I BRITISH JOURNAL OF PLASTIC SURGERY

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1 British Journal of Plastic" Surgery (t 998), 51, The British Association of Plastic Surgeons I BRITISH JOURNAL OF PLASTIC SURGERY Versatility of modified planimetric Z-plasties in the treatment of scar with contracture S. Suzuki, S. C. Urn, B. M. Kim, K. Shin-ya, K. Kawai and Y. Nishimura Department of Plastic Surgery, Postgraduate School of Medicine, Kyoto University, Kyoto, Japan SUMMARY. The planimetric Z-plasty proposed by Roggendorf provides elongation by excision of a pair of triangular pieces of tissue. The application of planimetric Z-plasties has been modified by making the vertical angle flexible, and making them continuous in the same or in opposite directions. Continuous planimetric Z-plasties in the same direction elongate an oblique contracture in the longitudinal direction. Continuous planimetric Z-plastics in an alternative direction elongate a disproportioned scar contracture in the longitudinal direction. Both techniques partially reduce unsightly scarring. Furthermore, they can be used in combination with V-Y-plasties. These modifications permit rational planing of the treatment of complicated scars with contracture. Z-plasty is one of the most common techniques used in plastic surgery. The execution of ordinary Z-plasty produces stereometric elongation.' Roggendorr4 reported a new version of the Z-plasty that produces planimetric elongation. The planimetric Z-plasty is useful for irregular scarring with mild contracture, since unsightly scarring can be reduced at the same time as contractures are released. Previously, we have proposed a new and comprehensive classification of V-Y-plasty and its analogues. 5 Combined use of planimetric Z-plastics with V-Y-plasty enables treatment of more irregular and longer scars with more complicated contracture. The planimetric Z-plasty is characterised by a vertical angle of 75 ~. The shaded portion is excised when the flaps are transferred. The longer lateral limb is twice as long as the shorter lateral limb, and four times as long as the shorter central limb. The longer central limb is as long as the longer lateral limb (Fig. 1). Its application is, however, limited to scarring where the degree of contracture is mild and equal in each direction. When the contracture is severe and the tensile strength is more marked in the direction of the longer central limb than that of the longer lateral limb, the longer central limb shrinks and becomes shorter than the lateral one immediately after incision with a scalpel and release of the contracture. As a result, they cannot be sutured to each other (Fig. 2, above). In order to make both lengths uniform after release of the contracture, a vertical angle more acute than 75 ~ is required according to the degree of the contracture. Therefore, we propose a new design of planimetric Z-plasty with a flexible vertical angle (Fig. 2, centre). In practice it is safest to prepare triangular flaps with slightly sharper angles than estimated to be required and to trim the excess tissue after transferring the flaps (Fig. 2, below). When the scar is wider and the skin tension in the transverse direction is less, more tissue can be excised by extended the planimetric Z-plasty (Fig. 3). In a d Figure t Planimetric Z-plasty reported by RoggendorP. The longer lateral limb (a) is twice as long as the shorter lateral limb (b), and four times as long as the shorter central limb (c). The longer central limb (d) is as long as the longer lateral limb (a). The vertical angle between the shorter lateral limb and the shorter central limb is 75 ~. planning, the width of excision is determined by checking that both corresponding sides picked up with forceps can easily be pulled together. Continuous planimetric Z-plasties Planimetric Z-plastics can be connected obliquely as shown in Figure 4, namely oblique continuous planimetric Z-plastics. Their execution produces planimetric elongation of an oblique contracture in the longitudinal direction. In the surgical planning, the shaded portions are designed on the scar to be excised. Though the vertical angles indicated by dotted lines are 75 ~, sharper angles are required according to the degree of contracture the same as with single planimetric Z-plasty (Fig. 5, left). When the scar is wider and the skin tension in the transverse direction is less, a modified design termed 363

2 364 British Journal of Plastic Surgery J. i f f Figure 3~Extended planimetric Z-plasty. When the scar is wider and the skin tension in the transverse direction is less, more tissue can be excised. A 7 D Figure 2--(Above) The original planimetric Z-plasty used where the contracture is severe. The longer central limb of planimetric Z-plasty shrinks and does not correspond with the longer lateral one after release of the contracture. (Centre) Planimetric-Z-plasty with flexible vertical angles. Though the vertical angles indicated by dotted lines are 75 ~, sharper angles are actually required according to the degree of contracture. (Below) Practical technique. It is rational to prepare triangular flaps with slightly sharper angles than the estimation and to trim the excess tissue after transferring the flaps. r Figure 4--Oblique continuous planimetric Z-plasties. extended continuous planimetric Z-plasties is applied to excise more tissue (Fig. 5, right). Though this design partially resembles W-plasty 6-8 it differs from it with respect to the effect on elongation. When the scar is distributed disproportionally or irregularly, planimetric Z-plasties can be continued in an alternative direction as shown in Figure 6, left. Though trapezoid flaps are designed wider than the size of the trapezoid regions to be cut, the defects produced by releasing the contracture following cutting the trapezoid scars become equal or rather wider than the flaps to be inserted. Therefore, angles sharper than 75 ~ are required, according to the degree of contracture, in the preparation of alternative continuous planimetric Z-plasties, similarly to oblique continuous planimetric Z-plasties (Fig. 6, right). It is a matter of course that both oblique continuous and alternative continuous methods can be mingled. Recently, we proposed a new comprehensive classification of V-Y-plasty and its analogues based on the selection of two items; that is, how to facilitate the advancement flap and the number of V flaps (Fig. 7). 5 J r Figure ~-(Left) Practical applications of oblique continuous planimetric Z-plasties. Though the vertical angles indicated by dotted lines are 75 ~ sharper angles are actually required according to the degree of contracture. (Right) Extended oblique continuous. planimetric Z-plasties. When the scar is wider and the skin tension in the transverse direction is less, more tissue can be excised.

3 Modified planimetric Z-plasties for scar contracture 365 J i Instead of Burow's triangle excision, it is possible to use modified planimetric Z-plasties (Fig. 8). The new comprehensive classification is convenient in operations to release scar contracture because the position and the size of the skin excision can be designed freely according to the shape of the scar and the degree of contracture. Carefully preplanned combination of planimetric Z-plasties with V-Y-plasties would seem to be the most rational approach to the treatment of multiform scars with complicated contractures. Y Figure ~Alternative continuous planimetric Z-plasties. Original design (left) and practical design (right). Case reports Case 1 A 6-year-old girl sustained crush injury of her left foot 14 months previously, leaving hypertrophy of the scar (Fig. 9A). The hypertrophic scar did not sink with pressure therapy employing a sponge because of latent contracture. Oblique continuous planimetric Z-plasties were planned (Fig. 9B). After skin incision, release of the contracture and ~Maneuver in Number ~each arm of V flap Burow's triangle excisions Inverted Burow's triangles excisions Transposition flaps Combinations Ordinary ~,~ V-Y-plasty [ (=, V-W-Plasty) \Y/ N {/ (Five-Z-plasty) OooO,e V-Y-plasty Na A (V-W-plasty) (V-M-plasty) (Seven-Z-plasty) Figure 7 Comprehensive classification of V-Y-plasty and its analogues based on the selection of two items, that is, the number of V flap and the manoeuvre in each arm to/:acilitate the advancement of V flap? Figure 8 An example of combined use of planimetric Z-plasties with V-Y-plasty.

4 366 British Journal of Plastic Surgery Figure ~ ( A ) Hypertrophic scar with latent contracture on the left foot of a 6-year-old girl. (B) Operative design of oblique continuous planimetric Z-plasties. (C) Appearance after skin incision, release of contracture and partial excision of hypertrophic scar. (D) Immediate postoperative appearance. (E) Seven-month postoperative appearance. partial excision of the hypertrophic scar (Fig. 9C), the transferred flaps were sutured (Fig. 9D). The remaining hypertrophic scar gradually became flattened after the second operation. Seven months after operation, both functional and cosmetic improvement were impressive (Fig. 9E). continuous planimetric Z-plasties were performed in the proximal wing instead of Burow's triangle excision (Fig. t0c). The 8 months postoperative appearance showed both functional and cosmetic improvement (Fig. 10D). Case 3 Case 2 A 40-year-old woman had a hypertrophic scar with contracture due to a burn on her right wrist and distal forearm (Fig. 10A). Because the contracture line was almost longitudinal on the wrist but oblique on the forearm, the combined use of V-Y-plasty with modification of extended continuous planimetric Z-plasties was designed (Fig. 10B). V-Y advancement was executed at the wrist crease, and an inverted Burow's triangle excision was performed in the distal wing and oblique A 5-year-old boy sustained burns of his right dorsal foot and lower leg, which resulted in hypertrophy and contracture of the scar (Fig. l la). V-Y-plasty with a pair of inverted Burow's triangle excisions was performed on the medial malleolar region, and fusiform scar excision with small Zplasty was performed on the lower leg (Fig. 11B). Fifteen months later (Fig. l lc), the remaining hypertrophic scar was treated by continuous planimetric Z-plasties in which both oblique and alternative connections were mingled.

5 Modified planimetric Z-plasties for scar contracture 367 Figure 10 (A) Hypertrophy and contracture of scar on right wrist and forearm of a 40-year-old woman. (B) Operative design of combination of V-Y-plasty with planimetric Z-plasties. Inverted Burow's triangle excision is used on the proximal wing of V-Y-plasty, and a modification of extended continuous planimetric Z-plasties is used on the proximal wing. (C) Immediate postoperative appearance. (D) Eight-month postoperative appearance. (Fig. 11D, E). Six months after the second operation, both functional and cosmetic improvement were excellent (Fig. llf). Discussion Though contractures must be elongated prior to the excision of scars, it is rational to try to reduce unsightly scarring when the contractures are released. Fusiform scar revision 6 and W-plasty ~'s are effective for most unsightly linear scars but not for many wide and/or hypertrophic scars? It must be considered that hypertrophic scars that do not seem to be associated with contracture sometimes have latent contractures. Fusiform scar revision with multiple Z-plasties may be effective for scars with contractures, but produces dog ears and a bulging effect. Furthermore, Z-plasties may not be executed in cases with excessive skin tension after closure of the skin defect following removal of the scar tissue. RoggendorP reported that since execution of traditional Z-plasties produces stereometric elongation, they are very effective when carried out on webs or clefts. In contrast, when they are carried out on a plane surface, they are not only less effective for plani- metric elongation but also produce a bulging effect. It is true that this bulging effect is partly suppressed by skin elasticity, tension forces and the changes in skin tension following the release of contractures, but the bulging effect emerges distinctively in inelastic skin. Roggendorf calculated that the efficacy of planimetric Z-plasty exceeds that of stereometric Z-plasty by 28%, though the elongation of scar contracture is less. In clinical cases, it is, however, difficult to anticipate the elongation effects well because each scar has different characteristics. Nevertheless, it is advantageous that some parts of an ugly scar can be excised by execution of planimetric Z-plasties. Planimetric Z-plasties are effectively used in the treatment of irregular scars with mild contracture. Oblique continuous planimetric Z-plasties designed in the same direction are especially effective for a long contracture oblique to the longitudinal line. This design appears to be very similar to the step-plasty advocated by Ship et al? Step-plasty, however, is effective only for a narrow scar without contracture, or even for a scar with contracture that can be eliminated by revision of the scar only. The original design of Roggendorf is applied in cases where the degree of contracture is even at each part of a wide scar. In most cases, however, the degree

6 368 British Journal of Plastic Surgery Figure ll--(a) Hypertrophyand contracture of scar on dorsum of right foot and lowerleg of a 5-year-oldboy.(B) Appearanceimmediately after the first operation. (C) Fifteen-monthpostoperativeappearance. (D) The operativedesign of continuousplanimetricz-plasticsin which both obliqueand alternativeconnectionsare mingled. (E) Appearanceimmediatelyafter the secondoperation. (F) Appearance 6 months after the second operation. of contracture is not even and is most marked on the centre line. Therefore, in those cases, vertical angles should be designed to be sharper than the original angle of 75 ~ according to the degree of the contracture. As mentioned previously, it is practical to design the sharper vertical angles by overevaluating the contracture to a small degree. When it is difficult to estimate the degree of the contracture, it may be more practical to elevate long narrow triangle flaps without any excision of tissue and to remove the excess cicatric tissue after releasing the contracture and transferring the flaps. In such cases, it is impossible to use the double-vested principle with planimetric Z-plastics as advocated by Roggendorf? The sharper the angles become, the poorer the blood circulation of the flaps becomes. Since inadequate blood supply is the most common cause of flap necrosis, 9 the flap must be dissected scrupulously just on the fascia to maintain adequate blood circulation. Alternative continuous planimetric Z-plastics seem to be effective in scars distributed disproportionally or irregularly with longitudinal contracture. Longer and more complicated scars can be accommodated by mingling both connections. It is a matter of course that when the scar is wider and the skin tension in the transverse direction is less, extended designs can be applied to excise more tissue in such plastics. We have proposed a new comprehensive classification s of V-Y-plasty and its analogues such as V-M -1~ V-W-', five-z-plasty 12 and seven-z-plasty ~3, based upon a new concept, the appropriate use of Burow's and inverted Burow's triangle excision and other cri-

7 Modified planimetric Z-plastics for scar contracture 369 teria. V-Y-plastics based on the new comprehensive classification are also convenient in operations to release scar contracture, because the region and the size of skin excision can be freely designed. Burow's triangle excision, inverted Burow's triangle excision and transposition flaps may not be appropriate for long running scars with contractures. In such cases, it is useful to use modified planimetric Z-plastics instead of Burow's triangle excisions. The directions of both wings of the V-flap are flexibly determined, and the apex of the V-flap is effectively designed at the inflected portion of the contracture line. In the treatment of scars and scar contracture, the most appropriate design must be selected from the many options including modified planimetric Z-plastics, various V-Y-plastics and so forth, according to the shape of the scar and the degree of contracture. Excision of the most unsightly regions should be planned, and contractures released as completely as possible before excision of the scar. References 1. Limberg A. The Planning of Local Plastic Operations on the Body Surface: The Theory and Practice. Trans. by S. A. Wolfe. Boston: Collamore Press, Roggendorf E. Planimetric elongation of skin by Z-plasty. Plast Reconstr Surg 1982; 69: Roggendorf E. The planimetric Z-plasty. Plast Reconstr Surg 1983; 71: Roggendorf E. Comment on chapter 12. In: Goldwyn, RM (Ed.), The Unfavorable Result in Plastic Surgery. Vol. 2. Boston: Little, Brown, 1984, pp Suzuki S, Matsuda K, Nishimura Y. Proposal for a new comprehensive classification of V-Y plasty and its analogues: The pros and cons of inverted versus ordinary Burow's triangle excision. Plast Reconstr Surg 1996; 98: Borges AE Chapter 12. Unfavorable results in scar revision. In Goldwyn, RM (Ed.). The Unfavorable Result in Plastic Surgery, Vol. 2. Boston: Little, Brown, 1984, pp Borges AE W-plasty. Ann Plast Surg 1979; 3: Ship AG, Weiss PR. Colloquium: W-plasty. Ann Plast Surg 1979; 3: Suzuki S, Isshiki N, Ogawa Y, Goto M, Hayashi O. The minimal requirement of circulation for survival of undelayed and delayed flaps in rats. Plast Reconstr Surg 1986; 78: Alexander JW, MacMillan BG, Martel L. Correction of postburn syndactyly: An analysis of children with introduction of the V-M-plasty and postoperative pressure inserts. Plast Reconstr Surg 1982; 70: Koyama H, Fujimori R. V-W plasty. Ann Plast Surg 1982; 9: Hirshowitz B, Karev A, Rousso M. Combined double Z-plasty and Y-V advancement for thumb web contracture. Hand 1975; 7: Karacaoglan N, Uysal A. The seven flap-plasty. Br J Plast Surg 1994; 47: The Authors Shigehiko Suzuki MD, Associate Professor Soon Chan Um MD, Staff Member Byung Mook Kim MD, Staff Member Kayoko Shin-ya MD, Staff" Member Katsuya Kawai MD, Instructor Yoshihiko Nishimura MD, Professor Department of Plastic Surgery, Postgraduate School of Medicine, Kyoto University, Shogoin, Sakyo-ku, Kyoto , Japan. Correspondence to Shigehiko Suzuki. Paper received 26 November Accepted 9 April 1998.