Reconstruction of an Axillary Postburn Scar Contracture with a Previously Burned Thoracodorsal Artery Perforator Flap

Dear sir, Reconstruction of burn sequelae presents a challenge. Sometimes, after failure of other less invasive measures, there is an indication for extended scar excision and reconstruction with a locoregional or free flap. In major burns, there is a limitation of local reconstructive options given the extent of burns and scarcity of donor areas. Here we report of a case of secondary reconstruction of an axillary postburn scar contracture with a previously burned skin flap based on a thoracodorsal artery perforator. A 45-year-old male suffered a high voltage electrical burn (25,000 volts) at the level of the right upper limb and right hemithorax (20% TBSA).During his prolonged hospitalization at a Burn Unit, the patient underwent surgical debridement and reconstruction with partial thickness skin grafts. The patient developed a contracture band at the right axilla, with significant limitation of abduction (<90 ) of the affected limb. The patient had been previously submitted to a Z-plasty with small improvement after physiotherapy butmaintaining important functional limitation (Figure 1a). After clinical evaluation and discussion of surgical options, we have decided for scar excision and reconstruction with a thoracodorsal artery perforator (TDAP) flap of the previously burned area (showing signs of a healed 2nd degree burn) after preoperative Doppler identification of the main perforator (Figure 1b,c). The flap (14 7 cm) was harvested based on proximal perforator of the descending branch of the thoracodorsal artery, leaving a shaft of muscular tissue surrounding it to prevent venous congestion (Figure 1d). It was rotated to 180 to reach the axillary defect (Figure 1e). The patient presented good aesthetic and functional results 3 months after surgery, with early improvement in shoulder mobility(>120 of abduction) and no significant scar bands formation (Figure 1f,g). The blood supply to the skin relies on the existence of vascular plexus parallel to the surface of the skin at various depths. Thus, the survival of a skin flap depends on the depth of tissue damage caused by a burn. Perforator flaps consist of skin and subcutaneous tissue flaps based on a perforator artery that can be isolated. A deep (full-thickness) burn destroys the dermal plexus and may also damage subcutaneous vessels. It is known that the healing process somehow restores skin irrigation. However, the dissection of healed/previously burned skin flaps is still debated. Some authors state that previously burned tissues can be safely used as local fasciocutaneous flaps (Borman et al., 1999; Das-Gupta & Bang, 2006; Pribaz & Pelham, 1994), without evidence of a higher rate of complications compared to the use of healthy tissues.(Barret et al., 2002) However, previous burned skin may have reduced skin elasticity leading to inferior functional results, so they should be used only when no other local/regional options are available, or when other possibilities (e.g., dermal matrices and secondary skin grafting) also have unpredictable results, while requiring several procedures. To the best of the authors' knowledge, perforator flap harvest from a previously burned area has not been reported before. This case shows the safety of a perforator flap dissection from previously burned skin, with good aesthetic and functional results. Reconstruction of scar sequelae in burned patients may involve the