Continuing Education Activity
Z-plasty, previously referred to as converging triangular flaps, is a common surgical technique in reconstructive surgery used in scar revision and contracture release. The technique changes the direction of a scar so that it is better aligned with natural skin folds or relaxed skin tension lines. Z-plasty involves the transposition of two equal and opposing triangular flaps. A benefit of this procedure over other scar revision techniques is that it does not require skin excision. This activity illustrates how Z-plasty is performed and highlights the role of the interprofessional team in the management of chronic scars.
- Summarize the indications for a Z-plasty.
- Describe the technique of Z plasty.
- Review the contraindications to Z-plasty.
- Explain interprofessional team strategies to enhance care coordination and communication to advance the management of scars and improve patient outcomes.
Z-plasty is a common interposition surgical technique utilized in plastic and reconstructive surgery to revise scars. Previously referred to as “converging triangular flaps,” Z-plasty involves 2 equal and opposing transposition flaps that are raised and transposed along a shared axis. A benefit of this procedure over other scar revision techniques is it does not require skin excision. This technique changes the direction of the scar, so it is more easily hidden within a border of facial regions or relaxed skin tension lines (RSTL). Additionally, this technique may be employed to release scar contracture after burns. Common variants of the basic Z-plasty include the planimetric Z-plasty, double-opposing Z-plasty, compound Z-plasty, unequal triangle Z-plasty, and four-flap Z-plasty, z-plasty in series or parallel. Unequal triangles, also known as the “half-Z,” can be subtly altered into an S-plasty to create flap tips that are less susceptible to vascular compromise. S-plasty is useful in areas with an altered dermis, frequently encountered in burns and skin grafts.
The earliest records of this technique date back to the early 1800s in a publication at the Philadelphia Hospital Department of Surgery when Horner described single transposition flaps. The geometry of what clinicians considered the Z-plasty then was not the same as it is today. At the turn of the century, the “Z-plasty method” became more popular. A publication by Berger in 1904 noted equal limbs and equal angles. In 1914, Morestin proposed multiple Z-plasties. However, it was Limberg, in 1929, who delved into the dynamics of the flap being a rotational and advancement flap. In 1973, Borges provided a review of the developmental history of the Z-plasty.
The indication for a Z-plasty is the lengthening of a contracted linear scar through a flexor crease and changing the direction of a scar to improve cosmetic appearance.
- Treatment of scars that distort facial landmarks
- Contracted/webbed scars
- McGregor Flap (to close the secondary defect in the preauricular area in order to decrease the risk of ectropion)
- Burn wounds
- Scar camoflauge
No absolute contraindications to the Z-plasty technique exist. Relative contraindications to Z-plasty include patients with keloids and hypertrophic scarring tendencies. Additionally, surgeons should be careful to consider this technique in patients with any factor that may adversely affect wound healing: poor vascular supply, uncontrolled diabetes, prior radiation exposure to the tissue, the presence of an active infection, and an uncooperative patient.
Preoperative required items
- Minor surgical procedure tray
- Surgical marker
- Local anesthetic
- Surgical antiseptic scrub
- Scalpel/ No. 15 blade
- Suture material
- Electrocoagulation device
- Needle holder
- Wound dressing
- Antibiotic ointment
The Z-plasty procedure may be performed alone or in concert with other surgical procedures.
A discussion must take place with the patient prior to the start of the procedure. During this discussion, the risks and benefits of the procedure should be discussed at length. Postoperative care and follow-up should also be discussed. This is an opportunity for the patient to ask questions to assure understanding. Informed consent must be obtained before starting the procedure. The surgical site is prepped utilizing a sterile antibacterial solution, usually povidone-iodine. Sterile drapes are applied to the area.
On a scar that is perpendicular to the lines of least skin tension, a thickened scar may develop due to tension. In an attempt to change the direction of the scar, a basic Z-plasty technique is employed utilizing 60-degree angles. A Z-plasty consists of a central limb. The central limb contains the scar that is to be lengthened or realigned. Each limb is the same length and results in each segment of the Z contract in different directions. A 60-degree angle will result in a 75% increase in length and a 90-degree reorientation of tension. Angles of the Z-plasty result in different changes in length and tension orientation. In general, the greater the angle, the greater gain in wound length. A smaller angle has a risk of flap tip necrosis. A broader angle can result in more difficult flap rotation.
In designing the Z-plasty, one must consider the angle of the design. The greater these angles are, the more lengthening will occur; however, the flaps become harder to transpose over one another.
Angles compared to gain in length are as follows:
- 30-degree angle results in a 25% gain in length
- 45-degree angle results in a 50% gain in length
- 60-degree angle results in a 75% gain in length
- 75-degree angle results in a 100% gain in length
- 90-degree angle results in a 125% gain in length
After the area has been prepared with a sterile solution, the “2 arms” of the z-plasty are drawn at both ends of the scar. It is important to design the Z-plasty prior to the injection of the local anesthetic as this will distort the tissue. These should be drawn with angles at 60 degrees to the linear scar, resembling the letter Z. The arms should be equal in length with the same angle measure. Next, the area should be anesthetized with a 1% lidocaine in a 1:100,000 units of epinephrine. Using a No. 15 scalpel, incisions are made into the skin through the marked areas. The area is then undermined at the subcutaneous fat level. Two equally-sized flaps should be created and undermined at the level of the subcutaneous fat to create full-thickness flaps. After this, the 2 equal flaps are transposed around each other. This results in a directional change of the original scar. The flaps are then held in place with anchoring sutures. The skin is then closed using interrupted sutures. Topical antibiotics or a nonantibacterial ointment is applied.
Before performing Z-plasty, the skin should be examined for laxity, and judicious planning must be made as to where the incision will be performed. The main disadvantage of Z-plasty is an increased scar length. In addition, the procedure requires 2 additional incisions. Sometimes, the edge of the incision may become depressed or even necrotic when the angle of rotation is acute.
Z-plasty is a very common interposition surgical technique utilized in plastic and reconstructive surgery to revise scars. The technique can also be used to prevent contracture of linear scars, decrease scar length, reposition malpositioned tissues, closing cutaneous defects, and correcting stenosis. Z-plasty is a technique, which is useful when there is scar crossing relaxing skin tension lines. While a single Z-plasty may be utilized for a scar, a serial/compound Z-plasty may be used to address larger scars. Understanding the technique of a basic Z-plasty allows the surgeon to realize the potential and versatility.
Enhancing Healthcare Team Outcomes
Z-plasty is a very useful reconstructive technique for the closure of wounds without tension. The nurse skilled in the treatment of plastic and reconstructive surgery patients is involved in the postoperative monitoring of these patients to ensure adequate healing is taking place. When closed without tension, Z-plasty has both functional and aesthetic benefits.