Page data
Part of Z-Plasty
Type Medical skill
SDG Sustainable Development Goals SDG03 Good health and well-being
Authors AmoSmile
Published 2021
License CC-BY-SA-4.0
Language English (en)
Impact Number of views to this page. Views by admins and bots are not counted. Multiple views during the same session are counted as one. 158

This video guides the trainee through the step-by-step process of performing a Z-Plasty on the physical simulator.

Annotations:
  • 0:00 – Identify Relaxed Skin Tension Lines (RSTLs) and Lines of Maximal Elasticity (LMEs).

Details: Use your thumb and index finger to pinch the fabric skin. The direction where there is the MOST laxity in the fabric skin (i.e. it is easier to pinch more fabric together) is termed the LME while 90 degrees or perpendicular to it should be the RSTL or direction of LEAST laxity. Although this fabric may not mimic skin exactly, it is important to practice this step and always remember to do so during the marking and planning stage.

  • 0:01 – Mark & Measure Central Limb.

Details: Clinically, the central limb is often in-line with a scar or incision. It is good practice measure the central limb to know it’s exact length in order to ensure that the lateral limbs are also equal lengths.

  • 0:12 – Mark & Measure Lateral Limbs.

Details: Ensure their lengths are the same and their angles are equal but opposite to one another in relation to the central limb. Commonly, 60-degree angles are used for z-plasties, but it is valuable for you to practice multiple different z-plasties where you make the angles wider and narrower to appreciate how the size of the flaps change as well as the amount of length that is created along the central axis.

  • 0:30 – Complete Final Markings for Central & Lateral Limbs.

Details: It is always good practice to re-measure all three limbs to ensure they’re the same length and check the LMEs to ensure optimal orientation of the z-plasty before committing to the markings.

  • 0:47 – Incise Along Markings.

Details: Use scalpel to perform incision along central and lateral limbs. For the incision, practicing slightly rounding the corners of the “Z” and the feel of the scalpel as it glides around the corners. It is good practice to incise along the entirety of a limb before lifting the scalpel blade in order to get used to controlled cuts and avoid double cuts or feathering that occurs with picking up and putting down the scalpel multiple times along a single incision. Practice stabilizing the scalpel by resting you’re the ulnar aspect of your hand on the surface as you glide across. Stabilizing your hand this way will minimize shaking and keep the incisions clean and straight. This is also an opportunity to practice the amount of pressure that is used while making the incision. Pressure should be constant and controlled so as not to inadvertently plunge through the skin which can damage underlying structures. Focus on only incising through the epidermis and dermis just until you see the subcutaneous tissue. Remember, in a real-life situation there may be significant scarring that can alter normal anatomy and bring neurovascular structures very close to the surface. It is also good practice to start the incision with the central limb, since this will often be the same line as the hypertrophic scar being released and even excised when the scar is small enough. When translated to clinical practice, it is important to pause at this point before flap suturing to assess flap perfusion and make sure both flaps are viable. You will be able to see bright red bleeding from the edges of the flaps, especially the tips, if perfusion is adequate. Although there is no way to simulate this synthetically, it is still good to practice pausing here after flap elevation to remind yourself of this important evaluation that is done before proceeding with flap closure.

  • 1:10 – Flap Elevation & Mobilization.

Details: Once the incisions are complete for all 3 Limbs, elevate the 2 triangular flaps from the underlying wound bed using a push-spread technique that avoids cutting and remains controlled with blunt dissection. The plane of elevation should be followed so as to avoid injuring the fascia underneath or the thin flap above. Use skin hooks or forceps with teeth (keep them open) to gently transpose the 2 flaps to their new positions and feel the change in tension on the fabric as the flaps are moved. While there may not be any subcutaneous tissue or fascia underneath the fabric to fully replicate flap elevation, practice switching back and forth between the scalpel (making gentle pressing movements) and dissecting scissors or hemostat (in a push and spread method) as both sharp and blunt dissection are used to carefully elevate the flaps off the underlying neurovascular structure. Also, it is helpful to practice feeling the thickness of the flaps between your index finger and thumb as you will want to ensure symmetrical, adequate thickness throughout the entire flap.

  • 1:24 – Flap Inset & Corner Suturing.

Details: Begin flap inset and wound closure by performing a 3-point stitch starting from one corner to the tip of a triangular flap that is going to align with that corner. Perform both 3-point sutures (1 per flap tip) to align the triangular flaps in their new orientations. Of the different suturing techniques used to inset the z-plasty flaps, this is perhaps the most specific of the suture methods. It requires a mattress style entry and exit on the non-flap side and a buried subcuticular pass on the flap tip side. Practicing this suture in particular will be a critical skill to develop to ensure that the flaps are properly and securely aligned in their new transposed positions.

  • 2:57 – Complete Flap Closure.

Details: Continue flap closure by performing simple interrupted sutures along the limbs of the triangular flaps. This example uses non-absorbable sutures and simple interrupted method. If absorbable sutures are available for clinical use, the same 3-point suture can be sued for the flap tips, but buried deep dermals can be used along the flap edges to close the remainder of the flap inset.

  • 5:02 - Completed Flap Inset & Closure.

Details: At this point, the flap is inset and all incisions are sutured close. Clinically, this is another point where it is good to pause and observe the flaps to make sure there are no signs of ischemia or congestion. Additionally, ensure there is no widening or gapping along the closure. Although there is no circulation on the simulator, it is good practice to get used to pausing at this point so that it becomes routine.

Surgical Instruments for Practice[edit | edit source]

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

[Alternative: any size scalpel]

Skin Hook single or double hooks

[Alternative: Adson with teeth]

Adson with teeth Surgical forceps with interdigitating teeth
Dissection Scissors Any scissors that are used for dissection such as tenotomy scissors may be used.

[Alternative: A hemostat or mosquito may be used for the flap elevation]

Needle Driver Any needle driver commonly used for cutaneous suturing.
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.

Self assessment[edit | edit source]

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Self-assessment

After watching the step-by-step guide to performing the Z-Plasty procedure on the physical simulator, go through on your assembled simulator and practice these key steps while paying attention to what is the purpose of each maneuver .