British Journal of Plastic Surgery (2003), 56, 100 105 q 2003 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved. doi:10.1016/s0007-1226(03)00035-3 Reconstruction of axillary scar contractures retrospective study of 124 cases over 25 years Rei Ogawa, Hiko Hyakusoku, Masahiro Murakami and Sachiko Koike Department of Plastic and Reconstructive Surgery, Nippon Medical School Hospital, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-0022, Japan SUMMARY. We present a retrospective study of 134 axillae treated in 124 cases of axillary scar contractures with the use of skin grafts and various flaps over the last 25 years in our department. Free skin grafts were performed in 25 axillae, and local flap transfers including skin elongation procedures such as z-plasty were performed in 76 regions. As regional flap transfers, i.e. pedicled axial local flap transfers, latissimus dorsi flaps, para-scapular flaps, superficial cervical artery flaps (SCA flap) and bilateral combined scapular flaps were used for the reconstruction of 23 severe axillary scar contractures. Free flaps and scarring flaps were also used for five severe contracture cases. The results were generally satisfactory, but five problematic cases and seven cases of recurrence were encountered. In this report, we classify axillary contractures into five types and present our conclusions on the criteria for selecting appropriate surgical methods according to contracture type. Our results suggest there are four key scar features to be considered in the selection of surgical methods for axillary reconstruction: (1) size; (2) depth; (3) location and (4) shape. We also discuss and evaluate the various methods of reconstruction. q 2003 The British Association of Plastic Surgeons. Published by Elsevier Science Ltd. All rights reserved. Keywords: axilla, scar contracture, reconstruction, square flap, propeller flap. Introduction Great care needs to be exercised in the reconstruction of axillary scar contractures: the axilla is a region with multi-direction activity, and post-operative scar contractures tend to recur easily. In our department, 134 axillary have been treated in 124 cases with the use of skin grafts and various flaps over the last 25 years. We present here a retrospective study in which we classified axillary contractures into five types for the purpose of clarity. Our results suggest there are four key scar features to be considered in the selection of surgical methods for axillary reconstruction: (1) size; (2) depth; (3) location and (4) shape. We also discuss and evaluate the various methods of reconstruction. It is important to select the appropriate surgical method for each axillary contracture reconstruction, because the shoulder is the most mobile joint in the human body and contractures tend to recur easily. Such selection is difficult, as there are many types of scar conformation in the axilla. The purpose of this paper is to present methods for the accurate determination of axillary scar conformation. We also discuss the efficacy of these methods and their appropriate clinical applications. Patients and methods In our department, 134 axillary regions in 124 cases of axillary scar contractures have been treated by various methods over the last 25 years. In this study, only primary operations are considered, and data on salvage operations after recurrence are not included. We classified axillary contractures into five types (with additional sub-types): (1) Contractures within the axillary area Type I: small, thin, flat contractures (a small part of the axilla is contractured, but the fat layer is conserved) Type IIa: band contracture on the anterior axillary line (Fig. 1A) Type IIb: band contracture on the posterior axillary line (Fig. 1B) Type IIIa: contractures on both the anterior and posterior line with no contractures between the lines (Fig. 1C) Type IIIb: contractures on both the anterior and posterior line with contractures between the lines (2) Contractures extending outside the axillary area Type IVa: contractures extending to both the chest 100
Reconstruction of axillary scar contractures 101 We also classified surgical methods into five types: (1) free skin grafts (2) local flap transfers (3) regional flap transfers (4) free flap transfers (5) scarring flap transfers Free skin grafts were usually taken with a dermatome as split thickness skin grafts (STSGs). On some occasions, full thickness skin grafts (FTSGs) were harvested and the donor sites were closed primarily. The anterior or lateral thigh were usually chosen as the donor sites for STSGs and the inguinal or subclavicular region for FTSGs. Skin elongation procedures such as z-plasty (Fig. 2A) and five-flap transfers (Fig. 2B) were classified as local flap transfers. Also included in this category were the square flap (Fig. 2C), the transposition flap (Fig. 2D) and the propeller flap (Fig. 2E). In our classification, regional flap transfer does not indicate a free flap but a pedicled flap including axial vessels or, in other words, an axial local flap. The latissimus dorsi flap, the para-scapular flap, the superficial cervical artery flap (SCA flap) and the bilateral scapular combined flap have been employed. Free flap transfers and scarring flap transfers were performed on patients with severe and extensive burns. Results The results are shown in Table 1. Free skin grafts were performed in 25 axillary regions. Complete necrosis occurred in three grafts, and the grafts were re-performed. Recurrence was observed in four axillary regions. Skin elongations (z-plasty and five flap transfers) were performed in over 30 patients. The small flaps all survived, but scar contractures recurred in two patients. Table 1 The results over the last 25 years Cases Regions Flap (grafted skin) necrosis Recurrence Figure 1 (A) Type IIa: band contracture on the anterior axillary line; (B) Type IIb: band contracture on the posterior axillary line; (C) Type IIIa: contractures on both the anterior and posterior line with no contractures between the lines. and upper arm with no contractures on the back Type IVb: contractures extending to both the back and upper arm with no contractures on the chest Type IVc: contractures extending to the both chest and back with no contractures on the upper arm Type V: extensive contractures except Type IV 1. free skin graft 23 25 3 complete 4 necrosis 2. local flap transfer 73 76 1 3 z-plasty 29 31 0 2 five-flap 4 4 0 0 square flap 25 25 1 partial necrosis 2 transposition flap 5 5 0 0 propeller flap 10 11 0 0 3. regional flap 23 23 1 0 transfer latissimus dorsi 17 17 1 distal necrosis 0 flap para-scapular flap 2 2 0 0 SCA flap 3 3 0 0 bilateral combined 1 1 0 0 scapular flap 4. free flap transfer 1 1 0 0 5. scarring flap transfer 4 4 0 0
102 British Journal of Plastic Surgery Figure 2 (A) Z-plasty; (B) 5-flap; (C) square flap; (D) transposition flap; (E) propeller flap. Square flaps were used for 25 patients, and the results were all satisfactory. However, partial necrosis of the distal end of the triangular flap was observed in one case. All transposition flaps and propeller flaps survived, and the contractures were released. Regional flap transfers, i.e. pedicled axial local flap transfers, latissimus dorsi flaps, para-scapular flaps, SCA flaps, and bilateral combined scapular flaps were used for the reconstruction of severe axillary scar contractures. Distal necrosis was recognized in one of the cases reconstructed with latissimus dorsi flaps. Free flaps and scar flaps were used for severe contractures, and the results were satisfactory. During the 25-year study period, a total of 134 regions in 124 cases were treated with five problematic cases and seven cases of recurrence. Discussion Axillary scar contractures restrict various movements, because the shoulder is the most mobile joint in the human body. Patients with these contractures have problems with such mundane activities as eating, dressing, writing, etc. because of difficulties with shoulder abduction. Scar tissues usually extend to the chest, back and upper arm, thus compounding the restrictions to body movement. Low-grade contractures, i.e. those causing single unity movement restrictions, can sometimes be improved with conservative therapy. Exercise and manoeuvers in the range of motion are very important, and splint fixation and pressure treatment with silicon gel sheets are sometimes effective. However, in cases of severe contractures, i.e. those in which compound movement restrictions occur, it is impossible to release the contractures with only conservative therapy. In these cases, surgical procedures are necessary. Various surgical reconstruction methods for axillary contractures have been reported. 1 13 In this report, we analysed the various surgical methods which have been employed in our department over the last 25 years, and we classified the contractures into five types for the sake of clarity. Others have also classified axillary contractures: Hyakusoku in 1989, 1 and Kurtzman in 1990. 2 According to Hyakusoku, they can be classified into three types depending on the condition of the adjacent skin: 1 (1) axillary scar contractures with normal adjacent skin on both the chest and the back; (2) axillary scar contractures with normal adjacent skin on either the chest or the back; (3) axillary scar contractures surrounded by extensive burn scars on the chest and the back. Kurtzman stated that appropriate treatment for axillary contractures can be determined according to the following classifications: 2 Type 1A: injuries involving the anterior axillary fold;
Reconstruction of axillary scar contractures 103 Type 1B: injuries involving the posterior axillary fold; Type 2: injuries involving both the anterior and posterior axillary folds; Type 3: type 2 injuries plus axillary dome injuries. We expanded on these classifications, drawing on 25 years of experience. Our classification is clear and allows for easy selection of the appropriate surgical method for each case. In addition to creating an expanded classification, we also identified the four key scar features in selecting the operative method: (1) size; (2) depth; (3) location and (4) shape. Firstly, scar size and depth should be evaluated. With small, shallow scars, skin grafts should be selected. Skin grafts should also be selected when the fat layer is conserved. This covers Type I contractures in our classification. In cases where the scars are small but there are no gliding tissues on the recipient site, flap transfers should be selected. This type of contracture occurs when debridement to the depth of the fascia is performed in the primary life-saving skin grafting. We have harvested 25 skin grafts for reconstruction, and necrosis occurred in three of them. In two of these, this was due to infections, and in the other, it was caused by incomplete post-operative fixation. Contractures also recurred in four cases, and we assume that the recurrences were due to inadequate rehabilitation. Skin grafts are clearly risky: even though they are simple to design and perform, grafted skin lacks elasticity; it is also weaker and more prone to infection than any kind of flap. Flap type should be selected according to the location and shape of the scar. For single band contractures on the anterior or posterior axillary line (Types IIa and IIb), a skin elongation procedure such as z-plasty or the five flap method should be selected. If the band contracture is of high grade and the contracted skin has a weblike appearance, a local flap should be selected. The flaps are placed on the normal skin area, anterior or posterior to the band contracture. Square flaps 3 (Fig. 3) and simple rotation flaps are useful, and we have found that square flaps in particular are effective in obtaining good elongation and complete release of contractures. (The square flap was reported by Hyakusoku in 1987. 3 ) When band contractures exist on both the anterior and posterior lines without contractures between the lines (Type IIIa), a propeller flap 4 should be used to decouple both contractures at the same time. This type of flap was reported in 1991 by Hyakusoku; 4 it is a subcutaneous pedicled flap with a pedicle in the center. It is placed in the center of the axilla between the anterior and posterior axillary lines. This is a hair-bearing area (we call it the axillary depressed area ), and if necessary, laser depilation should be carried out after reconstruction. We have experienced one partial necrosis in a square flap reconstruction, but this was due to a flap design mistake: an acute angle had to be designed in a small triangular flap because of the shape of the scar, and this small portion was necrosed. We were able to remedy the situation with simple conservative therapy using ointments. Figure 3 (A) A case of Type IIa contracture: a square flap was designed; (B) post-operative view; (C) six months post-operation: contracture was released completely. When contractures extend into the axillary depressed area (Type IIIb), the donor site should be outside the axilla. Furthermore, when contractures extend to the chest, back and upper arm (Type IVa c), flaps should be designed with avoidance of the contracture area. Our first choice is the regional flap, and the second is the free flap or scarring flap. 5,6 By regional flap, we mean a comparatively large local flap with axial vessels included in its pedicle. The latissimus dorsi flap and the para-scapular flap are classic conventional flaps, and the donor site can be sutured primarily. However, we have encountered distal portion necrosis in one latissimus dorsi case. This was
104 British Journal of Plastic Surgery due to pressure on the flap caused by incomplete postoperative fixation. The SCA flap was reported in 1990 by Hyakusoku, 7 and this flap is suitable for covering the axillary region (Fig. 4). Also with this flap, the donor site can be closed primarily. We have employed this flap three times for axillary contractures, and the results were all excellent with great improvements in range of motion. We have also used a bilateral combined scapular flap for one patient with a severe contracture that developed from the right axilla to the anterior chest after life-saving skin grafts following an extensive flame burn injury (Fig. 5). The bilateral combined scapular flap was harvested and transferred to the axilla and anterior chest. We thinned the flap to remain minimize fat tissues primarily, and the aesthetic and functional results were excellent. When there is no normal skin around the axilla (Type V), a free flap transfer or scar flap 5,6 should be considered. If the axial vessels are intact under the scar tissues, a scar flap is indicated. In such cases, preoperative Doppler flowmetry and/or color Doppler scanning are necessary. The four cases we have reconstructed using scarring flaps were satisfactory with functional results, although the flaps were much more scirrhous and less extensile than normal skin. We have performed one reconstruction with a free flap in a patient with severe burns. The flap was an anterolateral thigh flap, and the functional results were satisfactory. The regional flap, free flap and scar flap all present a problem of bulkiness. Flap bulkiness limits upper limb adduction and can be aesthetically unsatisfactory. If lipectomy cannot be performed in the primary operation, secondary liposuction should be carried out. Post-operative rehabilitation is also very important to avoid the recurrence of contractures. Post-operative splinting maintains the axilla at 908, and we think that night splinting should be continued for three months. The question of when rehabilitation should start is a problem. In our department, rehabilitation programs begin within seven days of the operation at the latest, before the removal of sutures. Continuous passive motion is also necessary to stretch the ligaments and muscles and prevent adhesions. Conclusion To select the appropriate operative method for axillary scar contractures, it is necessary to consider the scar s size, depth, location, and shape. When size and depth are of low grade (Type I), skin grafts should be selected. In cases other than Type I, appropriate flaps should be selected according to the scar s location and shape. For Type IIa and IIb scars, skin elongation procedures such as z-plasty and the five-flap method are indicated. For Type IIIa, a propeller flap should be used to decouple Figure 4 (A) A case of Type IVa contractures: a SCA flap was designed on the back; (B) six months post-operation: contracture was released clearly.
Reconstruction of axillary scar contractures 105 both contractures at the same time. For Types IIIb, IVa c, the donor site should be outside the axilla, and regional flaps are appropriate. Free flaps and scarring flaps should be selected for Type V scars. Post-operative rehabilitation is also very important to avoid the recurrence of contractures. References 1. Hyakusoku H, Fumiiri M. Operative treatment for burn scar contracture of the axillary region using various flaps. J J Burn Inj 1989;15:35 42. 2. Kurtzman LC, Stern PJ. Upper extremity burn contractures. Hand Clin 1990;6:261. 3. Hyakusoku H, Fumiiri M. The square flap method. Brit J Plast Surg 1987;40:40 6. 4. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Brit J Plast Surg 1991;44:53 4. 5. Fumiiri M, Ishii K, Hyakusoku H. Scar flap especially the scar flap containing the musculocutaneous system. J Jpn Plast Reconstr Surg 1981;24:470 5. 6. Hyakusoku H, Okubo M, Suenobu J, et al. Use of scarred flaps and secondary flaps for reconstructive surgery of extensive burns. Burns 1986;12:470 4. 7. Hyakusoku H, Yoshida H, Okubo M, et al. Superficial cervical artery skin flaps. Plast Reconstr Surg 1990;86:33 8. 8. Nisanci M, Er E, Isik S, et al. Treatment modalities for post-burn axillary contractures and the versatility of the scapular flap. Burns 2002;28:177 80. 9. Kim DY, Cho SY, Kim KS, et al. Correction of axillary burn scar contracture with the thoracodorsal perforator-based cutaneous island flap. Ann Plast Surg 2000;44:181 7. 10. Metaizeau JP, Gayet C, Schmitt M, et al. The use of free full thickness skin grafts in the treatment of complications of burns. Prog Pediat Surg 1981;14:209. 11. Ohmori S. Correction of burn deformities using free flap transfer. J Trauma 1982;22:104. 12. Suzuki S, Isshiki K, Ishikawa K, et al. The use of subcutaneous pedicle flaps in the treatment of postburn scar contractures. Plast Reconstr Surg 1987;80:792 8. 13. Tiwari P, Kalra GS, Batnager SK. Fasciocutaneous flaps for burn contractures of the axilla. Burns 1990;16:150 2. The Authors Rei Ogawa MD Hiko Hyakusoku MD, PhD Masahiro Murakami MD Sachiko Koike MD Department of Plastic and Reconstructive Surgery, Nippon Medical School Hospital, 1-1-5 Sendagi Bunkyo-ku, Tokyo 113-0022, Japan Correspondence to Rei Ogawa Paper received 4 December 2002. Accepted 10 March 2003. Figure 5 (A) A case of Type IVa contractures: scar contracture extended to the neck; (B) a combined scapular flap was designed; (C) six months post-operation: scar contracture was released completely.