Axillary post burn contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction that should be achieved and due to the common unavailability of local tissues to be used for reconstruction of the axilla. Twenty patients with post burn contractures of the axilla were treated in the Department of Burns, Cairo University in the period between May 2002 & June 2006. The patient's age ranged between 6 and 38 years with a mean age 24 years. 6 cases (30%) had contracture of anterior axillary fold, 4 cases (20%) had contracture of posterior axillary fold and 10 cases (50%) had contracture of both folds. The operative procedure was chosen according to the pattern of scar and state of surrounding skin. Multiple Z plasties were done in 5 cases (25%), local flaps were done in 4 cases (20%), parascapular flap was done in 5 cases (25%), island scapular flap was done in 2 cases (10%) and in 4 cases (20%), release and split thickness skin grafting was done. The rate of complications was 30%. All of them were minor. Functional improvement was quite satisfactory, except for one case of skin grafting which had re-contracture. The percentage of improvement in abduction had a mean of 160%. The cosmetic result was also satisfactory in most of the cases except for the two patients who had island scapular flap due to depression deformity in the donor area of the flap. The study concluded that the choice of surgical procedure for reconstruction of post burn axillary contracture can be made according to the pattern of scar contracture and the state of surrounding skin. The choice of a flap should have priority to skin graft because of the superior functional and cosmetic results of flaps. Z plashes and local random skin flaps are simple procedures and preferred to fasciocutaneous flaps due to simplicity of technique. Long term splinting and physical therapy are mandatory after release and skin grafting of axilla to prevent re contracture.
Burn of the upper extremity, even when limited in extent, may severely limit function by making job retraining necessary even rendering subsequent job performance impossible. The most susceptible are young adults and young children who use their hands in work activities and in the exploration of their environment [1].
Ill treatment or inadequate splinting and rehabilitation after burn injuries inevitably result in debilitating post burn contractures that impair various functional abilities of the involved limb. Among these, axillary post burn contracture remain a frequent problem due to difficulties of shoulder abduction against the contractile evolution of the scar [2].
Tight contractures of the anterior axillary fold are frequently seen after burns [31. Severe axillary contractures may be prevented by early prophylactic splinting and active exercises [41. The burned upper extremity should be splinted to maintain function and to minimize secondary deformities [51. The patient should be made aware of the potential limitation of movements and should be instructed in specific exercises to help avoid them [6].
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 procedure must be individualized. Traditional therapeutic measures include skin grafting, Z plashes and local flaps but these methods do not always produce satisfactory results. More recently such methods as the free flaps and the island flaps 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 [7].
Axillary contractures were classified by Kurtzaman and Stern [81 on an anatomical basis (Table 1). Proper treatment of axillary contractures can be planned in the light of this classification [8].
The study was conducted in the Department of Burns, Cairo University Hospitals in the period between May 2002 & June 2006. Twenty patients with post burn deformities of the axilla were treated.
Preoperative assessment:
The age of the patient and the onset of the condition were recorded. History was taken with special concern on the cause of the burn and the initial management in the acute phase. General examination was done to exclude any medical problem and looking for other burn deformities.
All the cases were examined locally for:
Degree of contracture (=degree of limitation of abduction) whether mild (>90), moderate (3090) or severe (<30).
Site of contracture, whether anterior or posterior axillary folds or both of them.
State of the surrounding skin of the adjacent chest, shoulder and back.
The choice of the operative procedure was determined according to the degree and site of contracture as well as the state of the surrounding skin as follows;
Linear contractures involving either the anterior or posterior folds causing mild to moderate degree of contracture with a good state of surrounding skin: Single or multiple Z plasties.
Moderate localized contracture band of the anterior or posterior axillary fold with healthy surrounding skin; Local flaps.
Diffuse scarring of the armpit (contracture of one or both axillary folds with scarred surrounding skin) of any degree; Release and either fasciocutaneous flap or skin graft. The choice between both was determined according to the state of the surrounding skin for the availability of fasciocutaneous flaps.
Preoperative marking was done while the patient was standing and the hand abducted at maximum to delineate the contracture and the expected release incisions and also to map the flap to be used. Photographs were taken preoperatively.
Preoperative broad spectrum antibiotic was given IV 2 hours prior to surgery. Operations were done under general anaesthesia.
Operative procedures:
1- Z plasties: Z plasty was the procedure of choice for linear scar contractures of the anterior or posterior axillary folds if the surrounding skin was healthy. Multiple Z plasties were employed for long linear scars while single Z plasty was done for a short web. If one of the defects could not be closed after release, a split thickness skin graft was added to that site.
2- Local flaps: Local skin flaps from arm, anterior chest, axilla or back were chosen for cases of localized moderate bands of contractures of anterior or posterior axillary folds, provided that the donor site is not scarred. We used advancement or transposition flaps from the normal uninvolved skin adjacent to the scar. The specific design of the flap was dependent upon the distribution and extent of the scar. The donor sites were either in the arm, anterior chest wall, back or armpit. The donor sites of the flaps were covered by split thickness skin graft.
3- Skin grafting: Split thickness skin grafting was done after release of contractures of the axilla involving one or both axillary folds. This operation was done if the surrounding skin is scarred and not available for any local or fasciocutaneous flaps that could cover the resulting defect or if the defect was bigger than any available flap as in severe axillary contractures.
Following release of the contracture, proper haemostasis was done. Skin grafts were taken from the thigh. Tie-over dressing was placed over the graft to secure it in place. Splinting was done in maximum abduction position.
4- Parascapular f lap: This was the flap of choice to cover the defect after release of the axilla if the width of the defect is less than 8cm provided that the parascapular area is not scarred. The operation is performed in the lateral position. The scar was first released. The width of the defect was estimated, a parascapular flap, based on the parascapular artery, was elevated with dimensions that can cover the resultant defect. The flap was secured in the axilla. Donor site was closed primarily after proper undermining.
5- Island scapular flap: This technique was done in severe contractures of the axilla if the skin of the back is healthy. The patient lies in the lateral position with the upper arm in maximal abduction. The scar is then released. The flap is located in the upper part of the back; the length can reach 1215cm, and the width 8lOcm. The flap was drawn with its longitudinal axis centered on the transverse line determined by the horizontal cutaneous branch of the circumflex scapular vessels. These are the feeding vessels. They emerge from the depth at a point 2cm lateral to the junction between the upper third and lower two thirds of the line joining the lateral aspect of the acromion and the lower margin of the scapula. They then run transversely on the back. Dimensions of the flap corresponded to the axillary defect.
Dissection started medially and extended laterally. The pedicle was identified as emerging through the triangular space. After dissection of the vascular pedicle, the flap was then rotated as an island flap and inset in the defect. The donor site was closed by a split thickness skin graft if primary closure could not be achieved.
Postoperative broad spectrum antibiotic was given for all cases for one week. Long term splinting and physical therapy were the rule in cases treated by skin grafting. Follow up visits were done after 3 days, 1 week, 2 weeks, 1 month, 3 months and 6 months to monitor the progress. Postoperative photographs were taken on follow up visits.
Patient's age ranged between 6 and 38 years with a mean age 24 years. Out of the twenty cases studied, the right axilla was involved in 6 cases (30%) and the left was involved in 14 cases (70%).
The cause of burn was mostly direct flame burn (16 cases = 80%), and less commonly due to scald burn (4 cases = 20%). Duration since burn ranged between one year and four years with a mean of 18 months. All the cases gave history of no or minimal physiotherapy or splinting for their axilla. Types of contracture were type lA in 6 cases (30%), type 1B in 4 cases (20%) and type 2 in 10 cases (50%). The degree of contracture ranged between mild and severe (Table 2). The degree of abduction ranged between 20° and 90° with a mean of 60°.
According to the pattern of scar, and accordingly the choice of procedure, cases were distributed as shown in Table (3).
The degree of abduction one month postoperatively ranged between 120° and 150°, with a mean of 130°. The degree did not change over the next 6 months of postoperative follow up except in one case from the group who had release and skin grafting i.e. one case of re-contracture (5%0). Still the range of abduction in this case was much better than that prior to operation.
The percentage of improvement in abduction in the studied cases ranged from 110% to 260% with a mean percentage of change in abduction of 160%. The maximum degree of abduction after each kind of operation is illustrated in Table (4).
As regards complications, there were two cases of tip necrosis of the Z plasties flaps, one case of wound infection, two cases of marginal flap necrosis (of less than 1 cm width) in the parascapular flaps used, one case of patchy skin graft non take (small areas). All the complications were mild and were managed by repeated dressing until healing occurred.
All the cases were satisfied about the functional results of the procedures done. Patients who had island scapular flap were complaining of the ugly depression deformity in the donor area of the flap.
Figs. (1-4) show photographs of some of the studied cases.
Burn around the axillary region frequently leads to axillary scar contracture, one of the most difficult problems to prevent in burn patient [9].
Axillary post burn contractures remain a frequent problem after thermal burns involving the trunk and upper arm. Difficulties in rehabilitation of shoulder abduction during the initial period and the contractile evolution of the scar contribute to this problem [l0].
Intensive exercise program under physical therapist supervision combine to give the patient the best chance of surviving his injury with minimal loss of function. Such a program is not easy for the patient who is experiencing severe pain or for the therapist who must insist that he moves the extremity in spite of the pain, but serious impairment of function will most surely result if it is not done [11].
This study included 20 cases of post burn axillary contractures. Age of patients ranged between 6 and 38 years with a mean age 24 year. The cause of burn was mostly direct flame burn (80%) and less commonly scald burn (20%), the latter was mostly the cause in children cases involved in the study.
Almost all the studied cases gave history of no or minimal physiotherapy and splinting of the axilla in the acute phase. Many authors stressed the importance of exercises and splinting in burns of the axilla to maintain function and to minimize secondary deformities [4,5,6,11-15].
In our studied cases, the right axilla was involved in 6 cases (30%) and the left was involved in 14 cases (70%). Types of contracture were type lA in 6 cases (30%a), type 1B in 4 cases (20%) and type 2 in 10 cases (50%). The degree of contracture ranged between mild and severe. The degree of abduction ranged between 20° and 90° with a mean of 60°.
The cutaneous gliding capacity of the shoulder area skin is important. Full abduction stretches both anterior and posterior folds of the axilla, and there is upward movement of the skin covering the lateral aspect of the trunk. Treating axillary contractures should replace these gliding possibilities [10].
Many techniques have been described for the release of contracted scar axilla. Skin grafting is the simplest reconstructive method but it has several disadvantages [16]. Free skin grafts are somewhat difficult to apply in the concave surface of the axilla, and after sometime can lead to secondary contracture [10].
Z plasties or local flaps such as transposition or advancement flaps usually can be used in linear scar contractures at the axillary folds, but they are not effective in severe axillary contractures or scarred adjacent tissue [161. Z plasty is generally the procedure of choice for linear scar contractures. However, a single Z plasty is not suitable in the axillary contractures, because it requires large skin flaps in a limited area with displacement of the hair bearing area [7].
Local flaps alone or in combination with split thickness skin grafts are helpful in correction of burn scar contractures. The specific design of the flap is dependent on the distribution and extent of scar or the more specifically the availability of normal uninvolved skin adjacent to it. The surgeon must avoid flaps containing a significant portion of scar tissue particularly at the base of the flap [17].
Fasciocutaneous flaps from the back such as scapular and parascapular flaps have been used for treatment of obliterated axilla. They have proved to be excellent for resurfacing large defects involving the axilla, and their donor sites can be closed primarily up to a l0cm flap width. However the normal skin and subcutaneous tissues are thicker in the back than in the axilla, whereas the adjacent burn tissues surrounding the contracted axilla are usually even thinner than the normal tissue because of the scar contracture. Therefore when the cutaneous flaps from the back are used for axillary reconstruction, they may induce the need for secondary debulking procedures [18].
The island scapular flap offers satisfactory functional and aesthetic improvement with its remarkable dimensions and acceptable thickness for the axillary region for all types of contracture [2].
In this study, the operative procedure was chosen according to the pattern of scar. In 5 cases (25%), the scar was linear contracture of anterior or posterior axillary fold with healthy surrounding skin. Multiple Z plasties were done for these cases. The functional improvement and the cosmetic result were both satisfactory to the patients and surgeon.
The disadvantage of this procedure is that unless the scar is a discrete band, they will not provide the desired release without skin grafting [191. Our study found this disadvantage of this technique which is the main reason for the limitation of its indications in contracted scar axilla.
In 4 cases (20%), the contracture was a moderate localized scar with healthy surrounding skin. Local flaps were done for these cases. The flap design and donor site was determined by the shape and location of the scar. Transposition flaps from inner arm were used in two cases of localized contracture bands in the posterior axillary fold. Advancement flaps from the axilla were used in two cases of contracture bands of the anterior axillary fold. The functional improvement and the cosmetic result were both satisfactory to both the patients and the surgeons.
The local flap consisting of non scarred and pliable skin is necessary to minimize residual contractures and to abduct arm without difficulty. Local random flaps are able to cover limited skin defects of the axilla [17].
In 11 cases (55%) of this study, the previous techniques were not feasible either because the adjacent skin was scarred, or because the contracture was severe. The choice of procedure in these cases relied on the state of the skin of the scapular and parascapular areas as well as the size of the defect. If the size of the defect was less than 8cm and the parascapular area is healthy, parascapular flap was done. If the size of the defect was more than 8cm, or if the parascapular area was scarred, island scapular flap was done provided that the area of the back was free of scars. If neither scapular nor parascapular flap could be done, generous release was made and the defect was covered by split thickness skin graft.
In 5 of the studied cases (25%), parascapular flap was done. The functional improvement and the cosmetic result were satisfactory. The disadvantage of this technique is that it is limited to axillary defects less than 8cm [101. We followed this rule in this study. Although bigger flaps can be taken from parascapular areas if preliminary tissue expansion is done.
The advantages of the parascapular flap are that it is possible to close the donor site primarily and it is possible to construct the axillary cavity [20].
In 2 of the studied cases, island scapular flap was done. The indication was a defect bigger than 8cm width, although the parascapular area was intact. The technique used was that described by Teat & Bosse [10]. The donor site in both cases was closed by split thickness skin graft. Both cases had excellent postoperative improvement in abduction. However, they both complained of bulkiness of the flap in their axilla and they are conscious about the depression at the grafted donor site. These disadvantages were mentioned in literature [10,18].
In 4 of the studied cases (20%), the condition was not feasible for any of the fasciocutaneous flaps due to scarring of the scapular and parascapular area. In these cases, release and split thickness skin grafting was done. Postoperative splinting was done for at least three months in these grafted cases. Functional improvement was noticed postoperative but in 1 case recontracture occurred, most probably because he did not maintain wearing the splint.
Skin grafting is the simplest reconstructive method but it has several disadvantages. Frequently there is a patchy take of skin graft due to the anatomy of the defect, and the prolonged splinting in abduction and faithful postoperative physical therapy are always necessary to avoid additional contracture. Furthermore the cosmetic result after skin grafting is poor [16].
The rate of complications in this study was 30%; two cases of tip necrosis of the Z plasties flaps, one case of wound infection, two cases of marginal flap necrosis (of less than Lcm width) in the parascapular flaps used, one case of patchy skin graft non take (small areas). All the complications were minor and were managed by repeated dressing until healing occurred.
Apart form the case of re-contracture after skin grafting, the overall functional improvement was quite satisfactory. The percentage of improvement in abduction had a mean of 160%. The cosmetic result was also satisfactory in most of the cases except for the two patients who had island scapular flap who complained of the ugly depression deformity in the donor area of the flap.
The choice of surgical procedure for reconstruction of post burn axillary scar contracture can be made according to the pattern of scar contracture and the state of surrounding skin. An algorithm is suggested. The choice of a flap should have priority to skin graft because the functional and cosmetic results of flaps whether skin flaps or fasciocutaneous flaps are superior to skin grafting in the axilla. Z plasties and local random skin flaps are simple procedures. Whenever feasible, they are always preferred to fasciocutaneous flaps due to simplicity of technique. Long term splinting and physical therapy are mandatory after release and skin grafting of axilla to prevent re contracture.
Algorithm for the choice of operative technique for reconstruction of contracted scar axilla