Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 393e399

The dynamic rotation of Langer’s lines on facial

expression
James Bush a,b,*, Mark W.J. Ferguson a,c, Tracey Mason a,
Gus McGrouther b

a
Renovo plc, The Manchester Incubator Building, 48 Grafton Street, Manchester M13 9XX,
United Kingdom
b
Plastic and Reconstructive Surgery Research, The University of Manchester, Stopford Building,
Oxford Road, Manchester M13 9PT, United Kingdom
c
Faculty of Life Sciences, The University of Manchester, Stopford Building, Oxford Road,
Manchester M13 9PT, United Kingdom

Received 9 April 2006; accepted 11 June 2006

KEYWORDS Summary Karl Langer investigated directional variations in the mechanical and
Langer’s lines; physical properties of skin [Gibson T. Editorial. Karl Langer (1819e1887) and his
Wrinkles; lines. Br J Plast Surg 1978;31:1e2]. He produced a series of diagrams depicting lines
Relaxed skin tension of cleavage in the skin [Langer K. On the anatomy and physiology of the skin I.
lines The cleavability of the cutis. Br J Plast Surg 1978;31:3e8] and showed that the
orientation of these lines coincided with the dominant axis of mechanical tension
in the skin [Langer K. On the anatomy and physiology of the skin II. Skin tension.
Br J Plast Surg 1978;31:93e106]. Previously these lines have been considered as
a static feature. We set out to determine whether Langer’s lines have a dynamic
element and to define any rotation of the orientation of Langer’s lines on the face
with facial movement.
One hundred and seventy-five naevi were excised from the face and neck of 72
volunteers using circular dermal punch biopsies. Prior to surgery a vertical line
was marked on the skin through the centre of each naevus. After excision distor-
tions of the resulting wounds were observed. The orientation of the long axis of
each wound, in relation to the previously marked vertical line, was measured with
a goniometer with the volunteer at rest and holding their face in five standardised
facial expressions: mouth open, smiling, eyes tightly shut, frowning and eyebrows
raised. The aim was to measure the orientation of the long axis of the wound with
the face at rest and subsequent rotation of the wound with facial movement.

* Corresponding author. Renovo plc, The Manchester Incubator Building, 48 Grafton Street, Manchester M13 9XX, United Kingdom.
Tel.: þ44 161 6037629; fax: þ44 161 6067333.
E-mail addresses: jim.bush@renovo.com (J. Bush), mark.ferguson@renovo.com (M.W.J. Ferguson), tracey.mason@renovo.com
(T. Mason), duncan.a.mcgrouther@manchester.ac.uk (G. McGrouther).

1748-6815/$-seefrontmatterª2006BritishAssociationofPlastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved.
doi:10.1016/j.bjps.2006.06.008
394 J. Bush et al.

After excision elliptical distortion was seen in 171 of the 175 wounds at rest.
Twenty-nine wounds maintained the same orientation of distortion in all of the
facial expressions. In the remaining wounds the long axis of the wound rotated
by up to 90 . The amount of rotation varied between sites (p > 0.0001).
We conclude that Langer’s lines are not a static feature but are dynamic with ro-
tation of up to 90 . It is possible that this rotation in the axis of mechanical tension
will affect the appearance of the resulting scar.
ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons.
Published by Elsevier Ltd. All rights reserved.

The orientation of a wound or surgical incision may
be a major determinant of the cosmetic outcome of
the resulting scar, although there is only limited
evidence for this in the literature. One retrospec-
tive analysis of the cosmetic outcome of facial
lacerations in children found that when wound
orientation was judged to deviate from Langer’s
lines by 20 or more the appearance was signifi-
cantly worse than when wound orientation deviated
from Langer’s lines by less than 20 .4 The seminal
studies of Karl Langer investigated the directional
variations in the mechanical and physical properties
of skin.1 He relied on an earlier observation by Du-
puytren that skin pierced by a round-bodied awl
produced linear clefts rather than circular wounds.2
Langer thrust conical spikes through the skin of ca-
davers producing multiple splits which, when
placed as closely as possible, and grouped together,
produced what we now term Langer’s lines.2 Gibson
translated Langer’s term ‘Spaltbarkeit’ as ‘Cleav-
ability’ resulting in the concept of Lines of Cleav-
age.1 In a separate series of studies Langer
realised that the wound edge retraction seen on
skin incision resulted from elastic recoil following
the release of tension inherent in skin.3 Langer pro-
posed that, in the absence of restrictions on elastic
recoil, wound edge retraction would be directly pro-
portional to the inbuilt tension in skin and hence,
could be used to gain information thereon. Further-
more, Langer observed that when a circular incision
was made in skin, information could be gained about
tension in all directions. In the absence of uniform
tension in all directions, the wound would gape in
a particular direction, and the circular island of in-
cised skin, which he termed a ‘kernel’, would have
a greater contraction along the same axis as the gap-
ing or retraction of the outer wound. Langer’s circu-
lar wounds always gaped in the same direction as
the Lines of Cleavage. Subsequently there have
been several descriptions of skin lines with empha-
sis on making elective incisions in the direction of
greatest skin tension,5 i.e. along Langer’s lines
rather than across them. Langer appreciated that
tension varied with body position3 but Langer’s lines
have been considered as a static and constant
feature. We suggest that Langer’s lines are
dynamic, with changes in their direction dependent
on the movement of joints, muscles and body
segments. This study aimed to define the rotation of
orientation of Langer’s lines on facial movement as
this will affect the wound healing environment
and subsequent scar formation.
Methods
This research was conducted in the course of
a randomised controlled clinical trial investigating
the scar-improving efficacy of a drug, given as an
intradermal injection, immediately after closure of
the wounds resulting from the excision of benign
head and neck naevi. The results of that trial will
be published separately. Ethical Committee and
Medicines in Health Regulatory Authority approval
were obtained prior to commencing the trial and
written informed consent was obtained from each
volunteer prior to participation. The operative
procedures were performed without the time
pressure of service commitment allowing extensive
data collection and photographic documentation.
One hundred and seventy-five naevi were
excised from 72 volunteers (28 male, 44 female),
aged 19e76, who responded to adverts placed in
local newspapers offering surgical excision of
benign head and neck naevi as part of a clinical
trial. Each volunteer was allowed to have up to
four naevi removed. Naevi were included if, on
examination by one of the authors (JB), they
were clinically benign, above the clavicle ex-
cluding the hair bearing scalp, less than 8 mm in
diameter, and more than 3 cm apart if more than
one naevus was to be excised from the same vol-
unteer. Naevi were excluded if they measured
8 mm or more in diameter as the largest punch
biopsy used for excision had a diameter of
8 mm. A minimum distance of 3 cm was chosen
between each naevus in an attempt to negate
any mechanical effect that one wound may have
had on an adjacent wound. If dysplasia or malig-
nancy were suspected in naevi on clinical
Dynamic rotation of Langer’s lines
examination, those naevi were excluded from the
research study, and referred to the regional Plas-
tic Surgery unit for appropriate treatment.
The positions of naevi excised were recorded
on a diagram of a face and a record was kept as
to which aesthetic unit of the face, as reviewed
by Fattahi,6 each naevus was included in.
Measurements of the maximum and minimum
dimensions of each naevus were taken prior to
excision, along with measurements of the dis-
tance between the centres of different naevi on
the same volunteer, with Yato Pro-Cal electronic
digital callipers.
Prior to surgery a vertical line was marked on
the skin through the centre of each naevus using
a plumb line, suspended from the vertex of the
skull, with the volunteer standing up and looking
straight ahead. Surgery was performed with vol-
unteers lying supine, or in either lateral position
for posteriorly placed naevi, under local anaes-
thesia achieved with 1% lignocaine with adrena-
line (1:200 000). Naevi were excised with dermal
punch biopsies, of between 3 mm and 8 mm in di-
ameter, according to the size of the naevus. Der-
mal punch biopsies were placed onto the skin
without any prior tensioning or support of the
skin. All excisions were full thickness skin exci-
sions and naevi were sent for histopathological
examination. Elliptical distortion of wounds was
observed after most excisions. The maximum
and minimum dimensions of each wound were
measured, with the face in a relaxed posture,
with sterile, non-digital callipers to the nearest
0.1 mm and the angle that the long axis of each
elliptical wound made with the marked vertical
line (Wound Orientation ¼ A ) was measured using
a goniometer (Fig. 1). The aim was to measure
this axis and all subsequent rotation relative to
a vertical axis.
Vertical line. Marked on Skin
with Plumbline
Long Axis of
Wound
Distorted Wound
Aº
A° = Wound
Orientation
Minimum
Dimension Maximum
Dimension
Figure 1 A diagrammatic representation showing a
distorted wound and the measurements taken.
395
Measurement of the rotation of the axis of
Langer’s lines on facial expression
Measurements were initially taken with the facial
muscles relaxed and were then repeated with the
volunteer holding their face in five facial expres-
sions which we endeavoured to standardise by
giving the patient a standard command, reinforced
by a demonstration of the required expression.
Expressions examined were as follows:
Mouth open,
Smiling,
Eyes tightly shut,
Frowning, and
Eyebrows raised.
Wounds were closed primarily, after excision of
any standing cone deformities, with one or two
layers of continuous subcuticular polyamide (Ethi-
lon, Ethicon, U.S.A.). Subcuticular closure was
chosen to prevent scarring of the wound margins
by interrupted sutures. Wounds were closed in the
same orientation as the maximal wound distortion
with the face at rest unless this would cause
unacceptable distortion of a nearby anatomical
structure. Wounds that remained circular at rest
were closed in the same orientation as the most
dominant distortion that occurred during the
different facial expressions. After closure, wounds
were immobilised with 12 mm steristrips (3M
Health Care, U.S.A.). Steristrips were secured
with Mastisol adhesive (Ferndale Laboratories,
Italy) and kept in place for 21 days. Sutures were
removed after 14 days. All surgical procedures
were performed by the same author (JB).
All measurements of wound orientation and
wound dimensions taken with the face at rest and
in the five standardised facial expressions were
databased. The orientations of the wounds, at
rest and in each of the facial expressions, were
plotted onto copies of the diagram of the face
used to plot the positions of the excised naevi.
The face was not depicted in the different facial
expressions as this would cause the position of
each wound site to move slightly which, in the
authors’ opinion, would make it more difficult to
interpret how the orientation of each particular
wound changed. The extremes of rotation, or
greatest change in wound orientation, at each
wound site were also plotted onto copies of the
diagram of the face, and an analysis of variance
and T-tests were used to determine differences in
the degree of rotation of wound orientation be-
tween different aesthetic units.
396
Table 1 Size and frequency of punch biopsy used
for naevus excision
Biopsy size (mm) Number
3 2
4 15
5 38
6 65
8 55
Results
Naevi ranged from 1.7 to 7.9 mm (Median, 4.7 mm)
in maximum diameter. The length of closed
wounds at the conclusion of surgery ranged from
3.0 to 15.8 mm (Median, 9.2 mm). The sizes of
punch biopsies used for excision are summarised
in Table 1 and the number of naevi in each aes-
thetic unit is shown in Table 2. Of the 175 lesions
excised 160 were confirmed to be naevi on histo-
logical examination. The remaining 15 lesions
were all benign skin lesions.
Wound distortions
Only four wounds were observed to stay circular,
after excisional biopsy, with the face at rest. Two
of these wounds were on the forehead, one on the
alar rim, and one on the upper cheek. These sites
did show elliptical deformation in other subjects.
The other 171 wounds were distorted into ellipses.
Twenty-nine wounds maintained the same direc-
tion of wound distortion, as that seen at rest, in
each of the five facial expressions. In the remain-
ing wounds the direction of distortion was
observed to change with the different facial
expressions (Fig. 2aef), with changes in the orien-
tation of the long axis of the wound of up to 90
(Fig. 3aee). The median rotation in the long axis
of wounds with the different facial expressions
was 30 .
Table 2 Number of naevi in each aesthetic unit
Aesthetic unit Number of naevi
Forehead unit 21
Nasal unit 5 strated with the mouth open, which may be due
Eyelid unit 4 to the unsupported jaw (mouth open) of the
Cheek unit 65
Upper lip unit 14
Lower lip unit 10
Mental unit 4 clude Kraissl and Conway’s wrinkle lines7 (Fig. 5)
Auricular unit 2 and Borges’ relaxed skin tension lines8,9 (RSTLs e
Neck unit 50
J. Bush et al.
The rotation of the axis of Langer’s lines
on facial expression
Most neck lines rotate little in the chosen facial
expressions and there are scattered non-rotating
sites, on the face, especially in the pre-auricular
area. The cheek and nasolabial fold lines largely
undergo intermediate degrees of rotation (11e30
and 31e50 ). In the crow’s feet area, fanning out
from the lateral palpebral fissure, and also on the
forehead and glabella, rotation commences after
30 and reaches 90 in certain individuals. The
upper lip, in different individuals, can rotate from
11 to 90 and the modiolus and chin, in particular,
show considerable rotation. The analysis of
variance showed a highly statistically significant
difference in the rotation of Langer’s lines on
facial expression in different aesthetic units
(p < 0.0001). Table 3 shows pairs of aesthetic units
which showed statistically significant differences
in the rotation of Langer’s lines on facial expres-
sion using T-tests.
Discussion
Langer’s lines have previously been considered to
be static. Langer, however, did find variations in
the pattern of cleavage lines in different individ-
uals,2 and also found that wide variations in the
distortions of wounds could be produced by varying
the positions of limbs,2,3 although his diagrams did
not illustrate this variation other than on the fore-
head. By comparing Langer’s lines on the face
(Fig. 4) to the orientations of the long axes of
wounds with the face at rest in our study
(Fig. 2a), similarities can be seen on the forehead,
medial part of the cheek, upper and lower lips,
chin and neck. Differences can be seen more later-
ally on the cheek where Langer’s lines radiate up
and laterally from the oral commissure and chin
into a large vertical component on the cheek
over the superior ramus of the mandible, whereas,
we observed lateral, oblique radiation down from
the lateral palpebral fissure and medial cheek, to-
wards the neck, with a thin strip of vertical lines in
the pre-auricular area. On the cheek Langer’s lines
resemble, more closely, the lines that we demon-
cadaver.
Other skin lines that have been described in-
Fig. 6). Kraissl and Conway7 suggested that wrinkle
lines could be used as a guideline for the
Figure 2 Diagrammatic representations of the orientations of the long axes of wounds at rest and in the five stand-
ardised facial expressions. For ease of comparison a standard diagrammatic representation of the face is shown rather
than depicting the specific expression. Circles show areas where there was no dominant axis of wound distortion i.e.
where wounds stayed circular. (a) Face at rest, (b) mouth open, (c) smiling, (d) eyes tightly shut, (e) frowning, and (f)
raised eyebrows.

Figure 3 Diagrams to show the maximum rotation of the long axes of wounds in all the different facial expressions.
The extremes of rotation are illustrated and each diagram represents wounds with different degrees of rotation.
(a) 0e10 , (b) 11e30 , (c) 31e50 , (d) 51e70 , and (e) 71e90 .
398 J. Bush et al.

Table 3 Pairs of aesthetic units which show statisti-

cally significant differences in the degree of rotation
of Langer’s lines on facial expression (T-tests)
Aesthetic units Mean Standard p-Value
error
Lower lip e neck 49.69 9.27 <0.0001
Lower lip e eye lid 51.69 14.82 0.0007
Lower lip e auricular 62.94 19.27 0.0014
Forehead e neck 42.85 7.22 <0.0001
Forehead e eye lid 44.86 13.636 0.0013
Upper lip e neck 31.55 8.07 0.0002
Cheek e neck 25.91 5.65 <0.0001

placement of elective surgical incisions on the face

and explained that wrinkles, formed when the skin
folded on contraction of underlying muscles, rep-
resent lines of relaxation in the skin. They pro-
duced a composite sketch of the wrinkle pattern
of the face by comparing photographs of elderly
subjects with loose facial skin. Despite the defini-
tion of wrinkles being formed on active muscle
contraction the lines illustrated by Kraissl and
Conway are similar to our lines on the forehead,
glabella, cheeks, chin and neck with the face at
rest. Fanning out laterally from the lateral palpe-
bral fissure the wrinkle lines are similar to the lines
we found with the eyes tightly shut, as would be
expected. On the upper and lower lips, however,
Kraissl and Conway’s wrinkle lines radiate out
from the mouth, whereas our lines run parallel
with the fibres of orbicularis oris on the upper lip
and radiate down and laterally, away from the
mouth, on the lower lip.
Figure 5 A composite drawing of the normal wrinkle
pattern of the face. Reproduced with permission from
Elsevier from Kraissl CJ, Conway H. Excision of small
tumours of the skin of the face with special reference
to the wrinkle lines. Surgery 1949;4:592e600.
Borges’ RSTLs are demonstrated by gentle com-
pression of the skin to reveal creases.8,9 Borges
maintained that his lines correspond with the
directional pull of tension in the skin in areas of
repose, secondary to the protrusion of underlying
bone and cartilage. By his own admission the RSTLs
are very similar to the wrinkle patterns described
by Kraissl and Conway but differ from them on
the dorsum of the nose, lateral to the eye and on
the lower lip and chin.9 The RSTLs differ from

Figure 4 Langer’s lines of the face. Reproduced with
permission from Elsevier and the British Association of
Plastic Surgeons from Langer K. On the anatomy and
physiology of the skin I. The cleavability of the cutis.
Br J Plast Surg 1978;31:3e8.
Figure 6 Borges’ relaxed skin tension lines. Repro-
duced with permission from Lippincott, Williams and
Wilkins from Borges AF. Relaxed skin tension lines
(RSTL) versus other skin lines. Plast Reconstr Surg
1984;73(1):144e50.
Dynamic rotation of Langer’s lines
our lines with the face at rest on the medial fore-
head and glabella, upper crow’s feet area, upper
and lower lips, nose and chin but agree on the
cheek and neck. The directions of the RSTLs on
the upper and lower lips are similar to the orienta-
tions of wound gape that we observed with the
mouth open.
Langer’s cleavage lines, Kraissl and Conway’s
wrinkle lines, or lines of relaxation, and Borges’
relaxed skin tension lines all illustrate directional
mechanical properties of skin. The fact that they
do not entirely agree with each other suggests that
these lines are variable and not static and that
each one may be a ‘snapshot’ of the wider
dynamic picture demonstrated by our study.
1. Langer’s lines on the face are dynamic, with up
to 90 rotation in their orientation, and the
amount of rotation varying between different
sites (ANOVA, p < 0.0001).
2. In some areas of the face, such as the cheek,
they are easy to define, showing intermediate
degrees of rotation.
3. In other areas such as the chin, modiolus and
lips they are more difficult to define due to
higher degrees of rotation.
4. It is possible that this rotation in the axis of me-
chanical tension will affect the appearance of
399
the resulting scar. This issue will be addressed
after further analysis of this cohort study.
Acknowledgement
Funding for this study was provided by Renovo plc.
References
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Br J Plast Surg 1978;31:1e2.
2. Langer K. On the anatomy and physiology of the skin I. The
cleavability of the cutis. Br J Plast Surg 1978;31:3e8.
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tension. Br J Plast Surg 1978;31:93e106.
4. Simon HK, Zempsky WT, Bruns TB, et al. Lacerations against
Langer’s lines: to glue or suture? J Emerg Med 1998;16(2):
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or not to use. Plast Reconstr Surg 1999;104(1):208e14.
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Maxillofac Surg 2003;61:1207e11.
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the face with special reference to the wrinkle lines. Surgery
1949;4:592e600.
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lines. Plast Reconstr Surg 1984;73(1):144e50.