T i s s u e Re a r r a n g e m e n t s

The Power of the Z-Plasty

Gabriel Hundeshagen, MDa,b, Ramón Zapata-Sirvent, MDa, Jeremy Goverman, MDc,
Ludwik K. Branski, MD, MMSa,*

KEYWORDS
 Burn scar  Contracture  Z-plasty  Adjacent tissue rearrangement

KEY POINTS
 The z-plasty is a highly versatile standard technique of reconstructive burn surgery.
 The z-plasty can elongate tissue along a scar or contracture, narrow a scar in its transverse direc-
tion, rearrange the direction of a scar along relaxed skin tension lines, disperse and camouflage
scar tissue in favor of cosmesis, and release tension, which ultimately reduces inflammation and
hypertrophic scarring.

INTRODUCTION summarized the z-plasty and its variations as

The z-plasty could be considered one of the oldest
tricks in every book of plastic and reconstructive
surgery. Its versatility and universal applicability
have placed it at the center of various publications
over several centuries. Fricke and Horner des-
cribed single transpositional flaps as early pre-
decessors of the z-plasty as early as 1829.1,2
While surgeons such as Serre and Denonvilliers
further improved the geometry of the technique
and were using it for the correction of facial defor-
mities and lower lid ectropion in the mid 1800s,3,4
the earliest publication of what is considered the
standard contemporary z-plasty with equal limb
dimensions and angles is attributed to French sur-
geons Berger and Bonset in 1904.5 The early
1900s saw a series of articles by Mc Curdy, who
first coined the term in use today and introduced
the technique to the correction of burn scars.6,7
In 1946’s first volume and second article in Plastic
and Reconstructive Surgery, Davis evaluated and
indispensable and versatile techniques.8 Since
then, innumerable variations of the basic surgical
concept and new potential applications have
been published throughout the century by surgical
pioneers such as Morestin, Davis, Limberg, and
others.9–11
To think of the z-plasty solely as workhorse of
plastic and reconstructive surgery falls short of
its actual impact on virtually all surgical specialties:
General surgeons have shown it to be useful in
the treatment of sinus pilonidalis.12
Oralmaxillofacial surgery uses it regularly in cleft
palate repair.13,14
Neurosurgeons have treated myelomeningo-
celes15 similar to how orthopedic surgeons
ameliorated patellar compression syndrome16
with a variation of the z-plasty
Aesthetic surgeons improve the appearance of
both genital17 and facial18 labia with this
technique.
plasticsurgery.theclinics.com

The authors have nothing to disclose.

a
Department of Surgery, Shriners Hospital for Children, University of Texas Medical Branch, 815 Market Street,
Galveston, TX 77550, USA; b Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG
Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Street 13, Ludwigshafen 67071,
Germany; c Harvard Medical School, Massachusetts General Hospital, Sumner M. Redstone Burn Center, 55
Fruit Street, Boston, MA 02114, USA
* Corresponding author.
E-mail address: lubransk@utmb.edu

Clin Plastic Surg - (2017) -–-

http://dx.doi.org/10.1016/j.cps.2017.05.011
0094-1298/17/Ó 2017 Elsevier Inc. All rights reserved.
2 Hundeshagen et al
Fig. 1. Basic principle of the z-plasty: 2 opposing triangles of equal angles to a central incision along the line of
tension are transposed. The result is a break up and lengthening of scar tissue and redirection of the scar in
perpendicular direction.
PRINCIPLES
The basic idea of the z-plasty was best described
by Limberg, who highlighted the flap’s simulta-
neous rotational and advancement properties
and deducted its versatility from this unique com-
bination.11 The main objectives of the z-plasty are
1. Elongate tissue, usually along a scar or
contracture, to release tension and enable
mobility
2. Narrow a scar in its transverse direction
3. Rearrange the direction of a scar, favorably
along pre-existing relaxed skin tension lines
(RSTLs)
4. Disperse scar tissue in favor of cosmesis
5. Soften and thin scar tissue
Technique
Fig. 1 illustrates the concept of rotation and
advancement of the classic z-plasty: a central ver-
tical incision is placed in line with the long axis of
the scar or line of tension. Two lateral limb inci-
sions of the same length as the central incision
are placed at its ends in a 60 angle. Next, the
resulting triangular flaps are raised to the desired
plane and rotated toward each other so that their
tips fall into place in their respective opposite
corners. The former shared sides of the triangles
are now located toward flexible skin next to the
limb incisions and a new, now horizontal, central
limb is formed. The line of tension of the incised
tissue is now perpendicular to its original direction.
The costs for longitudinal elongation and elimina-
tion of 1 prominent scar are relative perpendicular
tightening and 3 resulting smaller scars.19
Although this concept may appear simple and
straightforward on the pages of a surgery text-
book, its execution under real circumstances can
prove to be challenging. Wanzel and colleagues20
demonstrated that the ability of surgery residents
to properly execute a z-plasty (which they termed
a “spatially complex surgical skill”) correlated with
their performance in visual-spacial ability testing.
Those who scored lower according to their
visual-spacial ability required more supplementary
training and feedback to achieve comparable
operative results, demonstrating how challenging
this seemingly simple procedure can be.
Elongation, Remodeling, and Reorientation
Tissue lengthening in the direction of the scar
contracture after z-plasty is a function of the an-
gles of the limbs toward their central incision.
Mathematically, an increase in angle will result in
increased central elongation (Table 1). Likewise,

Table 1
Theoretic elongation of scar depending on
symmetric angles of lateral z-plasty, limbs, and
selected variations
Angle Between Lateral Mathematical
and Central Limbs Gain in
(Degrees) Length (%)
30 25
45 50
60 75
75 100
90 200
Variations
Two z-plasties in series 75
Double-opposing z-Plasty 75
Four-Flap-z-Plasty 100
with 45 angles
Four-Flap-z-Plasty 150
with 60 angles
Data from Thorne CH. Techniques and principles in plastic
surgery in Grabb and Smith’s plastic surgery. 6th edition.
Philadelphia: Lippincott Williams & Wilkins; 2007; and
Hudson DA. Some thoughts on choosing a z-plasty: the z
made simple. Plast Reconstr Surg 2000;106(3):665–71.
elongation increases with the length of the central
incision, but is proportionally dependent on suffi-
cient adjoining tissue for transposition. However,
these theoretic gains in length depend on the spe-
cific conditions encountered in each patient and
scar. Davis describes that the best tension relief
can be achieved when an isolated contracture
band is surrounded by normal lax skin, which
can be transposed, guaranteeing optimal flap
perfusion.10 However, especially in the recon-
structive treatment of burn contractures, this sce-
nario is rare, and the common findings are
transpositional flaps that are composed of scarred
tissue themselves. Therefore, careful planning is
paramount in order to produce the best possible
outcome and avoid overestimation of the tech-
nique’s potential.
It is clinically evident that scar tissue shows a
tendency to thin and soften after application of a
z-plasty even if the scar is merely rearranged
instead of excised. Aarabi and colleagues21 were
able to demonstrate that mere mechanical scar
tension alone can cause the development of hy-
pertrophic scars in mice, leading to manifold
increases in tissue volume, cell density, and
dysregulated, decreased apoptosis. On the con-
trary, the redirection of tension on the tissue into
the perpendicular direction causes mechanical
stress relief. Histologically, a reorientation of
collagen fibers resembling normal skin instead
Tissue Rearrangements 3
of hypertrophic scar as well as a replacement of
abnormally sulfated mucopolysaccharides with
normal acid mucopolysaccharides was demon-
strated by Longacre and colleagues22 through
immunohistochemical analysis of biopsies of
scar tissue before and 2 weeks after z-plasty. He
concluded that the surgical procedure had pro-
found impact on a molecular level.
Reorienting a protuberant scar in a more favor-
able direction can have great consequences for
its visible appearance. Burn scars over concave
surfaces such as the neck, axilla, and popliteal
area tend to hypertrophy, contract, and ultimately
form a bowstring structure. Through correct design
of the z-plasty in a way that the transverse limb after
transposition lies in a natural concavity, functional
and cosmetic outcome can be maximized.23
Furthermore, knowledge of the location and direc-
tion of naturally occurring folds and lines across the
body add valuable information to the planning
process of any incision, including a z-plasty. There
are numerous classic concepts for designing
optimal incision placement, such as Pinkus’ main
folding lines,20 Kraissl’s antimuscular lines,21,22
and the RTSLs described by Borges.23 Newer
approaches combine the data of these established
concepts with the distribution of striae distensae,
which form perpendicular to musculoskeletal lines
of tension, to create more detailed composite
diagrams that are also applicable to guide incision
planning in younger patients.24 In general, a
z-plasty executed in order to camouflage or dis-
perse an existing scar should be designed so that
the resulting transverse limbs after transposition
lie within a naturally occurring skin line or fold.
This, on the contrary, means that z-plasty should
be avoided in cases in which the initial scar to be
corrected is already located along the axis of a
fold or line and the resulting transverse limb would
be perpendicular and thus more conspicuous.
Borges formulated the practical general rule that
scars located 60 or more from an RTSL should
be corrected with a z-plasty with 60 angled limbs;
scars situated under 60 away from an RTSL should
consequently be addressed with a z-plasty whose
limbs fall on the RTSL.24
VARIATIONS
As described by Limberg, 1 considerable advan-
tage of the z-plasty is its potential for variation
and expansion of its core principles. A few of the
numerous examples are mentioned. A publication
by Furnas and Fischer, who experimentally
assessed the biomechanical consequences of
the most common variables of z-plasty modifica-
tions, is summarized in Table 2.
4 Hundeshagen et al

Table 2
z-plasty, the actual gain is always greater with
Biomechanical consequences of different the latter, as experimentally determined by Furnas
variations of the Z-plasty. Experimentally and Fischer27 and shown in Table 2.
assessed in dogs by Furnas and Fischer.
Z-Plasty with Asymmetric Angles
Biomechanical It may be feasible in areas of varied skin elasticity
Variation Consequence
to design a z-plasty with unequal angles of the
 Longer z-plasty  More force required limb incisions to the central incision, resulting in
(equal angles) for closure transposable triangles of unequal size. A useful
 Different,  90–90 requires 7–10 x variant of this approach places the limb incision
symmetric, the force for closure on the scar side perpendicular to the central
angles compared with 30–30 limb. The other limb on the side of normal skin
 30–30 provides 10% is designed with an angle of 60 . The resulting
length gain compared
fissure on the scar side is filled with the trans-
with 75% for 90–90a
posed triangle, and the gain in length is directly
 Serial z-plasties,  Greatest lengthening proportional to the width of the transposed trian-
different in effect with fewest
gle. A special variation of this technique uses the
number, equal in number of z-plasties
length  Greatest lengthening combination of a 90 angled limb within the scar,
with largest flap size and a triangular flap of normal skin at 45 is
 Asymmetrical  Narrow flap requires
rotated in to close the resulting defect. This pro-
angles less tension for cedure was termed a 3/4 z-plasty28 and can be
closure but is subject used to treat severe posterior axillary contracture
to more distortion as illustrated in Fig. 4.
 Greater strain in sur-
rounding skin of The Four Flap Z-Plasty
wider flap
This variation adds 2 extra limbs to the respective
 Measured vs  Actual lengthening end of the central incision of a regular z-plasty and
predicted always less than
results in a considerable gain in length. First
lengthening geometrically
predicted described by Limberg in 1929, advantages of this
technique result from its application to areas that
a
Measured, not theoretic gain. are highly constricted in their natural mobility by
From Furnas DW, Fischer GW. The z-plasty: biome- scar contractures such as the neck, elbow, or
chanics and mathematics. Br J Plast Surg 1971;24:144–60.
interdigital spaces.29,30 Four flap z-plasty is typi-
cally created by making 2 flaps with an initial angle
of 90 or 120 which are then divided into 4 equal
The Double Opposing Z-Plasty flaps of 45 or 60 . The theoretic gain in length of
the central limb for a 4 flap z-plasty is 100% and
Two mirroring z-plasty incisions can be placed 150% respectively (see Table 2).
directly adjacent to each other along their central
incision and undergo regular transposition of Musculocutaneous and Fasciocutaneous
the resulting triangles. This approach is advanta- Z-Plasties
geous when limited normal skin is available in
The z-plasty is a random flap and therefore relies
areas such as the medial canthus or the interdigital
on the naturally occurring vasculature present in
space.25,26
the tissue. Aberrant vasculature or tissue damage
inflicted by the burn or surgical treatment itself
Compound Z-Plasty (Z in Series)
may compromise the structural integrity of the
Whenever 1 large z-plasty is unfavorable due a flap and lead to skin necrosis, subsequent dehis-
particularly long scar, cosmetic considerations, cence, and failure to heal. One possible option,
or limited availability of transposable tissue, for those cases in which vascular compromise is
several z-plasties can be linked in a row and seri- suspected, is to include muscle or fascia in the
ally transposed to form a compound z-plasty. z-plasty flap (Fig. 5,28). This technique is especially
Figs. 2 and 3 show compound z-plasties for useful when deep burns have affected the quality
contracture release of an anterior cervical and of subcutaneous tissue or when normal adjacent
antecubital scar, respectively. Of note, even skin is absent. In a musculocutaneous z-plasty,
though theoretic length gain of multiple serial the desired geometry of the limbs remains conven-
z-plasties is mathematically identical to 1 large tional, but the underlying muscle is included into
 Tissue Rearrangements 5

Fig. 2. Compound z-plasty on a contracture of the anterior neck. Left: 3 sequential z-plasties with 60 angles are
marked around the central limb longitudinal to the line of maximal tension. Right: 24-hour postoperative result.
Note the substantial elongation without large incisions.

the transposition flaps. One technique commonly
using musculocutaneous and fasciocutaneous ap-
proaches is the 3/4 z-plasty described by Huang.28
Muscles such as the platysma or orbicularis oculi,
which are relatively pliable and thin, are particularly
useful for this approach.28 Alternatively, in circum-
stances in which it would not be feasible to sepa-
rate the skin from its underlying subcutaneous
tissue, the fascia overlying the muscle can be
raised with the triangular flaps to prevent the

Fig. 3. Compound z-plasty of antecubital scar contracture. (A) Left antecubital scar contracture. (B) Central line of
maximal tension. (C) Series of 2 z-plasties. (D) Raised flaps. (E) Transposition of flaps. (F) Complete transposition,
immediately after surgery.
6 Hundeshagen et al

Fig. 4. Unequal angle z-plasty for contracture of the right axilla. (A) right axilla after burn with severe posterior
contracture and movement inhibition. (B) Z-plasty incision with a 90 limb facing the scar and a 60 limb facing
normal skin of the chest. (C) Transposition of the anterior limb, interruption, and lengthening of contracture. (D)
Full range of motion 6 months after surgery.

Fig. 5. (A) Conventional 60 z-

plasty on an anterior neck contrac-
ture. (B) Incision placement and
flap dissection to include platysmal
musculature. (C) Complete trans-
position of the triangular flaps.
(D) Preoperative neck tightness
due to contracture. (E) 4 years af-
ter contracture release: z-plastic
release alleviated neck tightness.
 Tissue Rearrangements 7

Fig. 6. Axillary scar contracture release using STAR plasty. (A) Principle of incision placement and transposition.
(B) Bilateral anterior broad scar bands, limiting brachial abduction. STAR plasty incision placement superimposed.
(C) Immediate postoperative result following transposition. (D, E) Two-month postoperative result. Successful
release dispersion of longitudinal scar band. Functional improvement of abduction.

interruption of blood supply. Common areas in
which this technique is applied are contracture re-
leases of the knees and ankles.
STAR Plasty
with unilateral skin laxity. Such contractures are
commonly seen in the web spaces, axillae, and
antecubital fossa. Fig. 6 shows the sequence of
anterior axillary contracture release using the
STAR plasty.

The STAR plasty is a novel local tissue rearrange- SUMMARY

ment that was initially developed to advance unin-
jured palmar skin for the treatment of postburn
neosyndactyly involving the dorsal aspect of the
web space31 and more recently described for the
release of Kurtzman type I axillary contractures.32
Although a standard z-plasty is best suited for a
narrow scar band with skin laxity on both sides
of the contracture, the STAR plasty can be used
to treat broad-based contractures presenting
The z-plasty remains a fundamental surgical prin-
ciple and is an indispensable tool used in the
reconstructive treatment of scar contracture. Use-
ful modifications offer solutions for most circum-
stances of scar release and other related
scenarios. It is imperative that every reconstructive
surgeon deeply internalize its theoretic implica-
tions and master its practical execution.
8 Hundeshagen et al
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