A stratified reconstructive approach for the post burn axillary adduction contractures based on the anatomical study of thoracodorsal vessel perforator system

Abstract

Background

Post-burn axillary adduction contractures (PBAAC) are commonly seen burn sequelae. They occur in various forms. By imposing colossal restriction on the range of mobility of the shoulder, they completely intervene with the upper limb over head functions.

Methods

In 15 fresh frozen cadavers, 30 specimens of thoracodorsal vessel axes were studied after dye injection. Cadaveric study was conducted to standardise and stratify the clinical approach for harvesting perforator propeller flaps based on the thoracodorsal vessel axis (TDVA) by clear demonstration of various types of perforators arising from them. Three types of perforators (musculocutaneous, septocutaneous and direct cutaneous perforators were demonstrated), their dimensions, distribution and surface anatomy were defined. This knowledge paved the way for a stratified approach in harvesting the TDAPs (thoracodorsal artery perforator propeller flaps) for the reconstruction of PBAACs. The documents containing the data of 36 patients who underwent PBAAC reconstruction from 2010 to 2016 using perforators from TDVA (thoraco dorsal vessels axis) were collected for the retrospective study. Twelve patients underwent TDVA septofasciocutaneous perforator-based flap reconstruction for type 2 PBAACs. In 14 patients, post-burn axillary contractures were reconstructed with musculocutaneous perforator of TDVA (for type 3 PBAACs). Ten patients with type 1 PBAACs were reconstructed with direct cutaneous perforators of the TDVA. The average follow-up period was 18 months.

Results

All the flaps survived completely with no major complications. Average pre-operative range of abduction was 45.5°. The average post-operative pain free abduction obtained in 36 cases was 146.38° at an average of 18 months.

Conclusion

The challenging reconstruction of PBAACs can be simplified by the stratified approach using TDVA perforator-based propeller flaps. Perforator propeller flap based on the direct cutaneous perforator from the TDVA is most suitable for type 1 PBAAC reconstruction, whereas type 2 and type 3 PBAACs can be best served by septofasciocutaneous and musculocutaneous based perforator propeller flaps, respectively.

Level of Evidence: Level IV, therapeutic study.

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