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ORIGINAL ARTICLE
Year : 2012  |  Volume : 20  |  Issue : 1  |  Page : 23-29

Management of post burn axillary contracture along with breast contracture: Our experience


Department of Plastic Surgery, Gauhati Medical College, Guwahati, Assam, India

Date of Web Publication13-May-2013

Correspondence Address:
Seema Rekha Devi
Department of Plastic Surgery, Gauhati Medical College, Guwahati, Assam
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-653X.111776

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  Abstract 

Background: Post burn axillary contracture along with breast contracture is a challenging problem to the reconstructive surgeon. Most often both types co-exist. The goal is to achieve full functional range of movement of shoulder with reconstruction of the aesthetic breast unit. Materials and Methods: This is a retrospective hospital based study of 15 patients, conducted over a period of 1 year from Aug 2009 to Sept 2010. All the patients in this study were prepubertal and postpubertal females of ages ranging from 13 years to 36 years and having post burn contractures of the axilla with involvement of breast. Axillary and breast release was done in the same sitting in all the cases. Axillary contracture was released followed by split skin graft (SSG) and/or with different types of flaps including propeller flap, along with release of breast mound to its proper size and shape to match the opposite breast. Raw areas were covered with radially placed medium thickness split skin graft around the nipple areolar complex (NAC). Assessment was done on the basis of functional and aesthetic outcome. Results: Out of 15 cases, 10 cases were of type 3 axillary burn contracture with breast contracture of moderate degree in severity. The abduction angle achieved post-operatively was >90 degrees in 14 out of 15 cases. The patients were assessed on the basis of patient satisfaction, size and shape of the axilla and the breast and position of the NAC from defined landmarks. It was found to be aesthetically fair in 9 cases, good in 5 cases and excellent in 1 case.

Keywords: Breast, contracture axilla, nipple areolar complex, propeller flap, split skin graft


How to cite this article:
Devi SR, Baishya J. Management of post burn axillary contracture along with breast contracture: Our experience. Indian J Burns 2012;20:23-9

How to cite this URL:
Devi SR, Baishya J. Management of post burn axillary contracture along with breast contracture: Our experience. Indian J Burns [serial online] 2012 [cited 2019 Dec 16];20:23-9. Available from: http://www.ijburns.com/text.asp?2012/20/1/23/111776


  Introduction Top


Post burn axillary contracture along with breast contracture is a challenging problem for the reconstructive surgeon owing to the wide range of movement that should be achieved and also due to the unavailability of local tissues that can be used for reconstruction.

Chest burn in a female patient may lead to either maldevelopment or a distorted and disfigured breast. This has a tremendous social and psychological impact as the breast is a symbol of femininity. Burn scars may become hypo pigmented or hyper pigmented leading to loss of form and shape of the breast mound with or without loss of nipple and areola. Following burns in a young girl the breast bud is usually not damaged but the distorting scar may result in a hidden breast due to direct pressure on the developing breast. Complete release of scar tissue usually results in restoration of the shape and form of the breast which is esthetically and functionally pleasing and acceptable to the patient [Figure 1] and [Figure 2].
Figure 1: Effect of breast contracture in pretpubertal woman

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Figure 2: Effect of breast contracture in postpubertal woman

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In addition, axillary contractures pull the breast laterally and/or superiorly by contracting bands. A wide range of procedures are possible with full excision of scar tissue followed by post-operative splint and pressure garments.

Breast is normally seen to move to a higher level on abducted position along with the nipple areolar complex mostly along the line of anterior axillary fold. In burns involving the axilla and breast as well, the breast is stuck there and unless the axilla is released at the same sitting it is difficult to achieve complete release of the breast [Figure 3] and [Figure 4].
Figure 3(a,b): Position of breast on adduction and abduction of shoulder

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Figure 4: The differential position of NAC complex with and without abduction of shoulder

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Aim of the study

To study aesthetic and functional outcomes of reconstructing both axilla and breast in the same setting.


  Materials and Methods Top


This is a retrospective hospital based study of 15 patients, conducted over a period of 1 year from August 2009 to September 2010. All patients in this study were prepubertal and postpubertal females with age ranging from 13 years to 36 years and having post burn contractures of the axilla with involvement of the breast. Axillary and breast release was done in the same sitting in all the cases. Axillary contracture was released followed by split skin graft (SSG) and/or with different types of flaps including propeller flap, along with release of breast mound to its proper size and shape to match the opposite breast. Raw areas created by the release of the breast scar were covered with radially placed medium thickness split skin graft around the nipple areolar complex (NAC). Assessment was done on the basis of functional and aesthetic outcome.

Due to lack of any classification system which considers post burn contracture of the axilla along with that of the breast, the authors have categorized the patients, according to the following classification [Figure 5]:
Figure 5: Different types of contracture (type 1, type 2, type 3, type 4)

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  • Type 1: Contracture involving either anterior or the posterior axillary folds exclusively, with scarring on the inferolateral aspect of the breast sparing the NAC.
  • Type 2: Contracture involving both anterior and posterior axillary fold but sparing the intervening skin in the axillary dome with involvement of the breast on three sides of breast including part of the areola but sparing the nipple and medial side of the breast.
  • Type 3: Contracture involving both anterior and posterior axillary fold and the axillary dome, also described as pan axillary contracture with major involvement of the breast with scar tissue (hidden breast) and/or involvement of NAC.
  • Type 4: Minimal contracture of axilla but involvement of the breast with malposition and/or destruction of NAC.
Cases were also graded according to the functional disability due to axillary contracture [1] [Figure 6].
Figure 6: Different types of contracure according to severity in functional loss (Mild, Moderate, Severe)

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  • Mild type: The limitation of abduction above 90 degree
  • Moderate type: The limitation of abduction from 30-90 degrees
  • Severe type: The limitation of abduction below 30 degrees
The goal of axillary release is to achieve maximal shoulder movement, especially abduction. Aesthetic consideration is important as well to achieve good contour and texture of the axilla. Proper position of axillary dome, prevention of recurrence and maintenance of hairline has to be achieved. The goal of release of the breast is both aesthetic and functional. The evaluation is based on size and shape (form), color and symmetry. Function of the breast regarding lactation is assessed on follow-up visits.

Procedure selection

Different surgical procedures were selected [Figure 7] after assessment of local anatomic conditions of the axilla, surrounding areas, the type of contracture, range of movements and general assessment. Patient's preference and expectation were also taken into consideration in our preoperative planning.
Figure 7(a-d): Different types of surgical procedures for release of axilla

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Z-plasty was opted for linear scar contractures of the axilla. Propeller flap was done if apex/dome of axilla was normal and there was enough of normal skin. Parascapular flap or scapular flap was done only if scapular region was normal and other procedures were not possible. Release and SSG was done where the above were not feasible and also for covering residual defect after flap cover.

Management of breast contracture was done by incision or excision of the restricting scar and placing medium thickness split-skin grafts radially around the NAC and a single sheet along the inframammary fold [Figure 7].

Pre-operative measurements

Preoperative measurements were taken for both breast and axilla as depicted in [Figure 8], for planning and were compared post-operatively. Shoulder abduction angle was measured with a goniometer. Breast measurements, with patient in sitting position were taken to determine nipple areola distance from infra-mammary line (A), sternal notch (B), midclavicular line (C) and midline adjacent to 4 th intercostal line (D) [Figure 8].
Figure 8: The measurement in the chest

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Post-operative care

All the cases treated with SSG around axilla were splinted with POP slab and changed to custom made splint later. Physiotherapy was started once the graft became stable at 2 weeks and was continued for a period of 6 months to 1 year. Cases where combination of flap with graft were used, were splinted and maintained for a shorter period (8-10 weeks) with regular physiotherapy and massage of the grafted area. Different custom made pressure garments for the breast were used in all the cases.

Follow-up

The follow-up of our cases ranged from 6 months to 1 year. The patients were followed at 2 nd week, 4 th week, 12 th week, 6 th month and 1 year.

During the period of follow-up, patients were examined for functional, as well as cosmetic outcome. Functional assessment of the axillary release was done by observing the range of movement at the shoulder joint and functional gain by the patient in terms of additional abduction achieved post-operatively. The aesthetic assessment of the axilla was done by assessment of the size and shape of the axilla. Breast was also assessed for size and shape and the position of the NAC from various landmarks was noted and compared with the preoperative findings.


  Results Top


In this study 15 female patients, ages ranging from 13 years to 36 years, with post burn contractures of the axilla along with breast were treated in the Department of plastic surgery in our institute from August 2009 to September 2010. Out of 15 cases, 10 cases were of type 3 axillary and breast burn contracture and according to functional severity 10 cases were of moderate degree [Table 1].
Table 1: Showing distribution different types of
contractures of axilla and breast


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Axillary contractures were released with SSG in 8 cases, propeller flap in 5 cases, Z plasty and parascapular flap in 1 case each.

The abduction angle achieved post-operatively is >90 degrees in 14 cases out of 15 cases [Table 2]. The reconstructed breast was aesthetically assessed based on 3 factors i.e., (1) Patient's satisfaction, (2) Size, shape and contour of breast and axilla (3) NAC. If all 3 factors were fulfilled it was taken as excellent, if 2 of the 3 factors were fulfilled, as good; and if less than 2 factors were fulfilled it was taken as fair. They were found to be aesthetically fair in 9 cases, good in 5 cases and excellent in 1 case [Figure 9]. Representative case photographs are shown in [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14].
Table 2: Pre-operative and post-operative comparison of abduction angles and breast measurements

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Figure 9: Aesthetic look of the reconstructed breast

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Figure 10: (a) Type 1 PBC axilla with breast, (b) Propeller flap for axilla, (c) SSG after release of breast mound, (d) On 3 months follow up, (e) On 3 months follow up

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Figure 11: (a) Type 3 PBC axilla with breast, (b) Propeller flap for axilla and release of Breast with SSG, (c) 6 months post operatively

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Figure 12: (a) Type 3 PBC axilla and breast with NAC totally destroyed (lateral view), (b) front view, (c) after full release, of axilla and breast with SSG (lateral view), (d) oblique view after release (e) 2 months post operative (frontal view), (f) 2 months post operative (lateral view) (Reconstruction of nipple and areola planned at later stage)

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Figure 13: (a) Type 1 contracture with displacement of NAC and hair bearing area of axilla (oblique view), (b) front view of the patient (c) propeller flap planning for advancement of axillary hair, (d) Release and SSG of the breast and axilla with propeller flap for advancement of axillary hair

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Figure 14: (a) Type 4 contracture, (b) Release of the breast with SSG, (c) reconstruction of NAC with Nipple sharing and FTG (from upper inner thigh) for areola reconstruction (2 wks), (d) post operative (6 months)

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Complications

There was no serious complication in our group of patients, like flap necrosis or graft loss. However, 3 patients had scar hypertrophy and 2 patients developed recontracture with loss of abduction angle (15-20 degrees). In one patient with severe axillary contracture (type 3) we could not achieve abduction more than 90 0 .

Observation

Release of axilla along with breast provides good functional and cosmetic outcome, as release of axilla removes the pull on the breast and vice versa. Long term splinting and physical therapy is required for preventing re contracture in most of the cases. After releasing the breast, reconstruction of NAC should be considered at a second stage to provide aesthetic look to the reconstructed breast.


  Discussion Top


There are different types of management options in axillary and breast contracture.

Split skin graft was applied after releasing the contracture by incising or excising the scar. The tendency for recurrence following SSG was reported by many authors [2] and continuous splinting and massage for 3-6 months were suggested. We continued splinting and massage for 6 months to one year. Cases, where a combination of flap with graft was used were splinted and maintained for a shorter period (8-10 weeks).

Z-plasty is generally the procedure of choice for linear scar contractures. However, a single Z-plasty is not suitable in the axillary contracture, because it requires large skin flaps in a limited area with displacement of the hair-bearing area. Sometimes five-flap Z-plasty is more suitable for this type of contracture. The hair-bearing area is displaced to a lesser extent in this technique. [3] We used multiple Z plasty for a linear contracture of anterior axillary fold without any displacement of the hair bearing area.

The scapular flap is a versatile flap providing a thin cover in most cases with direct closure of the donor defect. [4] Scapular flap is a fasciocutaneous flap with a known artery in its pedicle, and can be used even when the superficial area is scarred. [5]

Free flaps [6] have been used but they are technically more difficult, require longer anesthesia time and a trained micro vascular surgeon. Also, latissimus dorsi [7] or pectoralis major myocutaneous flaps have been used, but the extra bulk of the muscle may limit the adduction of the shoulder. We have not used any free flaps in our cases.

A new development in reconstruction of axillary contractures is the perforator based propeller flaps. These flaps provide a high quality of reconstruction with minimal morbidity, good functional and cosmetic results. Operating time is reduced and it does not require any expensive microsurgical facilities. Teo TC did an extensive study of the propeller flaps and found it suitable for various other contractures also. [8] Hyakusoku H et al., in their study on propeller flaps, found that other benefits include easy design and rapid flap elevation that permits a single stage correction of the deformity without further sacrificing an artery or muscle. [9] We have used propeller flap in 5 of our cases with good functional outcome.

It is often difficult to maintain the release achieved post-operatively, in contracture of breast, as well as in axillary contracture. Complete contracture release is usually obtained by incision or excision of the restricting burn scar and thick split-thickness grafting. The skin grafts were placed radially around the NAC to maintain the shape of the breast and to avoid recontracture. Custom made splint is used post-operatively and should be continued under supervision of the treating surgeon. In axillary contractures, in addition to achieving maximum abduction, particular attention to hair bearing area of axilla is important so that the anatomy is not distorted. Management is more challenging in combined axillary and breast contracture as the area is scarred, local flaps are difficult to raise and skin graft tends to contract. Moreover, patient compliance and proper splinting is required for good results.


  Conclusion Top


Good shoulder movement is essential for day to day activity. The female breast is regarded as a symbol of femininity and it plays a decisive role in a woman's sense of physical and emotional vitality. Surgical intervention is aimed at obtaining good functional and aesthetic results and improving patients self esteem.

 
  References Top

1.Sakr WM, Mageed MA, Moez WE, Ismail M. Options for treatment of post burn axillary deformities: Egypt J Plast Reconstr Surg 2007;31:63-71.  Back to cited text no. 1
    
2.Obaidullah, Ullah H, Aslam M. Figure-of-8 sling for prevention of recurrent axillary contracture after release and skin grafting. Burns 2005;31:283-9.  Back to cited text no. 2
    
3.Higazi M, Mandour S, Shalaby HA. Post-burn contracture of the axilla evaluation of three methods of management. Ann MBC 1990. Available from: http://www.medbc.com/annals/review/vol_3/num_1/text/vol3n1p21.htm. [Last Accessed on 2012 Nov 30].   Back to cited text no. 3
    
4.Nisanci M, Er E, Isik S, Sengezer M. Treatment modalities for post-burn axillary contractures and the versatility of the scapular flap. Burns 2002;28:177-80.  Back to cited text no. 4
    
5.Dimond M, Barwick W. Treatment of axillary burn scar contracture using an arterialized scapular island flap. Plast Reconstr Surg 1983;72:388-90.  Back to cited text no. 5
    
6.Ohmori S. Correction of burn deformities using free flap transfer. J Trauma 1982;22:104.  Back to cited text no. 6
    
7.Achauer BM, Spenler CW, Gold ME. Reconstruction of axillary burn contractures with the latissimus dorsi fasciocutaneous flap. J Trauma 1988;28:211-3.  Back to cited text no. 7
    
8.Teo TC. The propeller flap concept. Clin Plast Surg 2010;37:615-26.  Back to cited text no. 8
    
9.Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap method. Br J Plast Surg 1991;44:53-4.  Back to cited text no. 9
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14]
 
 
    Tables

  [Table 1], [Table 2]



 

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