Management of postburn axillary contractures

Many epidemiological studies have revealed the incidence of axillary contractures next only to elbow contractures as sequelae to burn injury. Even if it may be possible to prevent adduction contracture of the axilla through early splinting and range of motion exercises that counteract the position of comfort, it continues to pose a frequent problem to burn surgeons. In the increasing degree of severity, axillary contractures may involve one or both axillary folds and also involve the hair-bearing dome of the axilla. Unless severe functional disability is present, we recommend a minimum 6-month wait following wound healing to allow for scar maturation to achieve better results. In milder presentations, it may be possible to perform Z-plasties, Y–V plasties, or many other local flaps on isolated axillary bands, with the caveat that if the contractile bands are in the midst of scarring, such linear contractures may only be effectively released and resurfaced with skin grafts. While the innovative use of local skin flaps must be encouraged, we recommend a low threshold of using acceptable thickness skin grafts for coverage. Controversy exists on the best technique for axillary resurfacing in severe cases of axillary involvement. While it is relatively simple and expeditious to release the contracture and cover the extensive defect with skin grafts, it requires meticulous postoperative regimen of splinting and physiotherapy. In selected cases, uninvolved adjacent scapular and back areas allow for many fasciocutaneous and myocutaneous flaps for durable long-term results. Free flaps, traditionally less popular in this region, may be an alternative option if areas adjacent to axilla are also involved.