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Z-Plasty Treatment & Management

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

Surgical Therapy

When the skin is undermined, 2 triangular flaps are created. Transposition of these triangles redistributes tension on the wound and changes central limb direction. The new scar elongates based not only on the character and elasticity of the surrounding skin but also on the angle size used in the Z-plasty. Classic 60° Z-plasty lengthens scars by 75%, while 45° and 30° designs lengthen scars by 50% and 25%, respectively. Lateral limb placement is crucial for satisfactory results. Place lateral limbs parallel to the line in which the new central limb will lie.

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Preoperative Details

Inspect the defect and establish how closure will affect surrounding facial structures. Assess the degree of skin laxity. A template of the defect can be used to visualize the best tissue-donor sites. Then, draw lines outlining the planned procedure. As long as symmetry is maintained, a Z-plasty may be designed as one of several configurations. Execute the most appropriate model based upon the relationship of the scar to relaxed skin tension lines and surrounding anatomic structures.

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Intraoperative Details

Once the desired Z-plasty has been drawn, make the incisions and undermine the flaps just below the dermal-fat junction. Sharply perform this procedure; then, control bleeding with bipolar cautery. Complete undermining of the donor area before incising the flap to ensure that donor skin has elasticity sufficient to transpose as planned.

After incising and transposing the flaps, place a few temporary sutures in key areas. When transposing flaps, remember that the apex of each flap will be sutured to the defect at the opposite side of the other flap base (see the images below).

The original scar is A-B. The limbs of the Z-plast 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 reori 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.

Additional undermining may be necessary to ensure minimal distortion of surrounding structures. Finally, after the flap is set into the final position and closed in 2 layers, excise dog ears/standing cones using Burow triangles.

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Complications

The main disadvantages of Z-plasty are increased scar length and 2 additional required incisions. Inform patients that increased scar length, although not considered a complication, is a consequence of Z-plasty.

Triangle tips may become depressed (or even necrotic) when angles are too acute. Handle tissue properly, especially at the tips, to prevent this unwanted complication.

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Future and Controversies

Multiple contiguous Z-plasties may be used at the perimeter of a trapdoor deformity to interdigitate the flap with surrounding skin. This redirection of scar tension that occurs with a Z-plasty elevates the trapdoor, thereby providing an aesthetically pleasing result.

A study by Chen and Song described the effective use of a modified five-flap Z-plasty procedure for elbow and axillary web contractures (from scars caused by burns, surgery, or trauma) that, according to the report, results in twice the extended length of the traditional five-flap Z-plasty. The technique replaces the V-flap used in V-Y advancement with a rectangular/trapezoid flap, with a small V located at the bottom of the Y limb and the major axis of the Z-plasty situated along the contracture lines.[4]

A curvilinear form of Z-plasty (referred to as S-plasty) may be used when straight lines may be particularly obvious, such as in the cheek. Design of the Z-plasty with unequal angles and limbs creates a situation in which the smaller triangle moves significantly less than the larger triangle. This may be useful in areas where small amounts of tissue need to be moved with as little distortion as possible (eg, near eyes, lips).[5]

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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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