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Z-plasty


Z-plasty

Z-plasty is a plastic surgery technique that is used to improve the functional and cosmetic appearance of scars. It can elongate a contracted scar or rotate the scar tension line.

A central limb incision and two lateral limb incisions that form a ‘Z’ make up the basic Z-plasty. The lengths of the three limbs and the angles formed between the central and lateral limbs are equal. Two triangular tissue flaps that are created by the incisional pattern, and are then transposed thereby changing both the orientation and length of a scar or wound.

 

INDICATIONS:

Improving contour, releasing scar contracture, relieving skin tension and mobilizing tissue for reconstructive surgery are the primary reasons to perform a Z-plasty. For the acute management of open wounds, this technique is rarely needed. The four main tissue effects of Z-plasty are:

 

  • Redirects the scar
  • The new scar reorients from the axis of the central limb to a line connecting the tips of the lateral limbs.
  • To improve cosmetic or functional outcome, Z-plasty is used to redirect scar into “relaxed skin tension lines” (such as Langer’s lines), natural skin folds, or along the border of an aesthetic unit (such as nasolabial fold).
  • Lengthening of scar; the initial wound or scar can be lengthened by Z-plasty. It is used to release flexion contractures, usually due to burns, occurring in the axilla, neck, popliteal fossa, or antecubital fossa.

 

The amount of lengthening is related to the angle between the central and lateral limbs. Larger angles can be difficult to close because of skin tension, but they produce the most lengthening. Narrow angles (<45º) produce minimal lengthening and have a higher risk of flap necrosis due to their precarious blood supply, but they are easier to close.

 

Central/lateral limb angle:
30º     45º     60º     75º       90º

Theoretical gain in length:
25%    50%    75%    100 %   120%

 

Because the classic Z-plasty (60º) provides the optimal balance between lengthening and ease of closure, it is the most commonly used method.

 

Tissue mobilization:

Adjacent tissue is mobilized by Z-plasty to close skin defects, which may have otherwise required a skin graft (such as correction of syndactyly, or deepen finger digital web spaces), management of pilonidal cysts, in transportation of lobules when correcting cases of microtia (small ears) and vaginal reconstruction.

 

Tissue realignment:

Z-plasty realigns tissue such as male cervicoplasty, and can be used to shift topographical structures such as nasal ala in craniofacial clefts and release epicanthal folds in the Asian eyelid.

 

VARIATIONS OF Z-PLASTY:

Z-plasty variations are available to lengthen incisions without creating excessively angulated or elongated flaps; they are used in situations where skin mechanics are altered. Z-plasties are combined in parallel or in series. Z-plasties that are in parallel such as the four flap, lead to greater longitudinal lengthening but at the expense of transverse shortening and require the availability of more adjacent tissue. While the Z-plasties that are in series such as the double-opposing one, don’t require as much adjacent tissue but they also offer less potential length gain. Some of the types of Z-plasty are:

 

Double-opposing Z-plasty: 

There are two incisions placed next to each other as mirror images in the double opposing Z-plasty. In this method, skin lengthening is achieved in areas of limited adjacent skin laxity, making this technique quite useful in scar contracture. Additionally, the larger central flap is less prone to necrosis, making this technique more useful in areas of decreased vascularity, such as in burns.

double opposing zplasty

 

Jumping man Z-plasty:

This is a modification of the double-opposing Z-plasty in which the Z-plasties are oriented adjacent each other and share a common central limb. The resulting scar is shaped like a Y because instead of triangular flaps, rectangular flaps are created.

jumping man zplasty

 

Unequal triangle Z-plasty:

In this technique, one of the Z-plasty limbs is perpendicular (90º) to the central incision, creating a fissure into which a triangular flap of normal skin is introduced. In areas where normal skin elasticity varies such as the eyelid or at a scar edge, this technique is quite useful. An S-plasty can be created with blunted flap tips that are less prone to vascular compromise in regions of compromised dermis, such as in the case of skin grafts and burns. The unequal triangle Z-plasty is also called the half-Z.

 

 

Four flap Z-plasty:

In this method, there are two additional limbs coming off of the central limb. This method is useful in releasing severe scar contractures in areas of otherwise normal flexion, such as the neck; and when compared with the classic Z-plasty, this method creates more length for a given angle.

four flap zplasty

 

Five flap Z-plasty:

This technique leads to less lengthening than the four flap technique, but it could be a good option when there’s less tissue mobility. This method is a double-opposing Z-plasty with the addition of a V-Y plasty between them.

 

Six flap Z-plasty:

This is a four flap Z-plasty with additional limbs. Creating a symmetric zigzag, it is used for release of short contracted bands. However, dog-ears occur commonly and transposing the flaps can be difficult because it recruits minimally from adjacent tissue.

 

Multiple Z-plasty:

To manage large wounds or scars that aren’t amenable to a single Z-plasty, multiple Z-plasties are used. When compared with a single large Z-plasty, multiple Z-plasties have a theoretical advantage that they provide the same amount of lengthening in the longitudinal axis with less transverse shortening. However, due to impingement of each Z-plasty upon its neighbor, the actual lengthening may be less than expected.

multiple zplasty

 

Planimetric Z-plasty:

A 75º angle is used in the planimetric Z-plasty and limb incisions that are twice as long as the central incision. After that, the central incision is elongated in both directions to twice the length of the limb incisions. Prior to flap transposition, the two triangular areas that are created are excised. Planimetric Z-plasties could also be linked as in the compound Z-plasty mentioned above. To address issues of stereometric elongation that predisposed to dog ears when performing Z-plasty on flat surfaces, this method was developed.

 

PROCEDURE:

 

Preparation:

An appropriately equipped office and an ambulatory surgery setting are the two places where Z-plasty can be performed.

 

Equipment:

Electrocautery unit
Suction device
Caliper or protractor for angle measurement.

 

Medications:

Local anesthetic: 1% lidocaine with or without epinephrine.

 

Materials:

Sterile gown, gloves, materials for skin preparation and a fenestrated drape.
Sterile skin marking pen
5 mL syringe with 16 to 20 gauge needle to draw up anesthetic and a 27 to 30 gauge needle for injection.
Instruments: number 15 scalpel, suture scissors, Adson forceps, smooth needle holder and fine skin hooks.
Suture: 4-0, 5-0, or 6-0 absorbable suture and/or 4-0, 5-0, or 6-0 nonabsorbable suture.
Wound dressing: semiocclusive dressing, nonadherent dressing.

 

Preoperative marking:

Taking the time to plan the incisions preoperatively is quite important. The optimal alignment of skin edges under minimal tension and successful wound closure is ensured by careful surgical planning. First, you should identify the desired orientation of the new scar or the orientation of the relaxed skin tension lines. You should keep in mind that the new central limb will be represented by a line connecting the distal tips of the two lateral limbs. The line should lie either along the division between two aesthetic subunits, or along the relaxed lines of skin tension, but preferably both.

 

When compared with the original scar length, the final scar length of the classic (60º angle) Z-plasty will be approximately 1.75 times bigger. The flaps could be rearranged mentally, or if needed, prior to making the incisions, the pattern could be cut on a piece of paper or drape as a model. There are also Z-plasty simulators. You shouldn’t forget that the planned geometry doesn’t always translate to identical clinical results, probably because of the unpredictable mechanics of the skin.

 

Anesthesia:

Usually, Z-plasty is performed with local anesthetic, with or without sedation. For most cutaneous surgeries, with the exception of surgery to an area perfused by terminal arteries such as the fingers, nose, toes and penis, the addition of epinephrine is preferred. General anesthesia and/or inpatient postoperative management could be required in the case of more extensive wound management or revision.

 

General technique:

No matter what Z-plasty configuration is chosen, the Z-plasty technique is similar. You can make or complete the central limb incision with a number 15 blade. You can excise the linear scar or lesion in a narrow ellipse along its longitudinal axis in the case of a scar revision or lesion excision. After that, to create the lateral limbs of the Z (or variation thereof), you should make the incisions on the previously marked skin. In order to maximize flap tip thickness and thereby their vascularity, you should bevel the incisions away from the narrow angles of the Z. Additionally, to decrease the chance of tip loss, the tips could also be rounded slightly. Elevate the skin flaps. To avoid damage to the nutrient vessels, the flap plane is created below the subdermal vascular plexus and just into the subcutaneous fat with care. To maintain a robust blood supply, include some subcutaneous fat as dissection approaches the base of the flap. To create additional flap mobility, you can undermine the skin where the flap is attached. Any bleeding should be controlled meticulously.

 

Rotate the triangular flaps and cross them over each other by using fine skin hooks to handle the skin; you should avoid handling tissue with forceps that can crush the tissue. To hold the flaps in place, you should place a suture at the tip of each flap. You should complete the remainder of the wound closure with interrupted subdermal 3-0 or 4-0 absorbable suture (eg, Vicryl) and then close the skin with interrupted 3-0 or 4-0 nonabsorbable suture such as nylon. You should use interrupted 5-0 absorbable such as plain gut in children so that the sutures don’t have to be removed. A running subcuticular suture could also be used if the limbs are long.

 

After this, you should place steri-strips as needed, a non-adherent dressing, and a protective occlusive dressing. Additionally, to keep the underlying dressing clean and dry, a thick overlying dressing of 4x4 inch gauze or other bandage is placed for 24 hours.

 

To improve contour, release scar contracture, relieve skin tension and close tissue defects, Z-plasty is used extensively in plastic surgery. The results of Z-plasty may be compromised, and relative contraindications may be present if the patient has medical conditions that affect skin vascularity, wound healing or skin mechanics, such as severe peripheral vascular disease, smoking, collagen vascular disease, prior skin irradiation and poorly controlled diabetes mellitus.

 

A central limb and two lateral limbs that form a “Z” are involved in Z-plasty, as well as the creation of two triangular skin flaps. The central limb is reoriented to a line that connects the tips of the lateral limbs by the transposition of these triangular flaps, but the orientation of the Z-plasty limbs isn’t changed. The measure of the angles between the central limb and lateral limbs is 60 degrees in the classic Z-plasty. Theoretically, the classic Z-plasty lengthens a scar by 75%. In special circumstances, other configurations are used. Z-plasty is performed as an outpatient surgery with local anesthesia. Significant complications aren’t common and the postoperative pain is minimal.

-------------------------------------

Prepared By: Dr. Mehyar Al-Khashroum
Edited By: Miss Araz Kahvedjian


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