(a) Complication of eclabium secondary to herpetic infection of an advancement flap of the upper lip. (b) A 45-degree Z-plasty is planned and drawn. (c) The flaps are widely undermined and transposed. Note the use of skin hooks to minimize trauma to the tenuous tips. (d) Flaps sutured in place. Transposition of the triangular flaps brings about the following changes: the central limb is rotated (from a vertical to a horizontal direction), the distance between the original vertical scar (or limb) is increased, and the final scar is “broken” from a straight line to a nonlinear Z configuration. (e) Patient at suture removal. Note the immediate correction of the eclabium. (f) Results at several months. The scar lines have become more subtle.

The degree of scar directional change and lengthening is affected by the angles of the flap. In the 30-degree Z-plasty, the direction of the change is approximately 45 degrees from the initial position of the central limb and there is a 25% gain in scar length. With a 45-degree Z-plasty, the resultant limb lies in a more oblique position, approximately 60 degrees from the initial position and there is a 50% gain in scar length. A 60-degree Z-plasty will yield a 75% increase in scar length and a 90-degree change in scar direction (the broken line represents the original scar).

A multiple Z-plasty.

For a scar that crosses the melolabial fold (black line) in an undesirable perpendicular fashion, there are two ways that the Z-plasty could be performed to change the scar direction (represented by the green and red inks in Figures and ). Although both options will change the scar direction to match the melolabial fold, only one of the designs (green ink ) allows for the limbs of the Z-plasty to align with the RSTLs of the cheek and lip. Conversely, in even though the mirror image also realigns the central limb appropriately, the resultant lateral limbs cross the RSTL of the lip and cheek in an undesirable perpendicular fashion.

(a) Alar retraction secondary to multiple tumor extirpations resulting in an ecnasion. (b) A Z-plasty is planned. One relatively simple way to estimate the angles is to draw out the peripheral arms at 90 angles to the central limb and then divide this in 1/2 to get 45-degree angles or trisect it to obtain 30- or 60-degree angles as shown. (c) Z-plasty sutured in place. ((d) and (e)) Frontal and lateral views demonstrating that alar retraction has improved but not completely resolved (cf. ). (f) Another, more inferior Z-plasty is planned at a later date. (g) A strip of cartilage is used underneath the flap to provide structural support to the alar rim. (h) Z-plasty sutured in place. (i) Patient at suture removal. (j-k) Frontal and lateral views demonstrating resolution of the ecnasion.

(a) Scar creating webbing in the retroauricular sulcus. (b) Z-plasty designed. (c) A Z-plasty is performed to release the contracture. (d) Patient at suture removal.