Famous lines in history: Langer lines.

Abstract

The orientation of surgical incisions over the skin iswidely considered to affect scarring and the final cosmetic outcome for patients. Whenmost surgeons visualize lines on the skin surface to guide such incisions, it is Langer lines (alsoknownasskincleavageor tension lines) thatmost readilycometomind.KarlLanger(1819-1887),themanbehindthefamouslines, was born in Vienna, Austria, where he spentmost of his life and later becameprofessor of anatomy at Joseph’s Academy. In 1861, Langer began publishing a series of 5 articles detailing his seminalwork on the physical andmechanicalpropertiesof theskin. In thefirstof thesearticles,Langer creditedDupuytrenandMalgaigne for their earlierobservations. In 1834, Dupuytren reported seeing a youngmanwhohad attempted to commit suicidebystabbinghimselfover theheart3 times.Thepatient claimedto haveusedaroundawlasthe instrument,buthedidnotfashionroundstab wounds onhis chest. This ledDupuytren to study thematter in cadavers anddiscover thata round instrument indeedproduced linearcleftswhen thrust throughtheskin.Healsonoticedthat thesecleftshaddifferentorientations in different parts of thebody.Malgaigne confirmed these findingsandobserved fromhisexperienceasa surgeon that the retractionof wounds differedwith the direction of incisions. Langer went on to use sharp conical spikes to produce wounds all over the body of a large series of cadavers—of different ages and body constitutions—toanalyze the relationshipof each small cleft to thenext. He further attempted to shed light on wound retraction and the tension in human skin bymaking small circular incisions all over the bodies of cadavers and documenting in the directions in which the resulting woundsnarrowedandbroadened, if at all. Bywayof these incredibly meticulous efforts, Langer was able to draw his famous lines. Unfortunately, Langer’sworkwas largely unappreciated and ignored during his lifetime. In fact, because his original publications were written in the classical scientific German of his era, with hints of his local Austrian dialect, it was not until 1978 that a translation of his work wasmade available to the English-speaking world. Today, elective surgical incisions may not follow Langer lines in all body areas, andother guides, such as relaxed skin tension lines running perpendicular to the direction of muscle contraction, may serve patients better. However, the concept of skin tension lines has helped improve the practice of surgery and forensicmedicine, and Langer’swork hasbeen instrumental inourunderstandingof themanyfascinatingproperties of the skin.