RECONSTRUCTIVE Triple Z Flap Technique for Reconstruction of Triangular Defects in Problem Areas Cenk Sen, M.D. Tonguc Isken, M.D. Hakan Agir, M.D. Cigdem Unal, M.D. Bahadır Ozkeskin, M.D. Deniz Iscen, M.D. Kocaeli, Turkey Background: Reconstruction of defects close to important structures where standard flaps cannot easily be used may sometimes challenge surgeons. Classic reconstructive options for such defects close to problem areas may not always yield the best result. Methods: The authors used the triple Z flap technique for triangular defects close to problem areas in 18 patients. The defects were triangular or close to triangular in shape, and three Z flaps were planned on each side of the defect. Flaps were transposed and the defects were reconstructed without any complications. Results: The results were quite satisfying for both the patient and the surgeon. Neither retraction nor any distortion was observed. Conclusion: The triple Z flap technique can be used in selected cases where local flap choices are scarce and it is difficult to achieve good anatomical and aesthetic results. (Plast. Reconstr. Surg. 119: 880, 2007.) R epair of defects for which standard flaps cannot be planned or when alternative re- construction methods are limited because of proximity to important structures presents a challenge for plastic surgeons. A good functional and aesthetic result is hard to achieve using a single large flap for reconstruction of defects with critical locations. For triangular defects where reconstruction is difficult, we designed a triple Z flap technique. Although it exactly fits triangular defects, trian- gular shape is not a requirement and the flap can be used for defects close to triangular in shape. The technique is easy to learn and exe- cute. It reduces the risk of donor-site morbidity because small flaps are elevated and trans- posed instead of a single larger flap. It reduces the eventual scar because it breaks the inci- sions into several smaller components. It also distributes the tissue borrowing all around the defect, which helps in preventing retractions and distortions. PATIENTS AND METHODS Eighteen patients were operated on with the triple Z flap technique between June of 2002 and December of 2004 (Table 1). Thirteen of the cases were malignant skin lesions mostly lo- calized to the head and neck region. Four cases were operated on for benign skin lesions and one for a traumatic defect. The ages of the pa- tients ranged between 41 and 92 years (average, 58 years). Fourteen of the patients were men and four were women. Most of the lesions were close to important structures, where limited re- constructive options were present. The tech- nique was planned to achieve the best results both functionally and cosmetically. For triangular defects where reconstruction is difficult, we used the triple Z flap technique. After excision of the lesion triangular in shape or close to triangular, we designed three standard Z flaps on each side of the defect. The bases and the limbs of the Z flaps, the lengths of which change de- pending on the length of a side of the triangle, are half as long as the sides of the triangular defect. The bases of the Z flaps do not come into contact with each other on each side of the triangular defect (Fig. 1, above). After excising the lesion, the three planned Z flaps were elevated onto the sub- cutaneous plane and rotated toward the center of the defect, and the other limbs of the Z flaps close the donor areas (Fig. 1, below). To make the trans- position of the Z flaps easier, a minor undermin- ing is recommended, extending outside the limits of the incisions. This undermining is not extensive and depends on the size of the defect. From the Department of Plastic and Reconstructive Surgery, Kocaeli University Medical Faculty. Received for publication May 3, 2005; accepted August 2, 2005. Presented at the 24th Annual National Meeting of the Turk- ish Plastic, Reconstructive, and Aesthetic Surgery Society, in Ankara, Turkey, October 18 through 20, 2002; and the 10th Congress of the European Societies of Plastic, Reconstructive, and Aesthetic Surgery, in Vienna, Austria, August 30 through September 3, 2005. Copyright ©2007 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000252011.43748.e9 www.PRSJournal.com 880