Z-Plasty Treatment & Management

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.

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.

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.

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).

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-plasty form 2 triangles with 45° angles at apices C and D.

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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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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.

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]