Beveled vs. perpendicular skin incisions on the back: a case report

This is a case report describing a within-patient self-controlled comparison of 45° beveled and 90° perpendicular skin incisions on the back in a 56-year-old female undergoing benign lipoma excision. Beveled skin incisions are routinely recommended in aesthetic surgery for their ability to enlarge dermal contact areas and facilitate favorable wound edge apposition, particularly in low-tension, thin cutaneous regions such as the face and neck. However, whether this cosmetic advantage extends to high-tension, thick-skin sites like the back remains unclear. This case report addresses this gap, and the specific novelty of this report is twofold: (1) it compares 45° beveled and 90° perpendicular incisions within the same patient and the same continuous dorsal wound, thereby reducing inter-individual confounding variables; (2) it focuses on a high-tension, thick-dermis, shear-prone dorsal site, whereas most prior evidence comes from low-tension facial or neck skin. This case report follows the CARE guidelines. One single continuous incision was split into two segments: the proximal segment adopted a 90° perpendicular full-thickness skin cut, and the distal segment a 45° beveled incision. All surgical steps and standardized postoperative anti-scar treatment were kept identical for both segments. Serial scar evaluations were conducted at 1, 3, 6, and 12 months postoperatively using the Vancouver Scar Scale (VSS) and the Patient and Observer Scar Assessment Scale (POSAS). At the 12-month follow-up, the beveled segment formed prominent, firm hypertrophic scars with pigment irregularities, while the perpendicular segment healed into flat, soft tissue with more favorable cosmetic outcomes. Differences in hypertrophic scar severity could be detected at every follow-up visit. However, exclusive causal attribution to incision angle cannot be confirmed, as subtle local differences between wound segments cannot be fully excluded. This case report is limited to a single patient and lacks comparison groups with intermediate bevel angles; therefore, it only offers hypothesis-generating preliminary observational evidence that the cosmetic advantages of beveled incisions may vary by anatomical site and may not translate to the back under high biomechanical stress. Observations raise the hypothesis that perpendicular skin incisions may merit consideration for dorsal operations; however, definitive clinical recommendations cannot be established from a single-patient experience alone.