|Year : 2020 | Volume
| Issue : 1 | Page : 63-68
Comparing different modalities of managing postburn axillary contracture
Arshad Hafeez Khan, Vivek Ambedkar, Rajesh Kumar Maurya
Department of Plastic Surgery, JNMCH A.M.U., Aligarh, Uttar Pradesh, India
|Date of Submission||29-Apr-2019|
|Date of Decision||09-Feb-2020|
|Date of Acceptance||01-Jun-2020|
|Date of Web Publication||21-May-2021|
Dr. Vivek Ambedkar
Department of Plastic Surgery, JNMCH A.M.U., Aligarh, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Axillary postburn scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction that should be achieved. The aim of this study is to highlight the various management options used in managing axillary contractures in our hospital and to minimize the complications commonly encountered.
Aims and Objective: The aim and objective of this study is (1) to evaluate different options for postburn axillary contracture treatment, (2) the functional outcome of different treatment methods, and (3) late squeals of treatment.
Materials and Methods: It is a prospective study which was conducted at the department of plastic surgery. Axillary contracture was released and resurfaced using split skin graft and/or with different types of flaps, including the Single Z plasty, Multiple Z plasty, Five flap plasty, Local fasciocuteneous flap, Propeller flap, and Parascapular flap.
Results: Eighteen patients were operated. Surgical treatment included split-thickness skin graft in five cases, square flap in three cases and square flap with split thickness graft in two cases, Multipe Z-plasties in two cases and Multipe Z plasty with split-thickness graft in one case, Parascapular flaps with split thickness graft in two cases, while five flap plasty in three cases.
Conclusion: Mean degree of abduction is maintain or increased in follow-up (after 6 month) is Square flap, Multiple Z plasty, five flap plasty, and Parascapular flap. Mean degree of abduction is decreased in split thickness graft in follow-up (after 6 month).
Keywords: Axillary contracture, five flap plasty, Multiple Z plasty, parascapular flap, split skin graft, square flap
|How to cite this article:|
Khan AH, Ambedkar V, Maurya RK. Comparing different modalities of managing postburn axillary contracture. Indian J Burns 2020;28:63-8
| Introduction|| |
India is a developing country. Due to the illiteracy, poverty, and low level of safety and poor socioeconomic condition in the population; the incidence of burn is high. The incidence of upper extremity burns is high. Those patients survive developed scar and contracture in the upper extremity, especially axilla causing severe functional impairment and difficulty in shoulder abduction.
The aims and objective of this study are to evaluate the different options for postburn axillary contracture treatment, the functional outcome of different treatment methods, and late squeals of treatment.
| Materials and Methods|| |
It is a prospective study which was conducted at the department of plastic surgery in our institute. Patients who fulfil the inclusion and exclusion criteria:
- Patient with axillary contractures, postburn injury, and 6 month or more post burn
- Patient fit for anesthesia with no underlying gross morbidity
- Patient giving consent for photography and publishing literature
- Patient of any age.
- Elsewhere operated cases of axillary contractures which presented with complication
- Patients not giving consent for photography and publishing literature
- Patients not fit for the surgery
- Patients with apparent psychiatric conditions.
Were selected, over a period of 2 years (September 2016 to September 2018) the study consisted of patients from all age groups and both sex. Moreover, Institutional review board clearance was taken from the institutional ethics committee faculty of medicine D NO. 642/FM (17/07/2017). We have applied to ethical committee before the study, but they have sent after 10 months due to office delay.
Axillary contracture was completely released and randomly resurfaced using split skin graft and/or with different types of flaps, including the Single Z plasty, Multiple Z plasty, Five flap plasty, Parascapular flap, etc., the Contracture occurs in the anterior, posterior, or both axillary folds. According to Kurtzman and Stern (1990), classification axillary contractures having three types:
- Type IA: Injuries involving the anterior axillary fold
- Type IB: Injuries involving posterior axillary fold
- Type II: Injuries involving both anterior and posterior axillary folds
- Type III: Injuries involving both axillary folds and axillary dome.,
The age of the patient and the onset of the condition were recorded. Clinical history was taken with special concern on the cause of the burn and the initial management in the acute phase.
All the cases were examined locally for degree of contracture (degree of limitation of abduction) whether mild (>90), moderate (30–90), or severe (<30).
Site of contracture whether anterior or posterior axillary folds or both involved. Data sheets was maintained patient's age, sex, involved axilla, degree of contracture, types of burn, methods of surgery, results and complications were recorded. Assessment was done on the basis of functional and esthetic outcome.
All patients were admitted in the plastic surgery ward, and after discharge were followed up in plastic surgery OPD; all patients were operated under general anesthesia.
Postoperative care and splintage
- Split thickness graft: In cases where only split thickness graft was used to resurface, the raw area after contracture release, splintage was done for a longer period. 24 h splintage was done for initial one month; subsequently, splintage was done during sleep only for another at least 2 months
- Five flap plasty with split thickness graft: In cases of five flap plasty with split thickness graft and also in cases of parascapular flap with split thickness graft, 24 h splintage was done for first 1 month followed by splintage only during sleep for another 1 month
- Square flap with split thickness graft: In cases of square flap with split thickness graft, 24 h splintage was done for initial 1 month followed by splintage during sleep for 15 days
- Square flap or multiple Z plasty: In cases where release was done by either square flap or multiple Z plasty without split thickness graft splintage was done for 3 weeks.
NOTE: During the period of 24 h splintage, after 15 day's splintage was removed during the day time for care of the graft and physiotherapy and then re-applied.
Proper physiotherapy was advised in every case. Patient's preoperative and postoperative degree of abduction and percentage of improvement (abduction) were recorded in the follow-up. Preoperative and postoperative degree of abduction was measured with GONIOMETER [Figure 1].
|Figure 1: Instrument to measure the preoperative and postoperative degree of abduction|
Click here to view
| Results|| |
A total of 18 patients were operated during the study period. There were 13 (72%) cases male and 5 (28%) cases female patients. Left side axillary contracture was found in 11 patients and right side in six patients, and one patient was found bilateral axillary contracture.
Type I: Axillary contracture was the most common and was found in 13 (72%) patients [Type IA 8 (62%) patients [Figure 2]a and Type IB 5 (38%) patients [Figure 3]a. Type II axillary contracture was found in 2 (11%) patients [Figure 4]a. Type III axillary contracture was found in 3 (17%) patients [Figure 5]a.
|Figure 2: (a) Right side Type IA axillary contracture (b) square flap marking (c) postoperative with goniometer|
Click here to view
|Figure 3: (a) Right side Type IB axillary contracture (b) Multiple Z plasty (c) tip necrosis of flap in the postoperative period|
Click here to view
|Figure 4: (a) Left side Type II axillary contracture (b) axillary contracture release with STSG (c) postoperative after 1 month|
Click here to view
|Figure 5: (a) Left side Type III axillary contracture (b) elevation of parascapular flap (c) immediate postoperative|
Click here to view
Preoperative degree of abduction <30° no patient was found and between 30° and 90° 14 (78%) patients was found and between 91° and 120° 4 (22%) patients was found. Preoperative degree of abduction was found (range between) 30° and 120° and Mean preoperative degree of abduction was 74°.
Different modality was done in axillary contracture [Table 1]. Multiple Z plasty was done in 3 (16%) cases [Figure 3]b, square flap was done in 5 (28%) cases [Figure 2]b, and split thickness graft was done in 5 (28%) cases [Figure 4]b, parascapular flap was done in 2 (11%) cases [Figure 5]b and [Figure 5]c; five flap plasty was done in 3 (17%) cases [Figure 6]a and [Figure 6]b.
|Table 1: Procedure wise pre- and post-operative, follow-up degree of abduction improvement|
Click here to view
|Figure 6: (a) Right side axillary contracture with marking of five flap plasty (b) immediate postoperative (c) after 1 month|
Click here to view
Mean degree of abduction is maintained or increased in follow-up (6 month) is Square flap, Multiple Z plasty, five flap plasty, and Parascapular flap. The mean degree of abduction is decreased in split thickness graft in follow-up (6 months) [Table 1] and [Table 2].
|Table 2: Patient's wise type of axillary contracture, pre-and post-operative, follow-up degree of abduction improvement and complication|
Click here to view
| Discussion|| |
Burn around the axillary region can leads to axillary contracture, axillary postburn contractures remain a frequent problem after thermal burns involving the axilla, chest, and arm. Due to the lack of physiotherapy and rehabilitation of shoulder abduction during the initial period and the contractile evolution of the scar contribute to this problem.
The axilla is one of the most frequent sites affected by the contractures after severe burns, and it often causes cosmetic as well as functional deficiency. The secondary contractures involve muscles and tendons, after which joint contracture develop. The purpose of the reconstructive surgery in a postburn contracture is, therefore, the removal of scarring, release of contracture, and the restoration of full range of movement to a joint without the recurrence of contracture.
According to Sarker et al.'s study, patients' age ranged between 6 and 38 years with a mean age 14.7 years, and in Karki et al.'s study, age range between 6 and 30 years, mean age 17.1 years. Moreover, as compare to our study, we have found that age ranged between 3 and 30 years; mean age was 14.66 years.
In Sarker et al.'s study, 61.9% were males and 38.1% were females. In Karki et al.'s study, male are more common 56.82% as compare to females 43.18%. In P Olaitan et al.'s study, they also found that male are more common 54.05% and then 45.94% female. In our study, we also found that 72% were males as compare to female 28%.
In Karki et al.'s study, right side axilla involvement 36.36% and left side 63.63% which was most common in her study. In Mahfouz Shehat (2013) study, they have done 20 cases, the right axilla was involved in 10 (50%) cases, the left was involved in 9 (45%) cases and both in one case (5%). In our study, we have also found that left side axilla involvement was most common 61.11% as compare to the right side 33.33% and 5.55% case having bilateral which is least common in our study.
In Karki's study, Type I is most common (41.52%) Type IA 18.18%, Type IB 22.72% then Type III 31.18%, and least Type II 27.27%. In Ibrahim Walash et al.'s study, Type I most common (64%), Type IA 48%, Type IB 16%, then Type III 20% and least one is Type II 16%. In our study, we have found that Type I is most common (72%), (type IA 44.44% and type IB 27.77%) after that Type III 17% and then Type II is 11% least common.
In Karki et al.'s study in multiple Z plasty, percentage of improvement was 188.3%. In Parascapular flap, percentage of improvement was 220%. In split-thickness graft, percentage of improvement was 151.6% and in Square flap percentage of improvement was 218.5%. In Huang and Ogawa study have done 13 axillary contracture with square flap, in their study preoperative degree of abduction was 86.15 and postoperative degree of abduction was 152.3, and percentage of improvement was 76.78% achieved. In our study, maximum mean degree of improvement was in Square flap (174°) follows up then five flap plasty and multiple Z plasty (173°), then Parascapular flap (170°) and split thickness graft mean degree of improvement in follow-up (148°) least improvement was found as compare to other modality.
We have observed that the mean degree of improvement is maintained or increased, where Square flap [Figure 2]c, multiple Z plasty, Parascapular flap, Five flap plasty done [Figure 6]c, after 2–6 months of surgery in follows up due to flap elasticity and lack of secondary contraction of flap. In split-thickness graft [Figure 4]c, mean degree of improvement is initially increased but in follows up decreased due to the secondary contraction of graft. Their disadvantage is that they have a tendency to re contracture necessitating further releases. Prolonged periods of postoperative splinting are required to maximize esthetic and functional results. They also have more complication rates such as graft loss, donor site morbidity hypertrophy, graft discoloration, sensory disorders, numbness, infection, and partial loss.
In Karki et al.'s study, 18.8% case had complications. Which include tip necrosis, graft loss, and re-contracture. In Sarker et al.'s study, 9.5% cases had complications. In Ibrahim Walash et al.'s study, complication seen 12% tip necrosis with five-flap procedure; and partial loss of skin graft.
As compare to our study, complications were seen in 22.2%. 1st patient IA five flap plasty was done, tip necrosis was present, managed with debridement. 2nd patient type III Parascapular flap with split thickness graft was done; wound dehiscence at donor site post operatively, managed with split thickness graft. 3rd patient Type IB five flaps with split thickness graft was done, wound dehiscence present post operatively, managed with split thickness graft 4th patient was multiple Z plasty was done; tip necrosis of flap was present and managed with debridement [Figure 3]c.
| Conclusion|| |
The choice of surgical procedure for reconstruction of postburn axillary contractures can be made according to the pattern of scar contracture and the state of surrounding skin and type of contracture. The choice of flap should have priority over skin graft because of the superior functional and cosmetic results of flaps. Post burn axillary contracture release with flaps or Z plasty gives very good result in terms of less hospitalization days, low re contracture rate and good patient compliance although it requires skill and knowledge to choose the right flap for each contracture type. Axillary dome should be reconstructed with flap otherwise there is chance of recontracture. Contracture release with split skin grafting, although easy to execute and can be done for any type of axillary contracture, has more re contracture rate and poor compliance because of long-term splinting. In our study, the results of contracture release with flap were good with no major complications, and it also does not require long-term splinting when compared to split skin graft. In our study, mean degree of abduction in follow-up (6 months) Maintain or >170° in Square flap, Multiple Z plasty, five flap plasty, Parascapular flap. Mean Degree of abduction in follow-up (6 month) decreased in split thickness graft (148°). Postoperative splintage and physiotherapy is crucial to prevent the recurrence and maintain good results.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gupta JL, Makhija LK, Bajaj SP. National programme for prevention of burn injuries. Indian J Plast Surg 2010;43:S6-S10.
] [Full text]
Moroz VY, Yudenich AA, Sarygin PV, Sharobaro VI. The elimination of post burn scar contractures and deformities of the shoulder joint. Ann Burn Fire Disasters 2003;16:140-3.
Hyakusoku H, Shirai H, Umeda T, Fumiiri M. The use of the square flap method for repair of axillary burn contracture. Jpn J Plast Reconstr Surg 1985;28:585.
Saker WM, AbdMageed M, El Moaz W, Ismail M. Treatment of axillary contracture. J Plast Reconstr Surg 2007;31:63-71.
Sarker B, Lenin LK, Hossain Z. Various methods of reconstruction of axillary burn contracture. BDJPS 2013;4:16-9.
Karki D, Mehta N, Narayan RP. Post-burn axillary contracture: A therapeutic challenge. Indian J Plast Surg 2014;47:375-80.
] [Full text]
Olaitan P, Onah I, Uduezue A, Duru N. Surgical options for axillary contractures. Internet J Plast Surg 2006;3:1.
Ibrahim Ahmed MS. Parascapular flap for reconstruction of severe axillary contracture. Z U M J 2013;19:1-2.
Ibrahim Walash AM, Kishk TF, Ghareeb FM. Treatment of post burn axillary contracture.Menoufia Med J 2014;27:278-83.
Huang C, Ogawa R. Three-dimensional reconstruction of scar contracture-bearing axilla and digital webs using the square flap method. Plast Reconstr Surg Glob Open 2014;2:e149.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]