in a developing country like india , the estimated annual burn incidence is approximately 6 - 7 million every year .
the high incidence is attributed to illiteracy , poverty and low level of safety consciousness in the population .
the incidence of upper extremity burns constitutes a major chunk amongst them . in their natural course ; burns of the upper extremity can lead to debilitating post - burn contractures , especially those involving the axillae , causing severe functional impairment and difficulty in shoulder abduction , due to the contractile evolution of scar . according to kurtzman and stern , axillary
kurtzman and stern classification of axillary contractures axillary contractures can be prevented by early prophylactic splinting and active exercises .
the goal of surgical correction should be to provide the maximum release encompassing the entire axis of rotation of the shoulder to facilitate complete range of motion with minimum or no local anatomic distortion .
in addition to the scarring of the fold(s ) , there are two local anatomic conditions that must be taken into consideration when surgical correction is contemplated .
they are : 
 the extent of scarring of the adjacent skin and , the involvement of the hair - bearing area of the axilla . 
 
the extent of scarring of the adjacent skin and , the involvement of the hair - bearing area of the axilla .
it is unusual for the hair - bearing area to be involved in thermal injury due to its anatomic location and because in most instances , the upper extremities are maintained in adduction , protecting the axillary hair - bearing area .
a variety of reconstructive methods has been reported for treatment of axillary contractures including release and skin grafting ; z - plasty ; local random flaps ; island flaps ; free flaps ; tissue expanders .
once surgical correction is indicated , the choice of the procedure must be individualised in order to achieve this goal . in this paper
, we present our surgical approach in the reconstruction of post - burn axillary scar contractures in a tertiary care centre .
the study was conducted in the department of burns and plastic surgery at safdarjung hospital between 2009 and 2013 .
local examination was done to note the degree of contracture ; site involved and condition of the surrounding skin .
operative procedures used with indications and patient details splinting was done post - operatively for a period varying from 1 to 3 weeks . in cases where release of contracture followed by skin grafting was done ,
continuous splinting was given for a period of 6 weeks and night splinting continued for a period of 6 months .
patients were asked to grade the aesthetic outcome of surgery according to global aesthtic improvement score [ table 3 ] .
global assessment improvement score following are the few cases to highlight the various operative procedures used : 
 case 1 : a 17-year - old boy with type 3 contracture of 5 years duration and abduction of 20 was treated with local flaps .
a good improvement with 170 abduction was noted [ figure 1].case 2 : an 8-year - old child with type 1b contracture of 4 years duration with 70 abduction was operated with square flap method which led to increase in the angle of abduction to 180 [ figure 2].case 3 : a 28-year - old female patient with a type 2 contracture with involvement of anterior and posterior axillary folds and sparing of axillary fossae was treated with a propeller flap .
the degree of abduction improved from 40 to 160 [ figure 3].case 4 : a 22-year - old male patient with type 1b contracture involving posterior axillary fold and a pre - operative degree of abduction of 70 was treated with square flap method .
case 1 : a 17-year - old boy with type 3 contracture of 5 years duration and abduction of 20 was treated with local flaps .
case 2 : an 8-year - old child with type 1b contracture of 4 years duration with 70 abduction was operated with square flap method which led to increase in the angle of abduction to 180 [ figure 2 ] . case 3 : a 28-year - old female patient with a type 2 contracture with involvement of anterior and posterior axillary folds and sparing of axillary fossae was treated with a propeller flap .
case 4 : a 22-year - old male patient with type 1b contracture involving posterior axillary fold and a pre - operative degree of abduction of 70 was treated with square flap method .
( a ) pre - operative photograph of the patient , with only 20 abduction .
( b and c ) intra - operative flap markings with flaps being raised from anterior and posterior adjacent healthy skin .
( f ) 1-year post - operatively ; increase in the degree of abduction to 170 type 1b contracture treated with square flap method .
( a and b ) preoperative photographs of patient showing scarring of posterior axillary fold and an abduction of 70. ( c and d ) intra - operative flap markings .
( f and d ) 1-year post - operative ; increase in the degree of abduction to 180 type 2 contracture ( with sparing of axillary dome ) treated with a propeller flap .
( a ) pre - operative photograph showing severe debilitation in abduction ; limited to 40. ( b ) intra - operative flap markings .
( e ) 1-year post - operative photograph showing increase in abduction to 160. ( f ) 1-year post - operative photograph showing spreading of flap to scarred area with maintenance of the hair - bearing region in the centre type 1b contracture treated with square method flap .
( b and c ) intra - operative marking of the square flap and two triangular flaps .
( d ) post - operative improvement showing increase in the degree of abduction to 160
local examination was done to note the degree of contracture ; site involved and condition of the surrounding skin .
splinting was done post - operatively for a period varying from 1 to 3 weeks . in cases where release of contracture followed by skin grafting was done ,
continuous splinting was given for a period of 6 weeks and night splinting continued for a period of 6 months .
patients were asked to grade the aesthetic outcome of surgery according to global aesthtic improvement score [ table 3 ] .
global assessment improvement score following are the few cases to highlight the various operative procedures used : 
 case 1 : a 17-year - old boy with type 3 contracture of 5 years duration and abduction of 20 was treated with local flaps .
a good improvement with 170 abduction was noted [ figure 1].case 2 : an 8-year - old child with type 1b contracture of 4 years duration with 70 abduction was operated with square flap method which led to increase in the angle of abduction to 180 [ figure 2].case 3 : a 28-year - old female patient with a type 2 contracture with involvement of anterior and posterior axillary folds and sparing of axillary fossae was treated with a propeller flap .
the degree of abduction improved from 40 to 160 [ figure 3].case 4 : a 22-year - old male patient with type 1b contracture involving posterior axillary fold and a pre - operative degree of abduction of 70 was treated with square flap method .
case 1 : a 17-year - old boy with type 3 contracture of 5 years duration and abduction of 20 was treated with local flaps .
case 2 : an 8-year - old child with type 1b contracture of 4 years duration with 70 abduction was operated with square flap method which led to increase in the angle of abduction to 180 [ figure 2 ] . case 3 : a 28-year - old female patient with a type 2 contracture with involvement of anterior and posterior axillary folds and sparing of axillary fossae was treated with a propeller flap .
case 4 : a 22-year - old male patient with type 1b contracture involving posterior axillary fold and a pre - operative degree of abduction of 70 was treated with square flap method . the resultant increase in angle of abduction was 160 [ figure 4 ] .
( a ) pre - operative photograph of the patient , with only 20 abduction .
( b and c ) intra - operative flap markings with flaps being raised from anterior and posterior adjacent healthy skin .
( f ) 1-year post - operatively ; increase in the degree of abduction to 170 type 1b contracture treated with square flap method .
( a and b ) preoperative photographs of patient showing scarring of posterior axillary fold and an abduction of 70. ( c and d ) intra - operative flap markings .
( f and d ) 1-year post - operative ; increase in the degree of abduction to 180 type 2 contracture ( with sparing of axillary dome ) treated with a propeller flap .
( a ) pre - operative photograph showing severe debilitation in abduction ; limited to 40. ( b ) intra - operative flap markings .
( e ) 1-year post - operative photograph showing increase in abduction to 160. ( f ) 1-year post - operative photograph showing spreading of flap to scarred area with maintenance of the hair - bearing region in the centre type 1b contracture treated with square method flap .
( b and c ) intra - operative marking of the square flap and two triangular flaps .
( d ) post - operative improvement showing increase in the degree of abduction to 160
forty - four patients including 25 males ( 56.82% ) and 19 females ( 43.18% ) with the post - burn axillary contracture were taken up for the study .
demographic details of patients included in the study patient distribution according to the classification of the axillary contracture given by kurtzman and stern has been shown in table 4 .
pre - op degree of abduction ranged from 20 to 100 with a mean degree of abduction being 48. the procedure opted , and their results are compiled in table 5 .
pre- and post - operative results and complications of procedures done the degree of abduction obtained 1-month post - operative ranged between 100 and 180 with a mean degree of abduction being 156. minor complications in the form of tip necrosis and partial graft loss were seen in 18.8% cases [ table 5 ] .
figures 14 shows some of the cases included in the study ; including pre - operative , intra - operative and post - operative photographs .
difficulty in management arises due to joint stiffness , difficulty in splinting and a high recurrence rate with inadequate care .
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 .
operative procedures available for axillary contractures include : this is the procedure of choice for linear scar contractures of the anterior or posterior axillary folds if the surrounding skin is healthy .
the incisions are designed to create a z shape with central limb aligned with the part of the scar that needs lengthening .
multiple z - plasties can be used for long linear scars while single z - plasty is done for a short web .
square flap method was proposed by hyakusoku et al . in 1985 , a modification of the method described by limberg in 1963 .
the method is an advancement transposition technique which consists of two triangular flaps ( transposed ) and a square flap ( advanced ) .
if the tip of one triangular flap is a right angle , it gives better lengthening , better advancement of the square flap and avoids the suture lines running parallel to the direction of lengthening .
when the angle of the t - flap is 45 and of the u - flap 90 , as proposed by hyakusoku et al . , there will be an increase of 2.80 times the original length after transposition of the flaps .
flaps from the arm , anterior chest , axilla , or back of the chest are chosen for cases of localised moderate band of contractures of anterior or posterior axillary folds , provided that the donor site is not scarred .
split - thickness skin grafting is performed after release of contractures of the axilla involving one or both axillary folds .
this operation is done if the surrounding skin is scarred and can not provide any local or fasciocutaneous flaps that can cover the resultant defect or if the defect is bigger than any available flap as in severe axillary contractures .
this is a flap of choice to cover the defect after release of the axilla if the width of the defect is less than 8 cm provided that the parascapular area is not scarred .
parascapular flaps have the advantage of being thin flaps which make it ideal for the reconstruction of axilla . a propeller flap can be defined as an  island flap that reaches the recipient site through an axial rotation .
 the term  propeller flap  was introduced in 1991 by hyakusoku et al . to describe an adipocutaneous flap , based on a random subcutaneous pedicle , with a skin island of a length largely exceeding its width , made of two portions ( the blades of the propeller ) , one at either side of the pedicle .
the flap is rotated 90 on the central pedicle , like a propeller , to resurface burn scar contractures at the axilla .
our study included 44 patients amongst which maximum patients had axillary dome involvement ( type 3 = 14 ) followed by involvement of both anterior and posterior axillary folds ( type 2 = 12 ) . the pre - operative degree of abduction ranged from 42 to 60 with mean of 49.5. the choice of the operative procedure was made according to the site involved , severity of the contracture and the state of surrounding skin . the above mentioned procedures
the range of abduction increased post - operatively to 100 - 180 with a mean of 156. 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 .
we used z - plasty and square flap method for mild to moderate contractures involving either of the axillary folds .
the percentage of improvement in the abduction at axilla noted in these two methods was 188.33% and 218.52% , respectively .
fasciocutaneous flaps from the back such as scapular and parascapular flaps have been used for the 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 8 cm flap width .
parascapular flaps were used in our study group for severe contractures of the axillae with sparing of the posterior chest wall .
propeller flaps were used in cases where axillary dome was spared . a subcutaneous pedicle flap with pedicle in the centre based on healthy skin spared in the region of the joint was raised and rotated to 90 to release the scar contracture .
a substantial mean improvement of 300% was noted in these cases , along with sparing of hair - bearing axilla which gave aesthetically good results . comparing the mean pre - operative and post - operative degree of abduction ; a fair improvement to the extent of 212%
few studies have been done categorically for patients with post - burn axillary contractures worldwide .
performed surgeries in 20 patients of axillary contractures who had a mean burn contracture of 18 months .
mean degree of abduction pre - operatively was 60 which increased to 130. complication seen in their study included tip necrosis , graft loss , wound infection , marginal flap necrosis .
studied 77 cases of upper extremity , neck and face contractures ; out of which 19 had an axillary contracture .
the group used z - plasty , k - plasty , thoracodorsal perforator flap and tissue expanders .
our study differs from the other study groups as we performed a large number of propeller flaps and square flap method with good success rate .
this is the procedure of choice for linear scar contractures of the anterior or posterior axillary folds if the surrounding skin is healthy .
the incisions are designed to create a z shape with central limb aligned with the part of the scar that needs lengthening .
multiple z - plasties can be used for long linear scars while single z - plasty is done for a short web .
square flap method was proposed by hyakusoku et al . in 1985 , a modification of the method described by limberg in 1963 .
the method is an advancement transposition technique which consists of two triangular flaps ( transposed ) and a square flap ( advanced ) .
if the tip of one triangular flap is a right angle , it gives better lengthening , better advancement of the square flap and avoids the suture lines running parallel to the direction of lengthening .
when the angle of the t - flap is 45 and of the u - flap 90 , as proposed by hyakusoku et al . , there will be an increase of 2.80 times the original length after transposition of the flaps .
flaps from the arm , anterior chest , axilla , or back of the chest are chosen for cases of localised moderate band of contractures of anterior or posterior axillary folds , provided that the donor site is not scarred .
split - thickness skin grafting is performed after release of contractures of the axilla involving one or both axillary folds .
this operation is done if the surrounding skin is scarred and can not provide any local or fasciocutaneous flaps that can cover the resultant defect or if the defect is bigger than any available flap as in severe axillary contractures .
this is a flap of choice to cover the defect after release of the axilla if the width of the defect is less than 8 cm provided that the parascapular area is not scarred .
parascapular flaps have the advantage of being thin flaps which make it ideal for the reconstruction of axilla .
a propeller flap can be defined as an  island flap that reaches the recipient site through an axial rotation .
 the term  propeller flap  was introduced in 1991 by hyakusoku et al . to describe an adipocutaneous flap , based on a random subcutaneous pedicle , with a skin island of a length largely exceeding its width , made of two portions ( the blades of the propeller ) , one at either side of the pedicle .
the flap is rotated 90 on the central pedicle , like a propeller , to resurface burn scar contractures at the axilla .
our study included 44 patients amongst which maximum patients had axillary dome involvement ( type 3 = 14 ) followed by involvement of both anterior and posterior axillary folds ( type 2 = 12 ) .
the pre - operative degree of abduction ranged from 42 to 60 with mean of 49.5. the choice of the operative procedure was made according to the site involved , severity of the contracture and the state of surrounding skin . the above mentioned procedures
the range of abduction increased post - operatively to 100 - 180 with a mean of 156. 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 .
we used z - plasty and square flap method for mild to moderate contractures involving either of the axillary folds .
the percentage of improvement in the abduction at axilla noted in these two methods was 188.33% and 218.52% , respectively .
fasciocutaneous flaps from the back such as scapular and parascapular flaps have been used for the 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 8 cm flap width .
parascapular flaps were used in our study group for severe contractures of the axillae with sparing of the posterior chest wall .
propeller flaps were used in cases where axillary dome was spared . a subcutaneous pedicle flap with pedicle in the centre based on healthy skin spared in the region of the joint was raised and rotated to 90 to release the scar contracture .
a substantial mean improvement of 300% was noted in these cases , along with sparing of hair - bearing axilla which gave aesthetically good results . comparing the mean pre - operative and post - operative degree of abduction ; a fair improvement to the extent of 212%
few studies have been done categorically for patients with post - burn axillary contractures worldwide .
sakr et al . performed surgeries in 20 patients of axillary contractures who had a mean burn contracture of 18 months .
mean degree of abduction pre - operatively was 60 which increased to 130. complication seen in their study included tip necrosis , graft loss , wound infection , marginal flap necrosis .
studied 77 cases of upper extremity , neck and face contractures ; out of which 19 had an axillary contracture .
the group used z - plasty , k - plasty , thoracodorsal perforator flap and tissue expanders .
our study differs from the other study groups as we performed a large number of propeller flaps and square flap method with good success rate .
surgical intervention is aimed at obtaining good functional and aesthetic results and improving patients self - esteem .
some of the factors to be considered in choosing the best option for a particular contracture include the type of contracture , the state of surrounding skin and the expertise of the surgeon . despite the availability of numerous surgical options ,
flap cover gives the best result with minimal or no flap loss and better range of joint movement and reduced recurrence rate .
 background : axillary post - burn scar contracture is a challenging problem to the reconstructive surgeon owing to the wide range of abduction that should be achieved . the aim of this paper was to highlight the various options used in managing axillary contractures in our hospital.materials and methods : this is a retrospective hospital - based study of axillary contractures managed at safdarjung hospital ( a tertiary care hospital ) from 2009 to 2013 . 
 the study consisted of 44 patients from all age group and both sex included in it . 
 patients with a bilateral axillary contracture were excluded . 
 axillary contracture was released and resurfaced using split skin graft and/or with different types of flaps including the propeller flap , parascapular flap . 
 all the reconstructed cases were followed - up for a period of 12 months . 
 assessment was done on the basis of functional and aesthetic outcome.results:forty-four patients consisting of 25 males and 19 females presented with axillary contractures that involved 44 axillae . 
 the mean age of the study group was 17.1 years . 
 injuries involved the anterior axillary fold in 8 ( 18.18% ) , posterior fold in ten ( 22.72% ) , both folds and axillary fossa in 14 ( 31.81% ) and both folds plus part of the chest wall and arm ( sparing the axillary fossa ) in 12 ( 27.27% ) axillae . 
 surgical treatment included split - thickness skin graft in 15 ( 34.1% ) , local skin flaps in 4 ( 9.1% ) , z - plasties in 4 ( 9.1% ) , parascapular flaps in 3 ( 6.82% ) , while propeller flaps in 12 ( 27.27% ) and square flap were used in 6 ( 13.64% ) patients . 
 the percentage of improvement in abduction had a mean of 156. the functional and aesthetic results were satisfactory.conclusion:the choice of surgical procedure for reconstruction of post - burn axillary contractures can be made according to the pattern of scar contracture and the state of the surrounding skin . 
 the choice of a flap should have priority over the skin graft because of the superior functional and aesthetic results of flaps . 
INTRODUCTION
MATERIALS AND METHODS
Pre-operative assessment
Post-operative care
RESULTS
DISCUSSION
Z-plasty
Square flap
Random pattern local skin flaps
Release and skin grafting
Parascapular flap
Propeller flap
CONCLUSION