Z-Plasty for First Web Space Contracture: A Reconstructive Approach
Main Article Content
Abstract
Introduction. Z-plasty is a local flap transposition technique widely used in plastic and reconstructive surgery for scar revision and contracture release. In the hand, contracture of the first web space can significantly compromise thumb abduction and opposition, as well as pinch and grip strength, thereby affecting overall limb function. Z-plasty and its various modifications allow for tissue lengthening, scar reorientation, and redistribution of tension forces, constituting a useful reconstructive alternative in selected cases.
Methods. A narrative literature review was conducted focusing on the principles, historical evolution, surgical anatomy, diagnosis, classification, and treatment of first web space contractures. Particular attention was given to the geometric foundations, indications, limitations, and surgical technique of Z-plasty, including its simple, multiple, four-flap, and five-flap variants. Conservative treatment modalities, objective methods for assessing thumb mobility, and reconstructive alternatives available for more complex contractures were also reviewed.
Conclusions. Z-plasty remains a versatile and effective technique for the management of mild to moderate first web space contractures, particularly when the restriction is predominantly cutaneous and adequate adjacent tissue is available. Reconstructive success depends on accurate assessment of the depth and extent of the contracture, appropriate flap design, complete release of the scar band, preservation of vascularity, and postoperative rehabilitation. Severe or deep contractures involving fascia, muscle, or joint capsule, or presenting extensive tissue deficits, may require skin grafts or coverage with local, regional, or free flaps. Outcomes should be assessed not only by the widening of the first web space but also by the recovery of thumb abduction, opposition, pinch, and grip. Comparative studies are needed to standardize indications and determine the optimal Z-plasty configuration for each contracture pattern.
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References
I. Kim KK, et al. Definition and measurement of functional first web space: a scoping review. 2025. The review found marked heterogeneity in methods for defining and measuring the first web space and the absence of a universal functional cutoff.
II. Bertone VH, Ottone NE. Anatomical considerations on the first commissural space of the hand. Rev Arg Anat Online. 2010;1(1):6–10.
III. Hove CR, et al. Z-plasty: a concise review. 2001. PMID: 11735063. Describes the classic 60° Z and its theoretical 75% elongation.
IV. Aasi SZ, et al. Z-Plasty Made Simple. 2011. Technical review of geometry, indications, and design of Z-plasty.
V. Fraulin FOG, Thomson HG. First webspace deepening: comparing the four-flap and five-flap Z-plasty. Which gives the most gain? Plast Reconstr Surg. 1999;104(1):120–128. PMID: 10597684.
VI. Rogers AD, Moltaji S, Wallace D. Five flaps or four? Z-plasty for the release of first webspace burn contractures of the hand. J Surg Case Rep. 2024;2024(11):rjae702. doi:10.1093/jscr/rjae702.
VII. Jensen CB, Rayan GM, Davidson R. First web space contracture and hand function. J Hand Surg Am. 1993;18(3):516–520. doi:10.1016/0363-5023(93)90103-A.
VIII. Wallace DR, et al. Operative First Web Contracture Management: Current Strategies. 2024. Review of etiologies, three-dimensional anatomy, and reconstructive options.
IX. Kim KK, et al. Definition and measurement of functional first web space. 2025. Scoping review of angles, intermetacarpal distance, goniometry, and function.
X. Miller EA, et al. Assessment Strategies for First Web Space Contracture. J Hand Surg Am. Published online August 26, 2026. Contemporary review highlighting the absence of a universal classification and outcomes framework.
XI. Borges AF, Gibson T. The original Z-plasty. Br J Plast Surg. 1973;26(3):237–246. doi:10.1016/0007-1226(73)90008-8.
XII. Oosterwijk AM, Mouton LJ, Schouten H, et al. Prevalence of scar contractures after burn: a systematic review. Burns. 2017;43(1):41–49. doi:10.1016/j.burns.2016.08.002.
XIII. van Baar ME. Epidemiology of Scars and Their Consequences: Burn Scars. In: Textbook on Scar Management. 2020.
XIV. Moody L, Galvez MG, Chang J. Reconstruction of First Web Space Contractures. J Hand Surg Am. 2015;40(9):1892–1896. doi:10.1016/j.jhsa.2015.06.113.
XV. Tiengo C, et al. First Web Space Reconstruction in Acquired Defects: A Literature-Based Review and Surgical Experience. J Clin Med. 2025;14(10):3428.
XVI. Bhattacharya S, Bhatnagar SK, Pandey SD, Ram Chandra. Management of burn contractures of the first web space of the hand. Burns. 1992;18(1):54–57.
XVII. Masanovic MG, et al. Scar Contractures. In: Textbook on Scar Management. Springer/NCBI Bookshelf; 2020.
XVIII. Kapandji A. Clinical test of apposition and counter-apposition of the thumb. Ann Chir Main. 1986;5(2):158–165. PMID: 3963909.
XIX. Kuroiwa T, Nimura A, et al. Measurement of thumb pronation and palmar abduction angles with a small motion sensor: a comparison with Kapandji scores. J Hand Surg Eur Vol. 2019;44(7). doi:10.1177/1753193419843837.
XX. McGee C, et al. Thumb carpometacarpal palmar and radial abduction: assessment using the inter-metacarpal distance method. J Hand Ther. 2022.
XXI. Coombs CJ, Thomas DJ. The Manta Ray flap: a technique for first web space release. Tech Hand Up Extrem Surg. 2010;14(1):41–45. doi:10.1097/BTH.0b013e3181d0d449.
XXII. Gonzalez-Morgado D, Sinclair V, Shen XF, et al. First Palmar Intermetacarpal Flap for Congenital First Web Contracture: A Case Series. Microsurgery. 2025.
XXIII. Fufa DT, Chuang SS, Yang JY. Prevention and surgical management of postburn contractures of the hand. Curr Rev Musculoskelet Med. 2014;7(1):53–59. doi:10.1007/s12178-013-9192-9.
XXIV. Therattil PJ, Datiashvili RO. First Web Space Contracture. Eplasty. 2014. Review of Z-plasties, grafts, dermal substitutes, and local, regional, and free flaps.
XXV. Stekelenburg CM, Jaspers MEH, Jongen SJ, et al. Perforator-based interposition flaps perform better than full-thickness grafts for the release of burn scar contractures: a multicenter randomized controlled trial. Plast Reconstr Surg. 2017;139(2):501e–509e.