Annals of the MBC - vol. 3 - n' 1 - March 1990

POST-BURN CONTRACTURE OF THE AXILLA EVALUATION OF THREE METHODS OF MANAGEMENT

Higazi M., Mandour S., Shalaby H.A.

Plastic Reconstructure Surgical Unit, Faculty of Medicine, Tanta University, Tanta, Egypt

SUMMARY. The surgical correction of 32 post-burn contractures of the axilla was evaluated using skin graft, Z-plasties and scapular flaps.

Introduction

The goal of the surgical correction of axillary scar contractures is to provide a maximum release with minimum or no local anatomic distortion. Once surgical correction is intended, the choice of the procedure must be individualized. Traditional therapeutic measures include skin grafting, Z-plasties and local flaps, but these methods do not always produce satisfactory results. More recently such methods as the free flap (1) and the island flap (2,3) have been reported. In these newer methods, a flap of sufficient thickness with less likelihood of recurrence and no need for splinting is inset into the axilla.
In this paper, we report the correction of 32 axillae in 30 patients (17 male and 13 female) by split skin graft, Z-plasties and scapular flaps.

Material and methods

Based on the local anatomic conditions of the axilla, the surgical procedure was selected. Hanumadass et al. (4) classified axillary contractures in 4 types depending on three local anatomic conditions:

  1. - Anterior and posterior axillary folds
  2. - Hairbearing area
  3. - Scarring of adjacent skin.

Our patients were classified in three groups according to the line of management.

Group 1 12 axillae (Types 11, 111 & IV) were treated by release and split skin graft (S.S.G.):
(a) 7 axillae by single release and graft
(b) 5 axillae by double release leaving a central bridge of normal or scarred tissue at the apex of the axilla (Fig. 1) as recommended by Salisbury and Pruitt (5).

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 Fig. 1: Double release, central skin bridge and SSG of upper and lower raw areas.

Group II 14 axillae (Type 1) were treated by Z-plasties:
(a) Single Z-plasty (5 axillae)
(b) YN advancement (3 axillae)
(c) Double Z-plasty with YN advancement (Five-flap technique) (6 axillae).

In the latter technique (Fig. 2) the CDE flap enclosing the hair-bearing area is minimally advanced and undermining was carried out on the undersurface of the web.
Group III 6 axillae (Types II, III & IV) were treated by scapular flaps.
The circumflex scapular artery passes through the triangular space and then courses around the lateral border of the scapula and directs itself toward the cutaneous territory of the back. There are two cutaneous branches, the horizontal (scapular) and oblique (parascapular). A flap that has the circumflex scapular artery as its nutrient vessel can therefore be designed in one of two directions: the scapular and the parascapular (6).
The pedicle is located by drawing a line (with the arm fully adducted) from the top of the posterior axillary fold to the lateral border of the scapula. Just adiacent to this border lies the triangular space and the vascular pedicle. In scarred and distorted anatomy of the posterior axillary fold the dissection is started from medial to lateral before locating the,pedicle. The donor area was closed primarily in a11 of our cases (6-10 cm breadth).

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 Fig. 2: Five flap technique, the triangle carrying the hair bearing area is minimally advanced.

Results

Thirty patients having 32 post-burn contractures of the axillae were included in this'study, 15 cases (506/o) in the age group 1-10 years (Table 1). The cause of bum is illustrated in Table 11. It shows that 63% were scalds. Table 111 shows the degree of contracture and Table IV the anatomical site of contracture.
The results were evaluated according to the criteria of Davies and Yacournattis (7):

  • Good: when full mobility with lax skin was found at the time of evaluation
  • Fair: when local discomfort or tight skin impaired full mobility but did not require secondary operation
  • Bad: impaired function requiring secondary operation.

 

Age group

 No of cases %
1 - 10 years 15 50.00
11-20 years 5 16.70
21-30 years 8 26.70
31-40 years 1 3.30
41-50 years 1 3.30
Total 30 100

Table 1 AGE OF PATIENTS

 

Type

No of cases

%

Scalds

19

63.30

Flame burn

11

36.70

Chemicals

0

0

Electric

0

0

Total

30

100

Table II CAUSE OF BURN

 

Degree of abduction at the axilla No %
Mild contracture (above 90') 6 18.75
Moderate contracture (30-90') 20 62.50
Severe contracture (below 30') 6 18.75
Total 32 100

Table III DEGREE OF CONTRACTURE IN 32 CONTRACTED AXILLAE

 

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Fig. 3: SSG on a single release, one year postoperative. Note recontracture of the anterior axillary fold.

 

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Fig. 4: Double release and SSG, 9 months postoperative.

 

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Fig. 5: Double release and SSG, loss of the graft on the lower area. Regrafting was followed by satisfactory result.

 

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Fig. 6: Five flap technique, 9 months postoperative.

The follow-up of our cases ranged from 6 months to 1.5 years with a mean of 11 months.

  1. Single incision and SSG (Fig. 3):
  • 7 cases treated by this method
  • 2 cases partial graft loss and regrafting
  • 2 cases evaluated good, 3 fair and 2 bad result
  • Hyperpigmentation of the grafted areas manifest in 3 cases
  1. Double incision and SSG:
  • 5 cases treated by this method
  • 4 cases evaluated good at their last follow-up (Fig. 4). * I case (Fig. 5) lost the graft on the lower area that was regrafted with final fair result at evaluation * Hyperpigmentation of the grafted area manifest in 4 cases
  1. Single Z-plasty:
  • This method used in 5 cases
  • Final result at evaluation good in 3, fair in 1 and bad in 1 * The displacement of the hair-bearing area was manifest in the 4 successful cases
  1. YN advancement flap:
  • 3 cases treated by this method Evaluated as good in all Displacement of the hair-bearing area was also evident in all cases
  1. Five-flap technique:
  • 6 cases corrected by this method All evaluated good (Fig. 6) Displacement of the hair-bearing area was minimal
  1. Scapular flap:
  • 6 cases corrected by this method All evaluated good, functionally a good

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Fig. 7: a) Scapular flap, immediate postop.

 

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Fig. 8: Widening of the donor area with maceration of the edges. One week postop.

Discussion

The feasibility of a particular procedure depends on a set of particular local anatomic conditions. The main' problem of axillary contractures is the inelasticity of either or both axillary folds which prevents the full extension and/or abduction of the shoulder joint. There are two local anatomic conditions that must be taken into consideration when surgical correction is intended. These are the amount of scarring of the folds and adjacent skin, and the involvement of the hair-bearing area.
In this study split skin graft was satisfactory when applied on a double release incision. The central flap created by the incisions or by mobilization of anterior and posterior bridges aids in preserving the hair-bearing area and the successful take of the graft. This also minimizes the tendency of the grafted axilla to recontract. This tendency of split skin grafted area was reported by many authors (8, 9, 10), and continuous splinting and massage for 3-6 months were suggested.
Z-plasty is generally the procedure of choice for linear scar contractures. However, a single Z-plasty is not suitable in the axillary contracture, because it requires large skin flaps in a limited area with displacement of the hair-bearing area. We found that five-flap Z-plasty is more suitable for this type of contracture. The hair-bearing area was displaced to a lesser extent in this technique. This finding coincides with that reported by other researchers (11, 12).
The cutaneous blood supply of the scapular region was described by Salmon (13). Dos Santos (14, 15) demonstrated the clinical application of the scapular flap. Mayou et al., (16) and Diamond and Barwick (2) each reported one case.
The scapular flap was successful in our six cases. It is a versatile flap combining a thin cover in most cases with direct closure of the donor defect. It was used in a superficially scarred scapular area as it is a fasciocutaneous flap including a known artery as its pedicle.
Free flaps (1) have been used but they are technically more difficult, require longer anaesthetic time and a trained microvascular surgeon. Also, latismus dorsi or pectoralis major myocutaneous flaps have been used (17), but the extra bulk of the muscle would appear to limit the adduction of the shoulder.

Conclusion

  1. - For axillary web contractures the five-flap technique is the procedure of choice.
  2. - Scar contracture of the anterior and/or posterior axillary folds with scarring of adjacent skin, but sparing the hair-bearing area, is preferably corrected by double incisional release and split skin graft.
  3. - In scars involving the hair-bearing area usually with one or both axillary folds as well as the periaxillary skin, i.e. a diffuse car contradture, the procedure of choice is the scapular flap. The parascapular flap is another alternative which is being evaluated in our unit.

RÉSUMÉ. Les Auteurs considèrent 32 cas de correction chirurgicale des contractures de l'aisselle, à la suite de brûlure, avec l'emploi des greffes cutanées à épaisseur variable, des plasties en Z et des lambeaux scapulaires.

BIBLIOGRAPHY

  1. Ohmori S.: Correction of burn deformities using free flap transfer. J. Trauma, 22: 104, 1982.
  2. Diamond M., Barwick W.: Treatment of axillary burn scar contracture using an arterialized scapular island flap. Plast. Reconstr. Surg., 72: 388, 1983.
  3. Budo J., Finucan T., Clarke J.: The inner arm fasciocutaneous flap, Plast. Reconstr. Surg., 73: 629, 1984.
  4. Hanumadass M., Kagan R., Matsuda T., Joyaram B.: Classification and surgical correction of postburn axillary contractures. J. Trauma., 26: 236, 1986.
  5. Salisbury R.E., Pruitt B.A.: Burns of the upper extremity. In Pruitt B.A. (ed): "Major Problems in Clinical Surgery", 19, 154, Saunders, Philadelphia, 1976.
  6. Takato T., Harii K., Sasaki A,: Our clinical experience with the scapular flap. Jpn. J. Plast. Reconstr. Surg., 27: 318, 1984. Cited from Yanai et al., Plast. Reconstr. Surg., 76: 126, 1985.
  7. Davies D.M., Yacournattis A.M.: A method of grafting hand burns following early excision. Br. J. Surg., 65: 539, 1978.
  8. Rintala A.E., Pironen J.: Secondary reconstructive surgery in burns. Ann. Chir. Gynecol., 69: 233, 1980.
  9. Tolhourst D., Haeseker B.: Fasciocutaneous flaps in the axillary region. Br. J. Plast. Surg., 35: 430, 1982.
  10. Mataizeau J.P., Gayet C., Schmitt M., Prevot L: The use of free full thickness skin grafts in the treatment of complications of burns. Prog. Pediat. Surg., 14: 109, 1981.
  11. Hirshowitz B., Karev A., Rousso M.: Combined double Z-plasty and YN advancement procedure for repair of thumb web contracture. Hand, 7: 29, 1975.
  12. El-Ottify M.A.: A versatile method for the relase of burn scar contractures. Br. J. Plast. Surg., 34: 326, 198 1.
  13. Salmon I.: "Artères de la peau". Masson et Cie, Paris, 1936. Cited from Yanai et al., Plast. Reconstr. Surg., 76: 126, 1985.
  14. Dos Santos L.F.: Le lambeau scapulaire et l'artère cutanée scapulaire. Mem. Labor Anat. Paris, 1984.
  15. Dos Santos L.F.: The vascular anatomy and dissection of the free scapular flap. Plast. Reconstr. Surg., 73: 599, 1984.
  16. Mayou B_ Whitby D., Jones B.M.: The scapular flap: anatomical and clinical study. Br. J. Plast. Surg., 35: 8-135 1982.
  17. Fridlander E, Lee K., Vaudeovord J.G.: Reconstruction of the axilla with a pectoralis major myocutaneous island flap. Br. J. Plast Surg., 35: 144, 1982.

 

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