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Z-Plasty

  • Author: Anthony P Sclafani, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Nov 13, 2015
 

Background

Z-plasty is one of many techniques for scar revision and camouflage. Z-plasty is a type of transposition flap that incorporates qualities of advancement and rotation flaps into its design. Whether used alone or in conjunction with other scar-camouflage techniques, Z-plasty is a versatile maneuver that, when mastered, provides aesthetically pleasing results.[1, 2]

In 1856, Denonvilliers first described the Z-plasty technique as a surgical treatment for lower lid ectropion. The first reference to this technique in American literature was in 1913, by McCurdy, as treatment for contracture at the oral commissure. Limberg, in 1929, provided a more detailed geometric description. Numerical data showing optimal angles and length relationships of Z-plasty limbs are credited to Davis (1946).

The image below depicts a Z-plasty.

The original scar is A-B. The limbs of the Z-plastThe original scar is A-B. The limbs of the Z-plasty form 2 triangles with 45° angles at apices C and D.
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Indications

Z-plasty is an especially useful technique when dealing with a scar that crosses relaxed skin tension lines. Simple redirection of the central limb into these lines can provide adequate camouflage. The redistribution of tension on the wound provided by Z-plasty can be very helpful when dealing with a contracted scar or with a scar near aesthetic units, such as the medial canthus or oral commissure.

Z-plasty is an effective method of wound irregularization. Since straight-line scars draw attention easily, multiple Z-plasties can break up the scar into smaller units, making the scar less noticeable.

Other uses of Z-plasty are as follows:

  • Limiting/preventing contracture of linear scars, especially when they cross the border of a facial aesthetic unit (eg, vermillion border) or when scars cross a concave surface (eg, the medial canthus)
  • Changing scar length (eg, scar contracture of lip, eyelid, or neck)
  • Changing scar vector (eg, repositioning a scar across the nasolabial fold)
  • Repositioning malposed tissues (useful for "trapdoor" or "pin-cushion" defects)
  • Effacing web/release contracture (similar to first listed use)
  • Closing cutaneous defects (eg, large oval defects, pharyngocutaneous fistulae)
  • Correcting stenosis (eg, tracheostoma, nares, external auditory canal) using single or multiple Z-plasties[3]
  • Transposing healthy tissue to close a fistula (eg, tracheostoma closure after irradiation)
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Relevant Anatomy

Z-plasty requires a proper skin thickness. A flap with too much subcutaneous tissue is difficult to position because of limited rotation. A thin flap contracts readily and is unattractive. Ideally, a plane developed between the subdermal plexus and the subcutaneous fatty tissue provides support but is not restrictive in the degree of rotation afforded.

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Contraindications

When designing a local flap, consider any factor that may compromise expected results. Attempt to identify health risks that affect vascular supply to the skin (eg, atherosclerotic heart disease, diabetes, smoking, collagen vascular disease, prior irradiation, anticoagulation). A history of poor wound healing, hypertrophic scarring, or keloid formation is a relative contraindication to Z-plasty.

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Contributor Information and Disclosures
Author

Anthony P Sclafani, MD Director of Facial Plastic Surgery and Surgeon Director, New York Eye and Ear Infirmary of Mt Sinai; Professor of Otolaryngology, Icahn School of Medicine at Mt Sinai

Anthony P Sclafani, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons

Disclosure: Received salary from Aesthetic Factors, Inc. for consulting; Received consulting fee from Meditech Medical Enterprises for independent contractor; Received royalty from Thieme Medical Publishers for author; Received royalty from Jaypee Medical Publishers for author.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Stepnick, MD Associate Professor, Departments of Otolaryngology-Head & Neck Surgery and Plastic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center

David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Acknowledgements

Gregory Branham, MD Vice-Chair, Director, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery, St Louis University School of Medicine

Gregory Branham, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, and Missouri State Medical Association

Disclosure: Nothing to disclose.

Andrew J Parker, MD Staff Physician, Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary, New York University

Disclosure: Nothing to disclose.

References
  1. Barreiros H, Goulao J. Z-Plasty: useful uses in dermatologic surgery. An Bras Dermatol. 2014 Jan-Feb. 89 (1):187-8. [Medline].

  2. Garg S, Dahiya N, Gupta S. Surgical scar revision: an overview. J Cutan Aesthet Surg. 2014 Jan. 7 (1):3-13. [Medline].

  3. Kim YH, Kim NH, Seong SY, Hyun DW, Choi HS. Double reversing Z-plasty with inferiorly widening stomaplasty for the management of tracheostomal stenosis. Auris Nasus Larynx. 2009 Dec 28. [Medline].

  4. Chen B, Song H. The Modification of Five-Flap Z-Plasty for Web Contracture. Aesthetic Plast Surg. 2015 Aug 27. [Medline].

  5. Koc MN, Orbay H, Uysal AC, et al. Z plasty closure of lower lip defects after tumor excision. J Craniofac Surg. 2007 Sep. 18(5):1120-4. [Medline].

  6. Dutton JM, Neidich MJ. Intranasal Z-plasty for internal nasal valve collapse. Arch Facial Plast Surg. 2008 May-Jun. 10(3):164-8. [Medline].

  7. Lee PK, Ju HS, Rhie JW, et al. Two flaps and Z-plasty technique for correction of longitudinal ear lobe cleft. Br J Plast Surg. 2005 Jun. 58(4):573-6. [Medline].

  8. Murakami CS, Nishioka GJ. Essential Concepts in the Design of Local Skin Flaps. Facial Plastic Surgery Clinics of North America. 1996. 4:455-464.

  9. Rohrich RJ, Zbar RI. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg. 1999 Apr. 103(5):1513-7; quiz 1518. [Medline].

  10. Zins JE, Fardo D. The "anterior-only" approach to neck rejuvenation: an alternative to face lift surgery. Plast Reconstr Surg. 2005 May. 115(6):1761-8. [Medline].

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The original scar is A-B. The limbs of the Z-plasty form 2 triangles with 45° angles at apices C and D.
After transposition of C and D, the scar has reoriented 90° and lengthened. Note the increased distance between hooks, as well as the changed position of asterisks compared with the previous image.
 
 
 
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