperle

Division of Plastic Surgery, University of California, San Diego, CA 92103-8890, USA.

Correspondence to: Prof. Gottfried Lemperle, Plastic Surgeon, Wolfsgangstr. 64, Frankfurt am Main D-60322, Germany.
E-mail: lemperle8@aol.com
How to cite this article: Lemperle G. Prevention of hyper - and hypotrophic scars through surgical incisions in the direction of the
“main folding lines” of the skin. Plast Aesthet Res 2020;7:40. http://dx.doi.org/10.20517/2347-9264.2020.14
Received: 30 Apr 2019 First Decision: 1 Jun 2020 Revised: 17 Jun 2020 Accepted: 20 Jun 2020 Published: 26 Jul 2020

Academic Editor: Alexis Desmoulière, Jérôme Laloze Copy Editor: Cai-Hong Wang Production Editor: Jing Yu

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

INTRODUCTION
Minimally invasive and endoscopic surgeries have revolutionized thoracic, abdominal, and orthopedic
surgery, and have become today’s gold standard, resulting in much smaller scars. However, children and

© The Author(s) 2020. Open Access This article is licensed under a Creative Commons Attribution 4.0
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