Reconstruction of the axilla after burn injury - A decade of experiences and lessons learned.

[BACKGROUND] Acute burns and their sequelae in the axilla are debilitating injuries. Reconstruction in this anatomically complex region is challenging due to limited tissue availability and the need to balance functional and aesthetic outcomes.

[METHODS] A retrospective review of patients undergoing axillary reconstruction at the University Hospital Zurich, Zurich, Switzerland, from 2014 to 2024 was conducted. Patients who received pedicled locoregional or free flap reconstructions for acute axillary burns or established contractures were included, while z-plasties and other local random pattern flaps were excluded.

[RESULTS] Twelve patients (8 males, 4 females; mean age: 44.1 years, mean BMI: 24.6 kg/m², mean TBSA: 36 %) underwent axillary reconstruction using 13 flaps: 10 free flaps (anterolateral thigh [n = 6], transverse myocutaneous gracilis [n = 1], profunda artery perforator [n = 2], superficial circumflex iliac perforator [n = 1]) and three locoregional flaps (parascapular [n = 2], split-latissimus dorsi [n = 1]). Acute reconstructions for third-degree axillary burns were performed in three patients (median time from injury: 12 days), and delayed reconstructions for axillary contractures were performed in 10 cases (median time from injury: 336 days). While no total flap loss occurred, five (38 %) cases experienced complications including delayed wound healing, seroma, or hematoma. Innovative strategies, such as fascial slings for flap suspension, two-stage scar release, and robotic-assisted microvascular anastomoses, enhanced surgical precision and outcomes.

[CONCLUSION] For acute burns and post-burn axillary contractures, free or locoregional flaps offer effective reconstruction, ensuring early functional recovery when compared to dermal substitutes. A multidisciplinary, individualized approach remains essential for optimizing care in burn survivors with axillary injuries and contractures.