The Z-plasty
Transposition flap that incorporates qualities of advancement and
rotation flaps into its design.
Transposition of 2 triangular flaps
First described by Denonvilliers, in 1856, for lower lid ectropion.
McCurdy, 1913 for contracture at the oral commissure.
Limberg, in 1929, provided a more detailed geometric description.
Davis 1946 - Numerical data showing optimal angles and length
relationships
Transposition of the flaps has two major effects:
There is a gain in length along the direction of the
common limb of the Z
The direction of the common limb of the Z is changed
The resulting central limb, after flap transposition, will be
perpendicular to the original central limb
In scar revision, the final central limb should lie in the direction of the skin lines and should be selected
first. The Z-plasty can then be designed.
The major areas of use are:
Treatment of contracted scars
Management of facial scars
Prevention of scar contracture
The limbs of the Z must be equal in length to the central limb but can extend at varying angles (from
30–90 degrees) depending on the desired gain in length
Gain in length is in the direction of the central limb of the Z and depends on the angle used and the
length of the central limb.
Angle size
Once the lengths of the limbs have been set the amount of lengthening is determined by the size of the
angle
Angles of Z-plasty(degrees)
30-30
45-45
60-60
75-75
90-90
Theoretical gain in length(%)
25
50
75
100
120
Limb length
With the use of 60 as the routine Z-plasty angle the length of the limb provides the major variable
The amount of tissue available on either side determines the practicable limb length
Single and Multiple Z-plasties
This allows reduction of the amount of transverse shortening without significantly affecting the amount
of lengthening
E.g.
The single Z-plasty achieves 2 cm of lengthening and 2cm of
shortening in the transverse axis
In the multiple Z-plasty, each of 4 Z-plasties achieve 0.5cm of
lengthening and shortening – the lengthening occurs in series
and is additive, the shortening is in parallel and remains 0.5cm
at each Z-plasty
When constructing a continuous multiple Z-plasty the side
limbs can be in parallel or skew
Blood Supply of the flaps
Need to provide maximum vascular capacity and avoid tension
Design the flaps broad at the tip
Cut the flaps as thick as possible
Avoid scarring at the base
Multiple z-plasties reduce tension by distributing it over each individual Z-plasty
Applications
1) Redirect scar
2) Break up straight line - straight-line scars draw attention easily, multiple Z-plasties can break up the
scar into smaller units, making the scar less noticeable.
3) lengthen scar
clinical uses of Z-plasty
* 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 Zplasties
* Transposing healthy tissue to close a fistula (eg, tracheostoma closure after irradiation)
Use in Contractures
The Z-plasty is most effective when the contracture is narrow and the surrounding tissues are
reasonably lax, eg. Bowstring
Unfortunately, the burn scar contracts in all directions and although a contracture may be present, skin
has actually been lost in all directions. So that successful Z-plasty may not be possible
One solution would be the multiple Z-plasty, bringing in smaller quantities of tissue from the sides
along the entire length of the contracture
In a well constructed Z-plasty,
the limbs will fall in to their
transposed position
Use in Facial Scars
When used to improve the
appearance of a scar, its effect is
to break the line of the scar and
change its direction. This
change in direction involves the
common limb of the Z-plasty,
and the object is to place it
postoperatively as nearly as
possible in a line of election
The diagram shows the plan of
attack
1. The line for the
postoperative common limb is drawn out
2.
3.
4.
The length of the intended common limb is measured along the scar
From each extremity a line of equal length is marked out to meet the line drawn out to
represent the postoperative common limb
This outlines the Z-plasty
Use in Bridle Scars
When a scar crosses a hollow, contraction tends to give rise to a bridle scar bridging the hollow
Correction of the bridle element requires lengthening of the scar to allow it to sit into the hollow and
shortening of the distance from one side of the scar as it rises to the line of the scar and drops to the
hollow on its other side
Use in Curved Scars
This is worst when a trapdoor of tissue has been lifted and sutured back into place
Contraction of the margin of the scar causes elevation of the tissue within
Lengthening of the scar is needed to prevent recurrence
Use in Overriding Scars