Plastic Surgery
Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘z-plasty’

Case Study – Z-plasty for Eyebrow Lowering

Sunday, June 28th, 2015


Background:The eyebrows provide an important framing structure for the eye area. Residing over the brow bones (supraorbital rims) their hairy composition provide an instantly recognizeable facial feature. While eyebrows have very variable shapes and hair features, and they are subject to considerable grooming and modifications based on contemporary style, the one consistent and important feature of them is symmetry.

Asymmetry of the eyebrows is a very noticeable facial feature. Even the slightest amount of eyebrow asymmetry can be detected.  It has been shown that as little as 2mms of difference in eyebrow position is noticeable to patients. While some degree of slight eyebrow asymmetry is present in many patients who present for periorbital rejuvenation for example, they can be very effectively treated by Botox injections for improved symmetry and less eyebrow movement. This works because the eyebrows are dynamic and have muscles that can be temporarily blocked or inhibited from moving.

But eyebrow asymmetry that results from nerve paralysis poses a much more challenging problem. The paralyzed eye brow is a fixed structure that is elevated rather than depressed. It can not be made to drop down by Botox injections nor can a surgical release  like in a browlift made it become lower. Eyebrow asymmetry from a lower then normal brow position is a much easier to improve as the eyebrow can be raised by a variety of browlifting techniques.

Case Study: This 19 year-old male had surgery as a young child to treat a large forehead lymphangioma. While the lymphangioma was cured, the resective surgery left him with a permanent paralysis of the frontal branch of the facial nerve. This caused the eyebrow to be permanently elevated. The forehead tissues were very scarred and immobile from the prior surgeries.

Eyebrow Z-plasty Dr Barry Eppley Indianapolisz-plastyUnder general anesthesia, his left eyebrow was repositioned lower using a classic z-plasty  tissue rearrangement technique. The entire tail of the eyebrow was lowered by switching the skin and deeper tissues below it and changing places with it.

Left Eyelid Reconstruction with Transposition Flap Dr Barry Eppley IndianapolisEyebrow Transposition Flap Dr Barry Eppley IndianapolisAt three months after surgery all skin flaps were healed. No loss of amy of the tips of the skin flaps occurred. The eyebrow position was much more symmetrical to the other side albeit not perfectly symmetric.

The overelevated or paralyzed eyebrow is a difficult challenge to reposition as all conventional methods of eyebrow repositioning rely on normal muscle movements and supple forehead tissues. A z-plasty method of reconstruction provides a simple and effective method of eyebrow lowering if the patient is scar tolerant.


1) Symmetry of the eyebrows is an important aesthetic facial feature.

2) An eyebrow that is too high is a much more difficult reconstructive challenge than an eyebrow that is too low.

3) The tail of the eyebrow can be lowered by a traditional z-plasty tissue rearrangement technique.

Dr. Barry Eppley

Indianapolis, Indiana

The Concept and Benefits of Geometric Scar Revision

Wednesday, October 13th, 2010

When topical therapies fail and the scar is unfavorable, resorting to scar revision is necessary. There is a lot to be said about time for scar maturation, but scars that are depressed, raised or excessively wide do not substantially improve as they heal in many cases. Many scars do not need an elaborate revision procedure and often simple linear excision and closure will suffice. This is particularly true for many scars on the trunk and the extremities.

But many facial scars are not improved by simple linear scar revision. The visibility of the face has a lot to do with the need for heightened scar revision outcomes as well as the location of the variable patterns of the relaxed skin lines of the face. For these reasons, better scar camouflage can be obtained through what is known as geometric, or non-linear, scar rearrangement. (GSR) A variety of GSR methods are known and they carry names that start with a letter followed by –plasty. Whether it be the classic Z-plasty or W-plasty or other combinations of the alphabet, the concept is to convert a straight line scar to a non-linear or irregular one.

The Z-plasty is a well known scar revision method that is easy to visualize. With a Z pattern in the middle of the scar, it is easy for patients to understand. The beauty of the Z-plasty is that it not only makes the scar irregular but also makes it longer. This is of great value in scars that have created skin tethers or contractures as they cross moving surfaces and concavities. Examples would be vertical scars of the upper eyelid, the inner area of the eye near the nose, the nostril rim, and the armpit. This lengthening benefit is also useful for contracted scars along the upper lip philtrum and the corner of the mouth. Scars around an orifice can also be helped with z-plasties including the oval nostril, a tracheostomy stoma scar, or those scars around or in the umbilicus.

The W-plasty scar revision turns the whole scar into an irregular ‘pinking shear’ pattern.Instead of a one or two areas with a Z pattern in a scar, the W-plasty turns the entire scar into a continuous zigzag pattern. The scar essentially becomes a series of alternating triangles. The theory is that an irregular line is harder for the eye to follow than a straight line. This is of great value in facial scars of the cheek, side of the face, or forehead in which there is no discrete skin fold or wrinkle in which to ‘hide’ the scar. While this does break up a linear scar, it also creates a regular pattern which may work against the concept of decreased visibility by making a regular pattern for the eye to follow, even if it is irregular.

For this reason, w-plasties are rarely done alone or throughout the entire scar. They are usually combined other patterns in what is a more sophisticated scar revision method known as geometric broken line closure. (GBLC) This method employs the W-plasty but with the addition of other shapes besides just triangular flaps of the W-plasty. The different shapes may be Ms or other shapes interspersed between the Ws. This makes the closure irregularly irregular and offers the best potential for maximal scar camouflage.The resulting scar is “irregularly irregular,” with the maximum potential for camouflage. This scar closure pattern, combined with sanding or dermabrasion later (no sooner than 2 to 3 months after), is the best bet for many scars that are in difficult or unfavorable facial locations.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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