JBUR-4252; No.

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Reversed Z-plasty and its variations to release

wide-scar contraction

Lu Zhang 1, Rong Jin 1, Yao-Ming Shi, Bao-Shan Sun, Zhe-Ming Pu *,

Yu-Guang Zhang *

article info summary

Article history: Background and aim: Z-plasty is one of the most widely used techniques in plastic and
Accepted 18 December 2013 reconstructive surgery. It is useful especially to release linear-scar contractures, yet difficult
to use for wide scars. The aim of this study was to report on a new technique for the effective
Keywords: release of contractures for wide scars using reversed Z-plasty and its variations.
Reversed Z-plasty Methods: This report describes a novel technique to release contractures effectively for wide
Wide scar scars using reversed Z-plasty and its variation. The design is a reverse style of conventional
Contraction Z-plasty. In our case series, the reversed three-flap, four-flap Z-plasty or its variation was
Randomised flap chosen depending on the width of the contracted scar.
Results: We performed this technique on 28 patients. All wounds healed well and the scar
contracture was satisfactorily released.
Conclusion: This procedure is useful and practical for wide-scar contractures.
# 2013 Elsevier Ltd and ISBI. All rights reserved.

Z-plasty is one of the most widely used techniques in plastic

and reconstructive surgery [1,2]. It is a practical technique that
can release scar contractures, adjust the position of the soft
tissue and create a stereo effect, especially for linear or
webbed scars. However, it is difficult to release wide-scar
contractures with conventional Z-plasty. Here, we report on a
new technique for the effective release of contractures for
wide scars using reversed Z-plasty and its variation.
1. The technique
Reversed Z-plasty and its variations (Fig. 1)
The design is a reverse style based on conventional
Z-plasty. In our case series, the reversed three-flap, four-flap
Z-plasty or its variation were chosen depending on the width
of the contracted scar.
2. Case reports
Case 1: a 25-year-old man with wide burn-scar contracture in
the right neck and the left arm (Fig. 2).
The patient had a post-burn contracture of the neck that
restricted the range of motion of the neck. Meanwhile, a
contracted wide scar was observed in the left arm. Reversed
three-flap Z-plasty was used for the neck contracture, and the
scar in the arm was released by a similar technique. As the
contracted skin in neck was about 15 cm in width, we designed
each limb at 15 cm length. The scar in the arm was 3 cm in width
and the varied three-flap Z-plasty was employed, which was
similar to the method described by Takatoshi Yotsuyanagi [3]:
the main limb is designed to incise the scar contracture. This
main limb is shared as a peripheral limb by two other Z-plasty
designs in which the central limbs of each design are at 908

* Corresponding author at: Department of Plastic and Reconstructive Surgery, Shanghai 9th People’s Hospital, Shanghai Jiao Tong
University School of Medicine, 639 Zhi Zao Ju Road, Shanghai, China 200011. Tel.: +86 21 23271699; fax: +86 21 63136856.
E-mail address: luzhangmd@gmail.com (Y.-G. Zhang).
1
These authors contributed equally in this work.
0305-4179/$36.00 # 2013 Elsevier Ltd and ISBI. All rights reserved.
http://dx.doi.org/10.1016/j.burns.2013.12.016

Please cite this article in press as: Zhang L, et al. Reversed Z-plasty and its variations to release wide-scar contraction. Burns (2014), http://
dx.doi.org/10.1016/j.burns.2013.12.016
JBUR-4252; No. of Pages 4
2 burns xxx (2014) xxx–xxx
Fig. 1 – Schematic illustration of reversed Z-plasty and its
variations.
angles to the side limb on the opposite side. The central limb
should be set along the axis of the margin of the wide scar. The
remaining peripheral limbs are then designed at a 908 angle to
the side limbs on each side, away from each other. All the limbs
are of 3 cm length. After the full skin incision, each flap could be
relocated naturally to the desired position with little under-
mining and the scar contracture could be well released. The
wound was easily sutured and no complications with the
healing occurred.
Case 2: a 30-year-old man with a burn-scar contracture in
the central right neck (Fig. 3).
Fig. 2 – A 25-year-old man with wide burn-scar contracture
in the right neck and the left arm. Reversed 3-flap Z-plasty
was used in the neck and its variation style was used in
the arm.
Please cite this article in press as: Zhang L, et al. Reversed Z-plasty and its variations to release wide-scar contraction. Burns (2014), http://
dx.doi.org/10.1016/j.burns.2013.12.016
Fig. 3 – A 30-year-old man with wide burn-scar contracture
in the central right neck. Reversed 4-flap Z-plasty was
used in the neck.
A patient who suffered flame burn in the face and neck was
partially treated using a split-thickness skin graft. As at the
right and centre of the neck about a 25 cm-width of skin
became gradually contracted, we performed the operation
using a reversed four-flap Z-plasty. The length of each limb
was about 12 cm. After skin incision, each flap could naturally
relocate to the desirable position without major undermining
and without the scar contracture being released. The wound
was easily sutured and no complication with the healing
occurred.
3. Results
Our technique was performed on 28 patients (32 locations)
with burn-scar contracture in the following locations: the neck
(18 patients), axilla (four patients), anterior chest (three
patients), thigh (three patients), knee (two patients) and arm
(two patients). The width of the scars ranged from 3 to 25 cm.
The sutures were removed 7 days after neck operations, 10
days after trunk operations and 12 days after limb operations.
All wounds healed well without any complications, such as
skin congestion or necrosis, and the scar contracture was
satisfactorily released after the operation. The long-term
effects of local flaps are already established [4,5]; nevertheless,
we have tried to contact the patients for long-term follow-up
but none of them could be located.
4. Discussion
Z-plasty is one of the most useful techniques for releasing
linear-scar contracture, which can elongate along the axis of
the scar, disperse the scar by breaking up the straight-line scar
and realign the scar within the lines of minimal tension. A
releasing effect can be accomplished based on the degree of
the contracture by changing the length of the limb or Z-plasty
angle. In addition, many variations of Z-plasty [6–10] have
been used in our group, including the three-flap Z-plasty and
the four-flap Z-plasty (Fig. 4). These techniques were
employed according to the severity of the contracture or the
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burns xxx (2014) xxx–xxx
Fig. 4 – Conventional Z-plasties and their applications.
region of the contracture. However, in wide-scar contracture,
there is no definite contracture axis. If a central axis is
designated, the release will not be sufficient and may cause a
local uplift because of not being able to mobilise the excess
skin and soft tissue in the contracture’s direction.
Our technique is a new method in which reversed Z-plasty
and its variations were used for contracture release in wide
scars. Compared with conventional Z-plasty, this new
technique widens the scale of application. Compared with
skin transplantation [11], our technique is easy to perform,
has no donor-site morbidity and provides similar texture and
colour without contraction, especially for growing paediatric
patients. However, this procedure is not applicable in cases
where the scar is not mature and softened. Furthermore, the
procedure is not effective when the contracture is very
severe, as it will leave a huge defect after incision as well as
releasing during the operation [12]. The local flap is not
sufficient to repair the defect. In addition, particular
attention is necessary when using this technique to ensure
that the suture line forms an oblique angle as a whole, and
three-dimensional change occurs in the same manner as in
other techniques.
In a sense, both the reverse three-flap and three-flap
variations in Fig. 1 are regular unequal traditional Z-plasties
in which a common limb is shared. In case a design of 308 and
908 triangles. As in the principles that govern the application
of Z-plasties, the lengthening of the scar is achieved by
transposing triangles to lengthen the scar by importing from
the lateral laxity. The highlight in this design is that instead of
designing a serial Z-plasty, as in single-band contractures, the
Z-plasty is designed on either edges of the broad band scar.
Please cite this article in press as: Zhang L, et al. Reversed Z-plasty and its variations to release wide-scar contraction. Burns (2014), http://
dx.doi.org/10.1016/j.burns.2013.12.016
3
The same effect is realised though, that is, lengthening of the
scar. The two variations of the three-flap Z-plasty are really
overlapped unequal double-opposing or a serial Z-plasty
design.
By contrast, in the four-flap reverse Z-plasty design, the
triangles are not designed such that the common limb of the Z-
plasty is oriented in line with the contracture with a view to
using the lateral laxity to add length to the contracture by
transposing the triangles [13]. Instead, the limbs of the four
triangles zigzag along the contracted band. When these four
triangles are transposed, a common limb is formed bringing
about shortening perpendicular to the broad contracture
band, thereby importing the laxity into lengthening the broad
contracture band. With reference to Fig. 3, this strategy
imports the horizontal laxity in the neck to lengthen the
vertically contracted neck with an added bonus of improving
the contour of the neck.
In conclusion, our technique is very useful for wide-scar
contractures, as compared with conventional Z-plasty. It is
important that the width and degree of the scar contracture be
appropriately evaluated and suitable techniques, including
various other techniques, selected as appropriate.
Statements
All authors have made substantial contributions to all of the
following:
(1) the conception and design of the study, or acquisition of
data, or analysis and interpretation of data, (2) drafting the
article or revising it critically for important intellectual content
and (3) final approval of the version to be submitted.
The manuscript, including related data, figures and tables,
has not been previously published and is not under con-
sideration elsewhere.
Conflict of interest statement
None of the authors has a financial interest in any of the
products, devices or drugs mentioned in this manuscript.
Acknowledgements
This study was supported by National Natural Science
Foundation of China (81101438 and 81201476).
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Please cite this article in press as: Zhang L, et al. Reversed Z-plasty and its variations to release wide-scar contraction. Burns (2014), http://
dx.doi.org/10.1016/j.burns.2013.12.016