PRESENT EVALUATION OF ‘THE MERUPS OF THE Z-PLASTIC OPERATION JOUN STAIGE DAVES, MuD. Baltimore, Ml Thave heen asked by Dr, Warten B, Davis, the Editor, te briefly evaluate for the first number of the new Journal, “Phistie and Reconstructive Surgery”, the use of Z-plastie operations and to sum up in a general way my long personal experience with the method, “The cause the outline of the aver is based on the tr ame Z-plastic is given to the procedure be: cision is roughly that of a Zor reversed Z. The nsposition of wo triangular flaps developed by: the eles may he equal qual mn he presence of Ix tissie on each side of the cont H In a paper read before the American Surgieal Association in 1931, Davis reported that the Z-incision with transposition of flaps was first used by De villiers in 1856, for the relief of an eetropion of the outer third of a lower and that he developed the procedure in steps, Tn-another paper by Davis with Kitlowski, published in 1939, a further study of Z-plastie: methods was m a Irasis of shifting, triangn limitations as worked out by A.A. Limberg of Leningrad was discussed. sion, whos nd its stieess elepends on the cle, al the mathematics Jar flaps with the possibilities and In these two papers the literature and the entire subject was fully covered, and there has been nothing of importance added sinee that time. Uh frecly from these papers in the preparation of this contribution, 1 is interesting to note that although the wats fist reported about 0 years ago, the procedure has during this period been eo drawn Z-ivcision with the transposition of flaps this 1 lost Hot, and rediscovered, and redescribed as new, by a number of surgeons, this will ever happen again as the value of the method rsties are described and illustrated in It is very improbable thy is now thoronghly est nearly all new books on plastic surger pedie surgery In spite of the fact that the Z-incision with the trunsposition of flaps is used more sand more frequently by surgeons dealing with cont os, there is still considerable confusion as to the actual Lof the utilization of the tri- tion, Many surgeons do not uneler- nif also in those on general and ortho: ures, as they become advan theory and use of Z-shaped rel gular flaps thus formed to relieve con jasation incisions su and the principles of the procedure at all. Mthough [have used the method for many: years sucessfully and formed the experience, since Limberg’s papers appeared, T have appr amore definite: mathematics sequence find the procedure les, which were effective hy hed the method from viewpoint for purposes of acenraey. and in con isier to explain and simpler to carry out although iny results have not _been improved. he ideal plice for the use of the Zineision with the Cransposition of Che tri 26ASTIC OPERATION a oF ALU \TION OF TET ur flaps thus formed, is in those instances where the skin is of normal texture, and where a web exists, sich as may be found in congenital webbing of the neck or popliteal spaces als anid of congenital displaccment of normal surface levels. ‘There are sometimes: cone enital grooves around the fingers, wrists, arms, toes and logs where a constrie- tion surrounds the affected part, and in these cases the Z-plistie procedure, nu o in cort 6H) cage, at ie a Ue preyposed he amule with the ce ul and its point is placed at t il dlown along jan, sl this I His then tral fin 19 il tHe same edge slong whieh was murke ng the contracted sear band, hut in a ceeersed posite ‘The othe eked ot rund the “arrawheni” is removed leweing a Zoe reversed Zp inl at x 60 nthe central line, AIP at these facilitate handling ea ei ped pives of capper ihe ps as Atewerilie TX an 1 hod series, hats heen in my experience the most sttistaet andl int the vast I. deformities however, are comparatively + where Z-p recused, the deformity is due to se extensive burns or trauma, and the tissues dealt with sire2s JOHN STMIGE DAVIS composed cither entirely of sear or of skin more or Jess infiltrated with sear, A Knowledge of the utilization, in the final repair, of sear Cisse and tisstes more or Fig. 2. 1: Schematic drawing of the Z incision. “The % is drawn with the central and arm lines of equal length. The ari bines are plared at an angle of to the central bine ane are parallel te euch other. ‘The central line CD is the short diagonal of the parallelogran and the broken line VB is the longediagonal, ‘The dotted half of the area ist show the Cranspasition iver clearly 2° The incisions have been made along the Z shaped Jar flaps N andl Yate complet rent test ir bi 3: The tla (hwen Transposcl. The tigeat the flay N being stttused tothe point 1s saul the tip pV to the point A. and the rest af the wot closer. ‘The elistire is HDL in thie ia Z bu it is rotated abit 4) .snd Uhe coat ral line of the original Zt fies tranneversn the line of sear pull. [t will be found that the distance bet woon the pains ¢ as been lengthened by the differrnee between the Iengths of the bang Higgconal AT we short diagonal CD, attern ACD Band the wot Ht Jess infiltrated with sear is essential for the surgeon in the sucessful perform: of Zplistic operations.EVALUATION OF MERITS OF Z-PLASFIC OPERNTION Fit, Biarerat Coscesrra Drvorsrries or Hays, Taasrea ni Yelserstos WHR THD TRANSHOSITION OF Lars to Riideye: Dike Minpit: ayn Rise Fixunis ov Riaer Haxp 1: Shows the deep grooves on ring and middle fingers of right hun, also various malforn Teslt of Z-plastivs on these fingers, Note the obliteration af the geunves Frac Tasreverse tin: Csi or Z-Dserstoxs iy Renvsine Presi Stave: Rens Anoisp Moti Ly Burn sear of face, 16 yeas duration, The whole face is involved. Th particularly thick around niaitth. ‘There is some eversion af lawer tip. and the the mouth are shortened 22 Whew month is opened pucker sea the yolabial folds are cont inions with these om hin. gles ot il mouth, The se Laerise the point of the Jn be sen ary AW xine wf aabial fold, snd the same rm eth note the relusition of th A Z-plastic was done to relax the sea procedure was earried out an each side begond the Compare this picture with No. Lot Figg 4 ad the nasolabial folds and alse t 6. Senmanvrie Drawixe or 4 Merton of Usixe Mu gris: Zs 1y Cox tixvars Sette: ‘Threw reversed Zs in series are outlined. ‘The incisions are rarallel te exch wtler, ane all sre a Tneisione are iad along. this outline Fu 1 Tedrawn from Limberg all of the game lengthy anal the arm lines are OF G0. to The central line, whieh is cont fill af these flaps are undercut Neste the positive it Shows the result of the transposition. Marked lengthening ean he ser rent haps an type of final lustre, nEVALUATION OF MERIPS OF ZPLASEIC OPER VION 31 q ¥ 4 RIE F B, ‘B} FL Se és, fe 514 7 D I a Frea; abursiarie Tingpie gw Ase rus ge Vena Soren Costes vir Zs in sories sre outtinel. ‘TI Tate it will be ince pire “space bet wenn neh wonis sin Pig. 6. sanispastd Fie. bar smevrise rays 1y Kiuaryixe 4 : Seq Gave RETWEES THE BREAST 4 vey Lise With the arn at the side, he jer Of thie groove has heen aeconiplished eZ pst ie with eau bee set the i Hat Set bkwelnd ott lar sear eat be seen, Note: iin the lower Ts Extensive old burs x Relaxation and nti right hautul earner of the phote 2 tended, the full extent af 2 Wit ang sear pull, ‘Phe sear is still fairly fresh sandFret, Gai srisnise tiny Usien Me geieni: 291s Ritanvese Seve Cos rinyeriey fe Burn contracture of many years di sx sear unl, san the paula itsell ix vont the thumb sind forefinger andl also bet w eStonsion of thi raise werd the poli Pavel between er fingers, sear btu prevents Full 2ENZ plastic was done between the Uiuanbs aad forefinger, One Z was done i the: forefinger. two Za were th midlle finger, anid the cananiigauses between the aniale saul rin, ated ving 4 were released by Zplasties, ‘The ultimate: testlt, has Town a useful hind 1. Fag, I, Scunannie Daawixe oF \ Misrnon + Txrerne prey Sha Ueixe Menu n Zs Te Three reverstd Zs with GH angles are ntarked ut bat instead « line continuous, there ie at area of tissue left agntentelead between the by the dotted lines. way be eite shirt or the distance nasy hee eeteiolora bless it lane seers 22 Type of elustire alter transposition of the fhips having the central 5. This, inde aeUe aR. Fie. 1h. Senew site De wise Stewiye Mictiion ar Ustse Mi cripn Zs 1s Z re shown, The slotted fives indiewte antoneled ror reversed yay eamnbinat ion desired, the select iat sab af available Hiss nsposition ab The triangular haps formed by che sates by the typedepwe 2 Ty Lineisintis = Fie 1. Taw srevniye ries Reni or Beas Darrin. Guarrise asZ oi Tet sron sind avilla after an estensive tied degree barn 2. The sain prurient, several vents kiler, after eveisions, Z plastics anil a shin graft im in thee suitienbital space, Phe Zs marked ia the asille, arnt forearm ata Fist are teh su longe Tine uf Sea pall Fron the axilla tor He avr 841 JOUN SEMGR Dts PRELIMINARY FIRE VV ELON 11 is advisable that every effort he made to put the patient itt the best possible physical condition by all availible methods before proceeding with operative work. ‘This is particulurly important on these patients beeause some of them: Il 2 Fra. 18, (ont) (From Davis, Pennsylvania Med. J.. April (988), 12 Same marks with: army extended showing the location of the Zs and the long Tine of sear pul 20 Miter the Zeplasties were alot and the triangular flaps had heen transposed, Note the sutures in place and the relaxation af the sear pull 1 2 hows the result alter S veins. ‘The left axilla is in ened eonudition, ting hand checking the elevation of the army. The lone ent racttare ‘atid wrist has heen pertnanently relieved by munitiple Z-ineisions with the b andl hetwee ratiaposit ion vor recovered from the depletion of the origin injury. [thas also been my custom form y operation at least six months has taken pice, until the sear bas fully matured and softe has heen improved by time and by physical therapy of one sort or another Many of these sear contractures are op Zeplasties fail on this account have ny years to del ter healing ed, and the eireukation ted. on much too carly, and frequentlyEVALUATION OF MERITS OF ZPLASFIO OPER TION Fig 1S TU Snevtise tH Use ors Mopiien % Phasne is cri Ren Ax vies or Sev Coxruacernes or Neck vse Laven Lae aural fal flaps sant A. way skin eral nes infor relaxation nf neck 1: Four yeane ayo. the patient wax severely shifted tothe neck fran the bark, elsewhere She “ition of lower lipron belt sie binding ser then anu chin wis exe al double eal in the sie wars ul thus relusing sear pull, Phe laver liane the le oe thie woul w oe Fri 16. Tuursmevrive cre Use or ZeDyasties iy Seeciaye Rea axveies seria cen ersies oF as Cuseevren Seve Betis wad. [0 is tightly adherent 19 underlying tis Lo Note the prominenes: of the sear id other typieal ehiaiges due ta aver 1 Adjawent Hisstex shuat atrophy and depression, 3 mhent with nudiann,. Thweulcerateal arm iseuverrd etl dey addi 2 Result af complete rseision of the ulceraten! hunsl sift relavations aise anal below by Zeineisions with transposition of Haps. Note the: heated won the filling of ee presse reas be the Ftc Henson3h 40 SSPAIGE DAVIS ANESTHESEN Either loca al anesthesia may be used. If local is used, nerve block infiltration of sear tissue unequestionabl fection, interteres with circulation and retards healing. When is used, Ehave had great satisfaction, during the last several Lor ge is preferable to infiltration + lowers its resistance to sthe ‘vous, with the intravenous use of pentothal-sodium supplement other, or evelopropane, as scoms wisest in the individual ease ene Thy ya-oxy gen. PREP AEATION OF THE SKIN ‘The skin is prepared hy any method in whieh you have confidence, La my work in recent years, [have been using ether and aleohol followed by several coats of tinchane of zephit OPERATIVE, FROCEDERE \ brief description of the simplest (ype of Z-plistie will be described for the benelit of these whe may be unfamiliar with the procedure. With the sear + lwillignt xveen in aleohol, ‘The central fine of the % is drawn along the mest prominent part of the web and the : re of the same length atre kid out parallel to exeh other at the ends of the central Tine on opposite sides, at about a GO angle fo the contral line, making the pattern ane atypical Z or reversed Z depending on the condition af the surrounding tisstes, The 60/ angle between bridle under tension, the propesed incisions ane marked out with the contial and arm fines of the Z has beon found to be the most satisfactory tical us the elasticity of the sear infiltrated surrounding skin, on the thickness of the flaps tion of the contraction and the contour of the reused, the arm lines naturally will not be parallel re made following the marked out Z pattern, two broad ar flaps are formed whose bases are opposite exch ather, ‘These angle for pr but angles between 69/ and 207 can be used depending on essential to viability and on (he lo part, 1 unequal angles When the incisions Dased tring Haps ave thoroughly mobilized, binding sear tissue beneath is removed as com pletely as possible, and all bleeding is carefully checked. 1 will then be found that the exttemitics of the central incision dew away from each other by sear pull, the central line becomes longer and the ave then tr nel are sutured without their outer margi ation and thei af the bases of the apposite flaps. The sutured wound is als Z-shaped, but the Zi turned through apprasimately 40, is elongated, and the central line of the original Z now lies transversely across the Tine of sear pull, Sometimes the tips oF the flaps become eyanotic after transposition, A few punetiare wounds with a pointed knife may relieve this. Gentle toward the bases with the finger Hips may be useful, Compresses saturated with cold sterile normal salt sobttio les herome blunted. The nsion with fine nylon se that tips touch the outer earners aire in approxi nay also help. “The flaps shonld be handled with small sharp hooks to avoid injury to the sear infiltrated tissues. Flaps should be thick enough to assure adequate eireulation,EVALUATION OF MERIPS OF Z-P1ASTIO OFFI TION a hut somotines the tips of dense sear flaps will slough, but this slough is usually on the suriice and docs little subsequent harayas far as recontyaetion is concerned DuSSING ted Lsoveral thicknesses of dry gsze The sutured wosnd is dressed with single thickness of gauze impre with 3¢¢ xerofarm ointment over whieh is ple and 2 sterile seasponge thoroughly wenng ot, of st mass af fine eatton waste ‘The whole is seeured imder even pressure by clasti« adhesive plaster and a woven age, Loose stitches are removed on the thin or fourth day: and st sim at. All stitches are ustually out hy the WOth day. Message is started alter three weeks and is continued for several months dressing is rep COMMENTS Limberg has demonstrated that the G0. angle between the central line af the Z ane the arms vill give the masimum relaxation, and it is vdvantayeons to use this angle, if possible. However length of the central fine and the sam lines, all of which should be equal, whatever angle is used, depends an the location af the cont the tissues. These fines vary from 5 mim, in certain areas, such as the angle of niles as low as 200 ean be nsed, The aetual ture sind on the condition of the eye, to 15. or 20 em, or more on the chest « should be used. then the length of the incisions making the Z should be short With the angles laid out properly. it ean be deter the incisions awe sbdominal wll, [smaller angles mined quite aceurately before nace the amount of relaxation, whieh will be obtained, “This ean be computed by taking the difference bet ween the length of the long and short Hologram made by projecting lines aeress the buses of the trinngles marked out hy the Z, the short diagonal heing the central fine of the Z, and the Jong diagonal being the distance between the distal ends of the sem lines The aetual amount of relaxation, whieh ean he obtained, varies between 50° aud 100%, of the length of the central fine of the Sear bridles, whieh are thin and reasonably soft, are utilized in making the triangular flaps. 1 the bridle is thiek sind rigid, then this portion is exeised, sane awn together with a few temporury sutures. “This sutured piral Hine of the ZW the sear is deeply grooved, the een- traf line of the % splits the groove lengthwise, sand the flaps sure formed. jus when a web is present When the % wrist or in the flaps should he short, Morestin was th The use of multiple Zs in long contracted sears is very helpful, ‘These Z may dlinyomals athe pi the margins are wound is used is the ¢ neision, either single or in series, is used on the fingers or on the ny region where there is seant tissue to bring in from the sides, then rst Lo use Zs in series, he in continuous series, or vat sear may he left between single Zs ar be= tions of the method, but multi ple Z-incisions are not being «tilized, ax vets much as they ean be, or should be, When Zs in series are used, the flaps must necessarily be short, Frequently whet the Z-incision is made and the flaps are mobilized, they naturally transpose them I into their 1 tween Zs in series. ‘There are numerous cont! selves sand w positions, Sometimes, however, it is necessary on3S JOUN SEMIGE DAVES recount of the unequal sear pull on the two sides of a sear bridle alter making the incision to adjust the flaps hy secondary ineisions in order to close the wound he final sutured wound may he a double Z cor some other irregular form of closure, In certain instances, the full amount of rolasation reqnived is not obtained hy the first Z-plastie. \iter sis months b oh nl the tissues have been softencd and ¢ ete, the same area ean he further relaxed hy s similar procedure, and this ¢ ary. This nal obtain the desired relaysttion, psc ilution improved by ay repeated. if nee particulely useful in growing children SUMAIVRY “By the use of Z-shaped incisions with the transposition of the triangular taps thus made, sitisfactory and elfective relavation can be accomplished in contracted sears with bridles or webs or grooves. Sear flaps whieh would otherwise have to, he exeised are utilized and are transposed and sutured in their new positions, thus diately closing the defect In other words, sear contractures are relieved, Dy the utilization of sear flaps. — In due time, after the relaxation is aceonyplished, the eh and becomes a usetul factor in the fi The method has for me greatly simplitied the problem of sear relaxation, sand prefer to use it, in preference to skin grafting or flap shifting from a distant part in practically every situation in whieh it ean be used, tractor of fhe sear itself changes, and i softens sud imprayes in appearance, result ‘bilities, it is diffieult 10 1 how much permanent relisation can be obtained by the Z-ineision with Unless one is familiar with the procedure and its po veal the utilization of thet ‘The operative procedure in suitable cases is simpler than other methods for relaxing sear contractures; tissues are successtully utilized whieh would otherwise be discarded: the appearance of the wbly with that of other methods: additional searring of unsearred areas is avoided ; contractions ean be permanently relived by this method which would be diffiewlt or impractical to correet by skin grafting, Puse the have used it on every part of the body with exeellent results wt could not de without it. [tis my considered opinion that the Z-ineision nxposition of flaps thus made is the most gencrally useful procedure for the relief of sear contractures, and for the readjustment of misplaced tissues, in the entire field of plistie surge spose (riangitbir sear flaps relayed by this method compares fave wision constantly and sat matter of und a with the try BIBLIOGRAPHY Sutiny of sear contractures by means of The Zor reversed Z-1y pe ig. New, WEBI, ps, ST Vier oof relasation inelsione when dealings with sears. Da, Mi Davis d. incision. An Davin. dS Th 19 Davis dS. aye Kirtowsks, No Phe theory aud practical use of the % ineision for the relief af'sear contractures, Mg, Sang. diane VER p HL Dexoxcriigens: Blépharaplastie, Bull, Soe. de Chir. de Paris, vol vii. p. 268, ISSH IN5 Livia. AON: Collection of Scientific Warks in Memory of Soh Niniversare of the Medivat Pict -grvahtate bnst tute fingered, fo HL ING, TSSS-1055 Lavina, X. No Skin Plistie with Shifting Trimngle Flaps. | Leningrad, ‘Traumatelogieal Tnstitiare. 1828, Sia) USVI, Hi: De la corrertion des flexion pertnanentes wal. Bape TE dtily TUE Suen, Feats) Z plistic operation. Military Surgieal Manual oa Plastic and) Masillo Tavial Surgery.) W, BeSumnders Co, Philadelphia EOP, A. Apeitl M figts. ete, Revue de Chir