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  • The Z-plasty is a powerful technique utilizing the transposition of triangular flaps to relieve tension, to lengthen, and to reorient scars parallel to relaxed skin tension lines.

  • A 60-degree Z-plasty is considered optimal when considering skin laxity, size of the flaps needed for viability, risk of vascular compromise, location, and theoretical limitations.

  • The Z-plasty may be used on its own for scar revision or repositioning, or as an adjunct to other flap closures to mitigate pivotal restraint.

image Beginner Tips

  • Z-plasty is useful for the functional improvement of contractures, web revision, or free-margin distortions

  • Two equivalent triangular flaps synchronously interchange into the space previously occupied by the other. The result of the position swap is a 90-degree reorientation of the common arm of the Z.

image Expert Tips

  • Fundamental goals of the Z-plasty procedure include:

    • Realignment of a scar within relaxed skin tension lines (RSTLs), or parallel to them

    • Lengthening of a scar

    • Release of a contracture by scar lengthening

    • Dispersal of a scar for better camouflage

image Don’t Forget!

  • In one study, survey respondents preferred a simpler and less complex linear scar over Z-plasty scars, suggesting that the purported benefit of breaking up long scars into smaller ones needs more study before it can be accepted.

  • Although the surgeon has two choices for the placement of these lateral limbs, only one combination will allow for optimal cosmesis or reorientation of lines in the direction of, or parallel to, the RSTL.

image Pitfalls and Cautions

  • If a scar already lies along RSTL, a Z-plasty may result in reorientation of the central incision perpendicular to the RSTL—a less desirable outcome.

  • Scars within 40 degrees of RSTLs may be better managed with simple excision rather than with Z-plasty.

  • Necrosis is more common with angles less than 30 degrees and therefore such acute angles should be avoided if possible.

image Patient Education Points

  • While a Z-plasty does result in a longer scar line, patients may be reassured that the net result is generally a less cosmetically obvious scar.

  • Other scar revision procedures may be needed after Z-plasty, and patients should be warned of this eventuality prior to surgical intervention.

image Billing Pearls

  • Z-plasty is billed using the adjacent tissue transfer (flap) code series, 140XX.

  • These codes include a 90-day global period.

  • If a Z-plasty is performed as part of a larger flap, only a single flap code should be used.


The Z-plasty is a standard technique utilizing the transposition of triangular flaps to relieve tension, lengthen, and reorient scars parallel to relaxed skin tension lines (RSTLs). This technique has been utilized for over a century with only slight modifications, relying on three incisions separated by angles of the surgeon’s choosing. Though a variety of different angles can be used, 60 degrees is considered optimal when ...

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