Incision Lines on the Female Breast

The direction of incision lines on the body are controversially discussed in surgical literature. Different approaches to the body and extremities have resulted in two contradicting theories widely found in the literature. Langer’s lines, defined as “Spaltrichtungen” or cleavage lines, lie partially in line with the underlying muscle fibres. Kraissl’s dynamic lines, as well as the Borges relaxed skin tension lines, suggest that incision lines should be placed perpendicular to the direction of the underlying muscles [1–3]. All these recommendations are entirely based on static or anatomical observations, without giving due consideration to other influencing factors such as active movement, tension, gravity, and ageing. Various authors have shown that perpendicular tension on a scar will create dehiscence [4]. Micro-movements and micro-tension are the main causes of stimulating myofibroblasts to produce collagen, which results in a hypertrophic scar [4, 5]. Immobilization and avoidance of perpendicular tension on a scar is one of the main factors in preventing hypertrophy [4]. Tension in the line of the scar minimizes hypertrophy and dehiscence in mice and in humans on the limbs [5, 6]. There is limited literature about incision/excision lines on the female breast, and only Langer [1] and Kraissl [3] have really dealt with the subject. Langer suggested concentric excision lines around the nipple, whereas Kraissl proposed horizontal dome-shaped excision lines (Fig. 1). Both Langer and Kraissl showed two contradicting approaches without taking into account physiological ageing, differences in shape, and the effect of gravity [1, 3]. These approaches were based solely on the static condition of a lying or sitting woman. However, they do not take into consideration the factors of movement and physical activity. Daytime activity is linked to physical movement, which is mostly walking or upright sitting, and has an important vertical tension factor on the skin of the breast. Nighttime sleep generates tension from various directions due to changing positions during the night. Lying on the back creates very strong tension forces on the medial parasternal part of the bust. Finally, tension is almost unavoidable in an excision on the female breast, but correct orientation can optimize tension in the line of the scar. An additional concern is physiological breast ptosis, as different a b