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Medical knowledge page data
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Part of Z-Plasty
Type Medical knowledge page
Keywords AmoSmile, Operation Smile, AmoDisc, Plastic Surgery, Reconstructive, Surgery, Flap, Burn, Trauma, Cancer, Congenital, Infection, Z-Plasty, Z Plasty, Indication, Steps, Procedure Contraindication, Anatomy, Complication
SDG Sustainable Development Goals SDG03 Good health and well-being
Authors AmoSmile
Published 2021
License CC-BY-SA-4.0
Affiliations Global Surgical Training Challenge
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The first official description of a procedure that could be described as a Z-plasty was in 1837 by Professor William E. Horner, a surgeon at the Philadelphia Hospital, Blockley and anatomy professor at University of Pennsylvania.1 In his 1837 case report, he described the surgical treatment of a burn patient who developed a lower eyelid ectropion due to a scar contracture solving this problem by releasing the scar and mobilizing the two opposing triangular shaped flaps that were transposed into an interdigitating position in this way lengthening the vertical skin of the lower eyelid. The appearance of the central incision along the scar and then the lateral incisions for the opposing triangles created a shape similar to that of the English letter "Z." Since that time, there have been many other surgeons who have popularized the Z-plasty as a means of recruiting tissue adjacent to scars and wounds in order to reconstruct the corresponding scar-related contractures, joint-space webbing, congenital conditions, and anatomic landmark repositioning, as well as positioning scars parallel to the skin tension lines. As a result, the Z-plasty is perhaps one of the most foundational and powerful tools in the reconstructive surgeon's repertoire for addressing conditions related to burns, trauma, cancer, congenital conditions, and infections. This page will address the functions, indications, limitations, complications, and step-by-step details for Z-plasty.

See the Thinking Like a Reconstructive Surgeon page for more details on other reconstructive options and an overview of the thought process that reconstructive surgeons utilize to determine the most appropriate reconstruction for a given patient.

Relevant Flap Anatomy[edit | edit source]

The z-plasty is classified as a random pattern flap (see Flap Classification Page, section "Flap Classification"), meaning that the two triangular flaps which make up the "Z" that are transposed in the process of the surgery are solely perfused by the subdermal plexus (see Flap Classification Page, section "Skin Anatomy"). The subdermal plexus is part of a complex vascular network that supplies the skin and subcutaneous tissues and is fed by perforators from underlying larger-caliber arteries. Each axial artery supplies blood to a defined area of skin known as "angiosomes," and the perforators that branch off the axial arteries supply smaller subunits known as the "perforasomes," which feed into the subdermal plexus. Because the Z-plasty is a random pattern flap and is perfused by the subdermal plexus, it is critical that the flap is planned and marked before the procedure to ensure vascularity through the underlying subdermal plexus.

Geometric Concepts[edit | edit source]

The Z-Plasty Shape (Limbs & Orientation)[edit | edit source]

  1. Central (1) & Lateral Limbs (2): The Z-Plasty is aptly named due to its resemblance to the english letter "Z" and consists of a single central limb plus two lateral limbs (see "Initial Z-Plasty Markings" in figure below). The orientation of these three limbs will change during the course of the surgery such that the central limb will be rotated 90 degrees from its original axis. See "Final Z-Plasty Orientation" in figure below.
  2. RSTL & LME: When possible, the Z-plasty should be designed so that the final orientation of the central axis is parallel to the Relaxed Skin Tension Lines (RSTLs) and perpendicular to the Lines of Maximum Extensibility (LMEs) so that the maximum tension from the RSTL is in-line with the central axis. This minimizes hypertrophic scarring and gapping of the central closure. See figure below for RSTL-LME axes in top left corner to compare to initial and final Z-plasty orientations.
  3. 2 Triangular Flaps: Once the 3 limbs are all incised, there will be two triangular-shaped flaps (see "Incised & Elevated Flaps 1 and Flap 2" in figure below) which will be elevated and transposed to their new positions (see "Flaps 1 and Flap 2 in New Positions" in figure below).

RSTL vs LME.png

RSTL Figure.png

Z-Plasty Overview.jpg

Angles of the Lateral Limbs[edit | edit source]

The angle between the central limb and each lateral limb is equal but opposite in orientation. The angle can be adjusted as needed with larger angles recruiting more tissue from adjacent areas than smaller angles. As a result, larger angles will transpose more tissue along the new central axis and create more lengthening in this direction. The figure below on the left shows how increasing the angle increases the length gained along the new central axis. The table to the right of it provides a summary of the z-plasty angle and the theoretical length gain as a percentage. Of note, real-life or clinical length gain is always less than the theoretical gain due to other factors that impact tissue pliability and mobility such as underlying scar tissue, skin quality, adjacent structures, and three-dimensional nature of the reconstruction site.

Z-Plasty Angle and Length Gain.png

Z-Plasty Angle Table 2.png

Single versus Multiple Z-Plasties[edit | edit source]

In addition to the orientation and angle of the z-plasty, it is possible to use multiple smaller z-plasties in place of one larger one. The figure below shows an example of one larger z-plasty next to 3 small z-plasties in-line with one another. The top two are before transposition of the triangular flaps and the bottom two images are after transposition. Not only does this show the change in the orientation of the limbs, but the overall change in length and width of the flap areas are compared. In both instances, the same amount of length gain is achieved with one large or multiple stacked z-plasties (i.e. 75% additional length with 60 degree angles in this example). The key difference is that compared to the length gained along the central axis, the single large z-plasty narrows or loses overall width in a 1:1 ratio whereas the 3 smaller stacked z-plasties only narrow the overall width by one-third relative to the length gained. Because of this geometric difference, multiple, small z-plasties are frequently used to release scars in areas with less tissue laxity or adjacent skin to recruit. The multiple stacked z-plasties also "deforms" the surrounding area less than the single larger z-plasty because of that decreased narrowing, and this can be advantageous in areas close to other important anatomic structures or landmarks like in the face, hands, or genitalia.

Single vs Multiple Z-Plasty Comparison.jpg

Function[edit | edit source]

  1. Increase the length of the skin in the direction of the scar.
  2. Modify the orientation of a straight-line scar to match with the skin tension lines (to make it less visible).
  3. Shift anatomical landmarks and features.
  4. Create or deepen a web space.

Indications[edit | edit source]

  1. Correction of linear scar contractures (i.e. hypertrophic scars that cross joints, skin tension lines, or cross subunits of the face, breast, and genitalia)
  2. Correction of webbing, bridle scars and constriction bands especially in the neck, popliteal fossa, axilla and digits
  3. Release of circular contractures around body orifices (e.g. nostril, ear, mouth)
  4. As a planned procedure to avoid scar contractures by interrupting linear closures to change the direction of scars (e.g. Dupuytren's contracture, facial flaps longitudinal incisions across bending folds)
  5. As an adjunct to achieve closure of surgical wounds

Limitations[edit | edit source]

  1. Requires significant knowledge about skin tension lines and how to assess skin laxity.
  2. Requires sufficient skin laxity and adjacent tissue availability to achieve flap interposition.
  3. Relies on thin flaps that are at risk for ischemia and other wound healing complications if not designed or elevated properly.

Complications & Management[edit | edit source]

  1. Flap Necrosis & Dehiscence
    1. Necrosis of flaps may occur due to a variety of reasons that include:
      1. Flaps made too thin causing damage to subdermal plexus.
      2. Flaps not handled delicately enough during dissection causing traction and shearing injury to small dermal vessels.
      3. Flaps elevated more than required from underlying tissue creating flaps that were longer than the 3:1 ratio of random pattern flaps.
      4. Too much scar tissue in the majority of the triangular flaps resulting in unreliable blood supply.
      5. Flap vascularity burned if electrocautery used too close to flap during elevation.
      6. Flaps inset and closed with too much tension.
      7. Sutures placed too tight or excessive mattress suturing utilized.
    2. Management
      1. If the area of necrosis involves just the tips and the incision has not dehisced, this small area of necrosis can be managed with wound care using topical antimicrobials. This allows the wound to heal underneath and re-epithelialize while the antimicrobials help prevent infection and the small necrotic eschar serves as a barrier.
      2. If the majority of the flaps are necrotic or significant dehiscence has occurred, it is ideal to debride the necrotic tissue and either 1) attempt reclosure if there is sufficient tissue laxity, 2) leave the wound to heal secondarily by contraction if the debrided area is small, or 3) perform a new method of coverage such as another flap or skin graft.

Required Surgical Instruments & Supplies[edit | edit source]

Instruments Description Purpose
Scalpel #15 or #15c are ideal for smaller, more precise cuts

[Alternative: any size scalpel]

Incision and flap elevation
Skin Hook single or double hooks

[Alternative: Adson with teeth]

Tissue mobilization (i.e. applying tension/counter-tension on flaps & assisting flap elevation)
Adson with teeth Surgical forceps with interdigitating teeth Used during suturing to assist with tissue control and needle passing. May also be used in place of skin hooks to mobilize flaps during dissection.
Needle Driver Any needle driver commonly used for cutaneous suturing. Holds the suture needle during the suturing process. Do not use it to move tissue as it will crush and injure it.
Dissection Scissors Curved or straight blunt-tipped dissection scissors like Metzenbaum, Littler, Cardinale, Goldman-Fox, Potts Smith, or other similar dissection scissors.

[Alternative: small blunt-tipped suture scissors or hemostat]

May be used for blunt dissection and/or cutting sutures.
Suture Either absorbable or non-absorbable sutures may be used. Ideally, 4-0, 5-0, or 6-0 sutures are used for most smaller z-plasties but 3-0s may be used for larger z-plasties or when smaller sutures aren't available. Flap inset and closure. Do NOT use staples, surgical glue, or other adhesives.

Step-by-Step Walk-through[edit | edit source]

Step 1: Identify anatomic landmarks & relaxed skin tension lines (RSTLs) to orient Z-plasty.[edit | edit source]

  1. Details: Identify the relaxed skin tension lines (RSTLs), the lines of maximum extensibility (LME), and the slack of the skin using the pinch test (i.e. pinching the skin in various directions between two fingers). A thorough knowledge of Relaxed Skin Tension Lines (RSTLs) in the area of the body being reconstructed will help confirm the ideal orientation for the flap markings.
    1. Pearls: Knowing where you have skin to borrow from is critical to the successful design of the Z-plasty. You also must take into account adjacent landmarks such as joints and facial features (i.e. aesthetic subunit boundaries or complex structures like lips, eyelids, and nose) that you may want to avoid disrupting with the flap designs. Orienting the flaps so they do not cross onto important landmarks is ideal when possible. However, there are times when the scar being released does involve these landmarks and therefore cannot be avoided. It is important to place the central limb perpendicular to the RSTLs for the flaps to end with a central scar aligned parallel to these lines.
    2. Pitfalls: Failing to assess skin laxity with the "pinch test" in order to orient the flaps as perpendicular as possible to the RSTLs will result in decreased flap mobility and potentially worse scarring due to the tension on the closure.
  2. Preferred instrument(s) & Usage: Use thumb and index finger to gently pinch skin to assess skin laxity. Try different orientations of the two fingers relative to the reconstructive site to see which direction provides the most amount of tissue between the fingers on pinch.
    1. Avoid: Pinching with forceps (e.g. Adsons with or without teeth) or clamps (e.g. hemostats, penetrating or blunt towel clamps)
    2. Reasoning for Instrument Selection & Usage: Skin should easily move along the LMEs which are perpendicular to RSTLs when doing the finger pinch test. Using instruments like Adsons or other forceps rather than fingers may damage fragile skin, especially if the surrounding skin is inflamed, damaged, or burned – especially in children.

Step 2: Determine the desired length & direction of the Z-plasty: Central Limb[edit | edit source]

  1. Details: The length of the central limb is most often the same length as the scar that is being released but may be lengthened beyond the scar being released depending on the reconstructive goals.
    1. Pearls: The length of the central limb should at a minimum be the length of the entire scar band that requires release but may go beyond the borders of the scar depending on the location, available nearby tissue for transfer, and desired lengthening.
    2. Pitfalls: If the central limb is too short relative to the overall scar, it may result in flaps not mobilizing easily and  fail to recruit sufficient volumes of adjacent tissue to redistribute the scar.. In addition, z-plasty flaps that are designed in a way that scar surrounds all boundaries will increase the risk of compromised circulation to the flaps due to scar-related damage to the subdermal plexus that supplies the two flaps.
  2. Preferred Instrument(s) & Usage: Best practice is to use a ruler and marking pen to ensure that the central limb is straight and the length is known when designing the lateral limbs.
    1. Avoid: Guessing limb length
    2. Reasoning for Instrument Selection & Usage: Measuring the central limb is important to ensure the lateral limbs will be appropriately sized to facilitate adequate flap transposition and coverage. Lateral limbs that don't match the central limb can create flaps too small to completely transpose and will therefore not allow for closure or even create ischemic flaps. Guessing rather than measuring the limbs increases risk for asymmetry and failed transposition.

Step 3: Determine the desired length & direction of the Z-plasty: Lateral Limbs[edit | edit source]

  1. Details: The two lateral limbs are then drawn as equal lengths to each other and the central limb, one at each end of the central limb with angles of 30 to 60 degrees depending on the desired scar lengthening. The two lateral limbs should be 180 degrees to one another but the same relative angle from the central limb.
    1. Pearls: Larger angles result in greater lengthening along the central axis (see table below for angles and length gain), but larger angles also require the recruitment of more adjacent tissue to achieve these angles and can create dog ears with angles larger than 75 degrees or even decrease the amount of mobility the larger flaps can achieve. The clinical lengthening that is achieved is always less than the theoretical gain which is why flaps are most often designed with 60 degree angles. This balances length gain with the limitations from trying to transpose flaps that have large angles. Angle selection must also take into account the proximity of the flaps to critical structures like facial features, fingers, and joints. Because larger angles recruit more tissue from the surrounding area, one may select angles less than 60 degrees to limit the impact on surrounding landmarks or features.
    2. Pitfalls: Angles less than 30 degrees are usually avoided because the tips of the flaps will be too narrow, which compromises blood flow from the subdermal plexus and results in flap ischemia and necrosis. In addition, if the lateral limbs of the "Z" are too long relative to the amount of available tissue that can be recruited, excess tension on the wound will be created and can increase risk for ischemia to the flaps as well as wound dehiscence.
  2. Preferred Instrument(s): Best practice is to use a ruler and marking pen to ensure that the lateral limbs are straight and their lengths are equal to each other as well as the central limb.
    1. Avoid: Guessing limb length
    2. Reasoning for Instrument Selection & Usage: It is important to ensure that the lateral limbs are the same length as the central limb in order to allow complete flap transposition and closure. Guessing rather than measuring the limbs increases risk for asymmetry and failed transposition.

Step 4: Confirm skin laxity & finalize flap markings.[edit | edit source]

  1. Details: Once the length of the 3 limbs and their angles have been determined, complete the final flap markings and again test the skin laxity to ensure that there is enough tissue available for recruitment from both lateral limbs.
    1. Pearls: Once the flap has been fully marked, always retest for skin laxity to ensure that maximal tissue will be recruited from areas of laxity or "excess." This means that the central limb should be oriented as perpendicular as possible to the LME or vector of maximum skin laxity. The central limb should be designed as close to  be perpendicular to  the RSTLs as possible, this way, after transposing the flaps, the resulting scar will be positioned parallel to the RSTLs. The direction of the scar and surrounding anatomic structures will limit the orientation of the Z-plasty to a degree, but the orientation can still be optimized relative to RSTLs and LMEs.
    2. Pitfalls: Failing to retest the skin laxity once the entire flap is marked out may result in a flap that is too large relative to available skin OR one that does not maximize the available laxity.
  2. Preferred Instrument(s) & Usage: Use thumb and index finger to gently pinch skin to assess skin laxity similar to step #1.
    1. Avoid: Pinching with forceps (e.g. Adsons with or without teeth) or clamps (e.g. hemostats, penetrating or blunt towel clamps)
    2. Reasoning for Instrument Selection & Usage: Using your fingers to test skin laxity once the flap markings are complete helps ensure that enough skin is available under gentle traction to achieve closure once the flaps are transposed. Using instruments to test tension can damage skin and give false assurances about skin laxity due to the ease with which increased force is generated by these instruments.

Step 5: Perform incision along flap markings.[edit | edit source]

  1. Details: Sharply incise the skin through epidermis and dermis just to subcutaneous tissue in-line with the markings.
    1. Pearls: Ensure tension and counter-tension during incision to maintain precise, controlled cuts. Incise the central limb first down through the scar tissue, or removing scar tissue, until normal underlying subcutaneous tissue is reached making sure to stay superficial to the underlying fascia and be mindful of neurovascular structures. Always remember that in scarred areas, the underlying anatomy can be altered such that critical structures can be displaced into non-anatomic locations and/or orientations that could place them at risk of damage during flap incision and dissection. Starting with the central limb helps release the most tension on the scar band and provide the surgeon with an improved understanding of the mobility that may be gained once the lateral limbs are incised. The lateral limbs can then be further adjusted based on the amount of release that is achieved after incising through the central limb. Also, it is helpful to very minimally round the tips of the two triangular flaps to improve tissue survival at the most distal aspects of the flaps.
    2. Pitfalls: Going too deep with the incision may damage underlying structures that have been abnormally displaced due to the scar contracture, initial trauma, or congenital conditions. This means that nerves, blood vessels, muscles, and tendons may be more superficial than usual or located in non-anatomic positions. Pressing too hard during incision, which can happen while trying to cut through scar, can inadvertently cause dissection to go deep to the fascia and/or musculature which will complicate flap elevation and impair flap mobility.
  2. Preferred Instrument(s) & Usage: Incise with a scalpel while taking care to avoid double cuts or feathering of the cut through the fragile tissue. Gently pressing down with the belly of the scalpel rather than slicing can facilitate a controlled incision down through the scar band or tissue and give sufficient tactile feedback so that the surgeon can feel once the blade has made it through the entirety of the scar tissue into underlying "normal" tissue. Feeling that release or give in the tissue once the blade passes through scar ensures that the incision isn't carried unnecessarily beyond that depth.
    1. Avoid: Electrocautery (monopolar)
    2. Reasoning for Instrument Selection & Usage: Precise cuts with a scalpel rather than electrocautery minimizes collateral damage to surrounding tissues, especially when the skin and underlying structures are already vascularly compromised due to scarring and other aspects of the initial injury. Electrocautery is not as precise and can damage the already compromised subdermal plexus of the distal flaps during incision. Furthermore, electrocautery will cauterize the flap edges and impair evaluation of perfusion of the flaps based on  bleeding from the edges.

Step 6: Elevate both triangular flaps.[edit | edit source]

  1. Details: Once all incisions are completed, the two skin flaps, which are triangular, must be elevated from the underlying fascia, aiming for a minimum of 4 mm of subcutaneous tissue attached to the skin flap when possible. Additionally, the flaps must be carefully dissected off any neurovascular structures that may be involved. In order to accomplish this, use a combination of blunt (i.e. spreading technique with scissors or hemostat) and sharp (i.e. gently pressing with belly of scalpel through scar and controlled "painting" along the undersurface of the flap [link to YouTube video with example of both techniques at 2:24-2:44]) dissection to preserve perforating vessels and identify any neurovascular, muscular, or tendinous structures contained within the scar tissue. In order to achieve adequate mobilization of the flaps, dissection outside the borders of the z-plasty might be needed, external to the lateral limbs or proximal to the base of each flap. This can be done with blunt scissors taking care not to use the cutting edge but rather by bluntly dissecting with the outer border of the scissor. Using the hand not holding the scissors, the index finger and thumb can be used as aid to sense the depth of the dissection to ensure that there is not any pin-holing or inadvertent skiving.
    1. Pearls: It is critical to avoid making the flaps too thin during elevation because the flaps survive through subdermal plexus perfusion given their random pattern design. As a result, it is good to leave a layer of subcutaneous fat with the flaps as they are elevated off of the underlying fascia. For this, it is particularly important to place the scissors or hemostat's tip parallel to the surface of the skin or slightly angled towards the underlying fascia in order to avoid a superficially pointing or skiving direction. Be careful to undermine or elevate the flap only as much as needed to facilitate adequate transposition of the flaps. Maintaining as much of the vascular connections at the base of these flaps as possible will greatly improve flap perfusion and increase success rates.
    2. Pitfalls: Completely separating the underlying subcutaneous tissue from the flap at the dermal-subcutaneous junction will absolutely lead to ischemia of the flap due to damage to the subdermal plexus. Using monopolar electrocautery to elevate the flaps can easily cause collateral damage as these flaps are very thin and the vascular supply is easily injured from the thermal spray of the electrocautery.
  2. Preferred Instrument(s) & Usage: Perform blunt dissection with scissors or a hemostat and sharp dissection by pressing or "painting" with the belly of the scalpel. Use skin hooks to gently apply tension to the flaps during elevation (in direction of the ceiling, avoiding bending the flap over itself) to avoid pin-cushioning or making the flap too thin.
    1. Avoid: Forceps or other clamps as a tool to apply tension. Slicing with the scalpel rather than pressing or painting.
    2. Reasoning for Instrument Selection & Usage: Blunt dissection with gentle spreading and sharp dissection with pressing and painting motions will minimize the risk of inadvertently transecting important perforators going to the flaps, damaging displaced neurovascular structures, and excessively elevating the subcutaneous tissue from the underlying fascia. This also minimizes risk of developing false planes. Skin hooks are ideal for creating counter tension during dissection as they minimize crush injury to the thin and already fragile flaps that can occur when forceps - especially non-toothed variants - are used. Forceps should be avoided when skin hooks are available, but toothed forceps can be gently applied to subcutaneous tissue only if hooks aren't available. In particular, use the teeth on the forceps like hooks to gently pull the tissue rather than closing or clamping the forceps.

Step 7: Transpose the triangular flaps.[edit | edit source]

  1. Details: Once the flaps have been carefully dissected and elevated from the underlying fascia and critical structures, the two triangular flaps are transposed by interchanging their tips to opposite corners.
    1. Pearls: During this step, it is important to gently handle the flaps as they are being repositioned. It is equally important to get a feel for the tension on the flaps as they are transposed. If it feels like there is significant tension on either flap or they are not transposing as much as desired (i.e. reaching opposite corners), then it is appropriate to carefully extend the flap elevation closer towards each base only until enough mobility is achieved. Unnecessary or excessive flap elevation and undermining can compromise the subdermal plexus integrity and result in flap ischemia. The repositioning of the flaps shouldn't feel tense.
    2. Pitfalls: Pulling too hard on the flaps during mobilization can cause traction injury on the vasculature, vasospasm, flap tears, and also a high tension closure – all of which compromise perfusion.
  2. Preferred Instrument(s) & Usage: Skin Hooks (or toothed forceps that are kept open) to gently transpose the flaps
    1. Avoid: Non-toothed forceps and/or closing toothed forceps
    2. Reasoning for Instrument Selection & Usage: Skin hooks allow controlled mobilization of the flaps with appropriate tension while avoiding crush damage that occurs with moving flaps with forceps. If skin hooks aren't available, toothed forceps are ok and can be used by utilizing the teeth as hooks to gently pull the tissue without closing the teeth completely.

Step 8: Confirm viability of the two triangular flaps.[edit | edit source]

  1. Details: After transposing the flaps into their new positions, confirm that there is bright red bleeding from the edges and tips of both flaps to ensure adequate perfusion.
    1. Pearls: It is important to ensure adequate bright red bleeding from the subdermal plexus (exposed edges) of the flaps once they have been completely elevated and transposed in order to ensure that the flaps are not ischemic. Being patient at this step is critical as it allows sufficient time for the flaps to equilibrate from the maneuvers of the elevation and transposition processes so that an accurate assessment of flap perfusion can be performed. All edges and the tips of both triangles should show robust bleeding, especially the tips which represent the most distal aspects of each flap and the areas with the greatest risk for ischemia. If the bleeding is not as robust as anticipated from the flap tips or other edges, return the flaps to their original positions, cover them with warm water lap sponges, and wait 10-15 minutes for the flaps to warm up and vasodilate. Then re-transpose the flaps, making sure not to apply too much tension, and re-assess bleeding. Another maneuver to assess perfusion if the edges are unclear is to take a small gauge hollow-bore needle (e.g. 30 gauge) or suture needle (e.g. 5-0 or 6-0) and gently poke the distal skin of the flap to ensure bleeding from the puncture site. This only needs to be deep enough to go into the dermis and should be done in as few places as possible to avoid excessive damage to the flaps.
    2. Pitfalls: Proceeding with closure of the transposed flaps prior to ensuring active bleeding from the flap edges, especially if additional elevation of the flap and extension of incisions was required to reduce tension on the flaps, runs the risk of missing compromised perfusion that can lead to flap ischemia, dehiscence, and reconstructive failure. Desiccation and hypothermia can occur if the flaps remain elevated and not transposed or in contact with the underlying wound bed for too long which will cause vasoconstriction and compromise perfusion.
  2. Preferred Instrument(s) & Usage: Skin Hooks (or toothed forceps that are kept open) to hold the flaps in their new positions while assessing perfusion
    1. Avoid: Non-toothed forceps and/or closing toothed forceps
    2. Reasoning for Instrument Selection: Using skin hooks or open (i.e. not closed) toothed forceps to gently hold the flaps in their transposed state, not the original orientations in which the flaps were incised, is the best way to assess whether or not the perfusion is adequate in this new position. Using forceps without teeth to position the flaps can crush the distal aspects of the flaps which may compromise vascularity and tissue viability. Damage can also be done if forceps with teeth are closed with too much force.

Step 9: Suture the flaps in place (a.k.a flap inset).[edit | edit source]

  1. Details: Once the viability of both flaps is confirmed, proceed with flap inset and closure using sutures. Depending on the availability of absorbable versus non-absorbable sutures, the type of suturing technique used to inset the flaps will vary slightly. Both methods will be discussed.
    1. Non-absorbable Method: Three-point sutures are used to inset the tips of each flap: 1) Drive the needle perpendicular to the skin surface passing superficial-to-deep on the corner opposite the flap tip, 2) take a horizontal bite of the dermis only on the tip side (do not go through epidermis), and 3) return to the original opposing corner passing deep-to-superficial the same distance as the initial entry site from the edge. Once the tips are appropriately oriented and inset, the remainder of the limbs are sutured using simple interrupted sutures sparingly so that only the minimum number are used to ensure edge approximation without gapping along the inset.
    2. Absorbable Method: When using absorbable sutures, it is ok to use a few deep dermal (i.e. buried) interrupted sutures rather than the 3-point method to help hold the key points (i.e. flap tips) in alignment. Additional deep dermals can be placed along the edges to ensure adequate approximation of the edges. Simple interrupted sutures can be used sparingly to address any remaining areas where the edges aren't well-approximated or additional eversion is desired.
    3. Pearls: Take extra caution when suturing these flaps because they are often very thin and susceptible to damage from excessive suture tension as well as strangulation and ischemia if mattress or running baseball sutures are used. Some surgeons will use horizontal mattress sutures for the edge eversion, but great care must be taken not to take overly large bites with the suture and not to tie the knots too tightly due to high risk of ischemia with this form of stitch.
    4. Pitfalls: Excessive sutures (i.e. too many or too closely spaced), especially if using a mattress technique or running "baseball" style, can result in flap ischemia along the edges. Due to this risk and the challenge of tensioning the suture knots appropriately with the mattress method, avoiding these closure methods is safest unless there is prior experience with these techniques in other similar situations.
  2. Preferred Instrument(s) & Usage: Needle Driver, Forceps with Teeth, Suture
    1. Avoid: Staples, Surgical Glue, Adhesive-strips, Forceps without teeth
    2. Reasoning for Instrument Selection: It is important to handle the flaps delicately during closure. Using the sutures to approximate the tips of the transposed flaps under progressive tension rather than relying on sutures to hold high tension at the distal flap tips maximizes flap viability. Using Forceps with teeth to manipulate the tissue during closure rather than forceps without teeth will minimize crush damage to the tissues while enabling facile control of the flaps. Staples should be avoided in these fragile flaps with compromised tissue. Surgical glue and adhesive-strips can provoke inflammatory or allergic reactions as well as adhesive-related damage to the skin, especially the flap edges. As a result, it is best to avoid these methods.

Self assessment[edit | edit source]

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Self-assessment
  • Review the contents of this page as well as the rest of the pages related to the Z-Plasty Training Module then go to the AmoSmile App to take the Self-Assessment quiz on Z-Plasty.
  • See Z-Plasty Module navigation page for app download instructions.

References[edit | edit source]

1.     Borges AF, Gibson T. The original Z-plasty. Br J Plast Surg. 1973;26(3):237-246. doi:10.1016/0007-1226(73)90008-8