Updated: Mar 26, 2021
Author: Anthony P Sclafani, MD; Chief Editor: Arlen D Meyers, MD, MBA 


Practice Essentials

Z-plasty is a common plastic surgical technique that at its core trades a shorter, simpler scar for a longer, more complex one. 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.

The decision to utilize a Z-plasty must take into account the increased length and complexity of the scar, and this must be a worthwhile tradeoff in improving an existing scar.

Z-plasty is one of many techniques for scar revision and camouflage. It produces 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-plast The original scar is A-B. The limbs of the Z-plasty form 2 triangles with 45° angles at apices C and D.


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)

A study by Scheller et al indicated that vertical Z-plasty is effective in the secondary correction of whistle deformities in patients who have undergone surgery for unilateral or bilateral cleft lip/palate. The procedure in the report involved the use of two triangular transposition vermilion flaps, with parts of the orbicularis oris muscle employed in the operation. All patients achieved a significant reduction in the defect score (DS), with the outcomes being rated as acceptable (DS >30), good (DS 10-30), and very good (DS 0-10) in 6, 5, and 23 patients, respectively.[4]

A study by Ahti et al indicated that in patients with isolated cleft palate who suffer velopharyngeal insufficiency after repair, Z-plasty can be safely and effectively used in palatal re-repair. This strategy had an 81% overall success rate, with the rates in nonsyndromic patients, nonsyndromic patients with Pierre Robin sequence, and syndromic individuals being 84%, 79%, and 58%. The investigators also found speech outcomes to be significantly worse in syndromic persons than in nonsyndromic ones.[5]

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.


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.



Approach Considerations

Z-plasty adds scars in the process of making the original scar less noticeable. It is important to discuss this with patients preoperatively, as well as the potential benefit of postoperative scar dermabrasion. If not discussed ahead of time, what is correctly anticipated in the postoperative process will be interpreted by the patient as a complication.

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.

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.

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 (see the video below).

The distance between the ends of the scar is increased as the tissue from the flaps is transposed.

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). Judicious use of a Gillies corner stitch can aid in smoothly insetting the flap.

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.


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.

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.[6]

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).[7]

A study by Ratnarathorn et al suggested that in terms of facial scars, the lay public perceives linear scars as having a better appearance than the zigzag scars of Z-plasty, at least in white patients. In the study, individuals surveyed viewed the computer-generated image of a mature scar, either linear or zigzag, overlaid on the headshots of four white persons, either on the temple, cheek, or forehead. Using the Patient and Observer Scar Assessment Scale, the investigators found that the scores for linear scars (mean score 2.9) were significantly better than those than for zigzag ones (mean score 4.5).[8]