ORIGINAL PAPER

Strategies in the management of post-burn breast deformities

Alaa Gheita & Aly Moftah & Husam Hosny

Received: 16 May 2013 /Accepted: 17 October 2013 /Published online: 4 December 2013# Springer-Verlag Berlin Heidelberg 2013

AbstractBackground Burn injuries to the chest area may end upwith severe breast deformity and asymmetry. They arefrequently complex and unique to each case, affectingparenchymal development, breast implantation on chestwall, nipple areola complex position, infra-mammaryfold definition, and skin envelope. Furthermore, con-tractures affecting adjacent territories may occur andadd to the deformity. Surgical correction should ad-dress all the deformity components. Thus, a structuredreconstructive plan that recruits different mammaplastytechniques and deals with adjacent territories is need-ed. This work presents different strategies used intreating severe post-burn breast deformities. Elaborateanalyses of the deformities, surgical techniques, andoutcomes are presented and a structured reconstructiveplan is proposed.Methods Sixteen deformed breasts in 11 patients (mean age,22 years) were managed. The techniques used included avariety of mastopexy techniques, prosthesis-based endoscopicbreast reconstruction, and autologous breast augmentationwith fat grafting or local flaps in some hypoplastic cases.Ancillary procedures to the neck, axilla, and abdomen werecarried out to release the breast when tethered by theircontractures.Results Considerable improvement and reasonable symmetrywere achieved in most cases. All patients were satisfied withthe results, tolerated the need for multiple procedures, andaccepted residual minor asymmetries.

Conclusions A post-burn breast deformity has a complexnature that may be addressed on multiple stages withdifferent techniques of mastopexy, augmentation, andreconstruction. Ancillary procedures to a contracted ad-jacent territory may be needed to release the breast iftethered. Adopting a structured reconstructive plan mayhelp obtain reproducible constant results.Level of Evidence: Level IV, therapeutic study.

Keywords Burn . Breast deformity . Reconstruction .

Strategies

Introduction

Burns to the chest and other nearby areas, e.g., neck,upper abdomen, and limbs, are common in youngchildren [1] and may affect the developing breastyears after the injury in many ways. The scar formedneeds to expand to allow development of the breast.Also, the breast bud itself may be affected by deepburns or by the early tangential excision and graftingthat have been the standard in acute burn management[2], the infra-mammary fold may be obliterated, themound is partially or completely flattened under thewide scar, the parenchyma usually moves toward areasof least resistance, and the nipple areola complex(NAC) may suffer from displacements of varying de-grees to total loss of the whole complex [3]. Thesefactors usually end with either hypoplastic and/or de-formed asymmetrical breasts and may cause significantpsychological burden to adolescent girls and youngwomen [4].

A. Gheita :A. Moftah :H. Hosny (*)Plastic Surgery Department, Cairo University, Cairo, Egypte-mail: husamhosny@kasralainy.edu.eg

Eur J Plast Surg (2014) 37:85–94DOI 10.1007/s00238-013-0904-6

Reconstructive options usually start with multiple releasesand grafting, depending on the time at which breast develop-ment launches [3]. Mastopexy techniques are frequently need-ed for the affected breast and/or the contralateral side in orderto reach reasonable symmetry [5]. Reduction techniques havealso been described in patients in whom scar release andgrafting have been successful and allowed breast developmentto proceed fully [3].

When the breast tissue itself is underdeveloped, more com-plex reconstructive procedures are required. In general aug-mentation mammaplasty techniques may be carried out withor without implants or expanders [6]. This may be achieved byusing neighboring fasciocutaneous flaps [7] or distant muscleor myocutaneous flaps [8, 9]. When there is complete lack ofbreast development, techniques similar to conventional breastreconstruction after mastectomies are usually applied. Amongthose is the use of tissue expanders followed by permanentimplant placement in either subglandular or subpectoralpockets [10]. They also may act as an internal compressiongarments leading to softening of the scars [11].

Thus, each breast deformity should be addressed separatelyaccording to its constituents. Deformity patterns, together withpatients’ expectations, may affect the choice of reconstruction.

This work tries to set a reconstructive guide plan thatcould be followed in order to obtain reproducible resultsthat can be assessed objectively aiming at higher patientsatisfaction. The procedures done, the results obtained,complications, and patient satisfaction were presentedand a reconstructive plan was deduced.

Patients and methods

This work involved 16 post-burn breast deformitiesin 11 patients (five bilateral and six unilateral affections)treated in the Plastic Surgery Department, Cairo UniversityHospital. Each deformity was analyzed thoroughly accordingto its constituents. They had breast asymmetry, distorted pa-renchyma, mound flattening, displaced NAC, and hypertro-phic scarring of variable degrees. Some patients had volumedeficiency and/or infra-mammary fold (IMF) obliteration.Patients’ expectations and management plans were discussedpreoperatively. All patients were subjected to operative inter-vention to correct their deformities. Multiple stages werefrequently employed. The mammaplasty techniques usedwere those of mastopexy, augmentation, reconstruction, andother procedures on adjacent territories that had influenced thebreast either at rest or motion, namely, the axilla, neck, andupper abdomen (Table 1).

Postoperative assessment criteria included restoration ofprojecting breast mound of adequate volume with NAC prop-erly placed on its top, well-defined IMF, reduction of scarredskin, reasonable symmetry, and, finally, patient satisfaction.

Twelve breasts were subjected to differentmastopexy tech-niques (Table 2). A superior pedicle technique was adopted inall patients.

The inverted T technique using the classic Wise patternwas employed when the injury had affected mainly the lowerhalf of the breast while the upper half was relatively spared.Discard of excessive scarred skin, internal parenchymal pli-cation, and flap support were then carried out.

The vertical scar technique was used in mild to moderateptotic breasts affected mainly in their central lower poles. TheLe Jour design was adopted, except for no dissection betweenthe skin and parenchyma. Internal parenchymal sutures werethen carried out.

B-type excision mammaplasty was used when skin scar-ring and the deformed areas could not be included in skinresection using the inverted Tor vertical-type mastopexy, e.g.,lower medial breast quadrants. Scar excision was done and adermoglandular flap was fashioned from the lateral part andtransposed medially; internal parenchymal sutures were thenapplied.

The crescent mastopexy technique was used when only aslight displacement of the NAC was required to match theopposite side.

Augmentation mammaplasty using autologous tissues wasused in cases with mild to moderate hypoplasia (Table 3).

Turnover de-epithelialized flap from the upper abdomenwas used whenever breast hypoplasia was accompanied bylimited scarred upper abdominal skin. A de-epithelialized U-shaped flap from the upper abdomen directly beneath thebreast was raised as a superiorly based dermofascial flap,folded upwards, and sutured to the pectoral fascia in aretroglandular pocket. The donor area was closed in a V–Ymanner and the infra-mammary fold is fixed in the appropriatelevel.

Fat grafting was done in a patient seeking breast augmen-tation after her mammaplasty procedure but refusing addingimplants while her local tissues were inadequate for flapaugmentation. After laxity of the skin has been regained, fatharvesting from the abdomen using the standard Colemantechnique was done [12] and injected into subglandular,intraparenchymal, and subcutaneous tunnels.

Autologous breast augmentation with a thoraco-epigastricflap was used in a case suffering from lateral breast deficiency.The flap was raised from the upper abdomen and rotated in a90° fashion to treat the deficiency.

Staged endoscopic expander–implant breast reconstruc-tion was performed to reconstruct both breasts in a patientwith severe bilateral hypoplasia. The reconstructive planconsisted of two stages. The first stage consisted of a bilateralinsertion of a 500-cc round tissue expander (Mentor®)through an endoscopic trans-axillary approach. After delinea-tion of both breast bases, endoscopic dissection of thesubpectoral pockets for expander insertion was done. Then,

86 Eur J Plast Surg (2014) 37:85–94

Tab

le1

Dem

ographicandperioperativedataof

patients

Case

Age

(years)

Side

Deformity

IMF

obliteration

NAC

displacement

Prev.

I&G

Abdom

eninvolvem

ent

Procedures

Com

plications

Patient

satisfaction

Follo

w-up

(months)

115

Lt

Hypoplasia,hypertrophicscarring

++

−+

AA(TOF),IMFdefinitio

n++

15

221

Lt

Hypoplasia

+−

−+

1st:AA(TOF),IMFdefinitio

n;2nd:

scar

revision

Widened

scar

++

24

318

Rt

Breastp

tosis,hypopigm

entedscar

−++

−+

1st:Mastopexy

(V);2nd:

scar

revision

++

14

417

Rt

Parenchym

aldistortio

n,hypertrophic

scaring

−++

++

1st:Mastopexy

(T);2nd:

scar

revision

Wound

dehiscence

+84

Lt

Parenchymaldistortio

n,hypertrophic

scars

−+

−1st:Mastopexy

(T);2nd:

scar

revision

Widened

scar

+

520

Rt

Severehypoplasia

−−

−+

1st:Endoscopicexpander

insertion;

2nd:

implantreconstruction

Mild

discom

fort

++

20

Lt

Severe

hypoplasia

−Absent

−1st:Endoscopicexpander

insertion;

2nd:

implantreconstruction

++

619

Rt

Hypoplasia,hypertrophicscaring

++

−+

Bilateralm

astopexy

(B),bilateralIMF

definitio

n,reversed

abdomenoplasty,

RtA

A(TOF)

IMFreflattening

+18

Lt

Ptosis,hypertrophicscaring

++++

−++

728

Rt

Parenchym

aldistortio

n,hypertrophic

scaring,axillarycontracture

++++

++

1st:Mastopexy

(T),IM

Fdefinitio

n,Z

plasty

axilla;2nd:

fatg

rafting200cc

Zflap

tipsuperficial

necrosis

+6

Lt

Parenchymaldistortio

n,hypertrophic

scaring,axillarycontracture

+++

+1st:Mastopexy

(T),IM

Fdefinitio

n,Z

plasty

axilla;2nd:

fatg

rafting230cc

++

827

Rt

Parenchym

aldistortio

n,hypertrophic

scaring,neck

contracture

+++

−+

Bilateralm

astopexy

(T),bilateralIMF

definitio

n,multip

leZ(neck)

+10

Lt

+++

+

933

Rt

Parenchym

aldistortio

n++

+−

Mastopexy

(T)

++

22

1028

Rt

Flatbreast

++

−−

Mastopexy

(V)

+18

1124

Lt

Hypoplasia,parenchymaldistortio

n++

−+

1st:AA(TEF);2

nd:m

astopexy

(C)

+32

Ltleft,R

tright,AAautologous

augm

entatio

n,I&

Gprevious

incision

andgraftin

g,NAC

nippleareolacomplex,T

EFthoraco-epigastricflap,T

OFturnover

flap,T

inverted

Ttechnique,Vverticalscar

technique,C

crescent

mastopexy

Eur J Plast Surg (2014) 37:85–94 87

the expanders were inserted into their proper places while thereservoir drums were placed on the lateral chest wall. Theywere overinflated to 750 cc over a period of 3 months. Thesecond stage consisted of the insertion of 450-cc, textured,round, high projection silicone implants (Mentor®) throughthe subaxillary wounds that may be extended to few millime-ters as needed.

Inframammary fold definition using the external approachdescribed by Ryan [13] was used—in conjunction with otherreconstructive procedures—when the infra-mammary fold hasbeen obliterated. A de-epithelialized lower thoracic flap issutured to the pectoral fascia with non-absorbable 2/0 stitcheswhile the lower pole of the breast is being approached during amastopexy technique or autologous augmentation, e.g., upperabdominal flap (Table 1).

Ancillary procedures—as an adjunct to a mammaplastyprocedure—were done when a breast deformity was aggra-vated by an adjacent territorial contracture, e.g., axilla, neck,and abdomen. Release of bilateral axillary contractures usingthe Z plasty technique, release of neck contracture with mul-tiple Z plasty, and reversed abdominoplasty were applied(Table 1).

Scar revision was applied in four cases, being two cases ofwidened scars, one case had healing with secondary intentionafter wound dehiscence and a case of hypopigmented scarring(Table 1).

Results

In this work, 36 procedures were executed to address 16 post-burn breast deformities (Table 4). Mean age was 22 years(range, 15–33 year) at the time of presentation. Among them,

four patients had been subjected to previous incisional releaseand grafting around the time of puberty. Follow-up rangedfrom 8 to 84 months (mean, 19.4 months).

Mastopexy techniques were used in 12 breasts (70.5 %;Table 2). Of these, the inverted T technique was used in seven

Table 2 Distribution ofthe mastopexy tech-niques used

Number Mastopexy technique

7 (58.3 %) Inverted T

2 (16.6 %) Vertical scar

2 (16.6 %) B mammoplasty

1 (8.3 %) Crescent

12 (100 %) Total

Table 3 Distribution of autologous augmentation procedures amonghypoplastic cases

Technique Number

Turnover de-epithelialized abdominal flap 3

Fat grafting 2

Thoraco-epigastric flap 1

Table 4 Distribution of reconstructive procedures among involved patients

Procedure Number

Mastopexy 12

Expander–implant reconstruction 2

Autologous augmentation 6

IMF definition 8

Scar revision 4

Ancillary procedures:

Reversed abdominoplasty 1

Axillary contracture release (Z plasty) 2

Neck contracture release (multiple Z plasty) 1

Total 36

Fig. 1 a Preoperative view of a 17-year-old patient having asymmetry,parenchymal distortion, NAC displacement, and hypertrophic scarring. bFour-year postoperative view after two stages 6 months apart of invertedT mastopexy technique and scar revision

88 Eur J Plast Surg (2014) 37:85–94

breasts (58.3 % of mastopexy cases). This allowed properreshaping of the breast mound, repositioning of the NAC,and worthy disposal of scarred skin (Figs. 1 and 2). Thecomplications reported included a case of wound dehiscencedue to wound infection and a case of widened scar. Both weretreated conservatively, and later scar revision was carried out.Patients were satisfied with the final results.

The vertical technique was used in two breasts with scar-ring limited to the central zone of the lower half of the breast.This technique yielded a nicer shape, and well-projectedbreast mound with NAC on its top (Fig. 3). No complicationswere encountered and the patients were satisfied with theresults.

The B-type mastopexy technique was used in two breasts.Although the final scar is away from the middle line, it helpedin discarding large areas of scarred skin that is eccentric.Moreover, it resulted in an increased roundness of the lowerpole and improved shape and symmetry of the breasts (Fig. 4).

Crescent mastopexy was used in one case associated withautologous augmentation by a thoraco-epigastric flap. Ithelped in elevating the NAC to match the opposite side,although an elongated NAC ensued (Fig. 5).

Endoscopic trans-axillary staged expander–implant breastreconstruction was used in a patient with bilateral severebreast hypoplasia (Fig. 6). Esthetically pleasing breastmounds were reconstructed with accepted symmetry. Onlymild discomfort at times of expander inflation was reported.The patient was satisfied with the final results.

Autologous breast augmentation—in conjunctionwith other mammaplasty procedures—using turnover

Fig. 2 a Preoperative view of a28-year-old patient with markedasymmetry, bilateral hypoplasia,distorted NAC more on the rightside, obliterated IMF, and bilateralaxillary contractures. bPreoperative planning of superiorpedicle inverted T mastopexy,external approach of IMFdefinition, and Z plasty to bothaxillae. c Postoperative view(4 months). Hypoplasia is stillnoted especially on the left side. dFinal results 6 months after twosessions of fat grating of 200 cc tothe right breast and 230 cc to theleft breast

Fig. 3 a Preoperative view of an 18-year-old patient presenting withright-sided breast deformity showing asymmetry, ptosis, andhypopigmented scarring. b Postoperative result (3 months) after first-stage vertical mastopexy and second-stage scar revision of thehypopigmented area

Eur J Plast Surg (2014) 37:85–94 89

de-epithelialized abdominal flap (three cases; Figs. 4 and 7),thoraco-epigastric flap (one case; Fig. 5), and fat grafting (twobreasts; Fig. 2) was done to augment the breast and correctdeformities in patients refusing implants. Considerable vol-ume of normal texture could be obtained together with cor-rection of volume deficiencies. No complications were report-ed, except for suboptimal shape in the thoraco-epigastric flapcase for which the patient required a crescent mastopexyprocedure later.

Infra-mammary fold definition using the external approachwas used in eight breasts in conjunction with othermammaplasty techniques. It restored those breasts long-lasting fine lower appeal (Figs. 2 and 7). Only one casesuffered from recurrent flattening of the fold on one side dueto disruption of the anchoring stitches between the dermis andpectoral fascia.

Tethering effect exerted by axillary contracture (one pa-tient), contracted neck (one patient), and upper abdominalscarring (one patient) has been addressed using Z plasty inthe former two cases and upper abdominoplasty in the latter.Although all these patients were basically the subject of amammaplasty procedure, superior results have been obtainedby freeing the breast from the distally transmitted tractionforces (Figs. 2 and 4); the patients were satisfied by addressingboth deformities.

Discussion

Burns that end with loss of one or both breasts or theirdeformity have negative impacts on a woman’s self-

Fig. 4 a Nineteen-year-oldfemale patient presenting withasymmetry, bilateral breast,ptosis, right-side hypoplasia, andhypertrophic scarring more on thelower inner quadrants of bothbreasts and upper abdomen. bPreoperative planning of bilateralB-type mastopexy, right. Breastautologous augmentation withturnover de-epithelialized upperabdominal flap and reversedabdominoplasty. c Postoperativeresult (1 month)

Fig. 5 a Preoperative view of a 24-year-old patient presenting with leftbreast post-burn hypoplasia. b Postoperative view (2.5 years) after twostages of thoraco-epigastric flap autologous augmentation and crescentmastopexy

90 Eur J Plast Surg (2014) 37:85–94

esteem and body image, added to the psychological traumaof the burn. The psychological consolation of a reconstruct-ed breast is invaluable even when the reconstruction is notperfect [14].

Although four patients had history of previous incisionalrelease and grafting around the time of puberty, this only hadsaved them volume deficiency during breast development.Their breasts grew along lines of least resistance, resulting inobvious deformities.

Reconstructive options in post-burn breast deformities areanecdotal and so diverse, ranging from release and graftingaround the time of puberty to complex mammaplasty proce-dures later on. Depending on the site of scarring to be releasedand the surgeon’s preferences, the technique used is adopted[3, 15–17].

This work presents different techniques that have beenused to treat 16 post-burn deformed breasts in 11 patients.Thirty-six procedures were needed to address those deformi-ties. The mean age at the time of presentation was 22 years, atwhich those young females were more concerned about theirbody image. Multiple factors are considered when the timingof breast reconstruction in young females is concerned. Thedevelopment of secondary sex characteristics, peer pressure,inability to have clothing fit properly, and, above all, patients’desires are all taken into consideration [18].

In this work, the deformities encountered were complex,involving breast volume in some cases, shape, skin scarringproblems, NAC displacement, IMF obliteration, and

noticeable asymmetry. They were sometimes aggravated byscar contractures in adjacent territories like the axilla, neck, orupper abdomen. Because of that complexity, no single tech-nique could address a deformity alone and many procedureswere frequently needed on multiple stages.

Mastopexy entails repositioning of the NAC with preser-vation of its vascularity, removal of excess skin, reshaping ofthe breast parenchyma, and repositioning over the chest wall.Nearly all these constituents are required in managing post-burn breast deformities. Thus, mastopexy techniques wereadopted in 12 deformed breasts (70 %; Table 2).

These techniques included the inverted T technique,vertical scar technique, B excision mammoplasty, andcrescent mastopexy in 58.3, 16.6, 16.6, and 8.3 %, re-spectively. Selection of the technique was based on pre-operative assessment of the site of maximum scarring anddeformity, i.e., selection criteria were followed. Thus,restoration of well-projected breast mound with NAC onits summit and discard of much of skin scarring could beachieved with predictable symmetry as standardization oftechnique selection was adopted.

The complications encountered included a case of wounddehiscence due to infection that was managed by frequentdaily dressing, allowing healing by secondary intension. An-other case developed scar widening. Both cases were subject-ed to later scar revision. Although some elongation of theNAC that is inherent to the technique has occurred in thecrescent mastopexy case, it was accepted by the patient as

Fig. 6 a Preoperative view of a20-year-old patient presentingwith severe bilateral breasthypoplasia. b Lateral view2 months following endoscopictrans-axillary expander insertionwith maximal inflation, showingthe subaxillary wound oppositethe third intercostal space andreservoir drum at posterioraxillary line. c , d Seven monthsfollowing implant insertionthrough the same axillary woundwhich is well hidden in the axilla

Eur J Plast Surg (2014) 37:85–94 91

the final results outweigh that drawback. All the patients weresatisfied with the final results.

The superior pedicle was used in all those cases as we thinkit gives a long-lasting better upper pole fullness. However,skin excision varied depending on the site of maximum scar-ring to be addressed.

Breast bud affection resulting in severe hypoplasia or evencomplete cessation of breast development is a well-known

complication [3]. Breast reconstruction using tissue ex-panders followed by permanent implant placement hasbeen used with varying degrees of success. Subpectoralinsertion is generally preferred especially when the burnhas caused breast hypoplasia [10, 19]. In spite of slowexpansion, the reported complications include ulcerationof the overlying skin envelope, infection, spontaneousdeflation, and implant or reservoir drum exposure [11,20, 21].

In this work, insertion of the expanders was done endo-scopically in a way similar to endoscopic breast augmenta-tion. The advantage of using this technique is bifold: first, thescar of expander insertion was transferred to the lateral chestwall. In this way, the scars added have been minimized anddiverted away from the area of future breast, allowing earlyand safe overexpansion of the expanders without endangeringtheir exposure. Second, the pocket was better visualized,leading to precise dissection, controlled release of medialpectoral fibers, and proper hemostasis.

Placement of the permanent implants was also carriedout through lateral chest wall wounds of expander inser-tion. Using this approach, none of the reported complica-tions related to the use of expanders in burn reconstructionhas happened. Although this is a preliminary report onusing endoscopic breast reconstruction in post-burn breastdeformities that needs further assessment, the expected lowincidence of complications might be attributed to theremote site of insertion of both the expanders andimplants.

Flattening of the IMF is a common consequence of theburn trauma itself or following the release and graftingprocedure. We found that IMF definition restoration usingthe external approach—in conjunction with othermammaplasty procedures—was very helpful in restoringa stable attractive lower breast pole appeal. Eight breastswere subjected to such procedure. Only one case who wassubjected to reversed abdominoplasty in addition sufferedrecurrent obliteration of the IMF. Disruption of anchoringsutures might be attributed to the tension exerted on themby the abdominal flap.

Because of the mobile implantation of the breast overthe chest wall, it is liable to be distorted by traction forcestransmitted from contractures of adjacent territories, e.g.,the neck, axilla, or upper abdomen. Release of these con-tractures as an adjunct to mammaplasty procedures is ofparamount importance in order to free the breast; otherwise,the breast shape would have been affected even with theexecution of appropriate mammaplasty techniques.

In reviewing the previous cases and their results, thefollowing treatment plan (Fig. 8) is proposed by the

Fig. 7 a Preoperative view of a 15-year-old patient with left breasthypoplasia. b Postoperative view (5 months) after de-epithelialized turn-over flap and IMF definition

92 Eur J Plast Surg (2014) 37:85–94

authors to achieve constant reproducible results. It is basedon preoperative analysis of the deformity constituents,especially volume, skin, and parenchymal scarring, IMFobliteration, and adjacent territory contractures. Then, astrategy is planned to address different aspects of thedeformity.

In conclusion, post-burn breast deformities have a com-plex nature being formed of several components. A pro-posed algorithm for operative management based on a thor-ough preoperative assessment is presented. Mastopexy con-cepts and techniques could correct the majority of thesecases. While breast augmentation with local flaps can treatmild to moderate breast hypoplasia, endoscopic trans-axillary expander–implant breast reconstruction may beconsidered in those patients with severe hypoplasia andmuch scarring over the chest area. Ancillary procedures toadjacent territories still have their role in optimizing theresults of those patients.

Conflict of interest None

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POST BURN DEFORMITY

Breast volume

Adequate

(mastopexy)

lower quadrants scarring

inverted T mammoplasty

lower central area

Vertical scar technique

Eccentric scarring

B type mammoplasty

Inadequate

Partial

with abdominal scarring

Upper abdominal flap

reversed abdominoplasty

No abdominal scarring

Local or distal flap

and/or Fat injection

Total

Endoscopic Expander-implant

recostruction

IMF obliteration

NO Yes

IMF definition

Adjacent terretory affection

e.g. axilla, neck...managed

accordingly

Fig. 8 Proposed algorithm for the analysis and management of post-burn deformed breasts

Eur J Plast Surg (2014) 37:85–94 93

16. Thai KN, Mertens D, Warden GD et al (1999) Reduction mammaplastyin postburn breasts. Plast Reconstr Surg 103:1882–1886

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20. De-Agustin JC, Morris SF, Zuker RM (1993) Tissue expan-sion in pediatric burn reconstruction. J Burn Care Rehabil14(1):43–50

21. Moor EV,WexlerMR, Bar ZY,Weinberg A, Chaouat M, Ad ED et al(1996) Chest wall deformity following maximal tissue expansion forbreast reconstruction. Ann Plast Surg 36(2):129–132

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