Author: Manal Nasir, Karachi, Pakistan. Final year MBBS
What is Z-Plasty?
It is a common and widely practiced plastic and reconstructive surgery technique used for revisional scar surgery resulting in a functionally better and/or a cosmetically appealing scar. It is a type of transposition flap incorporating advancement and rotation in its flap design. (1)
The three objectives of a Z-plasty are:
- Lengthening a contracted scar
- Change the direction of a scar and aligning it with relaxed skin tension lines.
- Interrupting and breaking the scar for better camouflage.(2)
- Limiting/preventing contractures of linear scars especially those that distort the facial planes.
- McGregor flap for eyelid reconstruction
- Lengthening contracted or effacing webbed scars.
- Repositioning of scars along skin tension lines for better cosmesis
- Correction of scars and contractures following burn injuries.
- Closure of large cutaneous defects or fistulas.
- Camouflaging scars for better cosmesis.(3, 4)
Absolute contraindications are non-existent. Relative contraindications may be
- Hypertrophic scarring tendencies
- Poor wound healing (uncontrolled diabetes mellitus, poor vascular supply, prior irradiation exposure, smoking, anticoagulation)(5)
A Standard Z-plasty comprises of 2 features that remain constant.
- 3 incisions of equal length. 2 perpendicular limbs and a central limb which is the scar to be corrected.
- 2 angles of equal degrees from the central limb; a 60̊ angle is standard resulting in 75% gain in length and 90̊ reorientation of tension.
Different angles will result in different gain in length as described below and is subjective to the scar that needs correction.(6)
ANGLE BETWEEN LATERAL AND CENTRAL LIMBS (̊- degrees)
GAI N IN
- After sterilizing the surgical site and before injecting the local anesthetic, the two lateral limbs of the Z-plasty are drawn on both ends of the scar on the skin.
- Procedure is usually undertaken in local anesthesia or regional anesthesia.
- Next, two full thickness skin flaps at the level of subcutaneous fat are undermined creating two triangular flaps of equal size and shapes.
- These flaps are then transposed around each other changing the direction of the original scar.
- The flaps are held in place using anchoring sutures.
- The skin is closed using interrupted sutures.
- Topical antibiotics and pressure dressings are applied.
- Wound is reexamined in 1-2 days and sutures removed in 7-14 days. (5)
- Double Opposing Z-plasty – Used in areas with limited skin availability example medial canthal web or scar contracture.
- Unequal Z-plasty or Half-Z – Used in areas with varied skin elasticity example scar edges.
- Four Flap Z-plasty or Limber Flap – Two additional limbs allow considerable gain in length and useful in severe scar contractures limiting movement example anterior or lateral neck.
- Compound Z-plasty – Linking several Z-plasties in series, used in exceptionally large scar.
- Planimetric Z-plasty – Allows skin lengthening within the plane of skin with limb incisions twice as long as the central incision. Useful in scar interruption or skin lengthening on planar surfaces.(6)
- Increase in Scar Length
- 2 additional incisions required.(3)
- Wound infection
- Flap necrosis
- Sloughing of Flap
- Trapdoor Effect (1)
3. 1. Z-Plasty: Practice Essentials, Indications, Relevant Anatomy [Internet]. Emedicine.medscape.com. 2021 [cited 5 February 2021]. Available from: https://emedicine.medscape.com/article/879878-overview#a7.
4. Ahmed M, Loh CYY. Double Z plasty advancement flaps for closure of large defects on the forearm. Int Wound J. 2018;15(6):1052.
5. Zito PM, Jawad BA, Mazzoni T. Z Plasty. [Updated 2020 Nov 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507775/.
6. Hove CR, Williams EF, 3rd, Rodgers BJ. Z-plasty: a concise review. Facial Plast Surg. 2001;17(4):289-94.