Background

Z-plasty is a widely used surgical technique in plastic and reconstructive procedures, particularly for scar revision. It involves the transposition of triangular skin flaps, typically aligned along a central axis, to reposition and reorient scars. This method has been successfully applied to a variety of anatomical sites, including the fingers, nose, chest, palate, face, eyes, and ears. One of its key advantages is that it often eliminates the need for skin excision, provided the overlying scar tissue is suitable in appearance and quality for reconstruction.

By redirecting the scar, Z-plasty can improve its cosmetic appearance, especially when aligned with natural skin folds or relaxed skin tension lines (RSTLs). The technique also has utility in releasing contractures, particularly those resulting from burn injuries. Several variations of the standard Z-plasty exist, such as the planimetric, double-opposing, compound, skew, and running (or serial) Z-plasties, each offering tailored solutions for different clinical scenarios.

The origins of Z-plasty can be traced to the early 19th century, with Horner’s documentation of single transposition flaps at the Philadelphia Hospital. Initially, the approach to flap geometry differed from modern practices. Greater refinement came in the early 20th century, notably with Berger’s 1904 recommendation of using equal limb lengths and angles, which helped standardize the technique. Further advancements occurred in 1914 when Morestin advocated for the use of multiple Z-plasties to manage extensive scarring. In 1929, Limberg made significant contributions by analyzing the rotational and advancement mechanics that define the modern Z-plasty technique.

Indications

The primary indication for Z-plasty is to lengthen and reorient a scar to improve its cosmetic appearance or restore function. By redistributing tension and redirecting scar lines, the technique can significantly improve both aesthetic and functional outcomes in a variety of clinical scenarios.

Facial Scar Camouflage
Used to reposition scars so they align with natural facial lines or borders, making them less visible.

Release of Contractures
Particularly effective for scars that limit motion in joints or digits, restoring range of movement.

Burn Wound Contracture Release
Helps improve mobility and appearance in areas where burn scars have tightened the skin.

Treatment of Stenosis in Circular Structures
Useful for releasing narrowing in areas such as the nasopharynx or nasal vestibule.

Restoration of Distorted Facial Landmarks
Employed to correct scarring that affects structures like the canthus (e.g., canthal webbing) or causes eyelid malposition (e.g., ectropion).

Cleft Palate Management
Assists in lengthening and achieving closure in cleft palate repairs.

Contraindications

Common contraindications to Z-plasty transposition include insufficient healthy tissue for transfer, as well as a predisposition to keloid or hypertrophic scarring. Surgeons should also exercise caution in patients with factors that may impair wound healing. These include vasculopathy, uncontrolled diabetes, prior radiation exposure, active infection, and the persistent inflammatory state often seen in burn patients. Additionally, patient noncompliance or anticipated noncompliance with perioperative care regimens poses a significant risk to successful outcomes.

Outcomes

Equipment

The equipment needed to perform a Z-plasty transposition is like that required for other cutaneous surgery:

Preoperative Items

Surgical antiseptic scrub

Surgical marker

Local anesthetic

Intraoperative Items

Scalpel (No. 15 blade)

Forceps

Needle holder

Dissecting scissors

Suture scissors

Surgical gauze

Retractors or skin hooks

Suture material

Electrocoagulation device

Postoperative Items

Wound dressing

Antibiotic ointment

Patient Preparation:

Before the procedure, it is essential to have a detailed discussion with the patient regarding the expected outcomes. This includes estimated changes to the scar’s direction and tension, any potential correction of distorted anatomical structures, and the creation of two additional incision lines. Meticulous planning of the Z-plasty design is critical particularly regarding the length, placement, and angle of the oblique limbs and careful preoperative marking of the flaps is advised. As with other minor procedures like upper eyelid blepharoplasty or direct brow lifts, the most critical part often lies in the planning and marking stages, while the surgical execution tends to be relatively straightforward.

Patient Position:

Face or Head: Supine position with the head supported and rotated as needed to expose the operative area. A headrest or donut cushion may be used for stabilization.

Neck: Supine with slight neck extension and head rotation to the contralateral side to maximize exposure of the surgical site.

Step1. Preoperative Planning and Marking

Sterile Preparation: Begin by prepping the area with an appropriate sterile solution.

Marking Before Anesthesia: Draw the Z-plasty design on the skin before injecting local anesthetic to avoid tissue distortion from fluid infiltration.

Flap Design Considerations:

The classic Z-plasty consists of two limbs of equal length extending at 60-degree angles from a central limb (the scar). This configuration typically results in a 90-degree rotation of the central segment and approximately 75% scar lengthening.

Larger angles (>60°) yield greater lengthening and rotation, while smaller angles provide less.

Asymmetrical Z-plasties (“skew” Z-plasties) may be used when anatomy restricts symmetrical limb placement.

Step 2. Variations in Flap Configuration

Compound Z-Plasty:

For angles greater than 60°, a single large angle may be split into two smaller flaps (e.g., a 90° angle into two 45° flaps at one end of the scar), reducing standing cutaneous deformities (“dog ears”) at the expense of additional scarring.

Serial (or Running) Z-Plasty:

For long scars, multiple Z-plasties may be placed along its length to achieve greater total scar lengthening and tension redistribution.

Step 3. Anesthesia and Initial Incisions

Local Anesthetic: Inject local anesthetic after marking the skin.

Excision of Central Scar: Excise the central limb (the scar) to be revised.

Hemostasis: Achieve hemostasis prior to flap elevation.

Step 4. Flap Elevation and Undermining

Incision: Use a No. 15 scalpel to incise along the drawn Z limbs.

Elevation Plane: Elevate flaps in a subdermal plane (or submucosal/submuscular if applicable, such as in oral or palatal locations).

Undermining: Widely undermine the surrounding tissue—typically 2 to 4 cm-to allow for tension-free flap transposition.

Step 5. Hemostasis and Flap Protection

Hemostasis: Reassess and control bleeding.

Flap Viability: Avoid aggressive use of electrocautery on flap undersurfaces to preserve the subdermal vascular plexus.

Step 6. Flap Transposition and Closure

Transposition: Rotate and transpose the flaps into their new positions.

Layered Closure: Close incisions in multiple layers to restore contour and maintain flap viability.

Special Applications

Soft Palate Repair (Furlow Double-Opposing Z-Plasty)

Used in cleft palate repair to both lengthen the palate and reorient muscular anatomy.

The cleft serves as the central limb; flaps are incised posteriorly (containing muscle and mucosa) and anteriorly (mucosa only).

A secondary Z-plasty is performed on the nasal mucosa with mirror-image flaps to reposition the tensor veli palatini muscle transversely for improved velopharyngeal function.

Stenosis or Scar Web Release

Design the central Z limb along the rim of the stenotic segment or free edge of a scar web.

This may feel counterintuitive but allows flap transposition to effectively lengthen and release the contracted segment.

Z-Shaped Designs Without True Transposition

Certain flap designs mimic the appearance of a Z-plasty but do not involve actual flap transposition:

Planimetric Z-Plasty

Triangular tissue wedges are excised from both sides of a defect to allow direct advancement of flaps. This resembles a Z but does not rotate tissue and is like S-plasty closure.

O-to-Z Plasty

A circular defect is closed using a Z-shaped closure via advancement and rotation of tissue flaps into the center. True transposition is absent.

Rhombic Flap (True Skewed Z-Plasty)

One flap (with a more acute angle) undergoes significant movement, while the opposing flap (with an obtuse angle) moves minimally. Though asymmetrical, the resulting Z-shaped closure classifies this as a true Z-plasty.

4. Complications

Z-plasty transposition carries similar risks to those seen with other types of skin flap procedures, including discomfort, bleeding, infection, increased scarring, and the potential need for additional surgeries. Due to the complex nature of Z-plasty’s geometric design, errors can occur in flap positioning or sizing. These miscalculations along with issues such as inadequate skin looseness or compromised tissue health may lead to less favorable aesthetic outcomes or even worsen distortion of the surrounding tissue compared to the original scar.

Since the technique involves elevating tissue flaps, it also presents unique risks. These include the development of hematomas or venous congestion, both of which can impair flap survival and contribute to wound breakdown. Factors that heighten the risk of tissue necrosis include insufficient blood supply, overly thin flaps that fail to capture the subdermal vascular network, or narrow flaps with angles less than 30 degrees at the tip. On the other hand, flaps that are too broad with angles exceeding 60 degrees may result in standing cone deformities (commonly referred to as “dog ears”), which often necessitate corrective surgery later.

References

Z-Plasty – StatPearls – NCBI Bookshelf

References

Z-Plasty – StatPearls – NCBI Bookshelf