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

Abstract

Surgical literature is inundated with references to Langer’s Lines, Cleavage Lines, Wrinkle Lines and Skin Tension Lines. The author undertakes a detailed literature review to understand the “state-of-the art” regarding skin lines in cutaneous surgery and puts forward a hypothesis that incisional and excisional lines are different. While the lines mentioned above are fine for making incisions, when wound tension is created after excision of skin lesions or cancers, as opposed to creating incisions for egress, the dynamics change -- and therefore (what the author terms) Biodynamic Excisional Skin Tension Lines matter and need to be determined accurately. On bony areas like the scalp (due to no underlying attachment of muscles and the galeal aponeurosis layer) or the lower limb (due to the vascular plane) need special considerations in cutaneous surgery. Therefore, when it comes to current practice in dermatological and cutaneous surgery, the science of skin biodynamics suggests that best excisional lines do not always conform to current surgical practice.