This post continues a series that asks a simple question with a long answer: What is a plastic surgeon?
Plastic surgery is not a single operation or a single anatomic region. It is a specialty built on shared foundation principles and then applied across reconstructive and aesthetic care. The first post in this series looked at Blair and Brown’s 1929 work on split-thickness skin grafts. This one turns to another paper that still sits underneath how we think about skin, scar, and local tissue rearrangement.
The paper
Davis JS, Kitlowski EA. The theory and practical use of the Z-incision for the relief of scar contractures. Ann Surg. 1939;109(6):1001–1015.
In June 1939, John Staige Davis and Edward A. Kitlowski published this article in Annals of Surgery. They were writing about a maneuver they called the Z-incision, or Z-plastic — what we now know as the Z-plasty.
Their purpose was practical. They wanted to call attention again to a method that had already been useful to them for contracted scars: transposing local tissue so that a tight scar could be lengthened without discarding skin that still had value, and without always needing a graft. The Z-plasty remains a local transposition of triangular flaps. It lengthens tissue along the line of a contracture by borrowing laxity from the direction at right angles to it, and it changes the direction of the scar in the process.
That is still a fair description of why the operation exists.
Burn contracture, and then a much wider tool
Historically, the Z-plasty was refined in the setting of large burn scars — scars that did more than look tight. They limited motion at joints and across the trunk. When excision of all scar would leave a wound too large to close, and when a graft was impractical, rearranging what remained of the local skin could restore length and function.
That origin still matters. Function and quality of life were the point.
Today the same geometry is used far more broadly. Z-plasties appear in burn reconstruction, but also in scar revision, web-space and syndactyly work, congenital bands, and many other settings where a linear scar is too tight, poorly aligned, or both. The indications have multiplied. The principle has not.
Why it still defines the specialty
This is the paper’s lasting claim on us, nearly ninety years later.
Davis and Kitlowski were not merely describing a clever incision. They were describing a way of seeing skin: how it moves, how it heals, how scar behaves under tension, and how adjacent tissue can be recruited instead of discarded. Those are still foundational principles of plastic surgery. They are why plastic surgeons are trained as experts in the surgical manipulation of soft tissue, and why our approach to skin healing is not an afterthought to a procedure list.
Board-certified plastic surgeons learn to judge vascularity, flap design, tension, and scar biology together. The Z-plasty is one of the clearest classroom examples of that judgment. It is also one of the operations that most plainly shows the specialty’s dual obligation: restore function, and leave a scar that the patient can live with.
Tension lines, algorithm, and the look of a scar
Geometry alone is not enough. Skin is not a flat diagram. It has a grain.
Relaxed skin tension lines (RSTLs) are that grain. They are not a head-and-neck concept only. They can be identified over the trunk and extremities as well, and they belong in the planning of a Z-plasty wherever the scar sits. A well-designed Z-plasty does not only lengthen a contracture. It can redirect a scar so that more of it lies in a kinder orientation — along RSTLs, in a crease, or at a border between aesthetic regions — which is how a scar becomes less visible as well as less tight.
In 1999, Rod J. Rohrich and Ross I. S. Zbar published a simplified algorithm for the use of Z-plasty. Their paper takes a maneuver that can seem opaque to the inexperienced surgeon and makes its indications and execution more systematic, including the realities of skin tension, flap thickness, and location. Read with RSTLs in mind, that algorithm is a modern teaching companion to Davis and Kitlowski: when to use the Z, how to design it, and how to let the final scar lie in a better line.
Put those strands together — foundational soft-tissue rearrangement, scar healing, tension-line planning, and the aesthetic appearance of the result — and you have a large part of the answer to what a plastic surgeon is. That combination is as relevant to cosmetic surgery as it is to reconstruction. The same training that releases a burn band is the training that cares how a scar will look on a face, a breast, a hand, or a trunk.
Anesthesia then and now
One detail in the 1939 paper is easy to pass over and worth pausing on.
Davis and Kitlowski taught that these patients were best managed under general or regional anesthesia. Local infiltration of anesthetic solution, they warned, could risk the viability of the transposition flaps — flaps already carrying the burden of scar.
That warning made sense in its time. In 1939, local anesthetic and epinephrine (adrenaline) were commonly mixed by hand. Those mixtures often carried much higher epinephrine concentrations than the standardized commercial preparations we use now. Lidocaine itself had not yet entered practice; today’s familiar lidocaine-with-epinephrine mixtures are a later, more uniform product.
With those standard mixtures, it is appropriate — and in many cases preferable — to perform Z-plasties and related small skin repairs under local anesthesia. The flaps remain a vascular concern, as they always were. The old objection to local infiltration as a routine threat to flap survival does not hold in the same way.
Two limits still apply. The patient’s comfort must be real, not assumed. And toxic doses of local anesthetic must be respected.
For small skin-repair procedures, local anesthesia is often the better choice: it avoids the additional risk of a general anesthetic and it avoids the additional cost. Larger contracture releases, children, and patients who cannot be made comfortable on the table still belong under regional or general anesthesia. The principle is unchanged: choose the anesthetic that protects the patient and the flaps.
Looking ahead
This series will keep asking what a plastic surgeon is by looking at the papers and principles that still train us. Skin grafting and Z-plasty are two foundations. Reconstruction, aesthetic judgment, and wound biology sit underneath almost everything that follows.
This post is educational journal discussion. It is not a substitute for peer-reviewed literature, individual clinical judgment, or patient-specific consultation.
Tobias C. Long, MD
Founding Member
References
- Davis JS, Kitlowski EA. The theory and practical use of the Z-incision for the relief of scar contractures. Ann Surg. 1939;109(6):1001–1015. doi:10.1097/00000658-193906000-00012
- Rohrich RJ, Zbar RIS. A simplified algorithm for the use of Z-plasty. Plast Reconstr Surg. 1999;103(5):1513–1517. doi:10.1097/00006534-199904020-00024