O-to-Z-plasty

E. J. Mayeaux, Jr, MD, DABFP, FAAFP
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Subject: O-to-Z-plasty

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Introduction

The O-to-Z-plasty is a versatile closure technique used for large defects that are not appropriately closed with a fusiform (elliptical) excision technique. Because of the multiple clinical indications, the O-to-Z-plasty can be readily learned by generalist physicians and used frequently in practice. Advantages of the technique include the sparing of tissue, closure mostly aligning with the lines of least skin tension, and production of a broken line (Z-shaped) final scar. The O-to-Z flap technique generally produces excellent cosmetic results. 
The O-to-Z-plasty combines advancement and rotation techniques, and some authors characterize it as a transposition flap. The O-to-Z flap can be envisioned as a large fusiform excision, with only the central circular area around the lesion excised. On each side of the central circular area, only one of the arms of the fusiform excision is incised. A flap is created on each side, and these two flaps are joined centrally to create a final Z-shaped scar. 
Large fusiform excisions can result in the removal of a large amount of tissue and subsequent pull on surrounding structures with closure of the wound. For instance, a large fusiform excision just above the eyebrow can produce permanent elevation of the eyebrow. Fusiform excisions on the upper lip can elevate the vermilion border. Because less total tissue is removed, the O-to-Z-plasty can obviate the difficulty of lateral pull on surrounding structures when closing the wound. 
Skin flaps are most commonly performed where the blood supply is extensive. The O-to-Z-plasty receives its blood supply through large pedicle bases (i.e., portion of the fusiform incisions that are not incised) and can sometimes work well even on sites with less vigorous blood flow. As with all skin flap techniques, meticulous attention to hemostasis is required. 
When the O-to-Z-plasty is performed after skin cancer removal, it is preferable to ensure clear margins using frozen sections or Mohs surgery before performing wound closure. Because these options may not be available to an office physician, a sufficient margin of normal-appearing skin must be removed around and beneath a cancer (see Appendix D) before closure is attempted. Postprocedure pressure dressings are recommended to reduce hematoma formation beneath the flaps and the development of complications. 

Equipment

  • Appendix G lists the instruments included in a standard skin surgery tray.

  • Suggested suture removal times are listed in Appendix J.

  • A suggested anesthesia tray that can be used for this procedure is listed in Appendix F.

Indications

  • Lesion removal next to linear structures that should not be pulled

  • Lesion removal on the upper lip

  • Closure of defects on the chin or beneath the chin

  • Closure of large forehead defects (especially if just above the eyebrows or near the hairline)

  • Repair of scalp defects

  • Closure of defects in temple region, lateral face beneath the ear, or along the mandible

Contraindications (Relative)

  • Closure of defects on breast tissue (use a running intracutaneous suture closure)

  • Widely separated wound edges that are better approximated with deeply buried sutures

  • Severe bleeding disorders

  • Extreme illness that would make wound healing difficult

  • Cellulitis in the tissues to be incised

  • Conditions that may interfere with wound healing (collagen vascular diseases, smoking, diabetes)

  • Concurrent medications that may increase the likelihood of intraoperative bleeding (aspirin, other nonsteroidal anti-inflammatory drugs, warfarin)

  • Uncooperative patient

The Procedure

The O-to-Z-plasty is based on the fusiform excision, with the overall length of the excision being three times the width. The long axis is aligned so that it is parallel to the lines of least skin tension (Appendix B) and has an adequate margin (Appendix D). However, in the O-to-Z-plasty, only one incision line (i.e., arm) is performed on each side of the central circular excision. The incision lines are drawn to slope toward a theoretical central line. One incision arm is above the central line, and one incision arm is below the central line. 
  • PITFALL: Make sure the incision arms are on opposite sides of the central line! Many novice practitioners unintentionally incise both arms on the same side of the central line, necessitating performance of a fusiform excision or an advancement flap technique.

    Figure 1
    Figure 1

Step 1

Perform field block anesthesia (see Field Block Anesthesia). Plan the anesthesia injections to create a large enough numb area to allow for undermining parallel to the long axis, as in a fusiform excision. Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry (see Appendix E). 
  • PEARL: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.

Step 2

Incise gentle sloping lines that end at the theoretical central line. The arms should be approximately 1.5 to 2 times the diameter of the central circular excision. 
  • PEARL: The center island containing the lesion may be excised first, although smoother excision lines occur when all of the excision is made at once. The corners of the central island are squared (if the island is removed first) to facilitate approximation of the flaps.

Step 3

The central island of skin containing the lesion is undermined, removed, and sent for histologic analysis. 

Step 4

The flaps are gently elevated with skin hooks, and horizontal undermining is performed with a no. 15 scalpel blade or scissors. The wider the undermining around the entire site, the easier it is to move the skin flaps together. 

Step 5

Test to see if the flaps are lax enough to come together without significant tension. If there is too much tension to close the flaps with minimal finger pressure, then more undermining of the flaps may be necessary. 
  • PITFALL: If the flaps are well undermined and still do not close with minimal pressure, check the overall length of the flaps. If the length-to-width ratio is <3:1, it is difficult to close the flaps, and there will be a greater risk of necrosis of all or part of the flaps due to lack of blood flow.

Step 6

The two flaps are brought together and anchored with one or two vertical mattress sutures. Place the anchoring stitch in the center of both flaps. 

Step 7

Corner stitches are placed in the flap tip corners. See Corner Suture. Elevated tissue formations at the ends of the arms (dog ears) may develop and are dealt with in the next step. 

Step 8

If dog ears develop, use the Burow triangle to remove them. See Burrow’s Triangle (Dog Ear) Repair

Step 9

Finish closing the defect using simple interrupted sutures. Dress with antibiotic ointment and a pressure dressing. 

Complications

  • Pain, infection, and bleeding

  • Nonunion of skin edges

  • Scar formation

  • Incomplete excision of lesion

Pediatric Considerations

Generally, pediatric skin has excellent blood flow and heals very well. However, pediatric patients often find it difficult to sit and lie still during lengthy procedures. The patient’s maturity and ability to cooperate should be considered before deciding to attempt any outpatient procedure. The maximum recommended dose for lidocaine in children is 3 to 5 mg/kg, and 7 mg/kg when combined with epinephrine. Neonates have an increased volume of distribution, decreased hepatic clearance, and doubled terminal elimination half-life (3.2 hours). 

Postprocedure Instructions

Instruct the patient to keep the pressure bandage on the rest of the day, then gently wash the area that has been stitched the next day. The patient should not put the wound into standing water for 3 days. Have the patient cleanse dry the area well after washing and use a small amount of antibiotic ointment to promote moist healing. Recommend wound elevation to help lessen swelling, reduce pain, and speed healing. Instruct the patient not to pick at, break, or cut the stitches. 

Coding Information and Supply Sources

These codes encompass excision or repair, or both, by adjacent transfer or rearrangement, including Z-plasty, W-plasty, V-Y-plasty, rotation flaps, advancement flaps, and double-pedicle flaps. When applied to traumatic wounds, the defect must be developed by the surgeon because the closure requires it, and these codes should not be used for direct closure of a defect that incidentally results in the configuration of one of the flaps or plasties. If the configurations result incidentally from the laceration shape, closure should be reported using simple repair codes. 

Bibliography

Chernosky ME. Scalpel and scissors surgery as seen by the dermatologist. In: Epstein E, Epstein E Jr, eds. Skin Surgery . 6th ed. Philadelphia: WB Saunders;  1987:88–127.
Hammond RE. Uses of the O-to-Z-plasty repair in dermatologic surgery. J Dermatol Surg Oncol .  1979;5:205–211. [View Abstract]
Stegman SJ. Fifteen ways to close surgical wounds. J Dermatol Surg.  1975;1:25–31. [View Abstract]
Stegman SJ, Tromovitch TA, Glogau RG. Basics of Dermatologic Surgery . Chicago: Year Book Medical Publishing;  1982:77–78.
Swanson NA. Atlas of Cutaneous Surgery . Boston: Little, Brown;  1987:102–104.
Vural E, Key JM. Complications, salvage, and enhancement of local flaps in facial reconstruction. Otolaryngol Clin North Am .  2001;34:739–751. [View Abstract]
Whitaker DC. Random-pattern flaps. In: Wheeland RG, ed. Cutaneous Surgery . Philadelphia: WB Saunders;  1994:329–352.
Zuber TJ. Advanced Soft-Tissue Surgery . Kansas City: American Academy of Family Physicians;  1998:92–97.
2008 MAG Mutual Healthcare Solutions, Inc.’s Physicians’ Fee and Coding Guide. Duluth, Georgia. MAG Mutual Healthcare Solutions, Inc. 2007.
 
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