The Impact of Skin Tension Line Orientation in Full-Thickness Skin Grafting for BCC

Skin tension lines are well established as a key consideration in planning incisions and closures to minimize scar visibility and distortion in patients with basal cell carcinoma (BCC). However, their role in graft orientation has received limited attention. A recent study investigated whether orienting skin grafts parallel to skin tension lines and improving color match at the donor site could enhance cosmetic outcomes and patient-reported quality of life (QoL) following surgical excision of BCC.¹

Background

BCC is the most common cutaneous malignancy in fair-skinned populations, with incidence continuing to rise globally due largely to cumulative ultraviolet exposure.² Surgical excision remains the cornerstone of treatment, with the primary objective being complete tumor removal. While Mohs micrographic surgery and margin-controlled excision represent the gold standard, these techniques are not universally available. In some settings, excision with predefined margins followed by defect closure using flaps or grafts is commonly employed.

Although grafting offers advantages—particularly preserving surgical margins for potential re-excision—it is often associated with inferior cosmetic outcomes compared with flap reconstruction. Optimizing aesthetic results without compromising oncologic safety is therefore an important clinical goal, particularly for head and neck tumors.

Clinical Trial Design

This prospective, observational study was conducted at a single center between November 2021 and February 2025 and included 71 patients with nodular or unspecified subtype BCC of the head and neck treated with surgical excision and full-thickness skin grafting. Participants were divided into 2 groups based on grafting technique. Group 1 (n = 40) underwent conventional grafting without specific attention to skin tension line orientation, with grafts harvested from the clavicular region. Group 2 (n = 31) underwent skin tension line–oriented grafting, in which grafts were harvested from a color-matched cosmetic area on the preauricular region and aligned parallel to relaxed skin tension lines.

Quality of life was assessed at least 3 months postoperatively using the Dermatology Life Quality Index (DLQI) and the Skin Cancer Quality of Life Impact Tool (SCQOLIT). Cosmetic outcomes were independently evaluated by 2 dermatologists using a visual analog scale (VAS), with one assessor blinded to the surgical technique. The study population had a mean age of 66.6 years and included slightly more women than men. Most patients had Fitzpatrick skin types II or III, and tumors were distributed across common facial sites, including the nasal ala, periocular region, malar area, and temporal or frontal regions.

Results

Cosmetic outcomes differed significantly between treatment groups. Patients who underwent skin tension line–oriented grafting demonstrated superior aesthetic results, with higher mean VAS scores compared with those receiving conventional grafts (6.13 vs. 5.64, p < 0.05). Clinically, tension line–oriented grafting was associated with less visible graft contraction and improved contour integration, particularly in cosmetically sensitive facial areas.

Despite these cosmetic improvements, no significant differences were observed in patient-reported quality of life between groups. Median DLQI scores were low in both groups, indicating minimal overall impairment, and median SCQOLIT scores were identical. A moderate positive correlation was observed between DLQI and SCQOLIT scores, confirming internal consistency between general dermatologic and skin cancer–specific QoL measures.

The authors propose several explanations for this discrepancy. First, commonly used QoL instruments may lack sensitivity to detect subtle differences related specifically to scar appearance or cosmetic satisfaction. Second, QoL following BCC surgery is influenced by multiple factors, such as cancer-related anxiety, tumor location, and patient expectations, which may outweigh incremental aesthetic improvements. Additionally, the timing of assessment and external factors such as heightened health care-related anxiety during the COVID-19 period may have influenced patient responses.

Conclusion

This study highlights both the potential benefits and limitations of tension line–oriented grafting. While the technique improved cosmetic outcomes without added risk, it did not demonstrate superiority in QoL as measured by existing tools. Because of this, authors stressed the need for more sensitive assessment tools when evaluating cosmetic interventions in surgery, particularly in areas like the head and neck.

References

1. Karakök Kışla H, Gundogdu M, Efe Sayın C. Efficacy of Orienting Skin Grafts Parallel to Skin Tension Lines and Color Matching on Quality of Life in Patients With Basal Cell Carcinoma (Skin Types II–IV), Dermatologic Therapy, 2025, 9105783, 6 pages, 2025. https://doi.org/10.1155/dth/9105783

2. Cameron MC, Lee E, Hibler BP, et al. Basal cell carcinoma: Epidemiology; pathophysiology; clinical and histological subtypes; and disease associations. J Am Acad Dermatol. 2019;80(2):303-317. doi:10.1016/j.jaad.2018.03.060