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Relaxed skin tension lines (RSTL)

RSTL · Langer lines · Borges lines · wrinkle lines

Relaxed skin tension lines (RSTL) are the directional axes of minimum skin tension at rest. Excisions and incisions aligned with RSTL produce the most cosmetically acceptable scars by minimising distraction force across the wound. RSTL differ from the older Langer lines (cleavage lines, defined from cadaveric circular punch deformation) and Borges lines (clinically more useful, derived from pinch tests). UK BAPRAS and BAD minor-surgery teaching emphasise pre-operative RSTL mapping.

CurrentLast reviewed 16 May 2026

Concept and history

  • Langer lines (Karl Langer, 1861): cadaveric study; lines of cleavage from circular awl deformation.
  • Kraissl lines (1951): living-subject wrinkle lines.
  • Relaxed skin tension lines (RSTL) (Borges, 1962): demonstrated by pinching skin — direction of minimum extensibility / maximum redundancy.
  • RSTL are the most clinically useful for facial / scar planning.
  • Wrinkle lines = RSTL in older patients; less obvious in young taut skin.

Principles for surgical planning

  • Excision aligned with RSTL → scar parallel to direction of minimum tension → narrower, less hypertrophic scar.
  • Identifying RSTL:
    • Observe age-related wrinkles at rest.
    • Pinch test: gentle skin pinch in different directions; direction producing parallel ridges is RSTL.
    • Animate facial muscles to make wrinkle lines visible.
    • Avoid stretching skin while marking (over-estimates).
  • Mark in upright position before infiltration of local anaesthetic.
  • For large defects, plan flap incisions along RSTL where possible.
  • Cosmetic units: align with RSTL within unit; respect unit borders.

Regional RSTL patterns

  • Face:
    • Forehead: horizontal.
    • Glabella: horizontal + vertical.
    • Periorbital: horizontal lateral; vertical medial.
    • Cheek: arcuate from preauricular curving inferiorly toward chin.
    • Nose: variable — dorsum vertical-oblique; lateral fanned outward.
    • Upper lip: vertical-oblique radial from philtral columns.
    • Chin: horizontal mental crease.
    • Neck: horizontal cervical creases.
  • Trunk:
    • Anterior chest: oblique inferolateral.
    • Back: oblique inferolateral.
    • Abdomen: horizontal at the umbilicus; slightly oblique below.
  • Limbs:
    • Generally circumferential (perpendicular to long axis).
    • Joints: across joints (perpendicular to flexion axis) → risk of contracture; consider Z-plasty.

Practical points

  • Always mark RSTL pre-operatively with patient upright.
  • Photograph markings.
  • Where RSTL run perpendicular to natural anatomical landmarks (e.g. eyelid margin, vermilion border), prioritise preserving the landmark over RSTL alignment.
  • For free-margin distortion risk (eyelid, alar rim, lip vermilion): plan flap design to direct tension away from the margin.
  • Z-plasty / W-plasty reorient scars when previous excision crossed RSTL.
  • Counsel patients about scar prediction — better but not invisible.

References

  1. Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg. 1984;73:144-150.
  2. Langer K. On the anatomy and physiology of the skin. Br J Plast Surg. 1978;31:3-8 (translation of 1861 original).
  3. Kraissl CJ. The selection of appropriate lines for elective surgical incisions. Plast Reconstr Surg. 1951;8:1-28.
  4. Borges AF, Alexander JE. Relaxed skin tension lines, Z-plasties on scars, and fusiform excision of lesions. Br J Plast Surg. 1962;15:242-254.

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