Plastic and Reconstructive Surgery • January 2019
A 69-year-old woman presented with longstanding
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REFERENCES
right upper extremity lymphedema following treat-
ment for right breast invasive ductal carcinoma. She
was treated 5 years previously with neoadjuvant che-
motherapy, lumpectomy and axillary dissection, and
postoperative radiation therapy. She underwent recon-
struction at that time with an oncoplastic reduction
through a Wise-pattern incision. After initial consul-
tation, the decision was made to proceed with vascu-
larized lymph node transfer based on the descending
branch of the thoracodorsal chain and performed in
conjunction with a distal lymphovenous bypass.
Lymphatic mapping proceeded with the intrader-
mal injection of 0.3 ml of indocyanine green along the
descending branch of the thoracodorsal system. Fluo-
rescence angiography was used to map the course of the
lymphatic drainage, which, to our surprise, proceeded
cranially toward the lateral chest along the sixth inter-
costal space rather than caudally along the thoracodor-
sal chain as expected (Fig. 1). Three lymph nodes were
identified along the sixth intercostal space, and an inci-
sion incorporating the previous Wise-pattern scar from
the prior oncoplastic reduction was designed. A vascu-
larized lymph node flap based off the sixth intercostal
artery perforator was carefully dissected, with perfusion
confirmed with handheld Doppler imaging (Fig. 2).
The flap was then transposed into the axilla following
axillary scar release and exposure of the axillary vein.
This is the first case of vascularized lymph node
transfer described based on an intercostal artery per-
forator and was successfully performed through a
prior surgical scar, allowing for ease of dissection and
improved aesthetics. This case demonstrates the option
of using this lymph node basin for the treatment of
upper extremity lymphedema following breast cancer
treatment.
DOI:10.1097/PRS.0000000000005157
James M. Economides, M.D.
Michael V. DeFazio, M.D.
Kenneth L. Fan, M.D.
David H. Song, M.D., M.B.A.
Department of Plastic Surgery
MedStar Georgetown University Hospital
Washington, D.C.
Correspondence to Dr. Song
Department of Plastic Surgery
Georgetown University School of Medicine
3800 Reservoir Road, 1-PHC
Washington, D.C. 20007
david.h.song@gunet.georgetown.edu
Instagram: @dreconomides, @drmdefazio,
@kenfanmd, @drdavidsong
Twitter: @dreconomides, @drdavidsong
DISCLOSURE
None of the authors has a financial interest in any of the
products or devices mentioned in this article.
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
1. Shah C, Vicini FA. Breast cancer-related arm lymphedema:
Incidence rates, diagnostic techniques, optimal manage-
ment and risk reduction strategies. Int J Radiat Oncol Biol Phys.
2011;81:907–914.
2. Huang JJ, Gardenier JC, Hespe GE, et al. Lymph node
transplantation decreases swelling and restores immune
responses in a transgenic model of lymphedema. PLoS One
2016;11:e0168259.
3. Schaverien MV, Badash I, Patel KM, Selber JC, Cheng MH.
Vascularized lymph node transfer for lymphedema. Semin
Plast Surg. 2018;32:28–35.
No Protractor, No Problem: A Different Angle
on Z-Plasties
Sir:
Z -plasty is a frequently used technique for scar revi-
sion and correction of free margin distortions in
facial plastic and reconstructive surgery. Several vari-
ations of this transposition flap have been developed
and described,1 making the Z-plasty a versatile tool
for elongation of contracted scars, for realignment of
scars to match relaxed skin tension lines, or to cam-
ouflage scars in natural skin creases. Z-plasties also
allow the repair of defects near free margins of the
face (i.e., eyes, nose, lips) without excision of addi-
tional tissue2 following micrographic surgery. Finally,
Z-plasties are reliable and reproducible repair mech-
anisms with variable angles of lines drawn to create
the transposable triangular flaps correlating to a
known degree of central rotation and increase in scar
length.2,3
Classically, the Z-plasty is two triangular flaps cre-
ated by three incisions. The central limb, or shared
side of the triangular flaps, may be a scar to be modi-
fied or surgical defect for closure. Lines drawn at
various angles from the central limb create the trans-
posable, triangular flaps. The angle of these lines rel-
ative to the central limb determines the length gain
of the scar and degree of rotation about the central
axis, thus determining the overall effectiveness of the
Z-plasty.
Angles would ideally be measured with a protrac-
tor, and tools have been developed for this specific
purpose.4 This is often clinically impractical for small
Z-plasties. For surgeons desiring improved precision,
we describe a method to accurately draw Z-plasties
at 60, 45, and 30 degrees using easily identified clini-
cal parameters and the trigonometric relationships
of special right triangles. (See Figure, Supplemental
Digital Content 1, which shows trigonometric proofs
of the relationships of special right triangles that allow
Supplemental digital content is available for this
article. Direct URL citations appear in the text on
PRSJournal.com; simply click the URL to access
this material..
 Volume 143, Number 1 • Viewpoints

Fig. 1. To design the various angles for the Z-plasty, divide the surgical defect or
scar to be modified by drawing a perpendicular bisector, creating two equal seg-
ments designated length x. The proximal and distal aspects of the surgical defect
or scar will be designated as the pivot points. For the 60-degree Z-plasty (α), rotate
from each pivot point (a) line 2x (length of scar) until it meets the perpendicular
bisector. For the 45-degree Z-plasty (β), measure distance x from the center of the
scar along the bisector and extend a line from the pivot point to the point distance
x on the perpendicular bisector, creating an equilateral triangle. For a 30-degree
angle Z-plasty (γ), start by drawing a 60-degree Z-plasty as described above. Next,
draw a line originating from the pivot point opposite the 60-degree Z-plasty limb
and terminating at the midpoint of the 60-degree Z-plasty limb.

creation of Z-plasties at 60, 45, and 30 degrees after Callie Burgin, B.S.
measuring only the length of the defect to be repaired, Indiana University School of Medicine
http://links.lww.com/PRS/D226.)
First, divide the surgical defect or scar to be modi- Ally-Khan Somani, M.D., Ph.D.
fied by drawing a perpendicular bisector (b), creating two Department of Dermatology
equal segments of length x. Next, designate the proximal Indiana University School of Medicine
(a) and distal ends of the scar as pivot points. To create a Indianapolis, Ind.
60-degree Z-plasty, rotate a line the length of the original Correspondence to Dr. Somani
scar (2x) from each pivot point away from the scar until it Department of Dermatology
meets the perpendicular bisector (Fig. 1). The 60-degree Indiana University School of Medicine
Z-plasty is frequently used, as it offers 75 percent increased 550 North University Boulevard, UH 3240
scar length and 90-degree change in direction.2 Indianapolis, Ind. 46202
To create a 45-degree Z-plasty, measure distance x somania@iupui.edu
on each side of the scar along the perpendicular bisec-
tor. Connect this point to the pivot points, creating an DISCLOSURE
equilateral triangle (Fig. 1) for a resulting scar that is
The authors have no commercial association or financial
50 percent longer than the original.2
interest to declare in relation to the products or devices men-
Creation of a 30-degree Z-plasty requires building
tioned in this article.
on the 60-degree Z-plasty design. First, draw a 60-degree
Z-plasty limb of length 2x as described above. Then, draw
a line that will create the 30-degree Z-plasty, originating
REFERENCES
from the pivot point opposite line 2x and terminating at
the midpoint of line 2x (Fig. 1). Use a 30-degree Z-plasty 1. Hove CR, Williams EF III, Rodgers BJ. Z-plasty: A concise
review. Facial Plast Surg. 2001;17:289–294.
to achieve 45 degrees of rotation about the central limb
2. Aasi SZ. Z-plasty made simple. Dermatol Res Pract.
and a 25 percent increase in scar length.2 The availabil- 2010;2010:982623.
ity of sterile rulers and surgical pens makes this a very 3. McGregor IA. The theoretical basis of the Z-plasty. Br J Plast
useful and simple technique for determining accurate Surg. 1957;9:256–259.
angles in Z-plasty and other surgical reconstructive flaps. 4. Gahankari D. Z-plasty template: An innovation in Z-plasty
DOI: 10.1097/PRS.0000000000005158 fashioning. Plast Reconstr Surg. 1996;97:1196–1199.

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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.