Local Flaps: Z, VY and combinations

Web space contractures may be congenital or traumatic, but most often involve a tight band of skin bridging the fingers. Many minimal to moderate contractures may be corrected with local skin flaps, avoiding the need for skin grafts. These are examples of some of the many approaches to web space deepening. In each example, the orientation is to achieve transverse widening, with "before" on the left and "after" on the right. For ease of comparison, flaps are illustrated as flattened two dimensional flap designs. The actual three dimensional geometry is certainly more complex.
Web Flap Designs
Designs using 2 flaps
Z Plasty
The Z plasty results from the paired transposition of two triangular flaps. A common design uses equal size, equilateral triangle (60°) flaps, but many variations are possible. Although simple Z plasty is very useful in the treatment of flat surface scars, it may result in an unnatural "cleft" appearance when used for web space deepening.
Transposition flap
This design is a zig zag like a Z plasty, but more accurately is called a transposition flap. Here, the narrow flap rotates and the wide flap advances to close the narrow flap donor site.
Designs using 3 flaps
Square Flap
Three Flap Plasty
This can be thought of as a double transposition flap. The narrow flaps rotate, and the wide flap advances to close their shared donor site. At first glance, the blue and yellow flaps look like a Z plasty, but they rotate away from, not toward each other.
Designs using 4 flaps
"90-90" Flap
Four Flap Plasty
This unique design combines the Z plasty and the bilobed flap designs. At first glance, the center red and blue flaps look like a Z plasty, but look how far apart they wind up. This flap takes advantage of the unique geometry of the interdigital web.
Multiple Z plasties
A single tight band may be lengthened with a series of Z plasties.
Double Z Plasty
Z plasties may also be immediately adjacent to each other. This allows more flaps to be used in a narrow space, as in this double Z plasty.
Designs using 5 flaps
Butterfly Flap
Double Opposing Z Plasty
This is a double Z plasty, with the flaps planned as mirror images. In addition to the two lateral Z transpositions, the upper (red) flap wraps around the additional inner (green) flap created with this design, increasing the length gain over a simple double Z design.
Alternate Butterfly Flap
Separating the Z plasties blunts the tip of the inner (green) flap, which improves the fit with the upper (red) flap.
Jumping Man Flap
Five Flap Plasty
This is a modification of the double opposing Z plasty. The upper (red) flap is partially split to allow Y-V advancement of the inner (green) flap. Because this split narrows the vascular pedicle to the lateral flap tips, their angles are planned more obtuse (75°) than for a typical double opposing Z plasty.
Alternate Jumping Man Flap 1
This design allows for greater Y-V advancement and lengthening. It requires supple skin other than the tight band itself.
Alternate Jumping Man Flap 2
This design places greater emphasis on the lateral Z plasties and less on Y-V advancement. It is more appropriate for use in a heavily scarred bed.
Repeating Flaps
Multiple Zs
Z Plasties can be constructed along a long narrow scar without limit.

Alternating Z-VY
5 flap plasties may also be constructed. This geometry allows for greater lengthening and more even redistribution of skin tension.

Advancement Flap Designs

V-Y Flap
Modest length gains can be achieved with a transversely oriented V-Y flap. Best application is lengthening a linear scar when geometry prevents the use of transposition flaps.
Multiple Y-V Flaps
No flap rotation is required, and the lenthening achieved is less than for the other multiple flaps illustrated. The final result resembles that of the 5 flap plasties above.
V-M Plasty
This is actually an extension of the Y-V principle, and is appropriate for dorsal burn syndactyly.
Modified V-M Plasty
The V-M plasty results in lateral "dog ear" skin redundancy, which may be incorporated into the flap design to increase lengthening.