One hundred nine patients with moderate to severe carpal tunnel syndrome were randomized to receive either ligament Z-plasty (n=55) or conventional surgery (n=54). The primary outcome was the incidence of pillar pain at 3 weeks and 6 months postoperatively. Secondary outcomes included changes in grip strength, pinch strength, and Boston Carpal Tunnel Questionnaire (BCTQ) scores. Follow-up assessments occurred at 3 weeks and 6 months. Overall, the results showed a significantly lower incidence of pillar pain at 3 weeks and greater improvements in pinch strength at 3 weeks and grip and pinch strength at 6 months in the Z-plasty group. The findings suggest that Z-plasty may offer functional advantages over conventional surgery in the short- to mid-term recovery period.