Ann. Medit. Burns Club - vol. VIII - n. 3 - September 1995

ISLAND PARASCAPULAR FLAP FOR THE TREATMENT OF DIFFUSE AXILLARY BURN SCAR CONTRACTURE

Shalaby H.A.

Plastic Surgery Unit, Tanta University Hospitals, Tanta, Egypt

SUMMARY. Fifteen parascapular flaps based on the oblique branch of the circumflex scapular artery were used to correct post-burn axillary contractures in 12 patients. The contractures were of the diffuse type (type IV), in which scarring involves all the anterior and posterior axillary folds, usually in association with the hair-bearing area. All the flaps remained totally viable and were successfully used to release the contractures. The donor area was either closed primarily or covered by split-skin graft.

Burns around the axillary region frequently lead to contractures which may be diffuse' and severe (Fig. 1). Hanumadass et al.' classified post-burn axillary contractures in four types according to the local anatomic conditions. The diffuse type (type IV) is characterized by involvement of the hair-bearing area, the anterior and posterior axillary folds, and the periaxillary region. In their view the procedure of choice is a single incisional release and splitskin grafting. A tie-over bolus, a bulky dressing and a plaster of Paris splint are applied. There is usually good take of the graft, as part at least is laid over muscles. However, unless the arm is kept in abduction for at least 3-6 months',' with a cumbersome splint, some degree of recurrence of contracture is inevitable and a repeat proce~ dure is often required. If the graft does not take, a prolonged and often frustrating period ensues.

Fig. 1 - Diffuse and severe post-burn axillary contracture: anterior and posterior views.

To overcome the problem of recurrence, several alternative techniques have been proposed. These include the inner arm fasciocutaneous flap,' the scapular island flap,' the fasciocutaneous flap from the anterolateral or posterolateral aspects of the chest,' the parascapular flap,' and the free flap. In a previous study,' we reported our evaluation of different techniques used in the treatment of post-burn axillary contractures. For the diffuse type the procedure of choice was the transverse scapular flap. Since then, i.e. 1990, we have shifted to the parascapular flap, and this study is an evaluation of this kind of flap, with a retrospective comparison to the transverse scapular flap.

The flap is designed while the patient is standing up, with the anus adducted to the sides. The circumflex scapu~ lar artery passes through the triangular space between teres major, teres minor and the long head of triceps.' The cutaneous branch passes through the deep fascia on the lateral border of the scapula, 2 cm above and medial to the apex of the posterior fold of the axilla. When the posterior axillary fold is distorted by scarring, the site of the cutaneous branch can be defined by drawing a point mirror-image to the contralateral side. The oblique branch passes downwards and medially, parallel to the lateral border of the scapula. The long axis of the flap is therefore drawn along the lateral border of the scapula. The flap can be extended down to the lower border of the last rib. After release of the axillary contracture, the defect is measured and a suitable flap designed with its base at the site of the perforator. If the defect is more than 10 cm, the flap can be used to cover the central area with grafting above and below it. The flap is raised, starting from below. The deep fascia overlying the latissimus is included in the flap and when it is dissected free from the muscle a rich vascular network can be seen on the underside of the fascia. When the teres major muscle is reached, its media] border is followed up to the pedicle vessels. At this stage, the pedicle vessels are mobilized from the triangular space. The medial and lateral incisions are then completed and the flap is either left pedicled or transformed into an island. If scarring at the donor area is extensive, it is better to leave it pedicled. The flap is transposed to lie in the axillary defect and sutured in place. When the defect is larger than the flap, split-skin graft is applied above and below the flap.Extensive undermining is needed to close the defect if it is more than 8 cm wide. As there are often other skin grafts and scars in the vicinity, a split-skin graft to close the donor defect is an acceptable and safe procedure.A tie-over dressing is applied to the grafted areas, and a light dressing is applied over the flap. The arm is kept in abduction for 1-2 weeks post-operatively, until the sutures are removed. Prophylactic antibiotics are given for 3-5 days. The first dressing is done on the seventh post-operative day. Follow-up visits and physical therapy for the shoulder start in the third week.

The parascapular flap was used to reconstruct 15 axillae in 12 patients (7 females and 5 males, age range from 4 to 52 years with a mean of 23 years) (Table 1). The contracture was on the right side in four patients, on the left side in five, and bilateral in three.
Flap length was 20-32 cm and width 7-10 cm. Three patients presented superficial scarring in the donor area. Five flaps were transferred as pedicled flaps while ten were islands. The pedicle of the flap was left, especially in the case of a scarred donor area. In the three cases with scarring of the donor area, primary closure of the donor defect was possible in one case, and a split-skin graft was applied in the other two. In these cases, superficial sloughing of the distal end of the flap occurred in one case (flap size 30 x 10 cm). The final result was however good, with free mobility of the shoulder region. Non-scarred donor defect was closed primarily in eight cases while split-skin graft was necessary in four. In one case superficial necrosis occurred at the distal end of the flap, but without affecting the final result.
To cover the axillary defect, a split-skin graft was applied below and above the flap (on the chest and arm) with eight flaps (Fig. 2), while in seven flaps the width was sufficient to fill the axillary defect (Fig. 3).
Adequate release and full abduction of the shoulder joint was obtained in all cases, and none of the patients complained of shoulder stiffness or required prolonged post-operative physical therapy.
The donor area was satisfactory accepted by 11 patients. The grafted donor area on the left side of the back of one female patient gave her some trouble, especially in the early post-operative period, as the area had hypertrophic edges.

Fig. 2a - Post-burn axillary contracture: anterior view. Fig. 2b - Post-burn axillary contracture: posterior view. Fig. 2c - Post-burn axillary contracture: parascapular flap filling the curve of the axilla with split-skin above and below the flap

Fig. 3a - Post-burn axillary contracture: pre-operative flap design. Fig. 3b - Post-bum axillary contracture: flap completely filling the axillary defect and the axillary folds clearly defined Fig. 3c - P 1 ost-burn axillary contracture: full abduction of the shoulder; the donor defect is covered by split-skin graft

Fig. 4 - Late post-operative: flap filling the axillary defect. In obese patients the bulkiness of the flap is evident.

The flap was thin and defined the concavity of the axilla in 12 axillae. In two rather obese patients the bulkiness of the flap was noticeable bilaterally in one patient and on the left side in the other (Fig. 4). The average hospital stay was 7-15 days, with a mean of 9 days. The maximum follow-up was 2.5 years.

The scapular flap, based on the transverse cutaneous branch of the circumflax scapular artery, was first described by dos Santos' following 70 cadaver dissections. In 1982, Nassif et al.11 described the parascapular flap and used it as a free flap. The circumflex scapular arter y passes through the triangular space, courses around the lateral border of the scapula and directs itself towards the cutaneous territory of the back. A vascular pedicle at least 6 cm long can be dissected, which makes the flap ideal as an island to the axilla. The artery and accompanying veins are constant and of large size, averaging between 2 and 3 min in diameter. The dissection of the flap is easy and it can be raised within 30 minutes. The deep fascia overlying the latissimus dorsi must be included in the flap. When it has been dissected free from the latissimus, the medial border of teres major has to be followed upwards as far as the vascular pedicle of the flap. Once the vascular pedicle is mobilized, the remaining dissection is easy and it can be transposed as pedicle or island. When transposed as pedicled, the dog-ear is minimal as the angle of rotation is acute. The pedicled flap is therefore preferable, especially in scarred donor areas.
The donor area can be closed primarily, especially in cases without scarring in the periaxillary area. However, split-skin grafting on the back on a muscular bed is a minimal cosmetic defect. Also, split-skin grafting above and below the flap is sufficient to cover very wide axillary defects,without affecting the final functional result of the shoulder. The transformation of the flap into an inverted-U shape' to simulate the axillary concavity is not mandatory. This latter technique needs a long flap that may not be possible in all cases. Also, the anterior reach of the flap may be limited.
The posterolateral fasciocutaneous flap described by Tollturst and Haeseker' is actually the pedicled variety of parascapular flap. It is the same territory of the descending branch.of the circumflex scapular artery. Its pedicle is however left wide, and the dog-ear is therefore more manifest.
The transverse scapular flap',' has the limitation of length and it cannot be used with diffuse and severe contracture of the anterior axillary fold and its periaxillary region. 0n the other hand, the parascapular flap can reach the clavicle and above.
The inner arm fasciocutaneous flap' may not be available in some cases. This flap is most suitable for contracture of the anterior axillary fold. The main cosmetic shortcoming is the dog-ear which is noticeable when the arm is adducted. Also, injury of the medial cutaneous nerve of the arm and grafting on the medial aspect of the arm may be disadvantageous.
The parascapular flap is quick and easy to raise and it can release most diffuse and severe axillary scar contractures. Its length can be extended up to 35 cm, and it can therefore be used to cover as far as the clavicle when this area is affected by scarring. The donor areas can be closed primarily. The flap can also be raised with superfical scarring of the donor area.

RESUME. L'auteur décrit l'emploi de 15 lambeaux parascapulaires basés sur l'artère scapulaire circonflexe utilisés pour corriger des rétractions axillaires dues aux brûlures dans 12 patients. Ces rétractions étaient du type diffus (type IV), dans lequel la cicatrisation touche tous les plis axillaires antérieurs et postérieurs, normalement en association avec la zone pileuse. Tous les lambeaux sont restés complètement viables et ont été utilisés avec succès pour libérer les rétractions. Le site donneur a été ou fermé primairement ou couvert avec une greffe cutanée d'épaisseune variable.

BIBLIOGRAPHY

1. Hanumadass M., Kagan R., Matsuda T., Jayaram B.: Classification and surgical correction of postburn axillary contractures. J. Trauma, 7.26:236,1986.
2. Tolhurst D.E., Haeseker B.: Fasciocutaneous flaps in the axillary region. Br. J. Plast. Surg., 35: 430, 1982.
3. Rintala A.E., Piironen J.: Secondary reconstructive surgery in bums. Ann. Chir. Gynecol., 69: 233, 1980.
4. Budo J., Finucan T., Clarke J.: The inner arm fasciocutaneous flap. Plast. Reconstr. Surg., 73: 629, 1984.
5. Dimond M., Barwick W.: Treatment of axillary bum scar contracture using an arterialized scapular island flap. Plast. Reconstr. Surg., 72:383,1983.
6. Yanai A., Nagata S., Hirabayashi S., Nakamura N.: Inverted-U parascapular flap for the treatment of axillary burn scar contracture. Plast. Reconstr. Surg., 76: 126, 1985.
7. Ohmori M.: Correction of bum deformities using free flap transfer. J. Trauma, 22: 104,1982.
8. Higazi M., Mandour S., Shalaby H.A.: Post-bum contracture of the axilla: evaluation of three methods of management. Arm. Medit. Bums Club, 3: 21, 1990.
9. dos Samos L.F.: The vascular anatomy and dissection of the free scapular flap. Plast. Reconstr. Surg., 73: 599, 1984.
10. NassifT.M., Vidal I., Bovet.I.L. et al.: The parascapular flap: anew cutaneous microsurgical free flap. Plast. Reconstr. Surg., 69: 591, 1982.
11. Barwick W.J., Goodkind D.J., Scrafin D.: The free scapular flap. Plast. Reconstr. Surg., 69: 591, 1982.