Egypt. J. Plast. Reconstr. Surg., Vol. 22, No. 2, 1998: 229 - 238

Reconstruction of Post-Burn Axillary Scar Contractures A Surgical Approach

SAMY A. M. SHEHAB EL-DIN, M.D. and OSAMA M. SHOUMAN, F.R.C.S.
The Plastic, Reconstructive and Burn Unit, Faculty of Medicine, Mansoura University.

ABSTRACT

Our study included 35 patients with postburn axillary scar contractures. The patients were admitted to the Plastic, Reconstructive and Burn Unit, Mansoura University Hospitals, from October, 1994 through October 1997. The axillary contractures were classified into 4 types: Type (I): Linear webs at either the anterior or posterior axillary fold with minimal adjacent scarring and no involvement of the hair-bearing area. Type (II): Scar contractures involving either anterior or posterior axillary fold, with adjacent skin scarring but sparing the hairbearing area. Type (III): Linear webs at both anterior and posterior folds without involvement of the adjacent skin or hair-bearing area. Type (IV): Involvement of the hair bearing area. The surgical procedures applied were five flap Y-V advancement and Z-plasty, for type 1 axillary contractures, inner arm pedicled fasciocutaneous flap and lateral thoracic pedieled fasciocutaneous flap for type II axillary contractures and parascapular island fasciocutaneous flap for type III and IV axillary contractures. The results were satisfactory and the complications were minimal.

INTRODUCTION

Deep partial- and full-thickness burns of the axillary region can result in scar contractures which limit motion at the shoulder joint, especially abduction and extension. In order to minimize or prevent axillary contractures, the initial management of bums in this region should include proper positioning of the shoulder joint in an abduction splint and aggressive physiotherapy [1]. Early surgical excision and skin grafting of deep and full-thickness burns will further minimize the development of contractures [2]. Active and passive excercises and the application of pressure garments after wound healing and/or graft take are essential in management of these injuries [3,4]. In spite of all these preventive measures, some patients nevertheless develop axillary contractures. Once scar contracture is established, immediate surgical correction must be performed to prevent further involvement of the underlying structures [5]. The goal of surgical correction of axillary scar contractures is to provide maximum correction with minimum or no local anatomic distortion. Once surgical correction is indicated, the choice of procedure must be individualized in order to achieve this goal. In this article, we present our surgical approach in the reconstruction of postburn axillary scar contractures.

Local anatomic conditions:
The main problem of axillary contractures is the inelasticity of either or both of the axillary folds which prevents the full extension and/or abduction of the shoulder joint. In addition to the scarring of the fold (s), there are two local anatomic conditions that must be taken into consideration when surgical correction is contemplated. They are: (1) the amount of scarring of the adjacent skin and (2) the involvement of the hair-bearing area of the axilla. It is unusual for the hair-bearing area to be involved in thermal injury due to its anatomic location and because in most instances, the upper extremities are maintained in adduction, protecting the axillary hair-bearing area [5].

Classification:
Hanumadass et al. [5] have classified the axillary contractures into four types:

• Type I: Is characterized by a linear web at the anterior or posterior axillary fold with minimal adjacent scarring and no involvement of the hair-bearing area.
• Type II: Is characterized by scar contractures involving either anterior or posterior axillary folds with adjacent skin scarring, but sparing the hair-bearing area.
• Type III: Is characterized by linear webs at both anterior and posterior folds without involvement of the adjacent skin or hair-bearing area.
• Type IV: Is characterized by involvement of the hair-bearing area.

PATIENTS AND METHODS

Patients population:
This study included 35 patients (14 males & 21 females) with postbum axillary scar contractures as outlined in table (1). These patients were admitted to the Plastic, Reconstructive and Bum Unit, Mansoura University Hospitals, Egypt, from October 1994 through October 1997. The mean age was 15.6 years with a range of 4.5-31 years. The mean % TBSA bum was 23.3% with a range of 10-40% 'and the mean % of full-thickness burn was 12.5% with a range of 5-25%. The mean time from initial burn to release being 3.3 years (range 0.5-13 years). All releases were performed electively with the most common etiologies of burn injury were flame 25 or scald 10 (Table 1).

Surgical Procedures:
The surgical procedures applied were fiveflaps Y-V advancement and Z-plasty, inner arm pedicled fasciocutaneous flap, lateral thoracic pedicled fasclocutancous flap and parascapular island fasclocutaneous flap. All patients had photographs taken of the involved axilla before and after surgery.

The five-flaps procedure [6]:
The triangular flaps of 2 Z-plastiesand Y-V advancement flap constitute the five-flaps and their design is shown in Fig. (1). The flap CDE encloses the apex of the axilla and its tip D lies at the midpoint of the line AB which runs along the ridge of the web. GA and HB complete the outline of the 2 Z-plasties; the angles 1 & 2 are about 60'. The incision DF opens into a triangular defect into which CDE is advanced. The part which is advanced and the only part undermined lies on the undersurface of the web and thus no change in position of the axillary apex occurs. The length DF is adjusted for the best fit. Because the ridge of the web is curved, the angles ADF & BDF are slightly larger than 90° and some trimming of excess may be necessary.

Lateral Thoracic Pedicled Fasciocutaneous Flap [7]:
The main band of contracture is cut across two-thirds of its width, the incision continuing one edge of the scar. A kite-shaped defect results. A flap large enough to fill the defect is raised in the remaining one-third through scar (or skin graft) and deep fascia. The integument is not disturbed from its attachment to the deep fascia. A length: breadth ratio of 3:1 is perfectly safe. It is important that the base of the flap is coterminous with the remaining edge of the scar so that full release of the contracture is effected. In less severe contractures the secondary defect can usually be closed by suture. If this results in unacceptable tightness a skin graft may be applied. However, this should be avoided if possible as the graft may be unsightly because of the deep secondary defect and the graft's consequent adherence to muscle.

The inner arm pedicled fasciocutaneous flap [8]:
An incision is made to completely release the tight contracture on the anterior surface of the axilla, extending onto the deltoid area and the arm is then adducted. A simple transposition flap, based proximally, is then raised deep to the deep fascia of the upper arm and avoiding cutaneous nerves wherever possible. This fascia is carefully separated from the intermuscular septum. In all cases, the dimensions of the flap exceeded the 2:1 length-breadth ratio. By fishtailing the incision to release the contracture, it was frequently possible to obtain extra relaxation and in these cases the distal end of the flap was similarly fishtailed to accommodate the defect. The donor site was closed primarily. A thin corrugated drain was placed beneath the flap to emerge at the point of transposition. The secondary defect was dressed, while the flap was left uncovered to permit inspection. A simple abduction splint was fashioned at the time of operation and remained until the stitches were removed around the tenth day.

Parascapular island fasciocutaneous flap [9,10]:
With patient in the lateral decubitus position, the arm abducted at 90 degrees, the emerging of the pedicle is first determined by accurate location of the omotricipital space at the lateral edge of the scapula. This space is easily palpable, or one can use the following measurement procedure. The omotricipital triangle is usually located at distance DI from the middle part of the spine of the scapula, given by the formula D1 = (D-I)/2, where D is the distance between the middle part of the spine and the tip of the scapula.Once the omotricipital space is located, the main axis of the flap is outlined along the lateral border of the scapula. The upper edge of the flap is outlined at the same level as the emerging of the pediele. The lower edge can be situated as far as 25 to 30 cm from the upper edge. The width of the flap consistent with closure by direct approximation is about 15 cm. For such a width, wide undermining of the surrounding skin and release of tension on the suture line by numerous deep mattress sutures are necessary.The cutaneous parascapular artery is a terminal branch of the circumflex scapular artery emerges from the scapular artery out at 4 cm from its origin from the axillary artery. It divides into one infrascapular branch, which runs horizontally towards the subscapularis muscle and one descending branch which runs backwards and emerges posteriorly from the omotrielpital space right at the edge of the lateral border of the scapula. The descending branch divides into the cutaneous scapular artery, which runs horizontally over the posterior aspect of the scapula and the cutaneous parascapular artery, which proceeds to the tip of the scapula that it overreaches.At operation, the contracture was released by transverse incision of the scar tissue until unrestricted range of motion was obtained in the shoulder joint. The resulting defect measured. The parascapular flap was elevated and the nutrient vessels in the pedicle part were ascertained. The flap was transplanted in the axillary region. Primary closure of the donor site was performed. Penrose drain was subcutaneously inserted after adequately fixing the flap to the base by suturing and the operation was completed.

RESULTS

Thirty five procedures had been performed to release post-bum axillary scar contractures in 35 patients (Table l): Type I comprised 10 patients reconstructed by 5-flap Y-V advancement and Z-plasty procedure (Fig. 2), type II included 20 patients reconstructed by lateral thoracic pedicled fasciocutaneous flaps in 5 patients (Figs. 3,4) and.inner arm pedicled fasciocutaneous flaps in 15 patients (Figs. 5,6) and five patients with types III and IV were reconstructed by parascapular island fasciocutaneous flap (Figs. 7,8). All flaps survived even when raised in scar tissue or areas previously grafted. Satisfactory release was obtained in all cases and non of the patients has required a second interference, with no recurrence of contracture. Splintage was not used after the initial postoperative period. The average time of hospitalization was 10 days. The maximum period of follow-up had been 9 months.

Fig (1): Five-flap Y-V advancement and Z-plasty. Fig. (2 - A): Postburn scar contracture of left anterior axillary fold in a male patient aged 8 years (Type I) reconstructed by five-flaps. Preoperative Fig. (2- B): Postburn scar contracture of left anterior axillary fold in a male patient aged 8 years (Type I) reconstructed by five-flaps. Post operative view Fig. (3-A): Postburn scar contracture of the left posterior axillary fold in a male patient aged 8 years (Type II) reconstructed by lateral thoracic pedicled fasciocutaneous flap.Preoperative Fig. (3-B): Postburn scar contracture of the left posterior axillary fold in a male patient aged 8 years (Type II) reconstructed by lateral thoracic pedicled fasciocutaneous flap.Postoperative.

Fig. (4-A): Postburn scar contracture of the left anterior axillary fold in a female patient aged 4.5 years (Type II) reconstructed by lateral thoracic pedicled fasciocutaneous flap.Preoperative Fig. (4-B): Postburn scar contracture of the left anterior axillary fold in a female patient aged 4.5 years (Type II) reconstructed by lateral thoracic pedicled fasciocutaneous flap.Postoperative. Fig. (5-A): Postburn scar contracture of the left anterior axillary fold in a female patient aged 20 years (Type II) reconstructed by inner arm pedicled fasciocutancous flap.Preoperative b) Postoperative. Fig. (5-B): Postburn scar contracture of the left anterior axillary fold in a female patient aged 20 years (Type II) reconstructed by inner arm pedicled fasciocutancous flap.Postoperative. Fig. (6-A): Postburn scar contracture of the left anterior axillary fold in a female patient aged 22 years (Type II) reconstructed by inner arm pedicled fasciocutancous flap.Preoperative. Fig. (6-B): Postburn scar contracture of the left anterior axillary fold in a female patient aged 22 years (Type II) reconstructed by inner arm pedicled fasciocutancous flap.Postoperative. Fig. (6-C): Postburn scar contracture of the left anterior axillary fold in a female patient aged 22 years (Type II) reconstructed by inner arm pedicled fasciocutancous flap.After 6 months.

Fig. (7-A): Postburn scar contracture of the right axilla (Type IV) in a male patient aged 20 years reconstructed by parascapular island fasciocutancous flap.Preoperative. Fig. (7-B): Postburn scar contracture of the right axilla (Type IV) in a male patient aged 20 years reconstructed by parascapular island fasciocutancous flap.Flap design. Fig. (7-C): Postburn scar contracture of the right axilla (Type IV) in a male patient aged 20 years reconstructed by parascapular island fasciocutancous flap.Flap elevation. Fig. (7-D): Postburn scar contracture of the right axilla (Type IV) in a male patient aged 20 years reconstructed by parascapular island fasciocutancous flap.Flap inset. Fig. (7-E): Postburn scar contracture of the right axilla (Type IV) in a male patient aged 20 years reconstructed by parascapular island fasciocutancous flap.Ten days postoperative.

Fig. (8-A): Postburn scar contracture of the right axilla (Type IV) in a female patient aged 15 years reconstructed by parascapular island fasciocutaneous flap.Preoperative Fig. (8-B): Postburn scar contracture of the right axilla (Type IV) in a female patient aged 15 years reconstructed by parascapular island fasciocutaneous flap.Flap design Fig. (8-C): Postburn scar contracture of the right axilla (Type IV) in a female patient aged 15 years reconstructed by parascapular island fasciocutaneous flap.Flap elevation. Fig. (8-D): Postburn scar contracture of the right axilla (Type IV) in a female patient aged 15 years reconstructed by parascapular island fasciocutaneous flap.Flap inset.

DISCUSSION

The armamentarium of the reconstructive burn surgeon comprises direct closure, grafts, flaps, free tissue transfer and tissue expansion [11].The standard method of correcting burn contractures running across the flexor surfaces of joints or of hollows in the body surface, is to cross-cut the scar tissue down to underlying normal tissue and to fill the defect created with a split-skin graft [12].This method has several disadvantages [7]: (1) The grafted area can recontract. Althoughthe amount can be reduced by the use of a thick skin graft, this may lower the percentage take of the graft. Some surgeons attempt to put in an excess of skin so that any further recontracture will take up this skin. This can have an ugly wrinkled area of graft. (2) Part of the split skin graft can fail to take, which may result in further surgery or repeated dressings, leading to a delay in healing. A greater extent of contracture can then occur. (3) In the case of severe burns, there may be an absence of suitable donor sites to yield a good single sheet of skin graft. (4) Pocket formation may occur at both ends of the incision. These may be unattractive and difficult to keep clean. This complication can be reduced by fish-tailing the ends of the incision. (5) A long hospital stay is involved so that the graft may have the best chance of taking and for the donor area to heal. (6) The skin graft donor area is painful. This is a very major problem for patients who need multiple readmissions for contractures in different parts of the body. (7) Long-term splining, often used to reduce graft contracture, can be cumbersome, need frequent checking and readjustment and may be expensive.Some clinicians have felt musculocutaneous flaps, specifically the latissimus dorsi, might play a role in axillary bum reconstruction. This flap is much too bulky for the axilla. The pectoralis may or has also been recommended for axillary reconstruction by Freedlander et al. [13]. Pectoralis flaps can interfere with function of the upper extremity. Free flaps have been reported for release of axillary burn contractures [14] but they are not practical on a routine basis.There are many methods of correction of postburn bridle scars of the axilla which include local rearrangement of the skin. Z-plasty (two flaps) [15], square flap (three flaps) [16], double Z-plasty (four flaps) [17], V-Y advancement and Z-plasty (five flaps) [6], six flaps Z-plasty (six flaps) [18], seven flaps plasty (two half Zplasties and one W-M plasty) [19]. X-plasty [20], propeller flap [21] and multiple Y-V plasty [22].The single Z-plasty, with its large flaps, is more prone to transverse tension, necrosis of the tip of a flap and displacement of the hairbearing skin of the axilla anteriorly over the chest wall. Using double Z-plasty procedure, one can avoid using large skin flaps, however, the local anatomic area (hair-bearing skin of the axilla) will be displaced. The use of combination of five-flap Y-V advancement and Z-plasty will preserve the local anatomic area and will reduce and diffuse the transverse tension, thereby minimizing circulatory embarassment.With the introduction of fasciocutaneous flaps by Ponten [23], there are now a number of larger flaps available in the axillary region which allow primary closure of total axillary defects. A series of axillary bum contractures released with the latissimus dorsi fasciocutaneous flap had been reported by Tolhurst [24,25] and confirmed by Achauer et al. [26]. Depending on the two cutaneous branches of the circumflex scapular artery, the scapular flap designed horizontally [27,28] and the parascapular flap designed obliquely [10,29] have been used to correct axillary postbum scar contractures. Maruyama [30] had used the ascending scapular flap, based on the ascending cutaneous branch of the circumflex scapular artery, for the repair of axillary burn scar contracture. A small, regional fasciocutancous flap of the inner arm had been reported by Beasley; Kaplan & Pearl and Budo et al [8,31,32] as useful for contractures of the anterior axillary fold. This flap was originally described by Kaplan and Pearl as an axial pattern (arterial) flap based on the superior ultiar collateral artery [32]. Budo feels that this inner arm flap is in reality a fasciocutaneous flap (superflap) because the dissection is carried out proximal to the origin of superior ulnar collateral artery. It is likely that the blood supply is based on the fascia of the axilla and anterior shoulder [8]. The posterior arm fasciocutaneous flap supplied by an unnamed but constant branch of the brachial artery had been described by Elliot et al. [33] in the reconstruction of the axilla. Roberts and Dickson [7] and Bhattachrya et al. [34] had reported the use of lateral thoracic fasciocutaneous flap in the reconstruction of postburn axillary scar contracture. The advantage of the fasciocutaneous flap is the simplicity of its concept. The surgical dissection may be performed rapidly with great facility, since the subfascial plan is relatively bloodless [35]. Thin flaps may be chosen that are extremely pliable to permit easy recontouring of adjacent defects using tissues similar to the original in color, texture and consistency. Many of these flap procedures may be done on an outpatient basis, especially if a skin graft can be avoided. No functional disturbance accrues, since muscle never has to be sacrificed. No special skills or equipment nor extended usurpation of operating theater time as demanded for microsurgical techniques is needed [29].An additional asset of the local fasciocutaneous flap specifically relevant to the burned patient is that a scarred or skin-grafted region itself may be used as part of the donor site in many cases, since the perforators to the deep fascia usually are found deep in intermuscular septa and are protected in most superficial burns. Also, even if the donor site for the flap must be skin grafted, little additional morbidity or aesthetic deformity is noticed, since all surgery is resticted to the site of injury [7].Unlike skin grafts, these flaps have a potential for growth with the patient, little risk of recontracture if properly performed and greater compliance to allow expansion with motion of the extremities. No cumbersome splints or intensive long-term physical therapy is needed for the sometimes uncooperative or noncompliant burn patient. Since only a single storage is required, the need for multiple surgical procedures, such as with tissue expansion, may be avoided, although the latter is another method that had advocates for local tissue reconstruction for bum deformities [36].From our study, we recommend the use of five flaps Y-V advancement and Z-plasty procedure in the reconstruction of type I axillary scar contractures. For type II axillary scar contructures, either the lateral thoracic pedicled fasciocutaneous flaps or the inner arm pedicled faselocutaneous flaps is suitable. As regards types III and IV axially scar contractures we prefer the use of parascapular island fasciocutaneous flap in their reconstruction as the defect resulting in these cases is surprisingly large needing a flap with large dimensions.

REFERENCE

1. Willis B., Larson D.L. and Abston S.: Positioning, and splinting the burned patient. J. Heart Lung, 2: 696,1973.
2. Burke J.F., Quinby W.C., Behringer G.E. et al.: Approach to burn therapy. Surg. Ann., 13: 1, 1981.
3. Larson D.L., Abston S., Willis B. et al.: Techniques for decreasing scar formation in the burned patient. J.  Trauma, 11: 807, 1971.
4. Larson D.K., Abston S., Willis R. et al.: Contrcture and scar formation in burn patients. Clin. Plast. Surg., 1: 653, 1974.
5. Hanumadass M., Kagan R., Matsuda T. and Jayaram B.: Classification and surgical correction of postburn axillary contractures. J. Trauma, 26: 236, 1986.
6. Hirshowitz B., Karev A. and Levy Y.: A 5-flap procedure for axillary webs leaving the ape?( intact. Br. J. Plast. Surg., 30: 48, 1977.
7. Roberts A.H.N. and Dickson W.A.: Fasciocutaneous flaps for burn reconstruction: a report of 57 flaps. Br. J. Plast. Surg., 41: 150, 1988.
8. Budo J., Finucan T. and Clarke J.: The inner arm fasciocutaneous flap. Plast. Reconstr. Surg., 73: 629,1984.
9. Nassif T.M., Vidal L., Bovet J.L. and Baudet J.: The parascapular flap: A new cutaneous microsurgical free flap. Plast. Reconstr. Surg., 69: 591, 1982.
10. Yanai A., Nagata S., Hirabayashi S. and Nakamura N.: Inverted-U parascapular flap for the treatment of axillary burn scar contracture. Plast. Reconstr. Surg., 76: 126, 1985.
11. Robson M.C., Barnett R.A., Leitch LON. and Hayward P.G.: Prevention and treatment of postburn scars and contracture. World. J. Surg., 16: 87, 1992.
12. Metaizeau J.P., Gayet C., Schmitt M. and Prevot J.: The use of free full-thickness skin grafts in the treatment of complications of burns. Progress in Pediatric Surgery, 14: 209, 1981.
13. Freedlander E, Lee K. and Vandervord J.G.: Reconstruction of the axilla with a pectoralis major myocutaneous island flap. Br. J. Plast. Surg., 35: 144, 1982.
14. Ohmori S.: Correction of burn deformities using free flap transfer. J. Trauma, 22: 104, 1982.
15. Bretteville-Jensen G.: Marking the 60° Z-plasty to achieve accurate lengthening. Br. J. Plast. Surg., 30: 72, 1977.
16. Hyakosoku H. and Funifiri M.: The square flap method. Br. J. Plast. Surg., 40: 40, 1987.
17. Woolf R.M. and Broadbent T.R.: The four flap Z-plasty. Plast. Reconstr. Surg., 49: 48, 1972.
18. Mir Y. and Mir L.: The six flap Z-plasty. Plast. Reconstr. Surg., 52: 625, 1973.
19. Karacoaglan N. and Uysal A.: The seven flapplasty. Br. J. Plast. Surg., 47: 372, 1994.
20. Vartak A. and Keswani M.H.: X-plasty for repair of burn contractures. Burns, 18: 326, 1992.
21. Hyakosoku H., Yamamoto T. and Fumiiri M.: The propeller flap method. Brit. J. Plast. Surg., 44:53,1991.
22. Cooper M.A. C.S.: The multiple Y-V plasty in linear burn scar contracture release. Br. J. Plast. Surg., 43: 145, 1990.
23. Ponten B.: The fasciocutaneous flap: Its use in soft tissue defects for the lower leg. Br. J. Plast. Sur,a., 34: 215, 1981.
24. Tolhurst D.E. and Haeseker B.: Fasciocutaneous flaps in the axillary region. Br. J. Plast. Surg., 35: 430, 1982.
25. Tolhurst D.E., Haeseker B. and Zeeman R.J.: The development of the fasciocutaneous flap and its clinical applications. Plast. Reconstr. Surg., 71:597,1983.
26. Achduer B.M., Spenler CM. and Gold M.E.: Reconstruction of axillary burn contractures with the latissimus dorsi fasciocutaneous flap. J. Trauma, 28: 211, 1988.
27. Diamond M. and Barwick W.: Treatment of axillary burn scar contracture using an arterialized scapular island flap. Plast. Reconstr. Surg., 72: 388, 1983.
28. Teot L. and Bosse J.P.: The use of scapular skin island flaps in the treatment of axillary postburn scar contractures. Br. J Plast. Surg., 47:108, 1994.
29. Hallock G.G.: The role of local fasciocutaneous flaps in total burn wound management. Plast. Reconstr. Surg., 90: 629, 1992.
30. Maruyama Y.: Ascending scapular flap and its use for the treatment of axillary burn scar contracture. Br. J. Plast. Surg., 44: 97, 1991.
31. Beasley R.W.: Burns of axilla and elbow. In: J.M. Converse (Ed.): Reconstructive Plastic Surgery, 2nd Ed., Vol. 6. Philadelphia: Saunders. P. 3391, 1977.
32. Kaplan E.N. and Pearl R.M.: An arterial media] arm flap-vascular anatomy and clinical applications. Ann. Plast. Surg., 4: 205, 1980.
33. Elliot D., Kangesu L., Bainbridge C. and Venkataramarkrishnan V.: Reconstruction of the axilla with a posterior arm fasciocutaneous flap. Br. J. Plast. Surg., 45: 101, 1992.
34. Bhattachrya S., Bhagia S.P., Bhatnagar S.K. and Chandra R.: Lateral thoracic region flap. Br. J. Plast. Surg., 43: 162, 1990.
35. Tolhurst D.E.: Fasciocutaneous flaps and their use in reconstructive surgery. Perspect. Plast. Surg.. 4: 129, 1990.
36. Hallock G.G.: Tissue expansion techniques in burn reconstruction. Ann. Plast. Surg., 18: 271, 1987.