PLASTIC REPAIR TECHNIQT]ES :

Skin Plasties and Local Flaps

Thomas J. Chang, DPM

Elaine G. Stani,fer, DPM
A. LouisJimenez, DPM

INTRODUCTION patients have a greater tendency to form hyper-

trophic scars than whites, and that among whites,
A variety of plastic surgical techniques may be blondes demonstrate better healing than
employed in the covering of a wound defect or bmnettes. It is possible that the increased tenden-
revision of a disfiguring scar. Many factors play a cy for hypertrophic scar formation is related to
role in choosing an optimal procedure, including differences in static skin tension between individ-
the size, orientation, anatomic region, and vascu- uals, however, this has not been proven. He also
lariry of the surgical site, as well as the age of the relates a greater tendency for hyper-pigmentation
patient. in Northern Europeans and Latinos.
Vhether a scar is excised and revised ) or a Both static and dynamic skin tension
deficit is remodeled and covered, the ultimate decreases with age. The response of aged skin,
result is the formation of a scar. Optimal scar for- and subcutaneous tissue, to indentation demon-
mation is not only important with regards to the strates a marked decrease in immediate resiliency,
cosmetic result, but more important in terms of when compared to younger subjects. Young chil-
the functional result. A 1arge, bound-down scar dren and obese patients form more prominent
may cause restriction of motion or loss of weight- scars due to the increased tension across the
bearing capabilities. Careful operative planning wound site. Children go through periods of
lends to a less conspicuous scar with greater func- growth where there is overactive fibroblastic pro-
tional results. liferation.
Regions on the body which are almost guar-
DYNAMICS OF SCAR FORMATION anteed to form hypertrophic scars are the sternum
and shoulder region (deltoid). Again, this tenden-
It is well known that a breach in the dermal layer cy is relate d to a high degree of tension and, in
will cause the formation of a scar, The degree to this case, tension exists in all directions, not just
which a scat is formed, and subsequently in apposition to the RSTL. Different surfaces also
matures, is dependent upon many factors. influence scar formation. Concave surfaces tend
Dynamic and static skin forces create tension
to produce a bowstr-ung, disfiguring scar. Convex
across a wound site. The greater the tension, the
surfaces are generally less disfiguring, unless
greater the proliferation of scar tissue. Dynamic
there is a loss of deep tissue structures.
forces include joint motion and muscle move-
Accidental wounds (i.e. trauma) do not heal
ment. Relaxed skin tension lines (RSTL) are, in
as well as clean surgical wounds, because necrot-
general, perpendicuiar to the axis of motion (joint
ic, devitalized, tissue will increase the amount of
or muscle). Static tension, which is the nat:ural scar tissue proliferation. Often, these wounds
tension that exists within the skin, varies in differ-
have a bevelled edge, or are oblique to the skin
ent parts of the body. Borges relates that black surface, producing a wider scar. Wounds that heal
1,67
by secondary intention produce a wider and provide an excelient culture medium for the
deeper scar than those healing by primary inten- growth of bacteria. At the other extreme) exces-
tion. Burn scars demonstrate increased tension in sive use of suture ligatures adds additional foreign
all directions. debris to the wound, and the over-utilization of
The vascular supply of local skin and fascio- hemostats for hemostasis will inflict unnecessary
cutaneous flaps relies principally upon perforating trauma to the tissues. Furthermore, electro-
muscle and fasciai vessels to supply the dermal- coagulation creates charred tissue, which increas-
subdermal plexus. This type of blood supply is es the repair load on the body.
known as a random pattern. Systemic factors
which may delay wound healing include anemia, TIYPERTROPHIC SCARS AND KELOIDS
diabetes, uremia, hyperproteinemia, and scuny.
In evaluating the age of a cicatrix, a well- The distinction between hypertrophic scar and
defined cycle of maturity is known to occur. In a keioid formation is often difficult to ascertain.
young, hypertrophic scar, a pink or reddish hue is Comparing the scar to that of a healed wound in
present which is representative of increased vas- another part of the body may help to distinguish
cularity to the wound site. As a scar matures, it the type of scar. A hypertrophic scar is limited to
softens and becomes paler, relating to a decrease the tissue which constitutes the wound. Keloids,
in vascularity. Scars generally look the worst however, extend beyond the boundary of the
between two weeks to two months following wound and produce tumor-like appendages in
injury. A keloid, on the other hand, does not fol- surrounding tissue. They grow slowly, and years
low this same progressive decrease in vascularity may elapse before they reach maximal dimen-
and cellularity. sions. Spontaneous resolution is rare. Hyper-
trophic scars are paler, softer, and less noticeable
TECHNICAL CONSIDERAIIONS over time, and complete maturation may occur
over several years. Keloids are most commonly
Cross-hatching the proposed incision line with a encountered in young, dark-skinned, persons
skin marker is beneficial for a more accurate between 20 arrd 30 years of age. In keloid revi-
realignment. A #11 blade is preferred when mak- sion, compression and immobility are key to suc-
ing sharply angled incisions. The blade should be cessful or improved outcome. Baker and Smith
angled perpendicular to the skin surface, and the have reported initial success by applying silicone
skin should be held taut and firm while making ge1 sheeting to hypertrophic scars and keloids.
the incision.
The specific suture material used is not criti- TECHNIQUES FOR SCAR REVISION
cal to the final outcome. According to Borges, the
result depends less on the rype of suture used, A scar may be revised and improved, but not
than on the direction and location of scar revi- erased. Disfiguring scars develop from increased
sion, as well as the surgical technique. He prefers tension on the wound, which is largely due to the
braided 5-0 silk on the face, and a larger suture dynamic forces below the skin surface (muscle
(5-0, 4-0) in areas requiring greater tensile and joint movement). RSTL generally run perpen-
strength. Silk is preferable, due to the ease of dicular to the longitudinal axis of muscle. The
tying and wound edge adjustment. One method resultant motion causes an increase in connective
of wound closure places the first suture in the tissue proliferation.
middle of the incision and the next two at mid- The primary objectives of scar revision are to
way points. 'Wounds sutured in line with RSTL redirect the scar into a position of increased
need less sutures than anti-tension line (ATL) dynamic activity (or closer to RSTL), to divide the
sutures. scar into smaller components, and to achieve a
In regards to hemostasis, bleeding should be leveling effect. Secondary benefits of scar revision
controlled to prevent the formation of a blood may include improvement in the condition of the
clot beneaah the skin. A clot separates the walls of wound, camouflaging, and the creation of elastici-
the wound, and interferes with blood flow to the ty. Common techniques for scar revision include
area, They can also act as a foreign body, and simple excision and "2", "\7", or "M" geometric

762
broken line plasty. It is best to choose a revision
technique that optimally improves a particular
scar, i.e. the arms of a Z-plasty follow RSTL as
much as possible.

FUSIFORM EXCISION OF A SCAR Ellipse

This is the oldest technique used in the treatment
of a linear scar, and repair of small defects. It
involves the excision of a fusiform segment of tis-
sue with direct apposition of skin borders.
Although the term "elliptical" has been used inter-
changeably with fusiform, they are not synony-
mous. (Figure 1) Fusiform excisions are used pri- Fusiform
marily where the long axis closely approximates
the RSTL. (Figure 2)
The usual iength:width ratio equals 4:7, and
undermining is performed on either side of the
incision. If at least a 4:L ratio is not maintained,
closure is more difficult, creating excessive ten-
sion on the wound, with dog ear formation at
either end of the incision. Normal tissue is sacri- Flgure L. Although the terms are used inter-
ficed, therefore, this technique is limited to changeably, elliptical and fusiform lesions each
have different configurations.
regions of greater mobility and elasticity.

The"Z-Plasty"
The Z-plasty technique allows for re-direction and
elongation of a scar without excision of normal
tissue. The central arm of the "2" Ties along the
line of contracture to be released or lengthened.
A helpful analogy was introduced by McGregor,
in which he refers to the Z-plasty as a parallelo-
gram. The short diagonal line of the paralielogram
corresponds to the central arm of lhe Z, and is
referred to as the "contractural" diag,onal. The
longer diagonal is the "transverse" diagonal
When the Z-plasty is performed, increase in the
length of the contractural diagonal will occur at
the expense of equal shortening of the transverse
diagonal. (Figure 3)
The broad spectrum of Z-plasty applications
extends to inelastic tissue where skin needs to be
deeply planed, and in burns where the prime
obiective is to preserve tissue. The arms and cen-
tral limb of each Z-plasty should be of equal
length. The central limb should always faIl over
the scar. The arms should approximate RSTL as Figure 2. Alignment of the long axis closely
close as possible, but not exceed a 60 degree approximating RSTL. This method is preferred
for optimal scar placement.
angle.
Although the surgeon is generally interested
in gaining length, it is crucial that transverse slack

153
 Single Z-PIastY

Lengthening,2cm
Shorlening,2cm

Scale
1cm
l--..-l

Lateral
tension
diffused
n*'
Multiple z-plasty
.)i.
-iB^
-{t}. + ,ot,
-itl-
Figufe 3. Transyerse :rncl contractural diagonals associatecl nith {l!-t +f
Z-plastl technique. Lenothening' 2cm
Sho-r1ening, 0.5cm

Figure 4. Sequence of multipie Z-plasties used

to reduce transverse shortening without compro-
mising the desired lengthening.

Figure 5. Iteorientation of an old scar using multiple Z-plasq- tech- Figure 6. Illustration of r,rnning'W-plasty technique in an attempt to
nique in an attempt to parallei RSTL. palallel RSTL.

is available for this method to work. Occasionally almost vertical scar (80 degrees from RSTL) can
the situation arises where the resultant shortening be divided into 2 new scar orientations; one
within the transverse diagonal compromises vas- closely paralleling RSTL, and one running
cuiar or functional capabilities. The search for a obliquely, but closer to RSTL, than the original
metl-rod of reducing the amount of transverse scar (50 vs 80 degrees). Dividing a lengthy scar
shortening, without compromising desired length- into multiple Z-plasties will decrease the trans-
ening, has led to the development of the "multi- verse tension on the skin. The cosmetic result is
ple Z-plasty". Dividing one single Z-plasty into further improved due to the added length in the
multiple Z-plasties in a series, where the central direction of tension. This creates a bunching-up
limb lies on the same axis, will effectively reduce of the triangular flaps, with subsequent narrowing
the transrrerse shortening proportionately by the of the angles (27 vs 50 degrees). (nigure 5) The
same amount. (Figure 4) decrease in tension created by the elongation of
Multiple Z-plasties are aiso useful in the re- tissue contributes to the overall improvement.
orientation of an unsightly scar. Theoretically, an Scars orientated 60 degrees or less to RSTL will

t64
result in oblique scars which are in the same sion of surrounding normal tissue is required, and
direction as the original scar, after transposition. it is not indicated in areas of extreme tissue loss.
Two other skin plasty techniques deserve In facial work, the largest flap should be no
mentioning and are included below for complete- greater than 6 mm in length or width.
ness. These techniques have been used primarily Circular scars, which commonly produce a
in facial surgery, however, the plastic principles "trap-door" effect, are more challenging to revise
behind their design are fundamental to under- and have a high rate of recurrence with simple
standing manipulations of RSTL and scar excision. Concentric, contractural skin forces
placement. cause a piling-up of tissue in the curved flap, giv-
ing rise to outward bulging or the "trap-door"
The Running W-Plasty effect. The circular pattern needs to be broken
The nrnning W-plasty is a method of scar excision up, and the geometric broken line and running
which employs a sequence of 60 degree triangu- \fl-plasty combination provides a more successful
lar flaps. In addition to excision of the scar, a por- revision.
tion of normal surrounding tissue is also excised.
For this reason, it is not indicated for tise in CIRCI.]I/.R DEFECTS
regions of skin inelasticity and limited mobility.
The greater the angle used, the greater the per- Ulcers and other various skin lesions commonly
cent of tension reduction. However, angles found on the lower extremity may require exci-
greater than 60 degrees increase the chance of sion as the treatment protocol. In excising skin
ischemia. Uniformity in the reduction of tension iesions, the ideal incisional approach should be
occurs where all of the angles are oriented at 60 circular. Since most skin lesions are round, this
degrees. With a near veftical scar (80 degrees to approach provides equal margins of resection
RSTL), a running V-plasty can theoretically while saving as much normal skin as possible.
improve scar orientation 20 and 40 degrees to Difficulty in primarily closing a circular
RSTL. The distal ends, however, will follow the defect is often encountered. In certain circum-
original direction of the cicatrix. (Figure 6) stances, only partial closure may be achieved
Technical points to keep in mind while per- before tension on surrounding tissue is affected.
forming the running W-plasry are as fo11ons. The The traditional approach to primary closure of a
base of the last triangle at each end should be circular defect entails the removal of a fusiform
perpendicular to the scar, while the tip of each tri- segment of skin. Although closure with this tech-
angle should be parallel to the scar. The length of nique is a viable option, the ratio of normal skin
each triangular segment varies, depending on the loss to the original defect is 3-1:1,. The normal
size and location of the scar (between 5 and 7 skin which is lost can be used more effectively to
mm on facial tissue). The larger the segments, the reduce tension along the suture lines.
greater percentage of normal surrounding skin Alvarado, in 1981, presented "reciprocal inci-
excised, and the greater the tension across the sion" techniques for the closure of a circular
wound. Smaller segments make for less conspicu- defect. He compared and contrasted the tradition-
OLIS SCAfS.
a1 fusiform ellipse with four variations of circular
skin closure. Objective analysis of these tech-
Geometric Broken Line Plasty niques included the following parameters: size of
skin extension, length of suture lines, wasle of
The geometric broken line closure consists of
normal skin, measurements of tissue after closure,
varying combinations of triangular, square, and
profile and plasticity of the suture line, and ten-
rectangular interposed flaps. The intention is to
sion at the suture line. (Figure 7A-C) For a cos-
divide the scar into smaller and more varying
metic and functional wound closure, the most sig-
compolieflts-_thus increasing the camouflage
nificant parameters described are the profile and
efiect. A criticism clf the \fl-plasty is its predictable
plasticity of the suture line. Flat lesions provide
ancr regular pattern, which is more readily notice-
the most optimal profile and plasticity of the clo-
abie:. This can be a time-consuming procedure
sure, which is inverseiy related to wound tension.
and is more practically performed with running
The "combined V" approach is attractive due to
W-and Z-plasties. As with the W-p1asty, the exci-

t55
 Double S Bow iie combined V

3o.

E
Lenoth ol the 9.6cm 10.1cm 3l
NI
s.ecm
sLtu-re line:

t.t"/

Waste: 156%

Figure 7A-C. Alvarado's description of reciprocal incision techniques Figure 78. Excision of circular defect and wound closure
for revision of circular defects. A, Surgical planning u'ith skin dimen- configuration.
sions illustrated.

$
*n'ttrT->'7tr'1^
DMMW ()
\_,/
\u -/
tl
+ <"-#
*-\
<-.

f*
:

Figure 7C. Side profile demonstrating scar contracture Figure 8. Double transpositional flap technique. Note the use of
dog-ears to assist in s,'ound closure.

the fact that no good skin is excised for closure of sure. This technique takes advantage of resultant
the defect. The profile and plasticity of this tech- "dog-ears", and utilizes them to assist in wound
nique is superior to the other techniques dis- closure. This technique also minimizes the sacri-
CUSSCd. fice of additional normal tissue by transpositional
The "double S" and "bowtie" closures offer flaps, rather than rotational flaps. This is ideal for
intermediate tension between the fusiform skin relatively small defects in inelastic areas such as
excision and the "combined V". In the authors' the anterior aspect of the leg. (Figure B)
experience, the central arm of the "double S" is Another unique technique described by
placed under considerably more tension than the Stewafi in 7992 is termed a "tissue sparing repanr".
peripheral arms during suturing. Care must be This repair uses primary closure to make a circu-
taken to achieve exact wound apposition in order lar defect into a line. While a fusiform excision of
to minimize dehiscence. Bolster sutures have a circuiar defect leaves a repair:lesion ratio of
been utilized for this technique with good suc- 3-4:7, thrs repair leaves a ratio of 1.5:1. The obvi-
cess. For small to intermediate-sized circular ous advantage is a smaller scar, and this tech-
defects, these approaches are indicated. For larger nique is useful where a fusiform excision is not
lesions, particularly in an effort to completely possible. Two new suture techniques, the hori-
negate any further tissue loss, the "combined V" zontal oblique dermal suture and the apex cuta-
technique is ideal. neous suture are illustrated in Figure 9A and 98.
Arnold and Bennett recently described a Primary closure, which is performed parallel
double-transpositional flap for circular defect clo- to RSTL, is ideal in regions possessing adequate

1,55
 {,=
-'L

'->

Flgure 9A. Horizontal oblique dermal sLrture. Note the oblique pass Figure !8. Apex cutaneous suture. Proper placement of the suture
of the suture within the dermal layer. The knot is buried deep within will effectively repair the dog-ear created.
the skin.

/)6,\
l-
il
------,>.- l ,'
{'E==
\- ts=J
ihi

--{=r' l

_/
'a$=i r@re
/4-r<,uro@aailra

H ffiZ_^K .€=

Figure 10. Cross-section illustrating movement of an advancement Figure 1.1. Illustration of single arm (top) and double arm (bottom)
flap. extended V-Y flaps, used where limitecl mobility of iissue exists.

skin flexibility. An area with extremely thin or a double flap may be a viable option. The posteri-
thick dermis/epidermis, such as the plantar aspect or, medial, and lateral aspect of the heel are areas
of the foot, is not amenable to a tissue-sparing of inelastic, but mobile tissue.
repair technique. When applicable, this new tech- The long axis of the flap should be in the
nique closes cutaneous wounds with no normal direction of maximal mobility, or as close to it as
tissue loss, and less tissue movement than a flap possible. Surrounding structures frequently pre-
ot a graft. clude the use of skin in the most optimal direc-
tion. The triangular flap is designed to be 7.5 to 2
FIAPS times the length of the defect diameter, in the
plane of advancement. The base of the triangle
The same principles for incision placement are equals the perpendicular diameter of the defect.
followed in wound coverage techniques using The pedicle is made as broad as possible, and is
local flaps. The V-Y advancement flap is simple in undermined deep to the fascia. The advancement
its use and design. It can cover a range of small pofiion (base of the triangle) is undermined iess
and large defects and may also be used for re- extensively, and splits the subcutaneous tissue.
adr.ancement one or more times. The degree of Undermining is continued until the flap moves
mobility of a V-Y advancement flap is dependent freely into the defect. (Figure 10)
upon the laxity of the underlying subcutaneous The extended V-Y flap is a modification of
tissue. In areas of limited mobility, where a single the standard V-Y flap. This modification is neces-
V-Y flap might be placed under excessive tension, sary in situations where there is limited mobility

r57
of the subcutaneous tissue. An extension is made Rotation flaps may be used to cover circular
at the base, where the diameter is increased for or triangular defects. (Figure 14) These flaps
one or two additional arms (extensions). (Figure require both rotational (primary) and advance-
11) Complications can occur with this type of pro- ment (secondary) movement. Again, dog ears
cedure in areas of inelastic skin, where excess commonly occllr at the pedicle bases, and can be
tension can cause necrosis of the tip. Dog ears are eliminated by the use of simple Burow's triangles.
common at the base of the transposed extension,
but according to Pribao et al., they spontaneously DOG EARS
resolve without further revision.
Another flap design is the rectangular "Dog-ear" is a term which describes the bunch-
advancement flap. (Figure 12) This flap is predis- ing-up of skin when closing a wound. Commonly,
posed to dog ear formation at its base, requiring these are redundant aggregations of skin created
the use of a Burow's triangles for remodeling. by forced movement of tissue. Although skin is
These triangles also function to relieve excess ten- extremely malleable, areas of tissue redundancy
sion from the skin edges. only become significant dog-ears when the visual
The pantographic expansion technique elim- absorbing limits of skin have been exceeded. The
inates the formation of dog ears by its inward siits degree of tissue redundancy will vary primarily
and expanded base. (Figure 13) However, even with patient age and anatomic site.
with its wider base, this technique runs the risk of Several basic points can be stated concerning
damaging the vascular supply with the possibility minimizing the potential of dog-ear formation.
of flap failure. First, careful incision planning and placement can

//.,

l,

Pantographic
expansron

Figure 12. Burow's triangle used to facilitate t'ound closure Figure 13. Pantographic expansion, used to facilitate closure while
minimizing dog-ears.

/,a\ p*59*A?
c- De{ect
JK
Burow's t
tnangle
D"f""t
P*ffi*K2
Figure 14. Appiication of Burow's triangle, used to relieve skin ten Flgure 15. Placement of curuilinear incision over convex surfaces to
sion in a rotational flap. prevent scar depression.

168
reduce dog-ear occurrence, especially on a con- subcutaneous tissue and dermis left behind. The
vex surface. When a slandard fusiform excision of excessive amount of deep tissue will elevate the
skin is performed on a convex surface, there is a skin at the tips, and can contribute to dog-ear for-
tendency for flattening of the wound in the cen- mation. The technique of orienting the scalpel
teq with dog-ear formation at each end. A com- blade p0 degrees to the skin is illustrated in
mon example of this is observed when perform- Figure 16.
ing a simple ellipse in hammertoe surgery. To Proper undermining can also help to mini-
decrease general wound tension during closure, a mize dog-ear formation. The length of the outside
safe guideline to follow is a length:width ratio of curve in a fusiform defect is always greater than
at least 4:1. If the long axis of the fusiform exci- the distance between the two ends. \[hen the
sion is too short in relation to the shofi axis, dog- wound is sutured together, there is a pushing
ears will form at the extremities of the sutured away of tissue from the wound center along the
wound. One common technique in repair consists Iong axis, with a tendency to increase the dis-
of extending the excision of tissue in the same tance between the ends. 'Vhen the elastic limit of
direction as the long axis, thus actually increasing the skin is exceeded, the tissue will tend to pro-
the length:width ratio of the original defect. A tr-ude upward or downward, producing a dog-ear.
golden rule in wound closure is to avoid dog- Undermining the tip and edges will allow the tis-
ears, even at the expense of lengthening the sues being pushed away to move horizontally,
wound. thus preventing dog-ear formation.
Although pianning a closure with adequate When faced with a fusiform defect to close,
length is important, the surgeon must also consid- one can anticipate and prevenl a dog-ear by the
er the effects of wound contraction during heal- direction of suturing. Dog-ears will tend to be
ing. A linear wound on a convex surface will tend "pushed" in the direction of suturing. Suturing
to contract and result in a depressed scar. The from each end, towards the center, will push a
depressed center also accentuates the dog-ear. An dog ear ton ards the center, while suturing from
"S" shaped fusiform excision with the same end the center outr.r,ard will create dog-ears at the
points can avoid this phenomenon. As this scar edges. Ser-eral techniques, in addition to under-
heals and contracts. the scar u,il1 tend to straight- mining. are illustrated in addressing dog-ear for-
en rather than become depressed. (Figure 15) mation along the u,ound line. Selection of the
A skin excision technique is another impor- best cosmetic technique also depends on the
tant aspect of addressing a dog-ear. It is a com- relaxed skin tension lines. Regardless of the orien-
mon error to change the angle of the blade tip tation of the long axis of the original defect, the
when approaching the tip of a fusiform defect. long axis of the fusiform excisions for dog-ear
The result is a skived skin border with excess repair should parallel the RSTL. (Figure 17A-C)

ffi+l-i#,_-B1it-+
.D
1234
+ ttstllut*H
415
<|ll>
I lrr i

+Gir+ffi1r+a=)
23
Figure 16. Proper (left) and improper (right) techniques in excision Figure 17A-C. Techniques for control of placement ancl ercision of
of full-thickness defect. dog-ears. A. DoEI-ear formation is influenced bv the direction of
\Ltt Ltring.

769
 +- RSTL 4
)-'>--i ,l\
<:l- -
.
i,'

)i +

tt
)

._,1.

Flgure 178. Three illustrations used for excision of dog-ears Figure 17C, Placement of dog-ear excision along RSTL, when possi-
ble, will minimize scar formation.

r{>

Figure 1.8. Use of Burow's tdangle is helpful when confronted with Figure 19A. Direction of suture required for wound closure without
fusiform defects of unequal length. dog-ear formation.

+RSTL+

/:

#z
r*i
Figure 198. Techniques for revision of dog-ears fonned by alterna-
tive suture technique.

170
 Certain fusiform defects will present with Dog-ears can also appear when a wound is
unequal length tissue edges, which adds another not properly sutured. This occurs most commonly
twist to wound closure. Three lengths must be with fusiform or straight defects oriented oblique
reconciled in this situation: the two differenr to the RSTL. Due to the tension on the skin, these
wound edges, as well as the intermediate length defects will appear as an "S-shaped" incision. If
long axis. Redundant tissue will develop from the defect is not too wide, coffect wound closure
attempting to match not only each edge to the should not create dog-ears. Commonly however,
long axis, but also from matching the edges to the skin borders of the defect are sutured in a
each other. The goal is to remove a sufficient simple straight advancement technique parallel to
amount of tissue from the longer edge, to permit RSTL, while the incision is oblique to the RSTL.
apposition to the shorter edge without visible To avoid dog-ears in this situation, the concave
bunching. Single or multiple Burow's triangles can border segments of the "S-shaped" fusiform defect
be utilized along the longer edge until a cosmetic must be pulled towards the center of the wound.
wound closure is achieved. (Figure 18) (Figure 19)

CASE STUDY #1.

Figure 21. Contracred fifth digit *.ith inr.olr.ement of the fourth digit
as n'e1i.

Figure 20. DP racliograph of a .l1-year o1d male

nho presented u,itl'r a 5th digital contr:rcture at 8
months postoperati\.e tailor's bunionectomy.

17r
Figtre 22. The central arm of the Z-plasty is placecl along the Figure 23. Reflection of the flaps for exposure ancl release of soft
previotrs scar, This is alna),s clirected along the axis of intended tissue contractures. A ZJcngtl'rening of the ertensor tendon s,'ith fllr-
lengthening. ther delamination of soft tisslres \\'as essential fbr complete release.
A PIPJ arthroplastv n'as also perfolmed to assist relaxation, :rnd a
K n'ire was used to maintain stabilitl, of the digit.

Figate24. Transposition of the flaps is perforrnecl

Figure 2J. Appearance after skrn closrtre.

Figure 26. Postoperative radiograph demonstrat-

ing elignment of tl-re digit an.1 position of K n ire.

172
 CASE STUDY #2

Figare 27. A 22-year o1d fernale presented u,ith Figure 28. A Double S approach is plannecl in
a painflll plantar velrucae of ser.eral months :rn effort to lninimizc excision of nonn:r1 soft tis-
dllr:rtion. Plantar s:rtellite lesions are also notecl. sue. This approach saclifices one half of the nor
mal tissue as corlparecl to a traclitional tirsifbln'r
ercision.

Figure 29. Ercision of the skin to the levt:l of Figure 30. The pointecl eclges are excised for
the subcutaneous tissue. Undermining is carried proper contolrring prior to closure.
ollt to f.rcilitxte skin mor.emeni and closr,rre.

773
 Borges AF: Electiue Incisions ancl Scar Reuisions. Boston, Little.
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Borges AFr Scar Analysis and Objectives of Revision Procedures. C/ln
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