the relaxation of scar contractures by means of t z-, or...

(~otwrighl, ~) 1966 I)5’ The Williams & Wilkins

JOHN STAIGE DAVIS, M.D. / Baltimore, Maryland

The Relaxation of Scar Contractures by Means of tZ-, or Reversed Z-Type Incision:* Stressing the Useof Scar Infiltrated Tissues

The purpose of this paper is to call atten- shortening of the tissues in the direction of

tion to a method by which flaps of scar tissue the contraction and usually excess or fullness

or of tissue considerably infiltrated with scar on both sides of the contracted band.

may be used in relaxing scar contractures. .The utilization of such tissue for the relaxa-

History

tion of scar contraction is not generally un- A review of the literature was made byderstood although the Z-type incision by ,~__~. He--and myself in order towhich it is accomplished is an old procedure, detei-m~,~ossible, who first devised the

It is a good plastic principle to remove all Z-type incision and transposed the flaps thusscar tissue before attempting any sort of re- made. As far as we can find, the earliest de-construction and this should be carried out scription of this incision with the transposi-whenever possible. However, there are many tion of the flaps thus made was by Denon-contracted scars where complete excision of villiers in 1856, who apparently developedthe entire scar is impracticable on account of the procedure in steps. He used it success-its extent and location. In these instances, fully for the relief of ectropion of the outerunless skin grafting or flap shifting from a third of the lower lid. This type of incisiondistant part is done, it is necessary to utilize may have been used even before Denonvil-scar or scar-infiltrated tissues, and often a liers, but we were unable to find an earliergreat deal can be gained and much relief report.given by the proper use of such tissues. Szymanowski, in his book published in

In order to utilize flaps of scar-infiltrated 1870, illustrated the use of a similar incisiontissue some manoeuvre must be carried out for the relief of a deviation of the angle of

which will relax the contracted band and mouth, so the method was well known tobreak the line of scar tension. In suitable him. Pidchaud reported in 1896 the use ofcases, this may be accomplished by the use a modified Z-type incision for the restora-of the Z, or reversed Z, or staggered Z, or S, tion of the axilla and for the relief of scaror reversed S-incision as one may choose to contractures in other regions. He stressedcall it. the utilization of scar-infiltrated tissues and

The transposition of the flaps thus formed apparently made considerable use of the

is made possible because there is always method. Berger and Bonset in 1904 used a

T.he editors and publishers of Plastic & Recon-Z-incision with the transposition of flaps for

structire Surgery acknowledge with thanks the per- the restoration of an axilla which had beenmission of the J. B. Lippincott Co., publishers of obliterated by scar contracture. Berry andAnnals o~ Surgery, in which this classic of Dr. Legg in 1912 employed the Z-incision forDavis originally appeared, to reproduce it here. adjusting the vermilion border in a

* Read before the American Surgical Associa-tion, San Francisco, California, July 1, 1931. repaired congenital cleft of the lip.

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,eans of theing the Use

in the direction ofily excess or fullnessxacted band.

ature was made bymyself in order to

zho first devised the;posed the flaps thusfind, the earliest de-: with the transposi-:ade was by Denon-

He used it success-tropion of the outer[’his type of incisionen before Denonvil-~le to find an earlier

book published in: of a similar incisionttion of the angle ofwas well known to

. in 1896 the use of;ion for the restora-~or the relief of scarregions. Henfiltrated tissues andiderable use of~nset in 1904 used atsposition of flapsxilla which had beenntracture. Berry~d the Z-incision for~ border in aft of the lip.

Vol. 37, No. 4 / CLASSICS 361

FIG. 1. Illustraling the Z and reversed Z-type incision. In the diagrams the length of thecorresponding lines making the incisions are the same, although they appear to vary con-siderably on account of the tilt of the figure. The longest line of the Z may be in any di-rection in which the scar contracture happens to be and the arms of the Z will necessarilychange their direction to conform with this. In each of the diagrams after the blunt-pointedflaps outlined by the incisions are raised and transposed,, the tip X is sutured into the angleformed at B, and the tip Y into that at A. The: line AX being sutured to the BY.

McCurdy in 1913, in 1917, and again inI924 wrote on the Z-plastic method and em-phasized the importance of implanting in thecentre of the wounds flaps of normal skinand shifting the burn scar to the ends of thefield of operation. Morestin in 1914 describeda method of relaxing a permanent flexion ofthe finger due to scar tissue by the use of amultiple Z-incision. An incision was madealong the rim of the scar bridle dividing itinto two leaves, then from this central in-cision several lateral incisions were madeforming a number of flaps. The finger wasstraightened and the flaps were drawn intothe angles formed by the incisions made onthe opposite side. In this way the scar bridlewas released and the scar pull broken by avery irregular closure. This procedure waswell illustrated diagrammatically by Rahn ini923.

Frank S. Matthews in 1915 illustrated amodified Z-type incision for liberating a bandof scar tissue which was quite similar to that

used by Pi6chaud, but was devised withoutknowledge of Pidchaud’s work. Pieri in 1919illustrated the application of a modified Z-type incision with the transposition of scarflaps in deepening the commissures on badlymutilated hands. Davis illustrates the Z-typeincision several times in his book on PlasticSurgery, published in 1919, and also in apaper on Arm-Chest Adhesions in 1924. Heagain demonstrated the use of this methodon the face and neck in 1930 in the Sectionon Plastic Surgery in Dean Lewis’ System ofSurgery.

Steindler in 1923 illustrated his idea ofPieris operation in relaxing a scar web on thethumb by the use of a modified Z-type inci-sion and also showed an excellent illustrationof the relaxing of a web between the thumband forefinger by a Z-incision. Bosch Aranain 1925 wrote on the use of a modified Z-incision with the transposition of flaps in thephalangization of the first metacarpal. C. N.Dowd in 1927 published an article on the use

362 PLASTIC & RECONSTRUCTIVE SURGERY, April 1966

FIG. 2A. Demonstrating the Z-type incision which we have fotmd most generally usefulwith the transposition of flaps. A piece of chamois skin was placed on a frame and the centralportion was stretched snugly between two tbumb tacks to represent a scar bridle. Note the"scar bridle" CD which projects quite markedly. Along the centre of this bridle is the longestline of the Z; the arms of the Z, DB and AC, are marked out so that the tips of the flaps Xand Y will be blunt. A portion of the skin has been dottedin order to show contrast after theflaps are transposed.

F~G. 2B. Illustrating the shrinkage of the flaps after the Z-incision has been made. Theincision has been made along the Z previously marked out ACDB and the flaps X and Ylie completely separated and theoretically undercut. Note the gaps along the arms of the Z,which in a real scar are often much more marked, as naturally the scar pull would be greaterthan that in a piece of chamois skin.

FIG. 2C. Illustrating the transposition of the flaps and breaking of the scar phil. Note theposition of the flaps after transposition. The flap X made in the dotted portion of the skinbeing drawn into the defect made by raising the flap Y in the undotted portion and vice versa.The tip of the flap X being sutured to the point B and the tip of the flap Y being sutured tothe point A. Note the approximation of the edges ot~ the flaps with horsehair sutures, theedge of AC of the dotted flap X being sutured to the edge BD of the undotted flap Y. Thebreaking of the "scar pull" and the relaxation of the bridle can be well seen. Note the increasein the distance between the thumb tacks as the relaxation obtained by the transposition of theflaps made it necessary to move them outward to the edges of the frame; also that the sutureline is the staggered reverse of the original incision.

Of contracted scar whose contracted portionsinks into a groove and has a deep attach-ment instead of projecting as a bridle or web.This latter type of contracture is, of course,much less commonly found.

I usually choose a general anaesthetic, se-lected to suit the individual case, but if localanaesthesia is preferred for any reason, nerveblock should be used, as infiltration of scar.tissue is inadvisable on account of its pre-carious blood supply. The technic, which isquite simple, is as follows: Prepare the areato be relaxed by the method in which youhave confidence. Mark out the proposed in-cision carefully with 5 per cent. brilliantgreen in alcohol on the contracted area, whenthe scar is under tension. The longest line ofthe Z is laid along the most prominent por-

of the Z-incision in the repair of cicatricialcontractures of the neck. Babcock in 1928illustrates nicely the use of the Z-type inci-sion in what he describes as Pieri’s operationfor the relief of a web between the thumb andforefinger.

It is probable that the Z-type incision hasbeen described in other articles which wehave not mentioned, but there is no questionbut that it was used over seventy years ago,and that it has been frequently rediscoveredand described as a new procedure.

Technic

It is with those contractures which presenta prominent bridle or web with which wemost frequently have to deal, but the methodis also very effective in dealing with the type

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as a deep attach-is a bridle or web.ture is, of course,

al anaesthetic, se-I case, but if localany reason,

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: Prepare the areaaod in which yout the proposed in~~er cent.tracted area, whenl’he longest line~st prominent


Illustrating the use of the Z-type incision on the neck.Fins. 3A. and 3B. Old burn scar of neck. Note the width of the bridle and the extent of the

scar. In this case a Z-shaped incision was made and the flaps were transposed.Fro. 3C. The rcsnlt of this relaxation after Iwelve days can be seen. Note the complete

relaxation of the scar bridle, the relief of tension and the satisfactory utilization of s~ar in-filtrated flaps. ,.

tion of the bridle or web, and the arms of theZ arc marked out on opposite sides of thecentral line, making the pattern a Z or re-versed Z depending on the condition of thesurrounding tissues. The arms begin at eachend of the central line on opposite sides andare carried outward and downward, or out-ward and upward, as the case may be, as faras seems necessary, usually ending at aboutthe level of the middle of the central line. Theincisions are then made following the pat-tern, and the two flaps thus formed are under-cut and mobilized and are transposed, thetip of one flap being sutured into the anglefound at the outer end of the "arm" incisionforming the other flap, and vice versa. Theirregular wound is then closed with horsehairsutures, and is dressed with a single thicknessof gauze impregnated with 3 per cent. xero-form ointment over which is placed a moiststerile seasponge applied under even pres-sure, and secured with adhesive plaster anda bandage. Finally the part is immobilized.When dealing with a grooved scar, the sameprocedure is carried out except that the longline of the Z splits the groove lengthwise andthe flaps are formed just as when a bridle ispresent.

Comments

The treatment of burns and other exten-sive surface lesions which frequently result

in contractures will not be considered exceptto say that every effort should be made toinduce rapid healing with the part in properposition, as in this way excessive scar forma-tion and subsequent contractures may beminimized. Some contractures may beavoided by very careful treatment of theoriginal lesion, but my experience has beent]hat contractures may and will occur in spiteof every precaution. These contractures arefound most frequently in the axilla; wherethe extremities join the trunk; around jointsand on the neck and face.

As a general rule, it is advisable to delayoperative work on contracted scars until na-ture, assisted by massage and passive motion,has had time to do all that she can. A fewmonths will make a great deal of differencein the condition of the scar and of the sur-rounding tissues and by making haste slowlyuseless operations may be avoided, so thatwhen we finally come to operate we will beable to see the scar as it eventually will beand can take steps to properly correct it.

This brings up the importance of the ageof the patient with a scar contracture. Duringthe growing period scar contracture, if notrelieved, may materially interfere with thegrowth of the bony structure as well as of theadjacent soft parts and may cause changesand deformities, which can never be com-pletely remedied. However, if the contracture


Illustrating the use of the Z-type incision for the relief of scar contracturesof the fingers.

Fro. 4A. Shows the hand of a child with contraction of the index, middle and ring fingersfollowing a severe rope burn. The middle finger was so badly burned that new tissue had tobe supplied after straightening the finger, by means of a measured whole thickness graft. Thering and index fingers were not grafted but were relaxed by Z-type incisions.

FIG. 4B. Result five months later. Note that the result following the Z-type incisions is assatisfactory as that following the whole thickness graft. All the fingers can be extended andfunction is fully restored.

is relieved, say six months after healing iscomplete, which gives time for preliminarymassage and other therapeutic measures,bone and soft part changes usually readjustthemselves. In adults, on the other hand,while the question of interference with bonegrowth does not have to be considered, wemust bear in mind the atrophy of disuse andin cases of long standing care must be takennot to cause fracture when manipulating apart, such as the arm, after relaxation. It hasbeen my experience also that it is better notto operate on an adult until six months haveelapsed after healing is complete, in order totake advantage of improved conditions madepossible by massage and stretching.

In many cases the flaps available are madeup entirely of scar tissue. Only occasionallydo we find a bridle or web with even com-paratively normal skin running up to the con-tracted band, and in these instances the cir-culation of the flaps is naturally much moresatisfactory. The ideal condition, of course,would be to break the scar pull with flaps ofnormal tissue.

If the scar bridle is fairly thin and soft, itis split its full length into two leaves, whichare utilized as part of the flaps. If on the

other hand the scar bridle is thick and hardand is unpromising for use, then an elongatedellipse of tissue including this portion is ex-ciised and the edges are brought together witha few temporary sutures. The Z or reversedZ is then marked out, the incisions are madeand the flaps are raised and transposed inthe usual way.

The lines marking out the prospective flapsmay vary considerably in shape and directionaccording to the pull of the contracture andthe type of the surrounding tissue, and in thisway many modifications of the Z-incisionmay occur. In planning flaps care must betaken to utilize the best available tissue andfor this reason the incision may be a Z orreversed Z depending on whether there is lessinfiltration with scar to the right or to the leftof the line of contracture and above or belowa transverse mark dividing this line. In otherwords, if the tissue is less infiltrated with scarin the upper left quadrant and in the lowerright quadrant (facing the patient), then theZ is used and vice versa. The contractionpull of the scar on the two sides of a centralbridle may be quite different and conse-quently after the flaps.have been formed andundercut, they may be drawn entirely away

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9rospective flapspe and directioncontracture andssue, and in this!the Z-incision;s care must beilable tissue andmay be a Z~ther there is lessght or to the lefti abovehis line. In.ltrated withlnd in theatient), thenThe c(;ides of a:ent and9een formedvn entirely away


Illustrating the use of several Z-type incisions for the relief of a long scar contracture.Fro. 5A. Burn scar contracture of the thigh and leg. Dtiration, seventeen years. Note the

thickened bridle in the popliteal space which has never healed. Also the extent of the scaron the thigh and leg. The patient is unable to fully extend the leg, and has the sensation oftightness and constant drawing. She tires easily and has considerable loss of function.

FIG. 5B. Result two months later. The ulcerated portion of the scar in the popliteal spacewas excised and the edges were drawn together with temporary sutures. Then the Z wasmarked out, the incisions made and the flaps transposed. Three other Z-incisions were madein different portions of the scar and good relaxation was obtained. The patient can now walkwithout discomfort and has entirely lost the sensalion of tightness on the back of the leg andthigh. It may be necessary subsequently to relax the depressed scar on the inner side of thethigh.

from the anticipated position. In these in-stances, readjustments by properly placedsecondary incisions may be necessary andmust be carried out before the desired relaxa-tion can be obtained and the wound closed.

In a wide scar bridle, relaxation may besecured in more than one place, or in morethan one direction by the use of the Z-inci-sions. In long contractures, say from thebuttock to the ankle, I have used three orfour of these relaxations at one operation,before the contracture was completely re-lieved. This was possible as there was suffi-cient tissue between the selected areas to pre-vent interference with the circulation of theflaps already made and transposed.

Should scar bands be found deep in thetissues after raising the flaps, they should beeither divided or better still removed, and alltension relieved before the flaps are trans-posed and sutured. The flaps should be han-dled with small sharp dural hooks to avoidbruising. The sutures should be of horsehair

threaded on fine half-curved needles and onlyenough should be put in to approximate theedges. All tension on the ffap should beavoided.

The tips of the flaps should be made bluntinstead of pointed, as when thus made theyare much less liable to slough. Even if the tipsof the flaps do slough, which sometimes hap-pens when there is much scar, we often findthat sufficient relaxation has been accom-plished and that soon the defect left by thesloughing tips will be filled up and the scarwill become smooth again. It is advisable tohave the flap as thick as may be, includingsc,me subcutaneous fat if it is present, in or-der to conserve the circulation. Should thetips of the flaps become bluish after a fewhours of the sponge pressure, it is advan-tageous to apply continuous compresses sat-urated with normal salt or boracic-acid solu-tion.

I have used the Z-incision for the relief oftension in fairly broad tight scars with con-


Illustrating the use of the Z-type incision for the relief of scar contracmresin the axilla, cubital space and at the wrist.

Fro. 6A. Scar contracture following a burn. Note the involvement which extends from thechest to the hand. Some operative work had been done elsewhere before the patient cametinder nay care.

FIG. 6B. Result, after two weeks, of relaxation at the wrist and in the cubital space, iiiii~:o ’Fro. 6C. The same arm after two years. During the interval further relaxation had been

done on the axilla. Note the improvement in extension at the elbow and wrist.F~GS. 6D. and 6E. One week later the final contracture in the axilla was relaxed by a Z- ,",

tncision which can be seen with the stitches in place. The wrist and cubital space were alsorelaxed by Z-type incisions made in scar partially relaxed by similar incisions done two yearspreviously. Note that full extension is now possible and that an excellent axilla has beenformed.

siderable success. In the relief of congenitalwebbing of the neck, the Z-incision with thetransposition of flaps is the method of choice.It is also most useful in deepening the com-missures in incomplete syndactylism with awide web.

When the Z-incision is used on the wrist,

the flaps must necessarily be fairly short andit is better to relax at two different pointsrather than to attempt the formation of flapswhich are too long. This may also be said offlaps about the fingers. The relaxation of ascar web, or of a congenital shortening of theweb between the thumb and forefinger can

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Voh 37, No. 4 / CLASSICS 367

Illustrating the Z-type incision, used several times in the same area,for relaxing scar contraction.

Fins. 7A. and 7B. Extensive very thick burn scar of neck, chest and axilla. Note the extentand character of the scar.

FIG. 7C. Result after eight months of the first use of the Z-type incision on neck and axilla.Note the difference in the character of the bridle and how much thinner and less dense it is.The Z-type incision was again used on the neck and in the axilla.

often be easily relieved by a Z-incision withthe transposition of flaps.

The Z-incision can be used for the reliefof long contractures such as those in theaxilla, and also very satisfactorily in shortones, such as we often find around the noseand ears. This gives an idea of the flexibilityof the method.

In marked contractures of long standing

with shortening of the underlying tissues, asmuch as possible should be gained at the firstoperation with the Z-type incision and sub-sequently the same procedure may be carriedout in the same area after the deeper tissueshave had time to stretch and soften. Thecharacter of the scar itself often changes ma-terially, for the better, after relaxation.

The Z-type incision may also be used most

he major por-

,s used for thea place.md axilla.

acision the scar isfaction is relievedps which are usu-scar-infiltrated tis-break the line of

after transposition~1 way, the reverseis difficult to rea-

Vol. 37, No. 4 / CLASSICS

lize how much permanent relaxation can besecured by the use of scar-infiltrated tissueand this type of incision, until one is familiarwith the procedure and its possibilities. Themethod has simplified the handling of manycases which would otherwise have had toundergo a much more extensive and seriousoperative procedure in order to obtain re-lief.

The Z-type incision has been of great useto me when dealing with contractures in allparts of the body. I have utilized it in a largeseries of cases and consider it one of themost generally useful manoeuvres in my ar-mamentarium.

REFERENCES

Arana, Bosch: Phalangization of the first meta-carpal. Surg., Gyn. and Obst., vol. xl, p. 859,June, 1925.

Babcock, W. W.: A Text-book of St~rgery. W. B.Saunders Co., Phila., p. 1294, 1928.

Berger, P., and Bonset, S.: Traitments de d6forma-tions cons6cutives aux cicatrices vicieuses del’6paule. Clair. orthop., p. 180, Paris, 1904.

Berry, J., and Legg, T. P.: Harelip and Cleft Palate.P. Blakiston’s Son & Co., p. 148, Philadelphia,1912.

Davis, J. S.: Plastic Surgery. P. Blakiston’s Son &Co., pp. 275, 372, 546, 547, 553, 632, 633,Phila., 1919; Arm-chest adhesions. Arch. Surg.,vol. viii, pp. 1-23, January, 1924; ContractedScars, Section on Plastic Surgery, Practice ofSurgery. Dean Lewis, vol. v, p. 108, Ch. 8,1930.

Denonvilliers: Bl@haroplastie. Bull. Soc. de Chit.de Paris, vol. vii, p. 243, 1856-1857.

Dowd, C. N.: Some details in the repair of cicatricialcontractures of the neck. Surg., Gym andObst., vol. xliv, p. 395, March, 1927.

Matthews, F. S.: Johnson Operative Therapeutics,vol. iii, p. 380, 1915.

McCurdy, S. L.: Z-plastic surgery. Surg., Gyn. andObst., vol. xvi, p. 209, February, 1913; Z-plastic surgery. Intern. I. Surg., vol. xxx, p.389, December, 1917; Correction of burn scardeformity by the Z-plastic method. J. Bone andJoint Surg., vol. vi, No. 3, p. 683, July, 1924.

Morestin, H.: De la correction des flexions perma-nentes des doigts, etc. Revue de Chir., vol. L,p. 1, July, 1914.

Pifichaud, T.: Deux observations de symphyse desmembres ~. la suite de brulfires &endues. Rev.d’orthop., vol. vii, p. 81, March, 1896.

Pieri, G.: Ricostruzione del poltice dal monconedella folange basale, La Chit. degli organi dimovimento, vol. iii, p. 325, 1919.

Rahm, H.: Die morestin’sche Plastik bei Finger-

369

kontrakturen, Beitrg. z. Kiln. Chit., vol. cxxvii,No. I, p. 214, 1922.

Steindler, A.: Reconstructive Surgery of the UpperExtremity. D. Appleton & Co., p. 119, NewYork, 1923.

Szymanowski, J.: Handbuch der Operativen Chi-rurgie, pp. 262-278, 1870.

Editorial Comment

Dr. John Staige Davis is recognized as oneof the great pioneers in American plasticsurgery. His preliminary training in generalsurgery prepared him well to develop plasticsurgery in Baltimore at the Johns HopkinsHospital. His was the first textbook of plasticsurgery in this country, published in 1919under the title Plastic Surgery: Its Principlesand Practice. ~ During his lifetime he mademany contributions to our specialty, one ofwhich, describing the well-known Z-plastictechnique, is reproduced here.

Although Davis considered the techniqueapplicable to scar contracture, there are to-day many who would doubt the indicationsfor its use for tissue relaxation where defi-ciency of skin exists. The tight web in onedirection can be relaxed by a Z-plastic butonly at the expense of slackness in the axisat a 90° angle to it. In this circumstance, itis considered preferable to replace the miss-ing skin by skin grafts rather than by localtissue shifts. However, the method of Z-plasty, in addition to the uses described byDavis, has found increasing popularity andusefulness in reorienting misaligned scarsand in obscuring a conspicuous linear scarby changing it to one with an irregular con-figuration.

Of interest in the diagram of the methodis the squaring off of the apices of the flaps,a refinement not stressed in other descrip-tions. The sharply tapered apex of the flapis often difficult to manage but is minimizedby blunting the point.

Another contribution by Davis was thepopularization of the small deep graft. Thisgraft, analogous to the Reverdin graft, wasa thicker patch of skin involving almost thefull thickness of the dermis. It was describedmany years before the revolutionary contri-bution by Blair and Brown of the split-thick-ness graft. The use of the Davis small deep

370PLASTIC & RECONSTRUCTIVE SURGERY, April 1966

graft gave to the general surgical public amethod of closing extensive raw surfacessafely and effectively. Although the cosmeticpicture both of the donor site and the re-cipient site left much to be desired, manylives were no doubt saved, and the days ofdisability shortened by the popularization of.this method.

John Staige Davis was a third generationof physicians in his family, and his son con.-tinues the plastic surgical tradition in Balti-

more. Dr. Davis will be re~nembered notonly for his fruitful contributions to the fieldof plastic surgery, but also for his able teach-ing to the general surgeon techniques de-veloped by the plastic surgeon."

BRADFORD CANNON, M.D.

REFERENCES

1. Blackiston, Philadelphia, 1919.2. Ann. Surg. 113: no. 5, 641, 1951.

the relaxation of scar contractures by means of t z-, or...

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