Options for Treatment of Post Burn Axillary Deformities - ESPRS

Egypt, J. Plast. Reconstr. Surg., Vol. 31, No. 1, January: 63-71, 2007 

Options for Treatment of Post Burn Axillary Deformities 

WAEL M. SAKR, M.D.*; MOHAMAD ABDEL MAGEED, M.D.; WALEED EL MO’EZ, M.D. and 

MAAMOUN ISMAIL, M.D. 

The Department of Surgery, Faculty of Medicine, Cairo and Beni-Suef* Universities. 

ABSTRACT 

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 plasties 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. 

INTRODUCTION 

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 

63 

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 [3]. Severe axillary 

contractures may be prevented by early prophylactic 

splinting and active exercises [4]. The burned upper 

extremity should be splinted to maintain function 

and to minimize secondary deformities [5]. 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 plasties 

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 [8] on an anatomical basis (Table 

1). Proper treatment of axillary contractures can 

be planned in the light of this classification [8]. 

Table (1): Classification of axillary contractures (Kurtzamn 

and Stern, 1990). 

Type 1A: 

Type 1B: 

Type 2: 

Type 3: 

Injuries involving the anterior axillary fold 

Injuries involving posterior axillary fold 

Injuries involving both anterior and 

posterior axillary folds 

Injuries type 2 plus axillary dome.

64 Vol. 31, No. 1 / Options for Treatment of Post Burn Axillary Deformities 

PATIENTS AND METHODS 

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 (30- 

90) or severe (

Egypt, J. Plast. Reconstr. Surg., January 2007 65 

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. 

RESULTS 

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 1A 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 20º and 90º with a mean of 60º. 

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 120º and 150º, with a mean 

of 130º. 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%). 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 1cm 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. 

Table (2): Degree of limitation of abduction before treatment 

in the studied groups. 

Mild >90º 

Moderate 30º-90º 

Severe


(A) (B) 

(C) (D) 

Fig. (1): Z-Plasty. 

(A) (B) 

Fig. (2): Z-Plasty.


(A) (B) 

(A) 

(C) 

Fig. (3): Parascapular flap. 

(A) 

Fig. (4): Local flap (V-Y). 

(B) 

(B) 

Fig. (5): Parascapular flap. 

(C)


Table (4): Range and maximum degree of abduction after 

each kind of procedure. 

Type of procedure Number 

of cases 

Multiple Z plasties 

Local skin flaps 

Parascapular flaps 

Scapular flaps 

Skin grafting 

5 cases 

4 cases 

5 cases 

2 cases 

4 cases 

Range of 

maximum 

degree of 

abduction 

1 month 

after surgery 

120º-140º 

120º-150º 

120º-150º 

140º-150º 

120º-130º 

DISCUSSION 

Mean 

maximum 

degree of 

abduction 

1 month 

after surgery 

130º 

140º 

130º 

145º 

125º 

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 [10]. 

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 

1A 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. The degree of 

abduction ranged between 20º and 90º with a mean 

of 60º. 

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 [16]. 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 10cm 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 [19]. 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 [10]. 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 re-contracture 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 1cm 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. 

Conclusion: 

The choice of surgical procedure for reconstruction 

of post burn axillary scar contracture can be 

made according to the pattern of scar contracture 

Linear contracture 

of anterior or posterior 

axillary fold with 

healthy adjacent skin 

Multiple 

Z plasties 

Algorithm for the choice of operative technique for reconstruction of contracted scar axilla 

Moderate localized 

band of anterior or 

posterior axillary 

fold with healthy 

adjacent skin 

Local transposition or 

advancement flaps 

REFERENCES 

Axillary contracture 

Parascapular flap 

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and general considerations in burns of the upper limb. 

Fourth edition, W.B. Saunders, Philadelphia, p 5-8, 1979. 

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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. 

Defect with 

8cm + healthy 

scapular area 

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skin grafting 

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scarred parascapular 

and scapular areas 

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Toronto. Little Brown and Company, 88-91, 1983. 

16- Kim D.Y. and Cho S.Y.: Correction of axillary burn scar 

contracture with the thoracodorsal perforator based 

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1985.

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