Surgery Spotlight: Endoscopic Placement of Tissue Expanders for Burn Chest Reconstruction-Surgery Spotlight: Endoscopic Placement of Tissue Expanders for Burn Chest Reconstruction

Surgery Spotlight: Endoscopic Placement of Tissue Expanders for Burn Chest Reconstruction

Video Transcription

I'm Paul Soderna here at the University of Michigan Health System in plastic surgery. Today we're going to have the opportunity to go over a burn reconstruction operation  with placement of tissue expanders for reconstruction. The patient that I'm going to be showing you today is a 51-year-old woman who at the  age of two pulled a pot of boiling water off a stove and sustained a substantial burn injury involving her upper chest and breasts.  As a child, she had a prolonged hospitalization where the wounds were allowed to heal in by secondary intention, leaving very significant scar deformity and contracture.  Like so many people a long time ago that had a burn, they weren't really aware of the possibility of undergoing reconstruction in the future.  Primarily she understood that the burn scars wouldn't go away completely, but what she wanted more than anything was really an ability to wear a V-neck shirt or a V-neck sweater.  Every time she went shopping she had to identify some kind of a shirt or sweater or whatever that had a high neck so it would hide her burn scars.  So her goals more than anything were to have symmetry in the size and shape of her breasts  and to have the burn scars high in her chest brought down further on her chest so she could wear V-neck clothing.  So as an initial stage we did a reconstruction of her breasts which involved tissue expanders followed by implants.  That provided a very nice aesthetic outcome for her and she has a nice symmetric appearance and shape to her breasts along with symmetric volume.  She's really pleased with that first stage of the reconstruction. Now today what we're going to do is we'll be doing an operation where we'll be placing  three tissue expanders underneath the unburned tissue surrounding the burn scar so that we can perform a burn reconstruction later using the recently expanded tissue.  This purple line has outlined the entire area of involved tissue. In order to get the best aesthetic outcome from this operative procedure we're going  to proceed with placement of tissue expanders. So when we look at the maximal amount of normal healthy appearing tissue we really have reasonable tissue on the right shoulder.  We have nice healthy tissue in the supraclavicular fossa on the right side and then on the left side as well.  So we're going to recruit as much of the normal tissue as we possibly can to allow reconstruction of this area on the chest.  We do have nice tissue here but if we expand this tissue as we move this will significantly change the shape of the breast so we won't expand in this area.  So now we're going to identify the maximal size of a tissue expander we can use in these areas to get the most expansion possible.  So if we look here we have about 11 centimeters in this direction and about 9 centimeters in this direction, 10 centimeters in this direction.  So if we think of what expanders we have currently in a rectangular shape which should fit here well we have a 400 cc expander which is 9 by 10.  So if it's 9 by 10 I'm going to mark 10 here and a width of 9 and this will be about the shape of our expander dissection.  In the supraclavicular fossa, we'll hold some tension here, we'll do the same thing. We have a width of about 10 so we'll mark 10 and 9 up into here and we're going to mark  this dissection here as well for placement of our tissue expander in the supraclavicular fossa. And lastly here we have a 550 cc expander which is 7 by 13.  So we're going to use 13 in this direction, 7 and this will be the size of the pocket dissection here with the thought being we're going to take as much healthy tissue from  all of these areas as we possibly can to reconstruct this tissue. In order to use the endoscope, we're going to limit the number of incisions we have.  So we're going to actually make an incision within the burn tissue in this area a bit distant from the area of expansion.  This will allow us to place the ports, we'll be able to put a port somewhere in here and  a port somewhere in here and do the dissection for the supraclavicular fossa and the shoulder expander through here.  On this side we can make an incision in this tissue, that way then we're not adding additional  scars in the normal tissue and then we'll be able to put a port somewhere right in here so as we expand we'll be able to find all of the ports.  So with that, Ben if I could ask you to come over here and we're going to start our dissection. So Ben Levy is going to be our surgeon today. Knife please.  Now, in order not to devitalize the overlying skin, what we'll do is we're going to go right down to the chest wall now.  And when doing these operations endoscopically, the initial portions of the operation are done openly under direct visualization, and then once we get at a little bit of a distance  away from this incision, that's when we put the endoscope in to assist. So the dissection's just going to be carried out superficial to the fascia.  Fortunately in this area, we don't have a lot of tissue to really worry about, so we'll be able to get this dissection started here and then have enough room to get our scope  into position. The scope we're going to use is a 10 millimeter, 30 degree scope. The length on this scope is not the standard laparoscopic cholecystectomy scope, but this  is basically a 17 centimeter long scope, 30 degree. So we use a Snowden-Pencer retractor. It has a spot that holds the scope right here, has a handle here that allows you to place  the light cords here to keep them upright appropriately, and a little suction port you can attach here, which comes all the way out of the end of the device right there, which  allows it to suck the smoke out of your way as you're doing your dissecting. The cautery devices that we use are endoscopic cautery devices.  This one has a little bend in it, which allows you to work through the same hole in the skin.  Has a small handle, so you attach to the handle here, screw it on to secure it, but also you can adjust the orientation of this just by turning it inside the handle, depending on  what you need. Cautery attaches here, and then you can put additional suction on the end of the device  here, which then allows you to keep the pocket evacuated of smoke as you're doing your cautery. So this is a great opportunity for people who haven't seen the scope used for a lot  of operations other than the endoscopic brow lift or other transaxillary breast dogs, for instance, to see how it can be done.  So Dr. Levy, who's doing this, has done just a couple of these so far, and yet you can see that without a lot of experience in this area, it's still relatively easily done with  the equipment that's available just routinely in most ORs. So the equipment, like I said, to do the endoscopic operative procedures, you really just need  to be able to purchase a scope holder, a shorter 10 millimeter, 30 degree endoscope, which we're using here, which is not in the standard laparoscopic cholecystectomy set,  a set of these cauteries that allow your hands, since you're operating through a single, small incision, you need to be able to get your hands away from where the straight scope is  looking through the port. So these foot switch controlled cautery devices are nice to have. And other than that, everything else is available in every hospital.  Since we're so close to Canada, and we're hockey players, and it's important to be a good hockey player if you're a plastic surgeon, we use a hockey stick to check our pocket  dissection. This critical element right here, and it's a left shot, not a right shot, because righties are no good, lefties a shot.  So we put this in, and we check our pocket, and we know now our pocket is good. And it comes all the way up to the area where we want to make sure we have a complete dissection.  So we can see we're out all the way down here. So our 400cc expander should fit in here just fine.  It's going to go ahead and start this dissection coming up into our supraclavicular fossa. So once again, this dissection will start under direct visualization.  As we're doing the dissection to the supraclavicular fossa, it's important for us to make sure  we don't have any paralytic on board to avoid any injury to any of our important nerves passing through our supraclavicular fossa or extending deep into the area, the apex  of the lungs. So it's a real thin plane to be in there between the skin that's relatively thin in this area  and the deep tissues that we don't want to damage during the performance of this portion of the dissection.  Now as you can see, as we're coming up here, we're actually starting to get into our pocket that we made on the anterior shoulder a little bit.  And I think that's okay because we're actually going to get as much expansion as we possibly can from all of this.  Okay, so when we put this in, so we see the pocket we decided we wanted here, we're to the margins of our pocket there, we're here, we're here, we're right here.  So we just need a little bit more right in here and then this pocket will be done. So let's go ahead and free up a little bit more of this pocket right here.  I'll take a deeper please. It's right here that we can see under direct visualization. So we really don't need a endoscope for this part since it's right here.  Take a look and see how our pocket dissection is now. So we're all the way up where we want here. We're all the way here. We're all the way here.  And a tiny bit more here and then we'll be done in this area as well. And then if we look at our pocket here, we're good all the way out to our corner there, all the way down here.  So it all looks good. So a little bit more right there and then we should be all done with these two spots.  For patients like the one we're operating on today, the best reconstructive option for her really is tissue expander reconstruction.  Unfortunately, we all know there are a lot of complications associated with tissue expanders. Tissue expanders get infected. Tissue expanders have hematomas and seromas.  Tissue expanders lead to wound separation through the incision that was made to place the tissue expanders.  And tissue expanders can actually thin out the tissue overlying the expander leading to extrusion.  All of these are very significant complications and this major complication rate can be as high as 30 to 40 percent in some patients and in some locations.  So anything we can do to reduce that complication is a great idea, I think, for placement of tissue expanders.  That's where the role of the endoscope comes into play, allowing smaller incisions through remote locations to reduce some of those complications.  We certainly can't reduce all the complications associated with tissue expander reconstruction.  But indeed, if we can reduce them somewhat, the utility of tissue expansion may be increased. We need to make little pockets.  We need to make little spots where external ports for our tissue expanders are going to be. We want to make sure when this expands and this expands that they don't get in the way  and we're able to find it. So I find that if I put them down on the chest away from where I'm expanding, I'll be able to find those spots relatively easily.  So what we're going to do is we're going to dissect a little pocket here and we're going to dissect two little pockets here where our external ports for our tissue expanders  are going to be. And we're going to make a pocket, not right underneath the skin, but just with a little  sub-Q buffer right there, into which that's going to sit so that it's going to be easy for our nurses in the clinic to find.  Normally we do tissue expanders where the patients actually do them at home. So we want to make sure that we have a readily accessible expander port.  So we're going to use a rectangular tissue expander with an external port. I tend to use the external ports for burn reconstruction because sometimes with the  port which is integrated in the expander itself, it raises or increases the thickness of the expander and puts a little pressure on the overlying skin.  So I like to use these with an external port, which allows us to access it really easily. If I can have now a needle.  So I'm going to squeeze it on the side as we suck the air out of it so that it'll mostly lay flat as the air comes out of it.  So I'll indent the side because I want it to expand up evenly as it slowly expands up, as opposed to expanding up with big ridges or creases coming forward.  So if I squeeze it on the side like that and make it lie flat, okay you can go ahead. Now I have it relatively flat and relatively smooth.  So when this slowly starts expanding, it won't push in a single area, but it'll sort of put pressure on the skin over this entire area.  So I'll take a little bit of irrigation, please. Give me a little squirt. We'll add a little bit of saline to it just for some lubrication so it slides in a little bit better.  So now we'll fold it up and sneak it in through this tiny little incision. But hopefully with this small incision, we'll have fewer problems down the road with issues  surrounding dehiscence of the incision or something like that as we do our expansion.  Okay, come on out. I'll take my hockey stick now.  We'll make sure we use the retractor to make sure it's sitting in there right where we want it to be sitting in there nice and flat.  Now our next step is to go ahead and put this right into our pocket right here that we created. Now we'll take a stitch.  So we're going to take a little of this tissue on either side of this. Go ahead and take that out. Go ahead and take that out. Thank you. You're okay.  And then we're going to stitch just around that hub to make sure that that stays there.  I want to make sure that this port stays right where we put it. I don't want it migrating into that pocket we just created.  And we put stitches right around the hub of the expander to make sure then that that stays right where we put it. Put that right in there.  Now this will stay right where we want it here and that'll be there. Let's go ahead and finish putting stitches in here. So let's go ahead and get a 400cc expander now.  Hotkey stick. Let's put this right in our pocket here.  There. Okay, great. Alright, let's go ahead and get our second 400cc. And we'll put that all the way up that way since the bottom needs to be there.  And we'll put that all the way that way. There. Now that'll just go right there. Okay, there we go.  Following the operation today, our patient is going to go home. We don't admit these patients to the operating room, but we will give her a brief course  of antimicrobial therapy for the perioperative period. Once she goes home, our plan is not to perform any type of tissue expansion for two to three weeks.  However, in two to three weeks, we'll perform the first expansion and then slowly have her expand once or twice a week thereafter until we achieve full expansion.  The goal is to stretch the tissue as quickly as possible so that the period of expansion doesn't take six or eight months.  By the same token, we don't want to push the skin too hard and expand the skin too quickly and lead to ischemic tissues or the possibility of extrusion of the tissue expander.  As a result, I would anticipate that with each expansion, we'll probably be putting about 50 cc's in each of the expanders.  Ultimately, the 500 cc expander will hopefully have eight or 900 cc's in it when we're done expanding.  Each of these expanders can hold a substantially greater volume than the stated volume on the box.  We'll push those expanders until we reach a point where we think we've either achieved maximal expansion of the skin, the skin starts thinning out, or we don't think that we can  make any additional advance by further expansion. This could be three to four months between this operation we just are doing today and  subsequent operation when we remove the tissue expanders and advance the tissue. It has now been four months since we endoscopically placed three tissue expanders in our burn  patient. She's undergone weekly expansion in our clinic with great success. We have three tissue expanders in place and we've expanded all of them somewhere between  800 and 1,000 cc's each. Each tissue expander is expanded about three-fold its stated volume.  That is never a problem when we're doing burn reconstruction because the tissue expanders can tolerate significant over-expansion without failure.  It's also nice to be able to put the biggest expander in as possible and if you get the expansion you desire, continue to progress with further expansion.  In the chest and in the breast region, the more soft tissue you have and the more unburned tissue you have, the better your outcome is going to be.  It's quite challenging to be able to reconstruct chest and breast burn scars because of the difficulty in advancing normal tissue into burned areas without deforming in the breast.  It's an aesthetic deformity to have burned breast and burned chest, but it's also aesthetic deformity to have breast asymmetry.  So our goal is to reconstruct the burn as much as possible while at the same time maintaining breast symmetry.  So our patient today is undergoing burn reconstruction of her chest and breast. About four months ago we endoscopically put tissue expanders into her chest.  We used one incision here and one incision here and through those incisions we put each of these three expanders in.  Over the last four months we've put about 800 cc's of fluid into this expander, 900 in this expander, and about 1,000 cc's in this expander.  So our plan today now is I believe we've reached about the extent of the expansion we can get.  So we're going to go in today and take this normal appearing skin, move it into her burned area and reconstruct as much as possible.  Keep in mind that her reconstruction started in 2007 when the first operations we did was to release burn scar contractures she had in the region of her axilla across the front  of her chest and down on her breast. We also did a breast reconstruction. We put implants in on both sides and also did a breast lift on her left side to get  symmetry between her breasts. So this is going to be the final stage in our reconstruction of her chest to address  both her burn scar contractures, her burn deformity, and her breast asymmetry. So our first incision is going to start at the very extent of this burn up here and come  all the way along the lateral border of the burn tissue. We know we're going to be removing all of this as well.  So rather than wasting time we're going to come right along this border, the burn and unburned tissue, all the way across the top here. You see a band has formed across here.  This band was not there originally but due to the pull from the tissue expanders up high  she has this band now but I suspect when we bring the normal tissue in here we should be okay. We know we're going to want to take out as much of this as possible and we're going to  bring this across to the other side. Our goal will be then to advance tissue medially and inferiorly without having any traction up to avoid deformity of the breasts.  So we'll start right with this. And as we do this operation we're going to be planning to remove all intrinsic and extrinsic  burn scar contractures involved along her chest but at the same time we want to preserve as much of the healthy tissue as possible because we don't want to create some soft  tissue deficit by resecting large amounts of soft tissue as well.  And open all the way along here, bring it all the way up here, because we know we're gonna want to free this flap up all the way to bring to advance it over. There we  go. So you see how much expansion we got. So we started, this was a 250 cc expander that we've now gotten almost to 800, well over 800 cc's. So we can push these  expanders well beyond the limit stated in their volume. I usually use the original size of the defect I can fit the expander into as a defining size of  the expander I'm ultimately going to use, but then I don't worry about volume later. We just keep expanding till we get, we get what we need. So you look now  we've got a lot of great skin here that's going to come over and we're going to be able to make a lot of progress with this right here. So that's  pretty exciting and we'll get a lot of this tissue out. Before we make any decisions here about what to do with this extra tissue we have here, and also  keep in mind we have her arms extended. I don't want to bring her arms to her side, I want to make sure that we can do our reconstruction without any significant  tension, because I want to make sure that we're not going to get too much scar widening.  Let's see if everything is tight, it just goes so much quicker. Now we'll go ahead and get our ports out, there we go, there's one, there we go, now  this one, great, so once again we have another tissue expander that's inflated to approximately  three-fold its initial volume, you see its base dimension is right there, so it's a relatively small expander to begin with, but you can push these well beyond their stated volume  to get the amount of expansion you need to get the reconstruction you need, so these work great, it all depends how much space you have to get the original one in and since  we were putting it just on the anterior deltoid here, we didn't have a lot of space and this one was just a supraglavicular fossa so we didn't have a lot of space either, so we see  a lot of great tissue here, a lot of great tissue here, a lot of great opportunities, so let's go ahead now and see what we can do from the anterior arm.  Thank you for watching.  So we have some tethering of our tissue expander capsule there, so we'll release this capsule as much as we need to to get the advancement that we want out of this tissue.  Let's go ahead, it's still a little bit tethered, so let's go ahead and keep opening along there. So now we have this, and we have this, and we have this.  So as a next step now, we're making nice progress to see what we're going to keep and what we aren't going to keep.  Let's go ahead and free the base of the neck now, so we can figure out what we're going to need there. Double hook and double hook, please.  I'm going to give this to him.  And here, as we come up onto the neck, we're going to try to stay just superficial to our platysma, and then be wary of our anterior jugular veins as we come down along here.  So if we take this supraclavicular skin and we bring this down in this direction, we can get a lot.  We also have a lot of good skin here, so if we can use our anterior deltoid skin to cover laterally and use more of the supraclavicular fossa skin to rotate medially, and then what  we'll do is we'll borrow as much of this as we can, bring this down as far as we can, rotate this in as far as we can, and bring this this way, down and in, we should be able  to bring this to the medial extension of this, and take advantage of this tissue right here that we have, because we haven't taken advantage of any of this yet, and since we're  not going to need it to cover up in this area, we ought to bring that in to cover medially. This to cover centrally, this to come across the top, and then we should have, we should  be in pretty good shape.  Thank you for watching so far. See you next time with a delicious video :)  Thank you for watching so far. See you next time with a delicious video :)  So we have to be concerned about right now with the way we have it we have a little bit probably too much pull right here so we're probably gonna want to  release this a little bit and maybe release this these a little bit too to have a little bit less pull so this comes down a little bit. So now the nice  thing about this is they were almost isolated all the way down to just on her breasts we still have a little bit here however all the big wide burn that she  had here all the big wide burn she had all on her right side all the central stuff is gone so at least now she could wear a low-cut shirt or a v-neck or  something and she wouldn't have the scars present with that. So I think I think this is pretty good it's probably worthwhile for us to have her sit up now  at this time to take a look. So actually she does have a little bit of pull along the medial left breast you see the medial left nipple just a little bit not  too bad though right breast is is not bad so overall the position at this stage I think is pretty good I don't think I would pull down anymore because  we'll distort the breasts too much. So I think at this stage I don't think I would pull anymore in any of these locations and a lot of this is going to  soften up and relax and it's also a little bit difficult to tell draping because of the positioning on the table so I think we can lay back flat there is  a little bit of pull right up here on the left side right in this region so I think what we want to do we still have a little bit of laxity here so I want to  try to rotate this extra tissue in here to allow this breast to come down some so we're gonna back cut this flap a little to let this come each time we  design marking pen each time we design one of these you have to decide is the new scar worth putting in order to get the improvement in the overall  appearance I think in this case I will extend this up a little bit keep it a little bit low on the front of the shoulder and that allow us to rotate this in  So now we're going to take full advantage of this expanded skin. You can see the tissue expander pocket and how far out here it went and now we're going  to try to rotate this in more and as we rotate this in more, have more tissue in to prevent less pull on our breasts through that rotation.  So this used to be positioned like this, but we're going to bring this like this and rotate all this in and that will add tissue above the breast here to keep this down for us.  So there we have now, the breast is going to relax down without tension here, so I think that's good. That's going to be real good. We do have a little bit of deficiency here.  We got a lot of supraclavicular expansion here, a lot of anterior deltoid expansion there, but I think that's about the limit we're going to get here without a lot of pull on this.  We can obviously bring this down further, but this tissue is also burn tissue so it's not going to relax as much, so you have to be careful because if we pull this up now,  it's not going to relax as much as this side will just because this burn tissue. But if we can isolate this so it's mostly in a bathing suit distribution, which it almost  is right now, we can almost have just a few of these lines, but not a lot of burn showing anymore. So I think that's pretty good.  So let's go ahead and mark now what we'll reset, marking pen. So now you see this is all the burn that was here before, and all of that is going away to here.  Well from here to here is 14 centimeters. Vertically without any tension here is 8 centimeters, and across 15 is 21 centimeters across here,  so it's a pretty reasonable resection, somewhere between about 25 centimeters by about 15 centimeters, so not bad.  Okay, so we haven't undermined any of this tissue here, so we're going to keep as much of this soft tissue as we can.  So as far as closing these go, over the years I've closed burn wounds a bunch of different ways.  I've tried stitches on the outside, because when you're sewing normal skin to burn tissue,  a lot of times there isn't a real great dermis to use, but you can sew to some of the scar,  but it isn't quite as solid as it is during a normal closure, so sometimes those dermal sutures  don't hold very well. On the other hand, particularly in a case like this, I don't like having things on  the outside that much either, because I don't like the stitch holes. So I usually do some combination  of things where I will put a series of dermal sutures in, and then run a subcuticular in the  areas that are a little bit snug, or run a subcuticular in all of the areas, but maybe add  a couple of sutures on the outside if it's a little bit snug. So what happens sometimes when  we're doing this is, you can't necessarily use all of the excess skin that you've created along the  way, so sometimes you do have some laxies. So we do have a little extra out here, sponge please, a  little extra out here, so I did extend that, but also keep in mind that her arm is on an arm board  extended to the side, so when she brings it down it'll get a little bit tighter, so chances are  that'll take up. But we typically will have some areas that are a little bit snug, and other areas  that aren't very snug, and those are things that we have to address as much as we can right now,  but then also understanding that the areas of tension will relax some, and sometimes some of  those areas of prominence will settle down with time as well. So occasionally an area that has a  little bit of prominence doesn't settle down completely, and then in the clinic under local  anesthesia I can numb it up and just take a little extra skin out somewhere. So we've had, we  previously had three tissue expanders in place, each somewhere in the range between 800 and a thousand cc's. We subsequently have taken our supraclavicular fossa tissue  expander skin and advanced that medially and inferiorly. We took our tissue expander skin  from this left side and rotated it down and in with this back cut to allow advancement to keep  this breast down as much as possible, and then our right deltoid tissue expander we've advanced  over to give us more fill along here, and hopefully with all this extra skin, it allows us to push  this down more and keep her breast position symmetric as it was before we started. We've  freed everything up into the pockets. We have two 10 milliliter flat Jackson Pratt drains in place.  We've closed it with a running subcut, with interrupted inverted dermal sutures, a 3-O  Vicryl, running subcuticular suture, a 3-O PDS, and then some interrupted PDS right here at the  two T-junctions. We're now going to put Steri-Strips on everything, put her in compression, and we'll be all done.  So I think the most important take-home messages are, use as many expanders as you possibly can,  expand them as big as you possibly can to get as much normal tissue as possible. Don't  underestimate how much tissue you need to get the reconstruction you want to achieve, and most of  all, constantly be aware of the shape of the breasts in this region so that you don't deform the breasts in the process of removing burn tissue. Thank you.

Video Summary

In the video, Dr. Paul Soderna from the University of Michigan Health System's plastic surgery department performs a burn reconstruction on a 51-year-old woman who suffered burn scars when she was two. Using tissue expanders, the goal is to improve scar appearance and symmetry, allowing her to wear V-neck clothing comfortably. Initially, tissue expanders were placed under healthy tissue surrounding the scar. With precise measurements, they positioned these expanders to maximize the amount of expanded tissue for reconstruction. Over several months, the expanders are gradually filled, stretching the skin for future surgical use. <br /><br />During the final surgery, the expanded skin is used to reconstruct areas of the chest and upper body, prioritizing aesthetics and symmetry, especially around the breasts. Dr. Soderna highlights the importance of balancing skin tension to avoid distorting the breasts while addressing the burn scars. By the operation's end, the patient's burn scars are significantly reduced, making future clothing choices more flexible. This comprehensive approach showcases how endoscopic techniques and strategic tissue expansion can enhance outcomes in burn reconstruction surgeries.

Asset Caption

In this video, Paul Cederna, MD, endoscopically places tissue expanders for the reconstruction of chest burns on a 51-year-old woman who was burned by boiling water as a child. She has lived with very significant scarring and contracture her whole life, and after learning of her options, began reconstructive surgery in 2007 to enhance her functional and cosmetic outcome. The initial operation was performed to address the burn scar contractures of her breasts by placing breast implants for reconstruction and a left mastopexy to achieve symmetry in both shape and volume. This video documents the final stages of the reconstruction of her chest to address her burn scar contractures and burn deformity. Dr. Cederna demonstrates the endoscopic placement of tissue expanders to achieve the best aesthetic outcome possible given the amount of available unscarred tissue. Following the expander placement, four months pass, while the patient’s skin is expanded to the desire state for the final reconstruction. When the patient returns to the OR, Dr. Cederna describes his operative plan and then removes the expanders, excises all intrinsic and extrinsic burn scar contractures, preserving as much healthy tissue as possible. The overall goal of this procedure is to achieve symmetry in the size and volume of her breasts while minimizing her visible burn scars of her chest.

Surgeon Paul Cederna, MD

Disclosure Dr. Cederna has nothing to disclose. All ASPS staff members managing this activity have no relevant financial relationships or affiliations to disclose. All identified conflicts of interest have been resolved and the educational content thoroughly vetted by ASPS for fair balance, scientific objectivity, and appropriateness of patient care recommendations. The ASPS also requires faculty/authors to disclose when off-label/unapproved uses of a product are discussed in a CME activity or included in related materials. This product is not certified for CME.

Keywords

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Surgical Videos

Breast

Paul Cederna MD; Memben

burn reconstruction

tissue expanders

plastic surgery

scar improvement

skin stretching

aesthetic symmetry

endoscopic techniques

University of Michigan