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Z-Plasty inCutaneous Surgery
Peter W. Simoneaux, M.D.
Clinical Assistant Professor of Dermatology,Tulane Medical School
Clinical Assistant Professor of Dermatology,LSU Medical School
Private Practice, Covington, LA
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Financial Disclosures
I have no financial conflicts to disclose.
Definition
The creation of a three-limbed, roughly Z-shaped incision producing two triangular flaps of skin, which are then transposed in position.
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Significance
Useful to maximize cosmesis and minimize or revise scars
The foundation of the design and function of all transposition flaps
Helpful in the design of other cutaneousflaps.
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Purposes of the Classic Z-plasty
Reorient the direction of scars
Reorient vectors of tension in tissue and increase tissue length along the central limb
“Break up” linear scars and aid camouflage.
Advantages
Less sacrifice of normal skin than running W-plasty
Less tension, less chance of scar spreading
Helps eliminate webs and contracted scars.
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Disadvantages
Tissue movement can lead to standing-cone deformities
Multiple Z-plasties may excessively lengthen scar and distort surrounding structures.
Geometry/Design I
Lengths of the two lateral limbs = the length of the central limb of the incision
Two angles are usually equal but need not be
In “classic” design, the two angles are both 60o.
Geometry/Design II
In classic 60o form, lines which are equal in length to the central limb will end on a line perpendicular to the central limb
Other angles alter the resulting orientation of the central limb
The classic 60o form changes the orientation of the central limb by 90o.
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Applications
Reorient scars lying counter to skin tension lines
Reorient scars crossing cosmetic unit boundaries
Correct contracted or webbed scars
Prevent scars which will cross flexion creases, to avoid webbing or bowstringing
Release of scars displacing structures.
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Technique I
Examine proposed area to identify any structures which might be distorted by tissue movements
“Mark twice, cut once”: mark all lines before making incisions; double check design particularly with multiple Z-plasties.
Technique II
Careful attention to design prevents inadvertent distortion of surrounding structuresOn the face, limb length less than 1cm; on the neck, 2cm or lessEvery potential central limb has two potential designs, which are mirror images; the preferable best camouflages scars in skin tension lines.
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Technique III
To reorient a linear scar to better follow skin tension lines, central limb created by excising the scar
To reorient vectors of tension and allow tissue release, central limb oriented parallel to desired vector of anticipated lengthening
Technique IV
In classic design, 60o angles made at either end of, and on opposite sides of, the central limbEach lateral limb = in length to the central limbOnce lines drawn, incise them; then undermine and transpose the flaps.
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Technique V
Underlying scar which inhibits lengthening must be transected to allow free mobility of the flaps
Undermining need not extend much beyond the flaps.
Technique VI
Skin hooks placed in incised angles and pulled in opposite directions aid flap transposition
Flaps sutured using standard techniques.
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Caveats I
Actual tissue lengthening always less than theoretical lengthening for any given designOne large Z-plasty produces more length than multiple smaller Z-plasties, but at expense of greater closing tensionMultiple small Z-plasties produce a better scar than a single large Z-plasty, with less tension across the wound.
Caveats II
Designs with flaps greater than 60o
produce worse standing-cone deformities
Designs with flaps less than 30o produce less lengthening
Designs with flaps less than 30o have a greater risk of flap tip necrosis.
Summary
An understanding of Z-plasty design and mechanics will help cutaneous surgeons improve cosmetic and functional outcomes for their patients.
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References
Bernstein G: Z-plasty. In Superficial Anatomy and Cutaneous Surgery Syllabus, 2002, UCSD.Borges AF: Z-plasty. In Borges AF, ed: Elective Incisions and Scar Revision, Boston, 1973, Little Brown.Frodel JL, Wang TD: Z-Plasty. In Baker SR and Swanson NA, eds: Local Flaps in Facial Reconstruction, St. Louis, 1995, Mosby - Year Book.Furnas DW, Fischer GW: The Z-plasty: biomechanics and mathematics. Br J Plast Surg 24:144, 1971.Limberg AA: Design of Local Flaps. In Gibson T, ed: Modern Trends in Plastic Surgery, 2nd series, London, 1966, Butterworth.
