|Year : 2014 | Volume
| Issue : 2 | Page : 278-283
Treatment of postburn axillary contracture
Ahmed Walash, Tarek Kishk, Fouad Mohamed Ghareeb
Faculty of Medicine, Plastic Department, Menoufia University, Shebin El-Kom, Menoufia, Egypt
|Date of Submission||26-May-2014|
|Date of Acceptance||26-May-2014|
|Date of Web Publication||26-Sep-2014|
Menoufia University, Faculty of Medicine, Plastic Department, Shebin El-Kom
Source of Support: None, Conflict of Interest: None
The aim of the study was to evaluate different options for postburn axillary contracture treatment.
Axillary postburn 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.
Patients and methods
A prospective study of 25 patients with postburn axillary contracture was conducted. The contractures were classified according to the Kurtzaman classification and reconstructed using different methods including skin grafting, local flaps (Z-plasty and five flaps), and regional flaps (parascapular, scapular, and thoracodorsal artery flap). Postoperative follow-up continued for 6 months. Patients had to undergo a physiotherapy course as a routine part of each technique.
The ages of the patients ranged from 7 to 46 years. Type of contracture was type 1A in 12 cases (48%), type 1B in four cases (16%), type 2 in four cases (16%), and type 3 in five cases (20%). The degree of abduction ranged between 50 and 130° with a mean of 100°. Split thickness graft was used in four cases (16%). Local flaps were used in 16 patients - Z-plasty in six patients (24%) and five flaps in 10 patients (40%) - and regional flaps were used in five patients (20%). The improvement in abduction seen postoperatively in the studied cases ranged from 25 to 80° with a mean of 55°. The overall functional and cosmetic results were satisfactory in most of the cases.
Z-plasty is suitable for short linear band contractures; the five-flap technique is indicated in longer ones. For type II and III contractures regional flaps are the treatment of choice whenever available. For severe cases release and split skin graft is indicated. Postoperative rehabilitation is very important to avoid recurrence and to maintain the result achieved.
Keywords: Axillary contracture, burn, fasciocutaneous flaps, local flaps, skin graft
|How to cite this article:|
Walash A, Kishk T, Ghareeb FM. Treatment of postburn axillary contracture. Menoufia Med J 2014;27:278-83
| Introduction|| |
Axillary postburn 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 . The axilla is one of the most frequently affected areas of postburn contractures, with associated cosmetic and functional problems. A variety of therapeutic options exist, but when the most suitable option is not chosen or postoperative rehabilitation is not properly adhered to, recurrence is often seen .
The hair-bearing part of the axilla is usually spared from the thermal injury because of the unexposed and hidden axillary skin of the arm pit, and because in most instances the upper extremities are maintained in adduction, protecting the axillary hair-bearing area. The common pattern of scar formation in this region is contracture of the anterior, posterior, or both axillary folds, with a normal axillary pit. Anterior axillary skin fold contracture is the most common deformity occurring at the shoulder .
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 .
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 the amount of scarring of the adjacent skin and the involvement of the hair-bearing area of the axilla .
Axillary contractures were classified by Kurtzaman and Stern on an anatomical basis into the following:
Type 1A: injuries involving the anterior axillary fold.
Type 1B: injuries involving the posterior axillary fold.
Type 2: injuries involving the anterior and posterior axillary folds.
Type 3: injuries of type 2 involving also the axillary dome .
Proper treatment of axillary contractures can be planned on the basis of this classification.
There are different options for treatment, including skin grafting, use of local flaps (Z-plasties, five flaps), and use of regional flaps (parascapular flap, scapular flap, and thoracodorsal perforator artery flap) .
| Patients and methods|| |
Twenty-five patients with postburn axillary contracture were operated upon at El Menoufia University Hospital and Shebin El-kom teaching hospital from October 2011 to December 2012.
Patients with axillary contracture, postburn injury, and 6 months or more postburn. After full history taking, including medical and surgical history, with special focus on the cause of the burn, percentage of burn, time of burn, and the initial management in the acute phase, all patients were subjected to a general and local examination with emphasis on the detection of contracture degree, site of contracture (whether anterior or posterior axillary folds, or both), axillary dome affection, and state of the surrounding skin of the adjacent area (chest, shoulder, and back).
Written consent was obtained from the patients before surgery after they had been informed about the advantages and possible adverse effects of the operation.
Patients were classified according to the Kurtzaman and Stern classification; the appropriate technique was selected for every patient taking into consideration the type of contracture and the state of surrounding tissue according to the clinical examination.
Split thickness graft was used in four cases. Local flaps were used in 16 patients: Z-plasty in six patients and five flaps in 10 patients. Regional flaps were used in five patients as follows: three patients had a parascapular flap, one had a scapular artery flap, and one had a thoracodorsal perforator artery flap.
All cases were followed up in the outpatient clinic. Follow-up was continued for not less than 6 months with respect to the viability and healing of the repaired area.
Physiotherapy was considered in the management of cases preoperatively and postoperatively, tailored to each case. Patients had to undergo a physiotherapy course under a specialist as a routine part of each technique.
Patients were examined periodically for complications of healing (infection, ulceration, necrosis, wound dehiscence, hypertrophic scar, and contracture) and maximum degree of axillary joint abduction.
| Results|| |
This study evaluated 25 patients with postburn axillary contracture, their ages ranging from 7 to 46 years with a mean of 20.04 years. Ten patients were female and 15 were male. The etiology of burn was direct flame in 19 patients (76%) and scald burn in six patients (14%). The type of contracture according to the Kurtzaman classification was type 1A in 12 cases (48%), type 1B in four cases (16%), type 2 in four cases (16%), and type 3 in five cases (20%) [Table 1].
The preoperative degree of abduction ranged between 50 and 130° with a mean of 100°. Split thickness graft was used in four cases (16%). Local flaps were used in 16 patients - Z-plasty in six patients (24%) and five flaps in 10 patients (40%). Regional flaps were used in five patients (20%) [Table 2].
The improvement in abduction postoperatively in the studied cases ranged from 25 to 80 degrees with a mean of 55° [Table 3]. Three cases of complications were seen: one case of tip necrosis with regional flap procedure; one case of distal necrosis with a five-flap procedure; and one case of partial loss of skin graft (nontake) [Table 4].
|Table 3: The relation between preoperative and postoperative degree of abduction (outcome)|
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|Table 4: The distribution of complications according to types of operations|
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All the complications were mild and were managed by repeated dressing until healing occurred. The overall functional and cosmetic results were satisfactory in most cases.
| Discussion|| |
Burn around the axillary region frequently leads to axillary scar contracture, one of the most difficult complications to prevent in burn patients .
An intensive exercise program under the supervision of a physical therapist gives the patient the best chance of recovering from injury with minimal loss of function. Such a program is not easy for the patient who would be experiencing severe pain or for the therapist who must insist that he move the extremity despite the pain, but serious impairment of function will most surely result if it is not implemented .
Yang  observed that axillary burn scar contractures are common problems after deep thermal burns involving the upper trunk or extremities because they are neither easily positioned initially nor easily rehabilitated later.
Disabilities of the axilla profoundly affect the hand function because it influences the strategic positioning of the hand . When there is significant contracture of this joint, full hand motion is impossible as the hand cannot be positioned for optimal function .
It is therefore imperative that the surgical correction of such a proximal contracture be given adequate attention as a favorable outcome has a positive impact on the overall functional rehabilitation of the burnt patient. This has made it crucial to evolve an objective means of assessing functional outcome following correction of axillary contractures .
Surgical correction of axillary contractures has remained a daunting challenge because of the complex anatomy of the axilla, which has been described as a unique three-dimensional pyramid-shaped hollow .
There are two local anatomic conditions that must be taken into consideration when surgical correction is intended: the amount of scarring of the folds and adjacent skin, and the involvement of the hair-bearing area .
In our study we analyzed the various surgical methods and we used Kurtzman's classification as our guide in management, as appropriate treatment for axillary contractures could be determined on the basis of this classification .
This study included 25 cases of postburn axillary contractures. The ages of patients ranged from 7 to 46 years with a mean of 20 years. Fifteen patients were male (60%) and 10 were female (40%). The cause of burn was mostly direct flame burn (76%) and less commonly scald burn (24%); the latter was mostly the cause in children. Almost all the studied cases showed a history of no or minimal physiotherapy and splinting of the axilla in the acute phase ,.
In our studied cases, the right axilla was involved in 12 cases (48%) and the left was involved in 13 cases (52%). Types of contracture were type 1A in 12 cases (48%), type 1B in four cases (16%), type 2 in four cases (16%), and type 3 in five cases . The degree of abduction ranged between 50 and 130° with a mean of 100°.
Although many therapeutic methods, including skin grafting, Z-plasties, local flaps, regional flaps, and free flaps, have been described, each technique has its own advantages and disadvantages in specific situations .
In our study, skin grafting with a split thickness graft was used in four cases (16%). In most of the cases the condition was not feasible for any of the fasciocutaneous flaps because of scarring of the surrounding area. In these cases, release and split thickness skin grafting was performed. Postoperative splinting was performed for about 3 months in these grafted cases. Functional improvement was noticed postoperatively, but in one case partial skin graft loss (nontake) was noticed, which healed primarily with repeated dressing.
We observed, as Kim et al. , that, although skin grafting is the simplest reconstructive method, it has several disadvantages. Frequently, there is patchy take of skin graft due to the anatomy of the defect, and the prolonged splinting in abduction and dedicated postoperative physical therapy are necessary to avoid additional contracture. Furthermore, the cosmetic result after skin grafting is poor .
Many authors such as Mataizeau et al.  have reported that continuous splinting and massage for 3-6 months is needed to prevent contracture of the grafted area .
In six cases (24%) of our study, the scar was linear contracture of the anterior or posterior axillary fold with healthy surrounding skin. Single or multiple Z-plasties were performed for these cases. The functional improvement and the cosmetic result were both satisfactory for the patients and surgeons.
As reported by Ahmet K. et al. and Yanai A. et al., the disadvantage of this procedure is that unless the scar is a discrete band it will not provide the desired release without skin grafting ,.
Our study found that this disadvantage of this technique is the main reason for its limitation in contracted scar axilla.
In 10 cases (40%) of our study the contracture was a moderate localized scar with healthy surrounding skin. Five flaps were used for these cases. The flap design and donor site were determined by the shape and location of the scar. Transposition flaps from the inner arm were used in one case of localized contracture bands in the posterior axillary fold. Advancement flaps from the axilla were used in seven cases of contracture bands of the anterior axillary fold. Double five flaps were used in two cases of axillary contracture type 2.
The functional improvement and cosmetic result were satisfactory for both the patients and the surgeons. However, distal flap necrosis was noticed as a complication in one case of type 2 contracture. Healing occurred without further intervention by repeated dressing.
As Siebert and Longaker  reported, we noticed that a local flap consisting of nonscarred and pliable skin is necessary to minimize residual contractures and to abduct the arm without difficulty. Local random flaps are able to cover limited skin defects of the axilla .
We also found that five-flap Z-plasty is more suitable for linear type of contracture. The hair-bearing area was displaced to a lesser extent in this technique. This finding coincides with that reported by El-Ottify  and others .
In five cases (20%) in this study, the previous techniques were not feasible either because the adjacent skin was scarred or because the contracture was severe. According to the Kurtzaman and Stern classification, four patients had type 3 axillary contracture and one patient had type 2 axillary contracture.
In three of the studied cases (12%), a parascapular flap was applied. The functional improvement and cosmetic result were satisfactory.
The advantages of the parascapular flap are that it is possible to close the donor site primarily and also to construct the axillary cavity .
We recognized that the disadvantage of this technique, as Teat and Bosse reported, is that it is limited to axillary defects with moderate size not larger than 8 cm . However, bigger flaps can be taken from parascapular areas if preliminary tissue expansion is performed .
From our result we noticed that, as Hallock  reported, use of the parascapular flap for reconstruction of severe contracted axillae yields excellent functional restoration together with very good esthetic results, as the parascapular flaps provide ample amount of soft, pliable, and relatively thin skin, together with minimal donor site scars, which are closed primarily in all of our cases .
In one of the studied cases, an island scapular flap was applied. The indication was a wide defect and a nonintact parascapular area.
The technique used was that described by Teat and Bosse . The donor site was closed by a split thickness skin graft. The patient had excellent postoperative improvement in abduction. However, he complained of bulkiness of the flap in the axilla and was conscious of the depression at the grafted donor site. Teat and Bosse  and Hallock  had mentioned the same disadvantages.
In one of the studied cases, a thoracodorsal perforator island flap was applied. The indication was a wide defect and a nonintact scapular and parascapular area.
The functional improvement and cosmetic result were satisfactory for surgeons and patients. The donor site was closed primarily, leaving a vertical scar that was considered to be negligible by the patient considering the comfort of free abduction.
The advantages of this flap were that it could be widened safely to meet any size required, even in the most severe contractures, and the donor site scar may be considered acceptable considering the functional gains. These advantages were also reported by Kim et al.  and Wilson et al. .
As reported by Tiwari et al.  the disadvantage of this flap is the bulkiness in the axilla, which may result in a poor cosmetic appearance and also limit the adduction of the arm.
Postoperative care and follow-up continued for 6 months for all patients. Patients underwent a physiotherapy course with a specialist as a routine part of each technique.
Colditz has reported excellent results with the use of serial splinting in the stiff joint ,. This therapeutic technique is time intensive for both patient and therapist, ranging from 4-8 weeks, or longer if the stiffness is longstanding .
Prolonged static splinting was required after skin grafting procedures, but therapeutic sessions were started within 2-3 weeks after surgery, removing the splint for each session. For different types of flaps, maintenance of released/corrected position was done until the flap margins had healed.
Postoperative use of static or dynamic splints, interspersed with daily physical therapeutic exercises, was required to keep the joints in full range of motion especially if static splintage was used .
The rate of complications in this study was 12%: one case of tip necrosis with the regional flap procedure, one case of distal necrosis with the local five-flap procedure, and one case of skin graft loss (nontake). All of these complications were mild and were managed by repeated dressing until healing.
The overall functional improvement was quite satisfactory. The percentage of improvement in abduction had a mean of 155%. The cosmetic result was also satisfactory in most of the cases.
| Conclusion|| |
We can conclude that a flap should be the preferred choice over skin grafts for axillary reconstruction. Z-plasties and local random skin flaps are always preferred to fasciocutaneous flaps. Z-plasty is suitable for short linear band contractures; the five-flap technique is indicated in longer ones. For Type II and III contractures regional flaps are the treatment of choice whenever available. For severe cases release and split skin graft is indicated. Postoperative rehabilitation is very important to avoid recurrence and to maintain the result achieved.
| Acknowledgements|| |
Conflicts of interest
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[Table 1], [Table 2], [Table 3], [Table 4]