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Lemperle Plast Aesthet Res 2020;7:40 I http://dx.doi.org/10.20517/2347-9264.2020.14 Page 21 of 25

A B

Figure 28. A horizontal approach to a ruptured Achilles tendon as in club foot surgery (Cincinnati approach) will prevent frequently
seen hypertrophic scars (A and B)

access joints, tendons or fractures through oblique incisions, no fear for the blood supply is indicated, since
the arteries are running in random pattern within the skin. Over the dorsum of the foot, shaped incisions
will result in improved healing over straight vertical ones.

CONCLUSION
In many areas of the body surface, the described “main folding lines” run closely to the Langer lines, with
which they are often confused. Langer lines were created by static forces in the skin of cadavers [Figure 29A].
The normal wrinkle lines are produced by dynamic forces acting on the skin of a living person.

If we exclude Langer lines as historic and not primarily intended as recommendation for the direction
of skin incisions, we are left with three well-known publications on skin incisions and optimal scarring.
[3]
Pinkus described MFL produced by “pinching” skin in 1927 , and Kraissl recommended incisions
perpendicular to the lines running perpendicular to Langer’s lines, especially as they cross joints and facial
folds.

In normal folding lines [Figure 29B], the predominant orientation of collagen fibers is parallel to the folds
and wrinkles. Collagen bands in scars also form parallel to the wound edges, regardless of scar location.
Striae distensae develop perpendicular to the direction of the strongest tension on the skin, and nature
reveals that the tension or MFL are perpendicular to the striae.

Surgeons, who have difficulty in identifying skin folds or striae, may use the graphics in this publication
as guidance. In elective surgery, most incisions or excisions can be planned in the direction of the MFL
[Figure 30A and B], even when the underlying structures such as ribs and other bones suggest the opposite.
[44]
Even small incisions for minimally invasive surgery should follow these folding lines .