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Surgery tray instruments are listed in Appendix G. Consider adding skin hooks to gently handle the skin flaps. Have at least three fine (mosquito) hemostats to assist with hemostasis while developing large skin flaps.
Suggested suture removal times are listed in Appendix J, and a suggested anesthesia tray that can be used for this procedure is listed in Appendix F. All instruments can be ordered through local surgical supply houses.
Revision of contractures or scars that cross flexor creases and result in bowstring-type scars (e.g., vertical scars over the flexor creases of the proximal interphalangeal joints of the hands)
Revision of scars that traverse concavities (e.g., across a deep nasolabial fold, a vertical scar that traverses between the lower lip and the chin)
Redirection of wounds that are perpendicular to joint lines or the lines of least skin tension (i.e., reorient to a direction that will produce a cosmetically superior result)
Creation of wound irregularity (i.e., improved cosmetic results with a line that is broken up or zigzag versus a long, straight line that is less appealing)
Repositioning of poorly positioned tissues that produce a trapdoor effect (i.e., rearranging a circular scar that is causing the central tissue to raise upward)
Poor skin vascular supply
Diseases causing poor vascular supply to the skin (e.g., atherosclerotic heart disease, diabetes, smoking, collagen vascular disease, prior irradiation, severe anemia, anticoagulation)
History of poor wound healing, hypertrophic scarring, or keloid formation
Presence of cellulitis, bacteremia, or active infection
PITFALL: Novice providers occasionally make the error of performing their first Z-plasty with the arms on the same side of the central wound. Drawing the proposed Z-plasty helps prevent this problem.
PITFALL: Many providers unintentionally incise the diagonal lines at 45-degree angles, rather than 60-degree angles. Flaps in a 45-degree Z-plasty are easier to transpose but only rotate the direction of the original defect by 60 to 70 degrees (rather than 90 degrees with a 60-degree Z-plasty).
PITFALL: Failure to undermine extensively makes the transposition very difficult. Liberal undermining is beneficial.
PITFALL: Undermine the flaps just below the dermal-fat junction. If too much subcutaneous tissue is attached to the flap, a poorer cosmetic result may result.
PITFALL: Handle the flaps gently, grasping the skin with skin hooks or Adson forceps without teeth. Many physicians transpose the flaps with toothed forceps, causing tears or damage to the flaps and adding unnecessary scarring.
Pearl: Consider half-buried, horizontal mattress sutures in place of the simple interrupted sutures (see Corner Suture).
PITFALL: Almost all 60-degree Z-plasties performed on human skin result in some pouching upward, or dog-ear formation, at the base of the flap after transposition. They will usually flatten with time, resulting in a good cosmetic outcome.
Pain, infection, and bleeding
Nonunion of skin edges
Sensory changes, which often subside with time
Sloughing of the flap caused by high wound tension
Increased scar length and two additional required incisions